Not all that wheezes is asthma!

A 62-year-old female complained of exertional dyspnoea associated with occasional wheeze over the past 10 years. She could not identify any trigger factors such as exposure to cold air, exercise or respiratory tract infections. She was treated empirically for bronchial asthma by her family physician with inhaled Salbutamol and inhaled Fluticasone without much relief in symptoms. She also recently complained of mild dysphagia on swallowing large boluses of food. There was no associated chest pain, weight loss or dyspepsia. The patient worked as a seamstress and was a non-smoker. Physical exam was remarkable for expiratory wheeze, which was monophonic. Her voice was normal and there was no associated cervical adenopathy or goitre on neck examination. A fl ow-volume loop showed variable intrathoracic upper airway obstruction (Fig. 1A). Spirometry was normal. The chest radiograph is as shown in Figure 1B. What is the diagnosis causing her symptoms? A. Intrathoracic goitre B. Paratracheal lymadenopathy C. Aortic aneurysm D. Vascular ring E. Teratoma The computed tomography scan of the chest (Fig. 2) confi rmed a right-sided aorta associated with a diverticulum of Kommerell, an aberrant left subclavian artery and the left carotid artery forming a vascular ring. Bronchoscopy showed a mild stricture of the mid-trachea due to extrinsic compression. Therefore this patient has congenital vascular ring anomaly causing narrowing and displacement of the trachea and esophagus resulting in dyspnoea and dysphagia lusoria.