All patients diagnosed with asthma should have a CXR. In addition to looking for pneumothorax and transient pulmonary infiltrates, one should pay attention to the tracheal air column. Any obstruction to the major airway can produce a wheeze. If the obstruction is high up, i.e. extrathoracic, the sound is described as stridor, i.e. during inspiration. This is in contradistinction to rhonchi which is classically expiratory and due to small airway obstruction. The CXR here shows a bulge in the lateral wall of the mid-trachea (Fig. 24.2) due to a tumor. Possibilities include squamous cell carcinoma, metastases, mucoepidermoid carcinoma, adenoid cystic carcinoma and carcinoid tumor. Flexible bronchoscopy in this patient showed a mid-tracheal tumor (Fig. 24.3) and biopsy showed adenoid cystic carcinoma (a low-grade malignancy).
Case 25. This was a routine CXR (Fig. 25.1) in an ICU patient who was admitted for aspiration pneumonia. Name the most obvious abnormality.
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