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A man in his late 70s presented with progressive dyspnoea and wheeze, initially treated as asthma. His symptoms were notably positional—worsening in the supine position and resolving when upright. Cardiopulmonary and neurological examinations were unremarkable. Contrast-enhanced CT of the neck revealed a retropharyngeal internal carotid artery (ICA) causing oropharyngeal compression and dynamic airway obstruction. This rare vascular anomaly, which mimicked obstructive airway disease, was managed conservatively with positional adaptations. This case highlights the importance of considering structural vascular causes in patients with respiratory symptoms unresponsive to standard therapies and introduces a relatively undocumented presentation of positional wheeze associated with retropharyngeal ICA.