Dr. Pepe’s Diploma Casebook: Case 9 – SOLVED!

Dear Friends,

As keen followers of my career will know, the chest is my particular area of expertise, so that’s where we’re returning this week. This case is a 39 year-old woman with a cough.

Fig. 1

Most likely diagnosis:

1. Mediastinal lymph nodes
2. Endothoracic goiter
3. Esophageal diverticulum
4. None of the above

Click here for the answer

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    25 Responses to : Dr. Pepe’s Diploma Casebook: Case 9 – SOLVED!

    1. Burak says:

      İn lateral view,there is slight dilatation of the eosaphagus.in PA graphy,there is a radiocontrast in Middle part of the oesaphagus.the answer should be Diverticulum.
      The pulmonary hilus and the vessels are at the normal size.the trachea is at the midline.

    2. Burak says:

      What other sources that we can study for the examination?

    3. Dr Hesham says:

      non of the above

    4. DR NAWAZ says:

      An elongated soft tissue shadow pushing the trachea anteriorly.
      This lesion is extending from above—Neck.
      I will go for Endothoracic goiter.

    5. DRR says:

      none of the above

    6. Katerina says:

      On the right anterior mediastinal border there is a slight curve which could be produced by an esophageal diverticulum.

    7. Xose says:

      None of the above.
      Right aortic arch!

    8. Genchi Bari Italia says:

      In AP dell’rx-torace, si osserva un lievissimo svasamento del profilo mediastinico alto a dx, con l’immagine tracheale che sembra mediana anzichè normalmente spostata a dx.In LL si osserva una impronta sulla superficie posteriore della trachea che sembra lievemente spostata in avanti.Inoltre lo spazio chiaro retrosternale non è chiaramente visibile.Non sono ben visibili le due arterie polmonarie lo spazio chiaro della finestra aorto-polmonare.Penso allora ad un ingombro adenopatico del mediastino medio.,.

    9. Mm says:

      Right aortic arch with aberrant left subclavian artery.
      Aortic arch is on the right.
      On the lateral film, the trachea is bowed toward. I think is by the presence of an aberrant left subclavian artery which passes behind it.

    10. Ricardo Macareno says:

      4. None of the above

    11. Albert says:

      I would suggest a right sided aortic arch (vs double aortic arch).
      Then would be necessary to complete with a CT to confirm the diagnosis and rule out other associated vascular anomalies and possible complications.

    12. Marcy says:

      I don’t see the aortic arch at the left, instead I see a upper right paramediastinic image that looks like a right aortic arch.

    13. Dr J says:

      Right aortic arch

    14. daca says:

      4. none of the above .
      Right aortic arch with aberrant left subclavian artery
      aortic knob is on the right and the trachea is slightly displaced toward the left instead of the right, as in normals. On the lateral film,the trachea is bowed toward by the aberrant left subclavian artery which passes behind it

    15. ABED says:

      endothoracique goiter at the left side

    16. Gkagkanasiou Maria says:

      I will go with mestiastinal mass (maybe a endothoracic goiter)

    17. burak says:

      Should be pulmoary sling .The radioopacity at the lateral view is obtained by the right aortic arc ,not a goiter .The most common abnormality seen in vascular patology is double aortic arc but there is not evidence of this .Then should considered the right aortic arc with left aberran subclavian .but the interrruption may be a least diagnosis in the vascular anomalies of the cardiac .

      • Dr. Pepe says:

        Good. I am glad the cavalry came to the rescue!
        .Remember that in every mediastinal mass it is imperative to rule out a vascular origin

    18. vaggoul says:

      Findings include:
      – widening of the right paratracheal stripe with focal mediastinal bulging (PA)
      – the aortic knob is not adequately visualised (AP)
      – minimum rotation of the film (AP)
      – loss of the retrosternal lucency (L)
      – anterior displacement of the trachea (L)
      – widening of the posterior paratracheal stripe (L)
      The pathology must be in the retrotracheal triangle (middle mediastinum).

      The intrathoracic goiter creates lateral displacement of the trachea.
      Lymphnode involvement extents laterally usually in the AP film.
      Esophageal pathology fits with the imaging findings and cough (due to eg aspiration) but a diverticulum might have an air-fluid level.
      Another diagnostic possibility is a vascular anomaly such as right aortic arch with aberrant left subclavian artery (though the right mediastinal bulging is somewhat higher than expected for an aortic arch and cough is not expected)

      So the correct answer should be 3 (with a consideration regarding the vascular structures)

    19. Mihai Comsa says:

      Endothoracic goiter