Cardarelli’s Sign, Castellino’s Sign, Oliver’s Sign)

Tracheal tugging is a visible recession of the larynx and trachea synchronized with cardiac systole. It commonly results from aneurysms or tumors near the aortic arch and may indicate dangerous compression or obstruction of major airways. The tugging movement, best observed with the neck hyperextended, reflects abnormal transmission of aortic pulsations due to compression and distortion of the heart, esophagus, great vessels, airways, and nerves.

Pathophysiology

1. Aortic pulsation transmission:Abnormal structures (aneurysm, tumor) near the aortic arch transmit pulsations to the trachea, producing visible systolic tugging.

2. Compression of mediastinal structures:Tumors or aneurysms may compress airways, vessels, and nerves, causing dyspnea, stridor, or vascular congestion.

3. Airway obstruction:Recurrent tugging may reflect partial obstruction of trachea or bronchi, especially if associated with dyspnea, brassy cough, or stridor.

Emergency interventions

If tracheal tugging is observed:

• Assess for respiratory distress: tachypnea, stridor, accessory muscle use, cyanosis, agitation.

• Airway management: check patency, administer oxygen, prepare for intubation if necessary.

• Circulatory support: insert IV line for fluid and drug access.

• Monitoring: initiate cardiac monitoring and pulse oximetry.

• Positioning: semi-Fowler’s to aid respiration.

History and Physical Examination

History

• Onset, duration, and progression of tugging.

• Associated symptoms: chest pain, dyspnea, cough, dysphagia, hoarseness.

• Past history: cardiovascular disease, mediastinal or thoracic tumors, chest surgery, trauma, or radiation therapy.

Physical Examination

• Neck and trachea: palpate for masses, enlarged lymph nodes, abnormal pulsations, and tracheal deviation.

• Chest: percussion and auscultation for abnormal breath or heart sounds.

• Heart: listen for murmurs, thrills; assess for jugular venous distention.

• Vascular assessment: palpate for pulsatile masses in suprasternal notch or intercostal spaces.

• Other systems: check for edema of face, neck, or upper limbs; hepatosplenomegaly.

Medical causes

Special considerations

• Place patient in semi-Fowler’s to ease respiration.

• Administer cough suppressants or pain medications cautiously, monitor for respiratory depression.

• Prepare for diagnostic studies:

  • Chest X-ray

  • Computed tomography (CT) scan

  • Lymphangiography

  • Aortography

  • Bone marrow or liver biopsy

  • Echocardiography

  • Complete blood count

Patient counseling

• Explain the underlying cause and treatment options.

• Discuss positions and techniques that ease breathing.

• Educate about warning signs: worsening dyspnea, stridor, hemoptysis, sudden chest pain.

Pediatric pointers

• In infants and children, tracheal tugging may indicate mediastinal tumors, including Hodgkin’s disease or non-Hodgkin’s lymphoma.

• Can also occur in Marfan’s syndrome or other congenital connective tissue disorders.

• Respiratory distress may develop rapidly, necessitating urgent intervention.

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. American Academy of Pediatrics; 2012.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. Mosby Elsevier; 2008.

3. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Mosby Elsevier; 2010.

4. Sommers MS, Brunner LS. Pocket Diseases. F.A. Davis; 2012.