EpistemisBitonal wheezing cough
Specialty: Respiratory.
Why it occurs
- Recurrent laryngeal nerve palsy associated with underlying bronchial asthma or COPD (the asymmetric vibration of the vocal folds paralyzed by mediastinal tumor compression is acoustically superimposed on the wheezing generated by the underlying peripheral bronchial obstruction, producing a characteristic two-tone cough combined with a terminal expiratory wheeze)
- Central bronchogenic carcinoma that simultaneously invades the middle mediastinum (injuring the left recurrent laryngeal nerve) and partially obstructs the lumen of a main bronchus (concomitant monophonic wheezing)
- Giant aortic aneurysm with tracheobronchial and ipsilateral recurrent laryngeal nerve compression.
Initial workup
Diagnostic flexible nasofibrolaryngoscopy; Computed tomography (CT) of the neck and chest with vascular contrast; High-resolution chest magnetic resonance imaging (MRI); Diagnostic bronchoscopy to rule out direct tracheobronchial neoplastic invasion; Forced spirometry with flow-volume curve analysis.
red flags
Presence of laryngeal stridor, central cyanosis, frank hemoptysis, disabling rest dyspnea, progressive dysphagia of mediastinal origin, or documented bilateral vocal cord paralysis (with risk of acute asphyxia due to glottic collapse).
Standard management
- Bronchodilator treatment is palliative for underlying asthma/COPD: Budesonide/Formoterol — 160/4.5 micrograms, 2 inhalations every 12 hours
- Tranexamic acid — 500 mg orally every 8 hours if associated with hemoptoic sputum
- Definitive management of nerve palsy and tumor obstruction requires chemotherapy, radiotherapy, or surgical/endoscopic intervention.
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 3
- Treatment options
- 3