Innominate artery compression of the trachea in infants

Compression of the airway by the innominate artery has been a controversial cause of stridor and apnea in infants. Magnetic resonance imaging has been applied to document the possible association of segmental tracheomalacia. Forty infants with symptoms of stridor were studied, 7 of 40 infants aged 3–21 months (mean 10 months) had innominate artery compression on the trachea. Five infants were treated conservatively and two infants underwent surgery. Flattening of the trachea was longer than the mass compression point by the innominate artery. Therefore, intrinsic abnormality of the trachea is the basis of the respiratory symptom.     

Cine magnetic resonance imaging for evaluation of focal tracheomalacia: innominate artery compression syndrome

BACKGROUND: The contribution of an 'aberrant innominate artery' to respiratory distress syndromes has been a matter of debate nearly since the introduction of this concept. Recent advances in dynamic imaging are proving to be of value in assessing tracheal function in patients with respiratory distress. We therefore evaluated patients with innominate artery compression syndrome using the cine magnetic resonance imaging (CMRI) modality. OBJECTIVES: To apply the CMRI modality to evaluate patients with respiratory distress who exhibited tracheal compression at the level of the innominate artery. METHODS: A cohort of three patients in respiratory distress underwent bronchoscopy, followed by CMRI using a Siemens 1.5T Vision system. RESULTS: These three patients exhibited tracheal compression at the level of the innominate artery in agreement with their findings during bronchoscopy. All three exhibited dynamic tracheal compression that varied with the respiratory cycle. The degree of tracheal compromise was readily appreciated using the dynamic, real-time CMRI modality. Due to the severity of symptoms, the two children underwent innominate arteriopexy with complete resolution of their symptoms. CONCLUSIONS: CMRI provides extremely rapid acquisition of images, as well as integrated information regarding relationships of mediastinal structures. By providing functional imaging of tracheal patency during the respiratory cycle, CMRI may provide additional insight into innominate artery compression syndrome as more patients are evaluated.     

Innominate artery compression of the trachea: Current concepts

One common vascular anomaly that causes airway obstruction in neonates and infants is innominate artery compression of the trachea. A great deal of controversy exists regarding the effect of this anatomic variant on symptom production. Several cases are presented that demonstrate the unique features of innominate artery compression of the trachea: 1. Innominate artery compression can occur in adolescent patients. 2. Flow volume loops are an effective method of documenting airway compromise in this condition. 3. Exercise intolerance should be considered as a relative indication for surgical intervention in these patients. 4. Reimplantation of the innominate artery is a viable surgical alternative in the treatment of affected patients. 5. Telescopic bronchoscopy during surgical correction of this condition will ensure that there has been successful correction of the tracheal compression. 6. Urgent repair is advocated in patients who experience periods of apnea.     

Fistula between the trachea and innominate artery--a rare complication following tracheostenosis treatment with silastic tubes

BACKGROUND: Fistulas between the trachea and innominate artery are rare but devastating complications that usually occur following tracheotomies. METHODS: One case a fistula after long-term treatment of a tracheal stenosis with an Montgomery silastic tube was analyzed. A literature review of the different strategies in diagnosis and treatment of this complication was undertaken. RESULTS: In the present case, the fistula occurred after long-term treatment of tracheal stenosis with silastic tubes (Montgomery). Summarizing our experience with this case and a review of the literature, it can be concluded that: Fistulas most frequently occur following tracheostomy or tracheal reconstructive surgery. Frequent bronchoscopic examination during long-term treatment of tracheal stenosis with silastic tubes is essential. Even minor tracheal hemorrhage in such cases must be thoroughly examined. In case of fistula hemorrhage, the most effective treatment consists of direct local compression, best obtained with a well placed respiration tube. CONCLUSION: Fistulas between the trachea and innominate artery constitute a rare but possible complication after tracheal stenosis treatment.     

Risk assessment of high-lying innominate artery with neck surgery

Conclusion: A high-lying innominate artery (the upper edge of the innominate artery across the anterior midline of the trachea located 2?cm above the suprasternal notch), a rare situation, may produce disturbance to related anterior cervical tracheal surgery and even cause serious complications.

Objectives: High-lying innominate artery is a high risk factor in anterior cervical tracheal surgery. Pre-operative assessment via imaging technique can help to familiarize the artery and reduce the related disturbance to the surgery.

Methods: A total of 829 patients were selected. Cervical computed tomography (CT) examination was conducted before surgery. The distance between the upper edge of the innominate artery across the anterior midline of the trachea and the suprasternal notch was measured. The exposure of innominate arteries in these cases during surgery was recorded.

Results: The upper edge of the innominate artery was located above the suprasternal notch in 26.4% (219/829) of patients. The upper edge of the innominate artery across the anterior midline of the trachea was 2?cm above the suprasternal notch in 18 cases, accounting for 2.2% of all cases, and innominate arteries were exposed in 11 cases (61.1%) during surgery.     

