Case Based Learning

Case One

68-year-old Caucasian male presents with sore throat x 2 weeks and left ear pain. Denies fevers. 8 pound weight loss.

  • PMH: HTN
  • PSH: appendectomy
  • Social Hx: Quit smoking in 2002. 30 pack year history.
  • Physical exam. AFVSS. Fullness left neck concerning for lymphadenopathy. Mild erythema to posterior pharyngeal wall. No oral cavity or oropharynx masses.
Case 1

Treated with 10 day course of augmentin.

Patient follows up 3 weeks later. He states that he initially felt better but he has left ear pain and sore throat again which became more severe 3 days after finishing antibiotics.

CT Neck with contrast

REPORT: Contrast enhancing mass in the supraglottic larynx. Enlarged lymph node left level 2A measuring 2.5cm in maximum dimension concerning to regional metastatic disease

CT Neck with contrast

Report: (potentially screen shot real report)

Contrast enhancing mass in the supraglottic larynx. Enlarged lymph node left level 2A measuring 2.5cm in maximum dimension concerning to regional metastatic disease

Patient returns for another follow up after second course of antibiotics. He states that he did feel better again on antibiotics and that initially he thinks that the lump in his neck went down. However, he is now having more difficulty swallowing foods and his left ear pain has been persistent despite antibiotics.

Refer to ENT

Flexible laryngoscopy reveals mass of the supraglottic larynx. CT imaging obtained shows a stage III tumor. Biopsy confirms Squamous Cell Carcinoma. Patient is treated with radiation and chemotherapy.

Case Summary

68-year-old Caucasian male with remote but significant smoking history with warning symptoms of laryngeal cancer persistent for > 2 weeks and refractory to antibiotics.

  • Referral to ENT would be indicated due to symptoms persisting > 2 weeks
  • Recommend avoiding treating warning symptoms with multiple rounds of antibiotics
  • Can consider CT Neck w contrast to evaluate upper aerodigestive tract further
  • Can consider FNA of persistent neck mass concerning for nodal metastasis

Case Two

65yo AAM presents with 3-month history of dysphagia. He has lost 20 pounds and can only tolerate liquids and some soft foods. He went to an urgent care last month and was given antacid which did not improve his symptoms.

  • PMH: HTN, CAD
  • PSH: none
  • Social Hx: Currently smoking 1.5 ppd x 40 years. Drinks 6 pack and 3 shots of whiskey daily.
  • Physical exam. AFVSS. No masses or lesions to the mouth or throat. No lymphadenopathy.
Case 2

Treat with antibiotics

Patient returns 2 weeks later for follow up. He had some initial improvement of his symptoms, but they worsened and now he is only able to tolerate liquids. He has some noisy breathing on exam but denies shortness of breath

GI performs endoscopy which shows a hypopharyngeal mass. Biopsy + for Squamous Cell Carcinoma.

Referral to ENT made:

Flexible laryngoscopy performed in ENT clinic which shows extensive left hypopharyngeal mass involving the left hemilarynx. Patient is taken to the operating room for tracheostomy and operative laryngoscopy with biopsy showing Squamous Cell Carcinoma. This patient had imaging which showed stage IV disease and total laryngectomy was performed followed by radiation therapy.

Refer to ENT

Flexible laryngoscopy performed in clinic which shows extensive left hypopharyngeal mass involving the left hemilarynx. Patient is taken to the operating room for tracheostomy and operative laryngoscopy with biopsy showing Squamous Cell Carcinoma. This patient had imaging which showed stage IV disease and total laryngectomy was performed followed by radiation therapy.

Obtain imaging

CT Neck w contrast shows advance appearing mass centered in the left hypopharynx concerning for malignancy. No cervical lymphadenopathy.

Refer to ENT

Flexible laryngoscopy performed in clinic which shows extensive left hypopharyngeal mass involving the left hemilarynx. Patient is taken to the operating room for tracheostomy and operative laryngoscopy with biopsy showing Squamous Cell Carcinoma. This patient had imaging which showed stage IV disease and total laryngectomy was performed followed by radiation therapy.

GI performs endoscopy which shows a hypopharyngeal mass

Biopsy + for Squamous Cell Carcinoma. Referral to ENT made.

Refer to ENT

Flexible laryngoscopy performed in clinic which shows extensive left hypopharyngeal mass involving the left hemilarynx. Patient is taken to the operating room for tracheostomy and operative laryngoscopy with biopsy showing Squamous Cell Carcinoma. This patient had imaging which showed stage IV disease and total laryngectomy was performed followed by radiation therapy.

Case Summary

65yo AAM presents with 3-month history of dysphagia. He presented with significant weight loss in a short period of time and difficulty tolerating solid foods. On later follow up, he additionally had noisy breathing concerning for stridor.

  • This is concerning for upper aerodigestive tract malignancy especially in a high risk demographic patient with a history of tobacco and alcohol use.
  • This patient should be referred to ENT for a flexible laryngoscopy.
  • Imaging can be helpful to evaluate upper aerodigestive tract and identify any neoplasm. Contrasted CT neck should always obtained, unless contrast is contraindicated in the patient. Can consider MRI in these cases.

Case Three

50-year-old AAF presents with 1 month history of hoarseness. She is tolerating diet without difficulty. No weight loss. Intermittent left ear pain. No lymphadenopathy.

  • PMH: Diabetes
  • PSH: Hysterectomy
  • Social Hx: 20 pack year tobacco use. Quit 8 years ago. Drinks socially.
  • Physical exam: AFVSS. Hoarse strained voice. EAC clear, TMs intact without effusion. No mouth or throat lesions. No cervical lymphadenopathy.
Case 3

Prescribe PPI

Patient returned 1 month later with continued hoarseness unchanged from prior exam. This is starting to interfere with her daily life as she is a manager at a restaurant. She is still having intermittent left ear pain.

Refer to SLP

SLP give patient voice exercises and recommends flexible laryngoscopy with ENT.

Refer to ENT

Flexible laryngoscopy performed in clinic which reveals a left sided vocal cord lesion. CT imaging performed which shows stage I lesion of the larynx without cervical lymphadenopathy.

  • Biopsy performed showing SCC.
  • Patient is offered radiation therapy versus laser excision for Stage I laryngeal cancer

Prescribe PPI

Patient returned 1 month later with continued hoarseness unchanged from prior exam. This is starting to interfere with her daily life as she is a manager at a restaurant. She is still having intermittent left ear pain.

Refer to ENT

Flexible laryngoscopy performed in clinic which reveals a left sided vocal cord lesion. CT imaging performed which shows stage I lesion of the larynx without cervical lymphadenopathy.

  • Biopsy performed showing SCC.
  • Patient is offered radiation therapy versus laser excision for Stage I laryngeal cancer

Refer to SLP

SLP give patient voice exercises and recommends flexible laryngoscopy with ENT.

Case Summary

50-year-old AAF who presents with hoarseness > 2 weeks and a remote history of tobacco use. Hoarseness for greater than 2 weeks can have multiple causes but referral to ENT is indicated to evaluate further with flexible laryngoscopy.

Otalgia in this case was caused by the laryngeal cancer.

Thank you for completing this course.

To claim CE credit for this course, please log back into the UMMC CE Central site. Click on E-Learning Courses under the My Credits panel, and then click ‘Continue’ under the Laryngeal Cancer Education for the Primary Care Provider course. Complete the Post-Test quiz and evaluation to claim your CE credit.

Questions? Contact ent@umc.edu.

References

American Cancer Society. Facts & Figures 2022. American Cancer Society. Atlanta, Ga. 2022.