Presentation
48 hours of worsening dyspnea, on a background of 6 months of voice changes and slowly progressing dyspnea. Heavy smoker.
Patient Data
Impression of an indistinct lobulated soft tissue mass measuring approximately 22 x 13 x 26 mm lying within the right posterolateral aspect of the hypopharynx.
There is complete obliteration of the aerodigestive tract at the level of the thyroid cartilage and persistent left-sided deviation of the trachea due to asymmetrical soft tissue thickening on the right side. No definite destruction of the hyoid bone, thyroid or cricoid cartilage.
No associated peripherally enhancing collections within the asymmetrical soft tissue thickening. Presence of enlarged cervical lymph nodes measuring up to 10 mm in short axis with no intrinsic calcifications or central necrosis. Further prominent subcentimeter lymph nodes were seen within the superior mediastinum with fat stranding.
Normal appearance of the parotid and thyroid glands. Incidental large cystic spaces within the right middle cranial fossa measuring 28 x 40 mm with associated displacement of the right MCA branches. This could potentially represent an arachnoid cyst.
There is a large lobulated predominantly supraglottic soft tissue mass involving the right posterolateral hypopharynx and larynx at the level of the thyroid cartilage with extension to involve the right vocal cord and right infraglottic respiratory epithelium; this measures 45 x 21 x 27 mm.
The lesion crosses the midline at the anterior commissure which is thickened and there is lobulated abnormal soft tissue in the left supraglottic larynx. This is associated with near complete obliteration of the aero-digestive tract and mild tracheal deviation to the left. The lesion demonstrates avid enhancement post gadolinium. There is no definite destruction of the hyoid bone, thyroid or cricoid cartilage. No collections identified. No further masses are seen.
Multiple enhancing enlarged (up to 10 mm maximum short axis) lymph nodes are identified in the cervical chain of the neck bilaterally.
Submandibular and parotid glands are unremarkable. Thyroid gland demonstrates normal contrast enhancement. Tracheostomy tract noted passing through the isthmus of the thyroid.
Conclusion:
Findings consistent with a transglottic soft tissue mass crossing the midline and resulting in near complete obliteration of the aerodigestive tract, consistent with a primary malignancy, likely a squamous cell carcinoma of the larynx.
Case Discussion
An awake tracheostomy was performed on presentation, with a transglottic tumor visualized. Laryngoscopy identified fixed vocal cords involving the right arytenoid muscle, entire right vocal cord over anterior commissure to subglottis, and entire right anterior wall.
The patient underwent a partial pharyngectomy, total laryngectomy, bilateral neck dissection and reconstruction with anterolateral thigh flap. He recovered well post operatively. He was also treated with adjuvant chemotherapy and radiotherapy.
Pathology confirmed a T4N1 transglottic squamous cell carcinoma. He had a PET scan that was negative for metastasic disease.
Pathology report:
Well to moderately differentiated squamous cell carcinoma, extending and involving cartilage and just into soft tissue of the neck, and clear of the corresponding mucosal resection margins by at least 3 mm.
No vascular invasion, no perineural invasion.
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