Utility of radiographs in the evaluation of pediatric upper airway obstruction

The evaluation of children with airway obstruction always involves a history and physical examination. The definitive diagnosis is most often made with microlaryngoscopy and bronchoscopy (MLB), and in cases of extrinsic compression, information is gained from magnetic resonance imaging. Although plain radiographs of the airway are often used as a primary diagnostic modality in children with airway obstruction, the accuracy of plain radiographs in predicting specific airway abnormalities has not previously been evaluated. This study was designed to correlate the findings of plain airway radiographs with the diagnosis made at the time of MLB. Medical records from 1991 to 1996 were reviewed to identify patients that had MLB and airway radiographs within 2 days of one another. One hundred forty-four cases were identified and divided into diagnostic categories. Statistical analysis showed a high sensitivity (>86%) for the accuracy of the radiologic diagnoses of exudative tracheitis, airway foreign body, and innominate artery compression. Laryngomalacia and tracheomalacia had a much lower sensitivity (5% and 62%, respectively). We believe that plain radiographic evaluation of the airway provides important information to the diagnostician. However, plain radiographs can be inaccurate and must be considered along with a history, physical examination, and clinical suspicion. Microlaryngoscopy and bronchoscopy remains the ultimate diagnostic test for airway disorders.     

Tracheo-innominate artery fistula

One of the most dramatic complications of tracheostomy is a fistula between the trachea and the innominate artery. Our study has shown that patients at highest risk are those requiring ventilatory assistance with a cuffed tracheostomy tube placed below the level of the fourth tracheal ring. Median sternotomy has been the initial surgical procedure reported for the control of the attendant massive hemorrhage. We have found that immediate control of bleeding can be rapidly and safely accomplished by making a small suprasternal incision and compressing the innominate artery between the surgeon's finger and the undersurface of the sternum. This previously unreported use of the mediastinoscopy approach is also applicable in traumatic wounds of the lower neck, trachea and great vessels.     

Vascular compression of the airway: Indications for and results of surgical management

Vascular compression of the airway is a significant cause of respiratory compromise in children. While the indications for surgical repair are sometimes life threatening, they can also be subtle. This retrospective study examines 45 surgical cases of tracheobronchial compromise secondary to vascular compression at a large children's hospital between July 1983 and February 1996. A total of 34 were diagnosed with innominate artery compression, ten with a double aortic arch and one with an anomalous right subclavian artery. The 45 patients, 25 male and 20 female, ranged in age from 12 days to 11 years at surgery (average 13 months). A total of 21 (47%) presented with proven or suspected episodes of cyanosis or apnea. All 45 patients had evidence of vascular compression during microlaryngoscopy and bronchoscopy. The diagnosis was confirmed by magnetic resonance imaging (MRI) in 23/45 (51%), barium swallow in 22/45 (49%) and aortogram in 3/45 (7%). There was one death. One patient had a tracheotomy before surgery and continues to require it after surgery. Complete resolution of symptoms was achieved in 39/45 (87%) with five requiring more than one operation before their symptoms resolved completely. A total of four patients experienced a recurrence of symptoms within a variable length of time after surgery. Surgical indications and treatment alternatives will be discussed.     

Die Megadolichobasilaris als Ursache einer sensorineuralen Schwerhörigkeit zur Differentialdiagnose des Hörsturzes

The megadolichobasilar artery is a rare vascular anomaly that can cause a variety of clinical symptoms but is usually asymptomatic. Not much attention has been given as yet to a possible sensorineural hearing loss caused by a megadolichobasilar anomaly. Vascular compression of the vestibulocochlear nerve must be assumed to be the pathogenic factor. The megadolichobasilar anomaly represents a rare entity in the differential diagnosis of sudden idiopathic sensorineural hearing loss. More common causes are acoustic neuromas, monosymptomatic Menière's disease and rupture of the round window membrane. We present the case of a 71-year-old white male in whom magnetic resonance angiography combined with contrast-enhanced computed tomography in three-dimensional reconstruction eventually led to the diagnosis of megadolichobasilar anomaly. The combination of both imaging techniques may be required for the effective diagnosis of similar vascular anomalies.     

Traumatic innominate pseudoaneurysm rupture during laryngeal dilatation

Endotracheal hemorrhage from the innominate artery is, fortunately, a rare problem encountered by the otolaryngologist. We present a patient with a tracheal-innominate artery fistula secondary to delayed rupture of a traumatic innominate artery aneurysm. The differential diagnosis of innominate artery hemorrhage is discussed, as is the management of this potentially lethal event. We propose, as the treatment of choice, cessation of hemorrhage through the use of a cuffed endotracheal tube, followed by ligation of the innominate artery using cardiopulmonary bypass. These techniques were used in this patient with a successful outcome.     

