Quiz #6: Barium Swallow Answers

Link to the question

Question 1: What is salient finding?
Answer: Anterior indentation of the esophagus. This means, the structure is passing inbetween the trachea and esophagus. The indentation in this condition is usually at the level of carina.

Question 2: What is the diagnosis?
Answer: "Pulmonary sling". This term refers to anomalous origin of LPA from RPA. The LPA courses inbetween trachea and esophagus to reach the left side.

2 bonus questions:
Question 3: What is the tracheal anomaly associated with pulmonary sling?
Answer: Complete rings in distal trachea - that may need additional surgical treatment (apart from correcting vascular anomaly)

Question 4: What cardiac anomaly is commonly associated with pulmonary sling?
Answer: Usually occurs by itself. Common associated cardiac lesion is Tetralogy of Fallot.
(Ref: Moss & Adams Fifth edition. p. 833. Chapter by Dr. Paul Weinberg)

7 out of 7 fellows responded. One fellow needed some "proding". But, ultimately everyone got the answer right. Dr. Agu sent a great article on this subject (Thorax 1969;24:295-306) with very illustrative figures.

The 2 MRI images are from one of our patients (Black arrow - Trachea. White arrow - Esophagus with NG tube). This patient did not have a barium swallow. Such is the trend these days! Barium swallow is still a good, straight forward study to demonstrate esophageal compression. Sometimes, this is unclear in MRI images.