A 62-year-old man comes to the office for evaluation of hoarseness. He says that he has always had a deep voice, but over the past 4 months, it has become "rough" and "scratchy" and the hoarseness is constant; it does not change throughout the day. Medical history is significant for chronic obstructive pulmonary disease and gastroesophageal reflux disease. The patient has smoked a pack of cigarettes daily for the past 40 years. He drinks 12 beers weekly. Vital signs are within normal limits. Nasal mucosa is dry, and oral cavity examination shows poor dentition with mild thrush seen on the lateral surfaces of the tongue bilaterally. There is no cervical adenopathy. Flexible laryngoscopy reveals a clear nasal cavity and nasopharynx. The base of tongue has normal mucosa, and the tonsils are small with no lesions. The vocal cords are mobile bilaterally. The right vocal cord is clear with a straight edge. There is a fungating, irregular mass on the left vocal cord that appears white in some areas and red in others with some blood crusting. Which of the following would most likely be seen on biopsy of this vocal cord lesion?
This patient with persistent hoarseness and a fungating laryngeal mass has laryngeal squamous cell carcinoma (SCC), which accounts for >90% of lesions in the adult larynx. The most important risk factors are smoking and alcohol use. Hoarseness is often the presenting symptom, due to impaired vibration or movement of the vocal cords. Persistent hoarseness (>30 days) should always be evaluated by laryngoscopy to ensure no delay in diagnosis of possible cancer.
Other presenting symptoms may include dysphagia or airway obstruction due to a mass blocking passage of food or air. Patients may have referred otalgia facilitated by either the glossopharyngeal nerve (CN IX) (which innervates both the base of tongue and the external auditory canal [EAC]) or the vagus nerve (CN X) (which innervates parts of the larynx/hypopharynx and the EAC). Hemoptysis may be seen due to tumor friability (eg, blood crusting). Regional nodal metastases manifest as cervical adenopathy.
(Choice A) Adenocarcinoma is unlikely in the larynx (<1% of laryngeal malignancies). Lung adenocarcinoma shares some risk factors (eg, smoking, age) and presenting symptoms (eg, cough, hemoptysis) with laryngeal SCC but would not metastasize to the larynx.
(Choice B) Aphthous ulcers are common, painful ulcers that typically resolve in <2 weeks and are usually seen in the oral cavity (eg, tongue, buccal mucosa) rather than the larynx and would not cause hoarseness.
(Choice C) Laryngeal candidiasis is an opportunistic infection that often occurs concurrently with oral candidiasis (thrush) in patients using corticosteroid inhalers (eg, due to chronic obstructive pulmonary disease). White patches or plaques on the mucosal surfaces are seen; a single, large laryngeal mass would not occur.
(Choice D) Pemphigus vulgaris is an autoimmune disease characterized by painful blisters of the skin and mucous membranes. However, the pain is severe, and there would be skin blistering and multiple ulcerations (not a mass isolated to the vocal cord).
(Choice E) Reflux laryngitis could cause hoarseness and dysphagia but not a laryngeal mass.
(Choice G) Recurrent respiratory papillomatosis is due to human papillomavirus. Wartlike proliferations described as multiple, raised, finger-shaped lesions are seen on the surface of the vocal cords. Squamous papillomas appear more uniform and do not invade deeper structures.
(Choice H) Vocal cord polyps often occur due to inefficient or excessive voice use (eg, teachers, telemarketers). They can cause hoarseness due to impaired vocal cord vibration. Polyps do not invade or ulcerate.
Educational objective:
A laryngeal ulcer in a smoker is likely squamous cell carcinoma. Persistent hoarseness should always be evaluated by laryngoscopy to ensure no delay in diagnosis of possible cancer.