Today I present images of an 89-year-old man with COPD and occasional pulmonary infections. What do you see?
Check the images below, leave your thoughts in the comments section and come back on Friday for the answer.
Findings: chest radiographs show signs of COPD, with in increased anterior clear space and flattening of the diaphragm. A small basal infiltrate is seen in the lateral view (B, arrow). The main finding is a mediastinal air-fluid level visible in both projections (A-B, red arrows).
The air-fluid level is more evident in the cone down views (C-D, red arrows) and it occupies Raider triangle in the lateral view.
The appearance suggests either oesophageal obstruction or Zenker diverticulum, although I favour the second possibility, given the absence of dysphagia, the rounded appearance of the lesion and the long-standing symptoms.
Oesophagogram (not available) showed a Zenker diverticulum, confirmed at surgery.
Final diagnosis: Zenker diverticulum
Congratulation to MK, who was the first to suggest the diagnosis.
Teaching point: This is a nice case of occupation of Raider triangle by esophageal pathology (the other one being congenital abnormalities of aortic arch)
In both proyections, I see an hydro-aerial level at the upper mediastinum (Zenker diverticulum vs esophageal estenosis/tumor?).
There is a parenchimal high density next to the right cardiac silhouette.
In the laterla view there is a flatened of both hemidiaphragms because of his COPD.
…oltre a livello idroaereo a livello faringo-esofageo…vi è una opacità alla base diaframmatica , posteriormente, in LL e che non credo sia una semplice bozzatura diaframmatica.
Hi,
flattening of the hemidiaphragms with blunting of the costophrenic recesses and barrel chest appearance on the lateral view, all are suggestive of emphysema.
Although, a possible mass lesion can be seen over the posterior costophrenic recess on the lateral view.
thanks
Hi,
on a second look, there is an air-fluid level posterior to the trachea at the thoracic inlet.
Hi!
-Air-fluid level in the upper mediastinum.
-Displacement of the trachea.
-Abnormal mediastinal lines and stripes.
Possible diagnosis: Achalasia
Lateral view : opacity in the posterior costodiaphragmatic recess
Hi,
the DDX of the upper mediastinal air-fluid level includes mainly: zenker diverticulum, bezoar, complicated esophageal duplication cyst.
The DDX of the posterior costophrenic mass: lung mass, pleural mass, diaphragmatic hernia, neurogenic tumor….
Profesor:
hay un nivel hidroaereo en el mediastino superior posiblemente por un divertículo esofágico o una estenosis alta.
Adema cambios marcados de EPOC
difficult! Old films may make it easier…
Air fluid level – Zenkers diverticulum (can’t see a dilated oesphagus on the lateral view )
On the lateral view I think there may be a doughnut sign but can’t see obvious adenopathy on the PA view.
There is opacity in the posterior costophrenic region on lateral but again can’t see it on PA view.
As a stand alone study I’d get a CT to exclude cancer.
Thanks to all of you for participating. Glad you saw the air-fluid level. Next case will be difficult, I promise! 😉