Mediastinal cyst as a cause of severe airway compression and dysphonia

Extrinsic compression of the central airway is usually related to the presence of adjacent solid lesions, the most common being primary or secondary mediastinal tumors. Cystic lesions account for 12-30% of mediastinal masses and are usually benign and asymptomatic. Obstructive or compressive symptoms are extremely uncommon. Here, we describe the case of a 56-year-old man with a 6-week history of progressive dyspnea who presented with dry cough and hoarseness. He had no fever, dysphagia, or weight loss. He was a former smoker (20 pack-years) and reported no history of surgical intervention or tracheal intubation. Physical examination revealed that the patient's blood pressure was 165 × 95 mmHg, he had tachydyspnea at rest, dysphonia, and noisy respiration, and he was unable to tolerate the supine position; there was a hard, painless, smooth-surfaced swelling at the left supraclavicular fossa, the thyroid gland was not palpable, and there was no lymphadenopathy in the neck. Heart and lung auscultation was normal. A chest X-ray revealed mediastinal widening and tracheal deviation to the right. A chest CT scan revealed a cystic lesion without capsular calcification, measuring 12.1 × 7.3 × 7.2 cm. The lesion was located in the middle mediastinum and caused compression of the mediastinal trachea, deviating it to the right and reducing its caliber. The unilocular cystic lesion extended to the superior mediastinal aperture, adjacently to the left lobe of the thyroid gland, displacing the esophagus to the left (Figure 1). The results of laboratory and thyroid function testing, as well as the marker levels, were within the normal range. Esophagogastroduodenoscopy, which was performed with the patient in a semi-sitting position because of severe dyspnea, revealed distal erosive esophagitis, severe erosive antral gastritis, and no compression or deviation of the esophagus. The presumptive diagnosis of bronchogenic cyst or thyroid goiter with compression of the airway and associated vocal dysfunction was regarded as an indication for video-assisted flexible laryngotracheal bronchoscopy under topical anesthesia with intubation under bronchoscopic visualization, because of dyspnea, during the same anesthesia. The examination revealed paresis of the left vocal fold, which remained abducted; severe extrinsic tracheal compression with narrowing of the tracheal lumen in its proximal two-thirds; and architectural distortion of the distal trachea with normal mucosa. The patient then underwent orotracheal intubation guided by video-assisted bronchoscopy, was anesthetized, was placed in the left lateral decubitus position, and underwent right posterolateral thoracotomy in the fourth intercostal space with preservation of …