ENT · Head and Neck Oncology
The facts most likely to be tested
Squamous cell carcinoma is the most common histologic subtype of laryngeal cancer, strongly associated with tobacco use and alcohol consumption.
Persistent hoarseness lasting longer than two to three weeks in a patient with a history of smoking is the classic pathognomonic clinical presentation.
Laryngoscopy with biopsy is the gold standard diagnostic procedure to confirm the diagnosis and determine the extent of the lesion.
Glottic tumors typically present earlier with voice changes, whereas supraglottic tumors often present later with dysphagia, odynophagia, or referred otalgia.
Computed tomography (CT) or magnetic resonance imaging (MRI) of the neck is the preferred imaging modality for staging and assessing local invasion.
Early-stage laryngeal cancer is primarily managed with radiation therapy or endoscopic laser resection to preserve laryngeal function.
Advanced-stage disease often requires total laryngectomy combined with neck dissection and adjuvant chemoradiation.
Vignette unlocked
A 62-year-old male with a 40-pack-year smoking history presents to the clinic complaining of a persistent, worsening hoarseness for the past two months. He also reports a mild, dull referred ear pain on the right side and difficulty swallowing solid foods. Physical examination reveals no palpable neck masses, but fiberoptic examination demonstrates an exophytic, ulcerated mass on the right true vocal cord. The patient denies any recent upper respiratory infections or fevers.
What is the most appropriate next step in the management of this patient?
Direct laryngoscopy with biopsy
The patient's presentation of chronic hoarseness and referred otalgia in a heavy smoker is highly suspicious for laryngeal squamous cell carcinoma, necessitating tissue biopsy for definitive diagnosis.
Full handout
High yield triage
Etiology / Epidemiology
Predominantly tobacco and alcohol use in males 50-70 years old.
Clinical Manifestations
Persistent hoarseness >3 weeks is the classic presentation.
Diagnosis
Laryngoscopy with biopsy is the gold standard for definitive diagnosis.
Treatment
Early stage: Radiation therapy or endoscopic resection; Advanced: Laryngectomy.
Prognosis
Survival depends on stage; cervical lymph node metastasis significantly worsens outcomes.
Full handout
Epidemiology & Etiology
Strongest association is with tobacco and alcohol synergy. Incidence peaks in the 6th decade of life, with a significant male predominance. Human papillomavirus (HPV) is an emerging risk factor for supraglottic lesions.
Pertinent Anatomy
The larynx is divided into supraglottis, glottis, and subglottis. The glottis (true vocal cords) is the most common site, often presenting early due to voice changes.
Pathophysiology
Chronic irritation leads to squamous metaplasia, progressing to dysplasia and eventually squamous cell carcinoma. Tumors spread via local invasion or lymphatic drainage to the cervical lymph nodes.
Clinical Manifestations
Persistent hoarseness is the hallmark symptom. Patients may report dysphagia, odynophagia, or a palpable neck mass. Referred otalgia (ear pain) is a red flag for advanced malignancy.
Diagnosis
Initial evaluation requires flexible fiberoptic laryngoscopy. Laryngoscopy with biopsy is the gold standard. CT or MRI of the neck is required for staging and assessing cartilage invasion.
Treatment
Early-stage (T1-T2) disease is managed with radiation therapy or endoscopic laser excision to preserve voice. Advanced disease requires total laryngectomy or chemoradiation. Post-radiation hypothyroidism is a common long-term complication.
Prognosis
Glottic cancers have a better prognosis due to early symptom onset. Cervical lymph node metastasis is the most significant negative prognostic indicator.
Differential Diagnosis
Laryngitis: usually acute and self-limiting
Vocal cord nodules: associated with vocal abuse
Laryngeal papillomatosis: HPV-related, common in children
GERD: causes chronic laryngopharyngeal reflux
Leukoplakia: premalignant lesion requiring biopsy