Vital Signs: Far From Oakay

A body scan reveals a lemon-size mass in the chest 
of a 16-month-old boy. Fearing cancer, surgeons perform a risky operation to save his life.

By W. Roy Smythe|Wednesday, October 05, 2011

<p>

I was reviewing my emails late in the day when I found a message flagged “Important” in the subject line. It was from Kelsey, one of our hospital’s new pediatric surgeons. “Consulted regarding a 16-month-old with a middle <a style="" class="external-link" href="http://www.indyrad.iupui.edu/rtf/teaching/medstudents/stf/pul1/pul3.htm">mediastinal mass</a>,” her message read. “Compression of trachea. Would love your thoughts.”</p>
<p>The mass Kelsey referred to in her email was in an area where a lot of things can go wrong, what we call the <i>mediastinum</i>—the middle of the chest between the lungs, where several important organs, such as the heart, trachea, and esophagus, reside.</p>
<p>As a thoracic surgeon, I specialize in operating on organs in this area and often review cases with colleagues.</p>
<p>I responded that I’d be happy to speak with her, and in less than 15 minutes she was tapping on my door. Kelsey was obviously very concerned about this one, so I quickly pulled the CT scan of the mass up on the computer as she relayed the details of the case. The patient was a 16-month-old boy who was developing normally but had recently been diagnosed with asthma.</p>
<p>He had been admitted to the hospital because of increasing <a style="" class="external-link" href="http://en.wikipedia.org/wiki/Stridor">stridor</a>, a high-pitched sound made during inhalation. Stridor indicates a narrowing somewhere in the main, or proximal, airways—the area of the respiratory tract between the vocal cords high in the neck and where the trachea, or windpipe, branches to meet the two lungs. Stridor is often thought to indicate asthma, but it usually doesn’t. Asthmatics make a different sound: a <a style="" class="external-link" href="http://en.wikipedia.org/wiki/Wheeze">wheeze</a>. Wheezes occur during exhalation and imply obstruction of the smaller airways that are in the lungs themselves.</p>
<p>The boy’s name was Ian, and it was clear that his breathing problems were not caused by asthma. The CT images showed a five-centimeter mass—about the size of a lemon—narrowing his trachea by more than half and encasing the adjacent esophagus, which carries food from the mouth to the stomach. It looked as if malevolent bees had built a rounded, ill-formed hive in Ian’s chest.</p>
<p>I took in a deep breath: “That looks bad, Kelsey...”</p>

<p><b><i>The full text of this article is available only to DISCOVER subscribers. Click through to the article to subscribe, log in, or buy a digital version of this issue.</i></b></p>
<p><i>Photo: oak leaves. Credit: iStockphoto.</p></i>

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