Aishwarya Padubidri Muralidhar
1, Tapan Kumar Dash
21Paediatric Cardiac ICU, CARE Hospitals, Banjara Hills, Hyderabad,
2Director and Head of Department, Paediatric CTVS department, CARE Hospitals, Banjara Hills, Hyderabad
Address for Correspondence: Aishwarya Padubidri Muralidhar, Paediatric Cardiac ICU, CARE Hospitals, Banjara hills road no 1, Hyderabad.
Email: aishu.padubidri.m@gmail.com
Keywords : Stridor, Vascular ring, Cardiology.
Question: A 15-month-old female child presented with a 6-month history of progressive refusal to eat solid food, intermittent choking episodes, noisy breathing, and failure to gain weight. The child was born out of a non-consanguineous marriage and third in birth order. The baby was born via normal vaginal delivery at term, cried immediately after birth, weighed 3.2 kg and had a smooth perinatal transition. The child was exclusively breastfed for the first 6 months and was started on complementary feeding thereafter. Initially, the mother reported that the baby accepted the feeds well, but gradually, the baby began to refuse solid food while continuing to accept the mother's milk, with intermittent choking episodes. The child was observed to have progressively worsening noisy breathing associated with fast breathing, which increased on crying. There was no history of fever, persistent coughing, regurgitation, drooling, snoring, mouth breathing, or recurrent upper respiratory tract infection.
On physical examination, the child was found to be alert. Her anthropometry was below the 3rd percentile for height and weight. Mild pallor was noted, but no cyanosis, clubbing, or oedema was present. Respiratory examination revealed tachypnoea (respiratory rate 40/min) and audible biphasic stridor. Cardiac examination was unremarkable. Other general and systemic examinations were normal.
Chest X-ray was done which revealed an abnormally widened superior mediastinum as in Figure 1, suggesting a possible vascular ring. This was confirmed by a contrast-enhanced CT scan of the chest, which showed a double aortic arch compressing the trachea and oesophagus (Figure 2 and Figure 3). No other associated cardiac anomalies were noted. Patient underwent surgical intervention to divide the anomalous vascular ring. Postoperatively, the child was initiated on liquid diet followed by a gradual transition to solids, which were accepted without difficulty. The child was discharged home on postoperative day 6. At 6 months of follow up the child is asymptomatic and gaining weight on regular diet.
Figure 1. Chest X-ray showing widened superior mediastinum (white arrow) and prominent right aortic arch (blue arrow).
Figure 2. CECT chest in axial section showing Double aortic arch that is right aortic arch and left aortic arch forming a vascular ring.
Figure 3. CECT chest: axial section(A), lateral section (B), oblique lateral section(C) and coronal section(D) showing compression of the trachea and oesophagus by the vascular ring.
