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Difficulty: EasyCardiothoracic and Vascular Surgery

A 68-year-old man comes to the physician because of a 3-month history of progressively worsening shortness of breath, a persistent "brassy" cough, and mild difficulty swallowing solid foods. He has a history of long-standing, poorly controlled hypertension and has smoked a pack of cigarettes daily for 40 years. His temperature is 37.0°C (98.6°F), blood pressure is 165/95 mm Hg, heart rate is 82/min, and respiratory rate is 18/min. Physical examination shows normal jugular venous pressure and no lower extremity edema. The lungs are clear to auscultation except for a faint, high-pitched expiratory sound heard predominantly over the central chest. Chest radiography reveals a significantly widened superior mediastinum and a prominent aortic silhouette. Which of the following is the most likely underlying cause of this patient's symptoms?

  1. Mechanical compression of adjacent structures by a dilated vesselAnswer
  2. B
    Progressive inflammatory airflow limitation affecting the small airways
  3. C
    Fluid transudation into the alveoli secondary to ventricular dysfunction
  4. D
    Reversible bronchospasm triggered by chronic respiratory irritation
  5. E
    Inappropriate relaxation of the lower esophageal sphincter with microaspiration

Answer

The most likely cause of this patient's symptoms is mechanical compression of adjacent structures by a dilated vessel (thoracic aortic aneurysm).
The correct answer is mechanical compression of adjacent structures by a dilated vessel. This patient's presentation is classic for a thoracic aortic aneurysm (TAA). Aneurysms of the aortic arch and descending thoracic aorta can compress adjacent mediastinal structures as they expand. Compression of the tracheobronchial tree leads to dyspnea, wheezing or stridor (often misdiagnosed initially as asthma or COPD), and a characteristic dry, "brassy" cough. Compression of the esophagus leads to dysphagia. The diagnosis is strongly supported by the chest radiograph finding of a widened mediastinum and prominent aortic silhouette in a patient with significant risk factors (smoking, hypertension).

Step-by-Step Solution

1
Analyze the patient's presenting symptoms.
The patient has a brassy cough, dyspnea, central chest wheezing (stridor), and dysphagia.
Identifying the cluster of symptoms helps localize the pathology. These specific symptoms point toward mechanical compression in the mediastinum (trachea and esophagus).
2
Evaluate the patient's risk factors and vital signs.
The patient is an older male with a heavy smoking history and poorly controlled hypertension.
These are the classic, primary risk factors for atherosclerosis and the development of aortic aneurysms.
3
Interpret the radiographic findings in the context of the clinical presentation.
Chest radiography shows a widened superior mediastinum and enlarged aortic silhouette.
A widened mediastinum combined with compressive symptoms in a high-risk patient confirms the diagnosis of a thoracic aortic aneurysm.

Key Concept

Thoracic aortic aneurysms often present asymptomatically but can cause distinct compressive symptoms as they enlarge, including a "brassy" cough and dyspnea (tracheal/bronchial compression), dysphagia (esophageal compression), and hoarseness (recurrent laryngeal nerve compression).
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Topics

Cardiothoracic and Vascular Surgery

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