Have we got the full picture?

A 59-year-old man with long-standing chronic obstructive airways disease (COPD), became progressively dyspnoeic, and repeatedly blacked-out during forced expiration. Spirometry suggested the possibility of large airways obstruction, and failing to respond to aggressive bronchodilator and steroid therapy, the patient was labelled as being non-compliant. Finally, he was assessed by an otolaryngologist and a cause for upper airway obstruction was suspected. Bronchoscopy and computed tomography (CT) scanning demonstrated tracheomalacia and the patient underwent resection of this segment of abnormal trachea. Tracheomalacia, although rare, results from the substitution of cartilage with fibrous tissue, leading to severe airway compromise. This case emphasizes the fact that although many conditions are uncommon, the total incidence of rare conditions is surprisingly high, and that care needs to be taken at all times in the management of 'labelled' patients with chronic illness, in order not to overlook such life-threatening diagnoses.