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Otorhinolaryngology Otorhinolaryngology |
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Laryngology Case
You are a head and neck otolaryngologist/ENT surgeon seeing a 78 year old woman who presents with a six week history of worsening hoarse voice.
MCQ 1
MCQ 2
The 78 year old woman has a fifty pack year history of smoking. Her voice has been increasingly more hoarse over two months.
There is no stridor or other signs of respiratory distress. She has a palpable 2cm right level III node. On endoscopic examination, you see the following (ignore the endotracheal tube):
Quickly describe what you see
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This is an endoscopic view of the larynx, with a close-up view of the vocal folds.
Anterior is at the top of the picture (anatomical description = anterior commissure).
The cuff of the endoctracheal tube is sitting in the subglottis.
There is an exophytic lesion centred on the right anterior vocal fold, spreading over the anterior commissure to the left vocal fold.
What do you do next?
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Inform the patient about your findings and that you are concerned about the laryngeal mass.
The patient needs an urgent biopsy and panendoscopy (examination under anaesthesia where the upper aerodigestive tract is examined as a whole. Patients with head and neck cancer are more likely to have secondary cancers).
A staging CT scan of the neck and chest to look for cervical lymph node and lung metastases, in order to guide treatment options.
Referral to head and neck MDM.
What are the treatment options for head and neck cancer?
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Early cancer: Single modality treatment is the goal with either surgery or radiotherapy.
Advanced cancer: Dual modality treatment is often necessary – a combination of surgery with radiotherapy or radiotherapy with chemotherapy (chemoradiotherapy).
Every treatment modality has advantages and disadvantages. Can you think of some?
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Surgery
Positives: Removal of tumour with margins and locoregional control (lymph nodes in the neck) offers the best prognosis in many cases; Allows treatment of the primary and neck nodes in a single sitting (resection with neck dissection); Good microscopic clearance of the tumour can allow single modality treatment in a lot of cases; Long-term side effect profile is the best
Negative: Can be scarring and disfiguring despite advanced reconstructive techniques; If the tumour has aggressive histological features (e.g. neural invasion, poor differentiation) then the patient may need radiotherapy as well as surgery (whereas they could have had radiotherapy from the start)
Radiotherapy
Positives: Non-invasive
Negatives: Tumours that do not respond or recur, will need surgery and wounds tend to poorly heal in irradiated tissues; Long-term side-effects are very common including swallowing difficulty, dry mouth and osteoradionecrosis
Chemotherapy
Positives: Non-invasive
Negatives: Toxic; Risk of secondary malignancy; Can worsen adverse effects of radiotherapy.
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