Background
A 58-year-old lecturer attended his GP with a 2-week history of hoarseness following a lower respiratory tract infection. On closer questioning it became clear that his voice had pro- gressively worsened over 3 months and become quite ‘deep and gravelly’. He also had noticed intermittent bloodstained phlegm. On subsequent referral to ENT via the 2-week sus- pected cancer pathway, there are no other upper aerodiges- tive symptoms such as dysphagia, odynophagia, stridor, neck swelling or referred otalgia.
History
The patient is otherwise fit and healthy, with mild chronic ob- structive airway disease. He has smoked 15–20 cigarettes per day for the last 30 years, and consumes 20–30 units of alcohol per week. He is taking omeprazole 20 mg once daily for long- standing dyspepsia.
Examination
A full ENT examination, including otoscopy, oral cavity and flexible nasendoscopy (nasopharyngoscopy), reveal a warty white lesion over the anterior one third of the right true vocal fold. There is full movement (abduction and adduction) of the vocal folds. Palpation of the neck does not reveal any lymph- adenopathy.
Investigation
A CT scan of the neck is performed prior to biopsy to determine the extent of the tumour, airway patency, cartilage involvement, subglottic extent and potential involvement of the paraglottic space and lymph nodes. Blood tests are performed to evaluate anaemia, nutrition and electrolytes.
Under general anaesthesia, a microlaryngoscopy is performed to examine the supraglottis (aryepiglottic folds, arytenoids and false vocal folds), the glottis (true vocal folds) and the subglottis (lower border of glottis to cricoid) (Figure 5.1). An excisional biopsy is performed.
All the investigations are discussed at the local mul- tidisciplinary team (MDT) meeting.
Differential diagnosis
Table 5.1 shows the main differentials of a patient presenting with hoarseness.
• Malignant tumours of the larynx A short history of persistent hoarseness with no improvement with conservative mea- sures should arouse suspicion of a malignant glottal lesion • Precancerous lesions: the presentation is similar to malig-
nant lesion
Figure 5.1
Microlaryngoscopy findings of a lesion of the right vocal fold in a smoker who presented with hoarseness. Presentation with recent onset
hoarseness (more than 4 weeks duration), difficulty in swallowing, or a lump in the neck requires an urgent referral (within 2 weeks).
Head and neck Clinical scenarios 153
• Benign lesions: these benign lesions have often a longer duration of dysphonia, and have characteristic features on laryngoscopic assessment (see section 5.3)
• Chronic inflammatory conditions: the history in Wegener’s granulomatosis and sarcoidosis is often longer than other presentations
• Infective conditions: fungal infections (e.g. Candida) can be seen in asthmatics who use steroid inhalers without a spacer device. Infection may not be limited to the glottis and could affect surrounding areas (e.g. supraglottis)
• Tuberculosis: isolated laryngeal tuberculosis is uncom- mon; it often involves the chest and the classic features of pulmonary tuberculosis (cough, night sweats, weight loss) may also be present.
Discussion
The diagnosis here is squamous cell carcinoma of the glottis. Glottal lesions present early, as hoarseness is an early symptom. The reduced lymphatics at glottal level are an impediment
Type of lesion Possible diagnosis
Malignant tumours of the larynx Carcinoma in situ Squamous cell carcinoma Undifferentiated carcinoma Adenocarcinoma
Adenoid cystic and chondrosarcoma Precancerous lesions Erythroplakia
Leukoplakia
Benign lesions Vocal nodules
Vocal cysts and polyps, Reinke’s oedema Laryngeal papilloma
Inflammatory lesions Chronic granulomatous conditions, e.g. Wegener’s granulomatosis
Sarcoidosis
Infective conditions Fungal infections (Candida) Tuberculosis
to rapid spread into the lymph nodes. However, supraglottic and hypopharyngeal lesions present with nodal spread early on owing to the rich supply of lymphatics. Glottal tumours, if picked up early without nodal involvement, have a much better prognosis.
Dysphagia
Background
A 48-year-old woman had long-standing intermittent dysphagia which worsened over 6 weeks, first in relation to solids and then fluids. She had persistent pain in the throat and otalgia. Her swallowing gradually deteriorated and she was finding it difficult to complete a meal.
History
She has iron deficiency anaemia, for which she takes ferrous sulphate. She smokes 20 cigarettes per day but does not drink.
Examination
The patient is apyrexial. She looks cachectic and has been losing weight over a number of months. Her oral cavity, oropharynx, anterior rhinoscopy and neck examinations are normal. Nasen- doscopy does not reveal any mucosal lesion, and both vocal cords are normal with normal mobility. However, pooling of saliva posterolateral to the arytenoids is seen in the pyriform fossae.
Investigation
The FBC shows iron deficiency anaemia. A barium swallow is or- dered, which shows a stricture in the postcricoid area (Figure 5.2). To better visualise the postcricoid area, panendoscopy with or without biopsy would be needed.
