Haemoptysis, dysphagia, and odynophagia

A 70 year old woman presented to the head and neck unit with a three month history of intermittent haemoptysis, progressive dysphagia, and odynophagia. On further questioning she reported no dysphonia or dyspnoea but complained of left sided otalgia. She had a 40 pack year history of smoking. Apart from controlled hypertension her medical history was unremarkable.

Physical examination showed a 3 cm lymph node in the anterior triangle of the neck but no other findings. Fibre optic laryngoscopy performed in the outpatient department showed a large epiglottic mass with normal vocal cords. She was admitted for examination under anaesthetic and imaging of the neck (fig ¹).

Fig 1 Computed tomogram of the neck

Questions

(1) What is the likely diagnosis?

(2) What immediate management problem does this present?

(3) Why does the patient have earache?

(4) What does the definitive management entail?

Answers

(1) The computed tomogram shows a large lesion of the supraglottic larynx, involving the epiglottis and invading the left lateral pharyngeal wall. The photograph (fig ²) shows the view at direct laryngoscopy performed in theatre, showing an exophytic mass extending from the epiglottis to obscure the vocal cords. These findings together with the history are highly suggestive of malignant neoplastic disease, specifically a supraglottic laryngeal carcinoma with regional metastases to the neck nodes.

Fig 2 View obtained at direct laryngoscopy using a rigid endoscope. The tumour can be seen extending from the epiglottis to obscure the vocal cords. Note the endotracheal tube

(2) The patient has a large tumour partially occluding the airway. Although there are no symptoms of airway obstruction, given the size and position of the tumour, compromise of the airway may occur rapidly, particularly after instrumentation. Securing an airway should be the immediate priority and is best achieved by an elective tracheostomy. Ideally this should be done under a general anaesthetic with the patient intubated. However, with large tumours such as this, intubation may be difficult and tracheostomy may have to be performed under local anaesthetic.

(3) This is an important symptom. The earache is caused by referred pain from the growth of the tumour into the left lateral pharyngeal wall, which is supplied by the glossopharyngeal nerve. This nerve also supplies the middle ear. Persistent earache with a normal ear examination indicates pathology in the mouth, pharynx, or larynx.

(4) This patient will be managed by the head and neck cancer multidisciplinary team, which consists of surgeons, pathologists, radiologists, and specialist nurses. Histological diagnosis is needed and in this case biopsy showed poorly differentiated squamous cell carcinoma.

The extent of the tumour and any metastases needs to be assessed clinically by panendoscopy (detailed endoscopic examination of the upper aerodigestive tract) and radiologically by computed tomography. The tumour should be staged according to the TNM system for supraglottic laryngeal cancers. TNM staging allows tailored therapy and aids prognosis according to the size of the primary tumour (T); the presence and extent of any lymph node involvement (N); and the presence or absence of any distant metastases (M). The tumour staging for supraglottic laryngeal cancer is given in box 1.

The case presented here is an example of a T4 tumour because it has spread from the larynx to involve the lateral pharyngeal wall. As part of staging a chest computed tomogram should always be obtained because synchronous lung cancer occurs in about 10% of head and neck cancers.^w1

Depending on the stage of the tumour and the patient’s wishes and comorbidities treatment may involve a combination of surgery, radiotherapy, and chemotherapy. Surgery may include laryngectomy, laser excision, or debulking of the primary tumour and a neck dissection for any nodal metastases followed by radiotherapy.

Discussion

Laryngeal cancer has a UK incidence of about 2000 cases a year.^w2 It is more common in men and rare in people younger than 45. Histologically, more than 95% are squamous cell carcinoma. Key risk factors include smoking and heavy alcohol consumption, which together act synergistically to increase risk. Additional risk factors include infection with human papillomavirus, chewing betel nuts, exposure to radiation, and gastric reflux.

Laryngeal cancers are classified by anatomical site into supraglottic (arising from the false cords, aryepiglottic folds, or epiglottis); glottic (arising from the true vocal cords); and subglottic (arising from the area between the vocal cords and the lower border of the cricoid cartilage). All may present with one or more of the symptoms in box 2.

The features of the different classes of laryngeal cancer are summarised in the table. As a result of profuse lymphatic drainage and a propensity not to cause voice changes early on, supraglottic cancers often present late with large tumours and neck lumps as a result of metastatic nodal disease, as in this case.

Features of laryngeal cancer

Early diagnosis of laryngeal carcinoma is important because with early treatment the prognosis is excellent. Attention should be paid to even mild or vague forms of the symptoms in box 2 and persistence of any beyond four weeks should prompt a referral to the ear, nose, and throat department for visualisation of the larynx.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

See Education http://student.bmj.com/issues/08/03/education/124.php.

1. Ferlito A. DiBonito L. Primary Cancer of larynx associated with primary lung cancer. J Otorhinolaryngology and related specialties. 1976. 38: 230-245.
2. Office of National Statistics. Cancer Statistics: Registrations. 2004.
3. Silverberg E: Cancer statistics, 1985. CA Cancer J Clin 1985 Jan-Feb; 35(1): 19-35.
4. Hornig J.D. Supraglottic Cancer. Emedicine .com.2006.
5. Santoro R, Turelli M, Polli G. Primary carcinoma of the subglottic larynx. European archives of otorhinolaryngology. 2004. 257: 548-551.

       

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