Authors: Heshila Shajanie Udumullage

Abstract

A 60-year-old male with a recent two-month history of bronchial asthma presented to the Emergency Department (ED) in severe respiratory distress, just nine hours after being discharged for an asthma exacerbation. At discharge, the only residual symptom was persistent hoarseness, which was under outpatient ENT clinic review.

On re-admission, he was breathless with SpO₂ of 79% on room air, respiratory rate 30/min, heart rate 114/min, and BP 146/92 mmHg. He could speak only in single words and had bilateral wheeze on auscultation. Arterial blood gas showed type 2 respiratory failure. Lung ultrasound was unremarkable except for a localized B-profile in the left lower zone. No pneumothorax or effusion was detected.

He received full escalation for status asthmaticus—oxygen, back-to-back bronchodilator nebulization, IV magnesium, IV steroids, salbutamol infusion, and BiPAP. Despite appropriate treatment, the patient did not improve as expected. A persistent, audible wheeze over the neck raised concern for a possible low-pitched, bidirectional stridor, suggesting upper airway involvement.

Urgent ENT consultation and bedside flexible laryngoscopy in the ED revealed a vocal cord mass, highly suspicious for malignancy, causing critical upper airway narrowing. A multidisciplinary decision was made to perform an emergency tracheostomy under local anesthesia with low-dose ketamine.

The procedure led to immediate relief of respiratory distress and stridor. The patient was stabilized and transferred to the ENT ward for further oncological evaluation.

Conclusion:
This case highlights the need to reassess presumed asthma exacerbations that fail to respond to standard therapy—especially when associated with voice changes or upper airway sounds. Differential diagnosis often focuses on pneumothorax, co-existing lung disease, or heart failure. However, upper airway obstruction due to malignancy must also be considered. Early recognition and multidisciplinary airway management were critical in saving this patient’s life.

Keywords: vocal cord dysfunction, Stridor