An 86-year-old woman with dementia presented to the emergency department with 2 days of progressive shortness of breath. The patient appeared dyspnoeic and her physical examination was significant for stridor without signs of cyanosis. Laryngoscopic examination revealed bilateral vocal cords paralysis and her initial chest radiograph demonstrated a huge round-shaped air density mass superimposed on cardiac shadow (figure 1A, arrows). Emergent endotracheal intubation was done for airway maintenance. Subsequent endoscopic gastroduodenoscopy and chest CT confirmed a large para-oesophageal herniated stomach with adjacent fat extending into the upper thoracic paratracheal space (figure IB) and retrocardiac region (figure 1C).
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