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Difficulty: MediumCardiothoracic and Vascular Surgery

During a routine follow-up appointment, a 74-year-old male patient reports three months of progressively worsening shortness of breath and a persistent, dry cough. He also notes a recent, unexplained change in his voice, describing it as increasingly hoarse. His past medical history includes a 45-pack-year smoking habit and chronic obstructive pulmonary disease (COPD). Two weeks prior, an urgent care provider treated him with oral corticosteroids and macrolide antibiotics for a presumed COPD exacerbation; however, his symptoms have steadily deteriorated.

Currently, his blood pressure is 158/92 mm Hg, heart rate is 88/min, and respiratory rate is 22/min. Oxygen saturation is 94% on room air. Physical examination reveals a palpable downward pull of the trachea synchronous with cardiac systole. Auscultation of the anterior neck and upper chest demonstrates a prominent, high-pitched inspiratory sound. The lung bases are clear, and there is no peripheral edema. A plain chest radiograph reveals a significantly enlarged aortic silhouette and widening of the mediastinum.

Which of the following is the most appropriate next step in the management of this patient?

  1. Computed tomography angiography of the chestAnswer
  2. B
    Initiation of daily inhaled tiotropium
  3. C
    Administration of intravenous furosemide
  4. D
    Referral for outpatient pulmonary function testing
  5. E
    Measurement of serum B-type natriuretic peptide

Answer

Computed tomography angiography of the chest
The correct answer is to perform computed tomography angiography of the chest. This patient's presentation of hoarseness, dyspnea, and a high-pitched inspiratory sound (stridor), combined with a tracheal tug (Oliver's sign) and a widened mediastinum on chest radiograph, is highly characteristic of a thoracic aortic aneurysm (TAA). An aneurysm of the aortic arch can compress adjacent mediastinal structures. Compression of the trachea or left mainstem bronchus causes dyspnea, cough, and stridor. Compression of the left recurrent laryngeal nerve, which loops under the aortic arch, leads to vocal cord paralysis and hoarseness. A tracheal tug is a classic physical sign caused by the transmission of aortic pulsations to the trachea. The most appropriate next step in management is to definitively image the aorta to confirm the diagnosis and plan for surgical or endovascular repair. CT angiography of the chest is the gold standard diagnostic test for this purpose in a hemodynamically stable patient.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms.
The patient has progressive dyspnea, dry cough, hoarseness, and stridor (high-pitched inspiratory sound).
These symptoms collectively suggest mechanical compression of the upper airway (trachea) and the left recurrent laryngeal nerve.
2
Evaluate the physical examination and basic imaging findings.
The exam shows a tracheal tug (Oliver's sign), and the chest radiograph reveals a widened mediastinum and enlarged aortic silhouette.
Oliver's sign occurs when an aortic arch aneurysm physically tugs on the trachea with each heartbeat. The radiographic findings confirm a large mediastinal vascular structure.
3
Determine the most likely diagnosis and the appropriate diagnostic test.
The presentation is classic for a thoracic aortic aneurysm (TAA). The definitive diagnostic modality is computed tomography (CT) angiography of the chest.
CT angiography accurately maps the size, location, and anatomical relationships of the aneurysm, which is essential for planning life-saving surgical or endovascular repair.

Key Concept

Thoracic aortic aneurysms of the aortic arch can present with compressive symptoms including hoarseness (recurrent laryngeal nerve), dyspnea/stridor (trachea), and a palpable tracheal tug (Oliver's sign). Diagnosis is confirmed with CT angiography of the chest.
Estimated Time:1m 15s
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Topics

Cardiothoracic and Vascular Surgery

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