Abnormalities of the thoracic cage are an unusual cause of dyspnea. This is a rare case of extrinsic compression of a proximal bronchus due to vascular infringement from severe kyphoscoliosis.
An 82-year-old female patient was referred to the Medical College of Virginia Hospital for evaluation of progressive shortness of breath. The patient’s history was remarkable for severe kyphoscoliosis s/p lumbar spine surgery and immobilization in the 1930’s. She also has a history of intermittent atrial fibrillation and breast cancer status-post mastectomy in 1999. The family history was remarkable for scoliosis in her children and grandchildren. Medications included tamoxifen.The patient describes symptoms of breathlessness with a persistent, non-productive cough. She was previously healthy and independent, but is now non-ambulatory and reports dyspnea at rest. She was twice hospitalized in recent months for pneumonia. A chest radiograph revealed profound skeletal abnormalities and a right pleural effusion with right lower lobe collapse. Chest computed tomography confirmed the skeletal abnormalities and the lower lobe collapse with effusion. Given her history of breast cancer, malignancy was suspected. Fiberoptic bronchoscopy was performed at the outside hospital and was negative for malignancy. She was referred to the University for further evaluation.On physical exam, the patient was an elderly, frail woman in moderate respiratory distress. Breathing pattern was rapid and shallow, and the patient had difficulty speaking in full sentences. Oximetry was 94% on room air. Weight was 98 pounds. HR was 82 and regular. The chest was asymmetric, with the right hemithorax much smaller than the left. Severe kyphoscoliosis with dextro-rotation was noted. The right mastectomy scar was observed. Breath-sounds were absent in the right base, with dullness to percussion over half of the right hemithorax. Egophony was not present. Left lung was clear to auscultation and percussion. Repeat computed tomography of the chest revealed partial atelectasis of right middle lobe and total collapse of the right lower lobe with a moderate right pleural effusion. There was marked rotation of the thoracic cage and mediastinal structures, with narrowing and extrinsic compression of the right bronchus intermedius between the right pulmonary artery and the rightward descending aorta. No mediastinal masses or adenopathy were noted. The patient underwent repeat bronchoscopy under general anesthesia. The airway inspection confirmed subtotal compression of the right bronchus intermedius. The distal airways beyond the bronchus intermedius were patent but filled with secretions. The patient underwent placement of a self-expanding metallic stent under fluoroscopic guidance (Ultraflex 12mm diameter, 20mm length). Re-expansion of the right lower lobe was noted immediately, and pulmonary toilet of retained secretions was performed. The patient was extubated after the procedure and was discharged to home the following day.Follow-up evaluation revealed both clinical and radiographic improvement. The patient regained her previous functional status, becoming fully independent and ambulatory. She reports walking “a mile a day”.DISCUSSION: Abnormalities of the thoracic cage are an unusual cause of dyspnea. Often, the respiratory limitation is due to restrictive pulmonary physiology or diaphragmatic dysfunction. Rarely, bronchial or vascular occlusion due to rotation of the thoracic cage has been reported, with vital structures trapped between vascular structures and the vertebral column. Bronchial obstruction due to vascular abnormalities is uncommon and is attributed mostly to enlarging thoracic aortic aneurysms or anomalous vascular anatomy. This is a rare case of extrinsic compression of a proximal bronchus due to vascular encroachment from severe kyphoscoliosis, treated with a self-expanding metallic stent.
This is an unusual case of kyphoscoliosis causing vascular distortion and bronchial obstruction, treated with a self-expanding metallic stent.
J. Perry, None.