MR imaging of airway obstruction in infants and children

Accurate diagnosis is important in the evaluation of airway disorders of infants and children. Today, multiple imaging techniques are available to evaluate the pediatric airway. In general, it is best to start with simple and readily available examinations, which may provide a diagnosis in most cases, and progress to more sophisticated studies such as MR imaging. We performed magnetic resonance (MR) imaging of 45 infants and children with symptoms of airway obstruction, 14 of 45 patient symptoms were related to masses of the airway and 31 of 45 patient symptoms were related to vascular compression.     

Real-time, cine magnetic resonance imaging for evaluation of the pediatric airway.

BACKGROUND: Standard magnetic resonance imaging (MRI) and computed tomographic (CT) modalities are limited in their ability to image dynamic organs. New real-time, dynamic, cine magnetic resonance imaging (CMRI) techniques have the potential to image moving structures. OBJECTIVE: We therefore investigated the feasibility of using CMRI techniques to dynamically image the human airway, to assess laryngeal and tracheal patency and function. METHODS: A cohort of 10 pediatric patients, 10 adult patients, and 10 normal volunteers underwent routine static MRI, as well as CMRI using a Siemens 1.5 T Vision system (Siemens, Erlangen, Germany). Patients also underwent endoscopic evaluation. Cine axial, coronal, and sagittal sequences of the larynx and trachea were obtained during quiet respiration, as well as during a variety of provocative maneuvers. RESULTS: CMRI readily demonstrated normal vocal cord mobility and tracheal stability in normal volunteers. Abnormal vocal mobility was easily appreciated using the CMRI imaging system. Similarly, dynamic effects of tracheomalacia were clearly demonstrated using CMRI. Dynamic extrinsic tracheal compression resulting from mass lesions or anomalous vasculature was also visualized using CMRI. CONCLUSIONS: Cine MRI of the airway has the potential to provide novel data regarding laryngeal and tracheal patency and function. This evolving modality may serve as a valuable adjunct to static MR and CT imaging, as well as endoscopy, in the assessment of the airway.     

Vascular Anomalies Causing Symptomatic Tracheobronchial Compression

Objectives/Hypothesis: To review the clinical presentation and diagnostic evaluation of patients with symptomatic congenital vascular anomalies causing tracheobronchial compression and to establish the short- and long-term results of surgical intervention with respect to postoperative complications, persistent symptoms, and ventilator and tracheostomy dependence. Study Design: Retrospective review. Methods: Chart review and telephone follow-up. Results: Between 1987 and 1996, 35 children underwent surgical intervention to relieve symptomatic tracheobronchial compression resulting from a congenital vascular anomaly. Historically, the onset of symptoms occurs within the first months of life; however, only 12 (34%) of patients were diagnosed by 6 months of age and 13 (37%) were diagnosed at greater than 1 year of age. Excluding anomalous innominate artery, chest radiography or barium swallow was suggestive of a congenital vascular anomaly in 30 (94%) of the patients. Magnetic resonance imaging correctly delineated the anatomy of the vascular anomaly in 29 patients. Bronchoscopy was diagnostic in all three patients with anomalous innominate arteries causing tracheal compression. Postoperative follow-up was obtained in 32 (91%) of patients; 25 (78%) of these were asymptomatic at the time of their most recent examination. The remaining patients had persistent stridor, recurrent respiratory tract infections, and/or chronic cough. In all three patients who underwent postoperative bronchoscopy for persistent symptoms, tracheomalacia was demonstrated in the region of previous compression. Conclusions: Tracheobronchial compression from congenital vascular anomalies is a rare but treatable cause of respiratory symptoms. Early diagnosis requires a prompt, thorough clinical and radiologic evaluation. Surgery affords excellent long-term resolution of symptoms.     

Radiographic diagnosis, surgical treatment, and long-term follow-up of cholesterol granulomas of the petrous apex

Cholesterol granuloma is an unusual lesion of the petrous apex. Accurate preoperative differentiation of the various lesions of the petrous apex by computed tomography scanning only has been difficult. We reviewed the clinical findings, computed tomography and magnetic resonance imaging scans, surgical approaches, and long-term follow-up in 10 patients with cholesterol granuloma of the petrous apex who were seen between 1971 and 1988. Headache and deficits of the 5th, 6th, 7th, and 8th cranial nerves were common presenting symptoms. Magnetic resonance imaging with special imaging techniques was accurate in diagnosing cholesterol granuloma in four patients preoperatively and three patients prior to revision surgery. The optimal surgical approach was chosen on the basis of clinical and radiographic findings and included the transsphenoidal, infralabyrinthine, transcochlear, and suboccipital routes. Our review reveals that magnetic resonance imaging is more specific than computed tomography in establishing a preoperative diagnosis and is also the technique of choice in follow-up. The long-term results are discussed.     

