PMC6446124_01
Bronchoscopic findings at rest with their corresponding changes during forced expiration revealing diffuse EDAC. The carina at rest showed normal patency (A1) with subsequent collapse greater than 50% during forced expiration (A2). The left mainstem bronchus at rest (B1) showed significant invagination during forced expiration (B2), while the right upper lobar bronchus (C1) showed complete collapse of the posterior segment (C2).
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During bronchoscopy the patient performed multiple forceful expiratory maneuvers that revealed diffuse EDAC with 50-60% collapse of the distal trachea, complete collapse of the right upper lobe (RUL) posterior segment and 70-80% collapse of the left upper lobe (LUL) takeoff (Fig. 1).
Proximal trachea without evidence of collapse during inspiratory phase of respiration (A). Subglottic mucosal protuberation manifesting during expiratory phase (B).
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Because of persistent symptoms of hoarseness and ausculatory findings, bronchoscopy with the patient actively exercising on a cycle ergometer one month later found that the patient still had no ILO, but now had a subglottic protuberation (and corresponding expiratory wheezing) believed to be the primary limiting segment of his previously diagnosed EDAC in addition to continued EDAC of distal trachea, RUL and LUL as described above. (Fig. 2).
(A) Chest x-ray on presentation displaying multi-focal pneumonia with endotracheal stent with Y-arms extending into the left and right mainstem bronchi. (B) Coronal chest CT displaying both arms of the stent in the left and right mainstem bronchi. Three days later CT imaging showed superior stent migration with proximal aspect of the stent erupting through the vocal cords (C), confined solely to the trachea and abutting the epiglottis (D). Stent arms were no longer deployed into the right and left mainstem bronchi (E).
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Imaging demonstrated dislodgement of the stent which was protruding through the vocal cords (Fig. 3).