Correct!
5. Tracheal narrowing
The contrast-enhanced thoracic CT shows no evidence of right heart failure or acute pulmonary embolism. No evidence of ground-glass opacity is seen. The central airways do not show abnormal thickening. No evidence of centrilobular nodularity is present. However, the upper thoracic trachea appears significantly narrowed, apparently compressed between the dilated esophagus and great vessels and anterior chest wall (Figure 6). This narrowing continues to the level of the carina. This finding is consistent with tracheomalacia, not readily seen on the previous thoracic CT (Figure 4).
It was noted that, although the patient did not offer complaints of dysphagia voluntarily, when questioned she admitted to such (particularly, and not surprisingly, solids) and suffered from significant protein-calorie nutrition. The patient subsequently underwent upper endoscopy for evaluation of her esophageal abnormalities, with botulinum toxin injection, which showed narrowing of the distal esophagus but without intrinsic abnormality or extrinsic obstruction. No upper- to mid-esophageal motility was noted, with a hypertonic lower esophageal sphincter, consistent with achalasia. Shortly after the procedure, the patient suffered hypoxic respiratory failure requiring intubation. The patient was subsequently stabilized, and extubated 30 minutes later. However, about 20-30 minutes following extubation, she again developed shortness of breath with hypoxia, requiring re-intubation. She was again stabilized and subsequently extubated. She did well over most of the ensuing night, but again developed shortness of breath and hypoxic respiratory failure, this time managed successfully with bag-mask ventilation. Arterial blood gas analysis suggested acute-on-chronic hypercarbic respiratory failure during these events. Pulmonary medicine was consulted and felt her complaints and respiratory failure events were a combination of restriction resulting from left diaphragmatic paralysis following her sternotomy, her malnutrition, and tracheomalacia resulting from compression by a megaesophagus. Pulmonary medicine did not feel tracheal stenting was appropriate for the patient, and efforts should be directed towards relieving the airway obstruction by the enlarged esophagus, avoidance of sedative medications, and use of positive pressure ventilation as needed. A percutaneous gastrostomy tube was placed to improve the patient’s nutrition prior to a planned Heller myotomy to address the patient’s achalasia, as this was felt to be the inciting factor for both the patient’s malnutrition and her tracheomalacia-induced respiratory failure. However, general surgery felt the patient’s clinical status presented significant surgical risks and was reluctant to perform a surgical intervention to address the patient’s achalasia. The patient was treated with repeat upper endoscopy with botulinum toxin injection.
Diagnosis: Tracheobronchomalacia due to achalasia
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References