50-year-old male presented with progressive hoarseness for the last 6 months. On indirect laryngoscopy, there is proliferative growth on the right vocal cord and the right hemilarynx is fixed. There are no neck nodes and no evidence of distant metastasis. a. What is the most probable diagnosis? (1 mark) b. What investigations will you do to confirm? (2 marks) c. What treatment options can you offer to this patient? (2 marks)
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laryngeal cancer AND treatment
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NCI laryngeal cancer treatment stage III glottis fixed vocal cord
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site:cancer.gov laryngeal cancer treatment PDQ glottis vocal cord fixation T3
a. Most probable diagnosis
Squamous cell carcinoma of the glottis (right vocal cord), T3N0M0, Stage III laryngeal carcinoma.
Vocal-cord fixation makes it T3 disease. This staging is consistent with the NCI laryngeal cancer criteria.
Vocal-cord fixation makes it T3 disease. This staging is consistent with the NCI laryngeal cancer criteria.
b. Investigations to confirm and stage
- Direct laryngoscopy or microlaryngoscopy under general anaesthesia with biopsy of the lesion for histopathological confirmation. Panendoscopy may also assess for synchronous upper aerodigestive tract lesions.
- Contrast-enhanced CT or MRI of the larynx and neck to define paraglottic space/cartilage invasion and occult cervical nodes. Assess distant disease with chest imaging, with PET-CT when indicated. Diagnosis requires laryngoscopy with biopsy, while CT/MRI helps define deep extension and nodal disease, as described in Cummings Otolaryngology Head and Neck Surgery.
c. Treatment options
- Total laryngectomy with appropriate postoperative radiotherapy, with or without concurrent cisplatin depending on adverse pathological features. In a clinically N0 neck, elective neck treatment is considered according to extension and institutional protocol.
- Larynx-preservation protocol: definitive concurrent chemoradiotherapy, generally cisplatin-based, followed by salvage total laryngectomy if residual or recurrent tumour remains.
Selected lateralized T3 lesions may be considered for a conservation operation such as supracricoid or near-total laryngectomy in an experienced centre; however, bulky fixed-cord T3 lesions are commonly treated by total laryngectomy or concurrent chemoradiotherapy. Cummings Otolaryngology Head and Neck Surgery recommends total laryngectomy, with or without adjuvant radiotherapy, or primary chemoradiotherapy for bulky T3 glottic tumours unsuitable for partial laryngectomy.
A 60-year-old chronic smoker male came to the emergency with complaints of progressive hoarseness and difficulty in breathing for the last 2 months. a. What is the most probable diagnosis? (1 mark) b. How do you manage the stridor in this patient? (2 marks) c. What are the confirmatory ENT investigations to make the diagnosis? (2 marks)
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laryngeal cancer airway obstruction stridor emergency tracheostomy diagnostic direct laryngoscopy biopsy
a. Most probable diagnosis
Advanced carcinoma larynx, most likely squamous cell carcinoma of the glottis/transglottis, presenting with malignant laryngeal obstruction and stridor.
b. Management of stridor
This is an airway emergency.
- Keep the patient upright, give humidified high-flow oxygen, monitor continuously, and call ENT and anaesthesia teams immediately. Avoid sedation and repeated traumatic laryngeal examination.
- Secure the airway by emergency tracheostomy under local anaesthesia, preferably below the tumour. If there is imminent complete obstruction and tracheostomy cannot be performed promptly, perform emergency cricothyrotomy, followed by a formal tracheostomy.
- Endotracheal intubation should only be attempted by an experienced anaesthetist if a safe airway is judged possible; it may worsen obstruction or traumatize a laryngeal tumour.
c. Confirmatory ENT investigations
- Flexible fibre-optic laryngoscopy / indirect laryngoscopy to visualize the lesion, assess its site, extent, cord mobility, and airway compromise.
- Direct laryngoscopy or microlaryngoscopy under anaesthesia with biopsy for histopathological confirmation of squamous cell carcinoma. Panendoscopy may be added to exclude synchronous lesions. Direct laryngoscopy with biopsy is the key diagnostic step for suspected laryngeal carcinoma, as described in Cummings Otolaryngology Head and Neck Surgery.
Why it is carcinoma of larynx
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laryngeal cancer symptoms hoarseness breathing difficulty smoking risk factor authoritative
It is suspected carcinoma of the larynx because the presentation has classic warning features:
- Age 60 years and chronic smoking: Tobacco is the most important risk factor for laryngeal squamous cell carcinoma. Textbook of Family Medicine notes that only about 2% to 5% of patients with laryngeal cancer have no smoking history.
- Progressive hoarseness for 2 months: A persistent, progressively worsening change of voice suggests a lesion affecting the vocal cords, rather than acute laryngitis, which usually improves within days to weeks.
- Progressive breathing difficulty/stridor: This implies that a laryngeal mass has narrowed the airway. In a smoker with persistent hoarseness, this is highly concerning for an advanced laryngeal malignancy.
- Common histology: Most laryngeal cancers are squamous cell carcinomas, since the larynx is lined by squamous epithelium.
So, the clinical diagnosis is carcinoma larynx until proved otherwise, but it is not confirmed solely by symptoms. Confirmation requires laryngoscopic visualization and biopsy with histopathology.
Horseness of voice cause according to duration
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dysphonia AND guideline
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AAO HNS dysphonia guideline hoarseness 4 weeks laryngoscopy
Hoarseness of voice: causes according to duration
| Duration | Common causes | Important concern |
|---|---|---|
| Acute: <2 weeks | Acute viral laryngitis, voice abuse/shouting, allergy/irritant exposure, acute smoking-related laryngitis, vocal-cord hemorrhage after strenuous voice use, trauma or intubation | Usually benign, but stridor or respiratory distress needs emergency assessment. |
| Persistent: 2-4 weeks | Persistent laryngitis, laryngopharyngeal reflux, vocal nodules/polyps, vocal-cord paresis, chronic smoking, tuberculosis/fungal laryngitis in appropriate settings | Perform or arrange flexible laryngoscopy, especially in smokers or patients with red flags. |
| Chronic: >4 weeks | Carcinoma larynx, chronic laryngitis, benign vocal-cord lesions such as nodules, polyps, cysts, Reinke edema, vocal-cord palsy due to recurrent laryngeal nerve lesion, hypothyroidism, neurological/functional dysphonia | Laryngoscopy is mandatory. Do not treat empirically for long without visualizing the larynx. |
Red flags requiring urgent laryngoscopy regardless of duration
- Smoker, especially age >40 years
- Stridor or dyspnea
- Neck mass
- Dysphagia, odynophagia, hemoptysis
- Weight loss, referred otalgia
- Recent neck/chest surgery or intubation
- Progressive rather than improving hoarseness
Exam point:
- Acute hoarseness is usually due to laryngitis or voice abuse and is rarely malignant.
- Chronic progressive hoarseness in a smoker should be considered carcinoma larynx until proven otherwise.
The AAO-HNS advises laryngeal examination if dysphonia does not improve within 4 weeks, or immediately where serious disease is suspected, such as tobacco exposure or respiratory distress, in its hoarseness guideline summary.
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