February Case of the Month: Courtesy of Dr. Firew

A 42 year old female, who was recently intubated approx 3 months ago (she had an intracranial hemorrhage requiring craniotomy), presented to the ED with progressively worsening shortness of breath, worse while lying flat, as well as vocal changes and a “sticking” sensation when swallowing.   Her initial vital signs were normal.  On exam, the patient had a mildly strained quality to her voice and mild stridor when supine.  The rest of her exam was normal.  A bedside ultrasound revealed the following:

subglottic mass 1a copy

ENT was consulted, and a bedside scope revealed the subglottic mass.  Additionally, she had further CT imaging of her neck which confirmed the diagnosis of a subglottic mass, posteriorly pedicled and 75% occlusive. ENT excised the lesion, with a final diagnosis of post-intubation granuloma.

Bedside ultrasound has been used to assess the subglottic diameter of the upper airway, notably in children to assess for proper ETT selection.  It can also be used to evaluate the subglottic area for signs of stenosis.   Such use of ultrasound as a quick, non-invasive tool was incredibly helpful in the care of this patient, in expediting her appropriate management and disposition.

January Case of the Month: Courtesy of Dr. Manikian

A 2 yo female presents with 4 days of cough, fever and poor oral intake. She is febrile and ill-appearing in moderate respiratory distress – with tachypnea, retractions, decreased air entry, scattered rhonchi and crackles bilaterally.  A chest xray was performed, which revealed hazy lung fields with small airway disease and increased markings and peri-bronchial thickening bilaterally.
A lung ultrasound was performed:

Lung ultrasound is a very sensitive diagnostic tool, with ease in portability, in diagnosing children with pneumonia. It is especially useful in following treatment progress and reduces exposure of children to radiation.
The lung US images for our patient demonstrate extensive small airway disease on the right, and 2 distinct consolidations on the left.  On the right, the pleural interface is very thickened and irregular with many heavy / confluent B lines emanating from small subpleural lesions – particularly in the lower posterior lung field. This is consistent with severe airway inflammation and perhaps early pneumonia.  On the left there is a very large area of hepatization with dynamic air bronchograms in the mid antero-lateral lung field consistent with pneumonia.