Epistemis

Harsh and wheezing bitonal cough

Specialty: Respiratory.

  • double-tone cough with harsh whistling
  • obstructive mediastinal tumor cough

Why it occurs

  • Central bronchogenic carcinoma of the left upper lobe that simultaneously invades the middle mediastinum (irreversibly damaging the left recurrent laryngeal nerve, causing a bitonal cough due to paralysis of the ipsilateral vocal cord, and partially obstructing the left main bronchus by endoluminal growth, generating a concomitant audible expiratory wheeze in the left hemithorax)
  • Large metastatic mediastinal lymphadenopathy due to breast cancer that compresses the recurrent nerve and causes extrinsic bronchial compression.

Initial workup

Computed tomography (CT) of the neck and chest with intravenous contrast; Magnetic resonance imaging (MRI) of the mediastinum; flexible nasofibrolaryngoscopy; Flexible bronchoscopy with ultrasound-guided bronchial and transbronchial biopsy (EBUS); Forced spirometry and arterial blood gases.

red flags

Presence of asphyxiating dyspnea at rest, persistent severe chest pain, massive hemoptysis, cyanosis, or inspiratory stridor suggesting critical tracheobronchial obstruction.

Standard management

  • Bronchodilator treatment is symptomatic support: Salbutamol — 100-200 micrograms inhaled as needed
  • Methylprednisolone — 40 mg intravenously every 12 hours in case of peritumoral edema
  • Definitive treatment is emergency oncology or endoscopic palliation with a tracheobronchial prosthesis.

Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.

PreviousHarsh bitonal cough
Area
Respiratory
Listed causes
2
Treatment options
3
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