Localized and fixed expiratory wheezing

Specialty: Respiratory.

• single localized expiratory wheeze
• fixed monophonic sibilance

Why it occurs

• Bronchial stenosis of neoplastic cause (the narrowing of a lobar or segmental bronchus due to direct invasion of a squamous cell carcinoma generates a whistling sound with a constant and single tone perfectly localized on auscultation that does not vary after coughing or with the use of bronchodilators)
• Chronic aspiration of semi-obstructive intrabronchial foreign body (such as seeds or small plastic objects that act as a partial expiratory valve)
• Active tuberculous or fungal endobronchial granuloma (scarring reaction of the bronchial mucosa in the presence of Mycobacterium tuberculosis or Histoplasma)
• Bronchial scarring stenosis after prolonged intubation with high-pressure cuff
• Extrinsic compression of the bronchus by an aneurysmal pulmonary artery or calcified adenopathy.

Initial workup

High-resolution chest computed tomography (CT) with intravenous contrast and three-dimensional airway reconstruction; Flexible bronchoscopy (diagnostic test of choice for inspection and biopsy of the bronchial lumen); Induced sputum cytology; Spirometry with flow-volume curve.

Standard management

• Treatment with bronchodilators is not effective in resolving the mechanical obstructive cause
• Methylprednisolone — 40 mg intravenously if there is associated peritumoral inflammatory mucosal edema that worsens bronchial obstruction
• Definitive management requires endoscopic resection, balloon dilation, or placement of a metal or silicone bronchial endoprosthesis (stent).