Presentation
Acute presentation with stridor and difficulty breathing. Few months history of left sided neck swelling and a few days of hemoptysis. Heavy smoker and high alcohol intake.
Patient Data
Main finding on admission films is of large soft-tissue swelling in the upper airway, consistent with the presentation of stridor and left-sided neck mass.
ENT performed a flexible nasoendoscopy in the ED revealing a large laryngeal mass obstructing the airway causing near complete occlusion. Awake fiberoptic intubation was not successful and an emergency surgical tracheostomy was formed.
Plain chest films following tracheostomy formation demonstrating left sided pneumothorax and surgical emphysema. Tracheostomy and nasogastric tube in situ.
Annotation of chest x-ray with altered windowing showing the position of the nasogastric tube tip - which should be slightly advanced.
- CT neck:
- large laryngeal tumor with extralaryngeal spread and bilateral necrotic lymphadenopathy
- sagittal demonstrating airway narrowing and occlusion with tracheostomy in situ
- tumor involving most of the left-sided neck structures with invasion through cartilage into strap muscles, bilateral necrotic lymphadenopathy, occlusion of the left internal jugular vein
- CT thorax:
- extensive surgical emphysema, pneumomediastinum and a left pneumothorax
- left basal collapse and consolidation, minor right basal consolidation and small bilateral pleural effusions
- multiple cervical and abdominal nodal and hepatic metastases consistent with stage IV disease
Case Discussion
This patient was an emergency presentation with near-complete airway obstruction from a laryngeal malignancy. They required immediate surgical airway control before further imaging was performed which established widespread metastatic disease.
The case also illustrates some of the side-effects encountered with surgical intervention - the pneumothorax was managed conservatively.
Pathology of biopsies taken at the time of tracheostomy formation showed invasive squamous cell carcinoma.