Radiology Quiz Case

Abstract

A 1-MONTH-OLD BOY WITH A HISTORY OF PREmaturity, duodenal atresia, and multiple skin hemangiomas underwent flexible fiberoptic endoscopy for workup of mild inspiratory stridor, dysphagia, and aspiration. Previous videofluoroscopic evaluation of his swallowing function had demonstrated moderate oral aversion, poor laryngeal sensitivity, and aspiration. Flexible fiberoptic examination of his larynx demonstrated normal true vocal cord function, pooling of secretions, and an intra-arytenoid area, which was suggestive of a laryngeal cleft. Formal direct laryngoscopy and bronchoscopy were scheduled to further inspect his intraarytenoid region. Direct laryngoscopy and bronchoscopy demonstrated several anatomical anomalies, including a type 1 laryngeal cleft (Figure 1), a small, nonobstructing, leftsided subglottic hemangioma, and an unusual “trifurcation” configuration at the carina (Figure2). Because there was a concern regarding a possible tracheoesophageal fistula with the history of aspiration, an attempt was made to pass a pediatric flexible bronchoscope into each of the distal orifices. Unfortunately, the orifice size would not allow the flexible bronchus to pass distally. Because of the atypical appearance of the carina and the patient’s history of respiratory problems, a computed tomogram of the chest was obtained (Figure 3). What is your diagnosis?