Intramuscular hemangioma of the posterior belly of the digastric muscle failing to highlight on magnetic resonance imaging

Intramuscular hemangiomas of the digastric muscle are rare. We present the fifth case reported and the second to be imaged in vivo with magnetic resonance imaging. Accurate preoperative diagnosis of these lesions is difficult, but may be facilitated by a high degree of clinical suspicion and imaging. Magnetic resonance imaging using T2-weighted sequencing has been reported to effectively highlight these lesions. We present a case in which magnetic resonance imaging failed to highlight an intramuscular hemangioma of the posterior belly of the digastric muscle. Possible reasons for this failure are discussed.     

Vascular relationships of the vestibulocochlear nerve on magnetic resonance imaging

Vascular compression of the vestibulocochlear (VIIIth) nerve may cause constant or recurrent positional vertigo, tinnitus, and/or hearing loss. At present the diagnosis is based upon history, physical findings, audiologic assessment, vestibular function testing, and auditory brainstem evoked responses. Delineation of the vascular and neural anatomy within the cerebellopontine angle (CPA) has not been part of the preoperative assessment. We recently treated a patient demonstrating the clinical features of this syndrome. A magnetic resonance imaging (MRI) study revealed a vascular loop of the anterior inferior cerebellar artery intimately associated with the VIIIth nerve at the porus acusticus. To better define the significance of this finding, we retrospectively reviewed the CPA neurovascular anatomy of 100 (200 sides) otherwise normal MRI scans performed for unrelated disorders. Vessels were identified on 59.9 percent of sides while nerves were seen on 40 percent of sides. Contact between vessel and nerve occurred on 12.5 percent of sides and when both nerve and vessels were seen concurrently, they were in contact 50 percent of the time. These findings may preclude the use of MRI as the definitive diagnostic test in the preoperative assessment of vascular VIIIth nerve compression.     

The use of the tidal breathing flow volume loop in laryngotracheal disease of neonates and infants

Flow volume loops have been valuable in the diagnosis of upper airway obstruction in adults; however, the use of this technique in neonates has been limited because of their inability to perform a forced exhalation. We have used the tidal breathing flow volume loop (TBFV) to evaluate upper airway function in 100 neonates and infants. Eleven of the neonates and infants tested with this method were found to have laryngotracheal abnormalities such as tracheal stenosis, innominate artery compression, subglottic hemangioma, and unilateral vocal cord paralysis. Normal neonates and infants demonstrate a round or oval TBFV loop pattern, while those with upper airway obstruction show a flat inspiratory or expiratory curve. Tidal breathing flow volume loops offer a new, rapid and noninvasive method for evaluating the upper airway function in neonates and infants, and may play an important role in diagnosing upper airway dysfunction and evaluating the need for therapeutic intervention.     

Imaging of the age-related anatomical relationship between the innominate artery and the trachea

European Archives of Oto-Rhino-Laryngology - To measure the age-dependent changes of anatomical positions and relations between the trachea, cricoid cartilage (CC), and innominate artery (IA) in...     

Unilateral macroglossia as sole presenting manifestation of internal carotid artery dissection

A patient presented with acute-onset, painless, unilateral enlargement of the tongue. Steroid treatment for angioedema was ineffective, and a biopsy of an apparent mass of the tongue base showed normal tissue. Subsequent magnetic resonance imaging showed enlargement, enhancement, asymmetric T2 hyperintensity of the left half of the tongue, and dissection of the left cervical internal carotid artery (ICA) at the skull base. Unilateral enlargement of the tongue due to acute neurogenic denervation may be the sole clinical presentation of a spontaneous arterial dissection at the skull base. The hypoglossal neuropathy resulted from compression by the pseudoaneurysmal ICA dilatation or ischemia from interruption of the vasa nervorum.     

Tracheostomy in tortuous brachiocephalic artery

Tracheostomy, frequently used to ensure airway maintenance, involves complications such as bleeding and pneumothorax. Major vessel damage is also a lethal complication that must be avoided. We report tracheostomy in a case of tortuous bracheocephalic artery. A 74-year-old female with slight dyspnea due to amyotrophic lateral sclerosis (ALS) referred for tracheostomy had a pulsating mass in front of the trachea, found in by magnetic resonance (MR) imaging and MR angiography to be a tortuous bracheocephalic artery. In surgery, the displaced bracheocephalic artery was confirmed between the sternothyroid muscle and lower pole of the thyroid gland. This vessel was carefully dissected, the thyroid gland was divided at the isthmus, and the anterior wall of the trachea was fenestrated in an inverted U shape. The flap created by fenestration protected the vessel wall and was sutured to the skin so the vessel would not be exposed to the tracheostoma. A tortuous major artery is not uncommon in the neck, and care should be taken to avoid damaging such a vessel during tracheostomy.