And finally, to look at another group of patients

And finally, to look at another group of patients with this kind of presentation; we have here a two-month old and a toddler with some similarities in their presentation. The two-month-old with mild upper respiratory symptoms for a few days but presents now in respiratory distress. If you can get a history you may find that this child has had noisy breathing since birth, certainly thereafter, and has been noticed to favor a positioning of the hyperextension of the neck. The toddler may give you a history of frequent choking spells, a history of difficulty swallowing solid foods, often with some choking. Physical examination in both of these kids may be focused on the stridor with which they present. What is it that these two kids may have in common? Vascular. The common pathology here would be tracheoesophageal compression. Due to the compression on the trachea and/or the esophagus with involvement usually of the residual of the fourth arch in the embryologic development. We see different forms of this. This is a double aortic arch here which affects the compression of, usually, both the trachea and the esophagus. Here is a right aortic arch with the remnants of the ductus arteriosus ligament here on the left side to effect a ring. Then other forms like a right aortic arch with a left ductus. But parts of the arch that cause the obstruction of the trachea and/or esophagus presenting with the symptoms that we’ve indicated in these two cases.

The diagnosis can be made by the history. The physical examination of stridor. Chest x-ray may not be very helpful. Usually the diagnosis is made by some imaging, such as MRI or CT, and less often these days with cine-angiography. These are some examples. This is a lateral view of a child with a double aortic arch where you can see that there is compression of this esophagus in which there is barium, and if you look very closely, there is some compromise of the trachea as well. Another example where you can see a compression anteriorally and posteriorally of this esophagus. In fact, this was a child with a pulmonary sling. Pulmonary sling where the left pulmonary artery actually arises from the right pulmonary artery and usually courses between the airway and the esophagus. Women’s health information.

The treatment, once we have recognized and made the diagnosis, is surgical intervention. So we’ll stop here. Just to emphasize that not only do we want to recognize these patients, for example with cyanotic congenital heart disease, but to be prepared to intervene with early medical management to try to prevent progression of the hypoxemia and the acidemia. In the children with coarctation or hypoplastic left heart, then to treat the shock but to remember – important to us – is the initial assessment before you give the prostaglandin as to whether there was a discrepancy in pulses or blood pressures that might help us to know that we are dealing with coarctation rather than hyperplastic left heart syndrome.

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