Case history
Case history #1
A 57-year-old man presents with a 6-month history of hoarseness. He has a reactive airway disease diagnosis and is treated for asthma. Over the past week he has noted progressive difficulty breathing. He also has otalgia, dysphagia, odynophagia (painful swallowing), and a 9-kg weight loss. He has an 80-pack-year tobacco history and drinks 8 beers per day. On physical examination, oral cavity and oropharynx are within normal limits. Neck examination demonstrates a right-sided mass that is firm and fixed. Cranial nerve examination is normal. There is mild biphasic stridor with deep inspiration and expiration, but the patient has no increased work of breathing at rest, and breath sounds are clear. Flexible fibre-optic laryngoscopy demonstrates a necrotic, ulcerating mass involving the right true and false vocal cords, and extension onto the epiglottis and aryepiglottic folds. The right true vocal cord is immobile. The glottic airway is partially obstructed.
Case history #2
A 45-year-old man presents with a 3-month history of sore throat and painless, enlarging, left-sided neck mass. Two courses of antibiotics and a trial of corticosteroids did not clear the sore throat and mass. He also reports dysphagia with solids and worsening odynophagia (painful swallowing), and a 7-kg weight loss over the last 2 months. His past medical history is significant for hypertension and COPD, both well controlled with drugs. He has a 50-pack-year smoking history. Physical examination finds a 2-cm, firm, mobile, and non-tender mass anterior to the sternocleidomastoid muscle in the patient's mid left cervical lymph node chain. There is no overlying erythema or induration. The oral cavity and oropharynx are normal, as are the cranial nerves on examination. Breath sounds are clear without stridor or stertor. Flexible fibre-optic laryngoscopy demonstrates a thickened epiglottis with an ulcerating and necrotic mass on its laryngeal surface that extends to involve both aryepiglottic folds and the left true and false vocal cords. The true vocal cords are mobile bilaterally and appear normal.
Other presentations
Subglottic cancer is rare and presents as progressive difficulty breathing. Many of these patients may be mistakenly thought to have asthma, but pulmonary function testing shows a pattern consistent with upper airway obstruction.
A few patients present with distant metastases. The most common sites of metastases are the lungs, liver, and bone.[2] Patients with laryngeal cancer are at high risk of a second primary malignancy, most commonly in the lungs. Neck masses (metastases to the cervical lymph nodes) and weight loss are typical findings of advanced disease.
Immunocompromised patients may present with aggressive tumours in the absence of significant tobacco or alcohol histories.
Patients may present with a voice change, if the lesion begins on the true vocal cords, or without symptoms, if the lesion begins on the epiglottis or arytenoids. As the tumour grows, it may ulcerate or become necrotic. Voice changes are usually evident in tumours of the true vocal cords, and patients experience pain and haemoptysis. Patients with laryngeal cancer have an increased risk of developing dysphagia as a result of the certain patient factors (e.g., age), cancer factors (e.g., size, location), or treatment side effects. Dysphagia and odynophagia (painful swallowing) are more common in tumours involving the supraglottic larynx (e.g., epiglottis) but may also occur with vocal cord tumours. With severe dysphagia, patients may present with aspiration pneumonia.
If not treated, the tumour will cause deviation and obstruction of the airway. This occurs over a period of days, as opposed to hours, and patients often have an insidious shortness of breath that ultimately becomes intolerable. Stridor and dysphonia are common. Patients may also present in extreme respiratory distress, requiring immediate intervention to secure the airway.
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