Laryngeal tumor - squamous cell carcinoma

Case contributed by Derek Smith

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

Age: 50 years
Gender: Male

Admission films

x_ray

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.

Follow up films

x_ray

Plain chest films following tracheostomy formation demonstrating left sided pneumothorax and surgical emphysema.  Tracheostomy and nasogastric tube in situ.

Annotated NG tip

Annotated image

Annotation of chest x-ray with altered windowing showing the position of the nasogastric tube tip - which should be slightly advanced.

Staging CT

ct
  • 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.

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