Background: Inflammatory myofibroblastic tumor (IMT) is a rare, intermediate-grade neoplasm of the airway that can present with nonspecific respiratory symptoms, often mimicking asthma. In resource-limited settings, delayed diagnosis may increase morbidity, particularly in children with underlying nutritional deficits. Case Presentation: We report the case of a 3-year-6-month-old female with a history of twin gestation, low birth weight (2.14 kg), and severe acute malnutrition (SAM) at 11 months. She presented with recurrent episodes of cough, wheeze, and respiratory distress over the past year, with poor response to bronchodilator therapy. On examination, she was tachypneic with inspiratory stridor, and her weight was 11 kg—below the 3rd percentile for age according to WHO growth standards. Airway imaging and endoscopic evaluation revealed a tracheal mass. Initial histopathological and immunohistochemical findings confirmed an inflammatory myofibroblastic tumor. The patient underwent multiple surgical excisions for recurrent airway obstruction. However, following the third surgical removal, histopathological examination demonstrated fibrovascular granulation tissue rather than recurrent IMT, indicating a reactive post-surgical process. Nutritional rehabilitation was initiated to address her underweight status and support recovery. Conclusion: This case highlights the diagnostic challenge of distinguishing recurrent IMT from post-surgical granulation tissue in children with persistent airway obstruction. It underscores the importance of histopathological confirmation, early airway evaluation in treatment-refractory respiratory symptoms, and the role of nutritional optimization in improving clinical outcomes.