Case 43: Wheezy and hypoxic
February 6th, 2012Author: Dr Ian Stell
A 82 year old female was brought to ED because of breathlessness. She was noted to be ‘wheezy’ by the ambulance crew, and assumed to have asthma.
On arrival she was initially managed as lower airway obstruction, until subtle inspiratory stridor was noticed. A lateral soft-tissue x-ray of the neck was taken.
1. What abnormality is shown?
Click to see the answerThere is a soft tissue density swelling extending down from glottic level and occupying the posterior half of the larynx; the air density can be seen to deviate around the mass. The calcification visible in the laryngeal cartilage is normal.
A CT scan was then performed. The image shown is a coronal section. Note the mass in the left subglottic region of the larynx.
This was assumed to be squamous cell carcinoma. She was transferred to a tertiary centre for further care.
2. Why is wheeze expiratory whereas stridor is inspiratory?
Click to see the answerDuring inspiration the extrathoracic airways (i.e. the larynx and trachea) become narrower, whereas the intrathoracic airways become wider. In expiration the opposite happens, so bronchi become narrower and upper airways get wider. The features of obstruction and hence the symptoms get worse depending on which of the ‘tubes’ is narrowed.