A smoker with a change in voice (hoarseness) and cough may not have another ‘chest infection’ – laryngeal assessment is essential. Hoarseness persisting for more than 4 weeks should be referred for laryngoscopy.
Head and neck Clinical scenarios 155
Differential diagnosis
• Postcricoid carcinoma usually results in rapid progressive dysphagia associated with loss of weight and cachexia • Patterson–Kelly–Brown/Plummer–Vinson syndrome
consists of a triad of glossitis, iron deficiency anaemia and dysphagia which usually improves after iron replacement. The dysphagia is due to oesophageal web. It has been associated with increased risk of upper alimentary tract cancers
• Benign oesophageal strictures usually produce dysphagia with slow and insidious progression (i.e. months to years) of frequency and severity, with minimal weight loss
Figure 5.2 Barium swallow showing a filling defect (arrow) in the hypopharynx in a patient who presented with long-standing intermittent dysphagia.
• Achalasia or collagen vascular disorders (motility disorders) cause dysphagia to solids and liquids simultaneously • Postcricoid web usually has slower progression of dyspha-
gia and rarely causes absolute dysphagia in the way that a neoplastic lesion does
• Pharyngeal pouch may manifest with regurgitation of undigested food and occasional gurgling
• Globus pharyngeus is usually intermittent and more often a ‘feeling of a lump’ in the throat rather than a true lump.
Discussion
The diagnosis here is a malignant stricture of the upper oe- sophagus. Malignant oesophageal strictures result in a rapid progression (i.e. weeks to months) of severity and frequency of dysphagia, and are frequently associated with significant weight loss. Prognosis and survival are poor compared with laryngeal cancers. When diagnosed early without regional, nodal or metastatic spread, treatment of malignant stricture is surgical (oesophagectomy). Sometimes chemotherapy, radiation, or a combination of the two may be used instead. Palliative treatment includes endoscopic dilation of the oesophagus, sometimes with placement of a stent to keep the oesophagus dilated.
Neck lump
Background
A 32-year-old woman with no previous medical history presented to her GP with a neck swelling that had gradu- ally increased in size over several months. She had no upper respiratory tract infection and was generally asymptomatic, but had recently felt pressure in and around the region of the lump. Despite having a normal FBC, she was treated with antibiotics (amoxicillin 125 mg three times daily for 5 days). However, the lump continued to grow very slowly and was True dysphagia needs to be referred
urgently (within 2 weeks). Barium swallow and pharyngoscopy/ oesophagoscopy and upper GI endoscopy are essential to establish a diagnosis.
Head and neck Clinical scenarios 157 also noted to regress spontaneously. Her GP was uncertain as to what the lump could be and sent her to the emergency department for further management.
History
The patient recently started to smoke. She drinks less than 10 units of alcohol per week. She has a cat at home.
Examination
After examining the patient, the triage nurse refers her to the resident ENT doctor, who finds nothing untoward on head and neck examination, except for a 4 x 3 cm fluctu- ant non-tender swelling in the left anterior triangle of
the neck, below the angle of the mandible and in front of the sternocleidomastoid muscle (Figure 5.3).
Investigation
A straw-coloured fluid is aspirated from the lump and sent for cytological/histopathological studies and microbiology (Figure 5.4). No conclusive results are noted besides some Cat scratch disease (Bartonella henselae) and toxoplasmosis (Toxoplasma gondii) should be considered in cases of lymphadenitis, especially when there has been close contact with cats. Relevant serological tests should be performed.
Clinical insight
Figure 5.3 Cystic lump in the left anterior triangle of the neck.
macrophages and lymphocytes. All blood tests performed at this time are normal.
Differential diagnosis
• Lateral cervical (branchial) cyst usually presents as a pain- less, fluctuant mass in the anterior triangle of the neck. Lateral cervical cysts can rarely be cystic metastatic lymph nodes and a high index of suspicion is needed in smokers or those over 40 years of age.
• Thyroglossal cyst usually presents as a midline, painless spherical neck swelling which rises on tongue protrusion. • Submandibular gland hypertrophy, sialadenitis or sialo-
lithiasis will present as a neck swelling, but in level I of the neck below the ramus of the mandible.
• Lymphadenitis is associated with a tender neck swelling which may develop into a fluctuant neck abscess with overlying inflammatory skin changes.
• Necrotic lymph node secondary to TB or other granuloma- tous disease may present with a fluctuant ‘cold’ neck abscess. • Metastatic lymph node has the possibility of presenting as
a cystic neck mass.
Figure 5.4 Fine-needle aspiration from a cystic neck lump for cytology.
Head and neck Clinical scenarios 159 • Lymphovascular mal-
formation is due to mal- formed vessels of either the lymphatic or the vas- cular systems.
• Paraganglioma (e.g. carot- id body tumour) presents as a pulsatile neck mass.
Discussion
The diagnosis here is a bran- chial cyst. Management is
total excision under general anaesthesia via a transverse skin crease neck incision.