CASE:

This is a 6-month old male who presents to the pediatric clinic with difficulty breathing. He has had similar episodes in the past. He has been diagnosed with asthma and has been treated with albuterol with only modest improvement. He has some nasal congestion, but no fever, vomiting or diarrhea. He feeds well and he has been gaining weight well.

His past history is remarkable for multiple upper respiratory infections and wheezing during the past several months. He was born at term. His family history is significant for asthma in several relatives and his older siblings. He has three siblings who currently have colds.

Examination:

VS T 37, P 114, R 39, BP 100/75, oxygen saturation 99% in room air. He is alert, active, and in no distress. He is not toxic. HEENT significant for clear nasal mucus, normal TM's and a clear pharynx with normal oral mucosa. Heart regular without murmurs, but his breath sounds are noisy so it is difficult to be sure. He has mild inspiratory and expiratory "wheezing". His lung fields demonstrate good aeration. He has no retractions. His abdomen is soft, non-tender and without organomegaly. His neurologic exam is unremarkable. An albuterol aerosol is administered and following this, his lung exam is unchanged. A chest radiograph is ordered. An airway anomaly is also suspected so a lateral neck is also ordered.

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Lateral view

View lateral neck

This is a 6-month old child with a history of several episodes of dyspnea, noisy breathing and/or wheezing. A chest or airway anomaly of some sort is suspected. Take a minute to review these carefully.

View esophagram

What is the diagnosis?