Dyspnea and tracheal mass in an elderly man.

T he patient was a 72-year-old man with a supenor mediastinal, paratracheal mass that was first noted on a chest x-ray film obtained 3 years earlier during a hospitalization after a tractor accident. Further evaluation was not undertaken at that time given the seriousness of the patient’s trauma. The patient survived his injuries and over the following 3 years noted progressive breathlessness with exertion. The patient had never smoked and denied weight loss, dysphagia, or chest pain. Medical history was otherwise noncontributory. Physical examination revealed an elderly man in no apparent distress at rest. Vital signs were stable but chest examination revealed scattered rhonchi. Stridor could be provoked with voluntary hyperventilation. An x-ray film examination of the chest, shown in Figure 1, illustrates a left paratracheal mass causing significant tracheal compression. Pulmonary function tests confirmed a severe obstructive ventilatory defect with impaired expiratory flows suggesting a variable intrathoracic obstruction of the trachea. A chest computed tomography (CT) scan confirmed a well-defined mediastinal mass measuring about 5X4X5 cm. The mass caused significant lateral compression of the left side of the trachea, and a portion seemed to be intraluminal. Multiple punctuate calcifications within the mass were noted (Fig 2). Bronchoscopy confirmed high grade, extrinsic, midtracheal compression with minimal mucosal abnormality. A thoracotomy was performed.