Clinical Case Discussion: Carcinoma Larynx (Glottic Carcinoma)
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🩺 Clinical Case Discussion : Carcinoma Larynx (Glottic Carcinoma)
Today, we'll have a clinical case discussion on a very common and important ENT case: Carcinoma Larynx (Glottic Carcinoma).
This case discussion format will be helpful for both undergraduates and postgraduates.
We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.
Let's begin!
📋 Patient History
Patient Demographics:
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Age: 60-year-old male
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Residence: Hyderabad
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Occupation: Teacher
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Chief Complaint:
- Change of voice for the last 4 months.
📜 History of Present Illness
The patient was asymptomatic 4 months prior. He then developed a change in voice with the following characteristics:
- Onset: Insidious (gradual)
What are the common Causes of Voice Change?
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Progression: Gradually progressive
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Nature: Hoarse
What are the Different Types of Voice Change? Give examples of each type.
Define Hoarseness of voice.
What are the Danger Signs Associated with Hoarseness?
- Pattern: Constant throughout the day
What are some diseases where you see diurnal variation in change of voice? Why?
Why is voice change worst in the morning in Chronic Laryngitis?
- Associated Factors: Associated with a dry cough; no known aggravating or relieving factors.
🚩 Red Flag Rule: Any change in voice lasting more than three weeks requires a complete laryngoscopic evaluation to rule out malignancy.
Negative History:
| Symptom | Possible Indication |
|---|---|
| Pain during speech | Advanced disease (infiltration into muscles/perichondrium/cartilage/nerves); secondary infection |
| Fever & night sweats | Systemic disease (laryngeal TB, HIV, malignancy); Secondary infection; Rarely distant metastasis |
| Weakness of voice | Earliest symptom of laryngeal TB; RLN or SLN palsy; Muscle tension dysphonia |
| Dysphagia | Supraglottic involvement, hypopharyngeal malignancy; Tumor extension to pharynx/esophagus/pre-epiglottic space; Poor prognosis indicator |
| Odynophagia | Supraglottic/pharyngeal wall/pre-epiglottic involvement; Spread to sensory-rich areas (SLN); Ulceration or infiltration; Supraglottic carcinoma; Secondary infection |
| Difficulty in breathing | Glottic chink lesion causing obstruction; Lung metastasis; Aspiration pneumonia; TB; COPD |
| Noisy breathing (stridor) | Airway compromise |
| Foreign body sensation | Earliest symptom of supraglottic carcinoma; Suspicious in smokers/alcoholics; Differentiate from benign causes (pharyngitis, reflux) |
| Choking / Aspiration | Supraglottic involvement; Impaired protective reflexes; Airway compromise; RLN/SLN invasion |
| Vocal abuse history | Suggests vocal nodule, polyp, Reinke's edema |
| Neck trauma | RLN injury; Laryngeal fracture; Arytenoid dislocation; Crico-arytenoid joint injury |
| Surgery under General Anaesthesia | Intubation granuloma (injury from intubation) |
| Radiation exposure | Thyroid malignancy |
| Reflux disease | Acid reflux causes chronic laryngeal irritation → hoarseness; Mimics laryngitis, nodules, early malignancy |
| Loss of appetite / weight loss | Malignancy; TB; Granulomatous diseases (e.g., Wegener's granulomatosis) |
| Swelling in neck | Lymph node metastasis; Advanced stage disease |
| Chest pain | Rule out cardiac causes; GERD |
| Dental caries | Important before radiotherapy (risk of osteoradionecrosis); Important before surgery (septic foci) |
| Ear pain (referred otalgia) | Early clue of deeper spread (advanced disease); May precede other symptoms; Seen in pyriform sinus cancer (early disease) |
What is Odynophonia? Name some causes.
Where do you see Inspiratory Stridor, Biphasic Stridor and Expiratory Stridor?
What is Referred Otalgia? Name the causes of referred otalgia.
Past Medical & Family History
- No similar complaints in the past.
- No history of previous surgeries, known drug allergies, or significant family history of malignancy or tuberculosis.
What family history is important in this case?
Personal & Addiction History
- Smoking: Smokes 5 bidis (a type of thin cigarette) per day for the last 35 years.
- Alcohol: Consumes 200 ml of alcohol per day for the last 30 years.
What is pack year?
What are the Carcinogens in Smoking & Alcohol?
What is the mechanism of action of carcinogenesis by Tobacco and alcohol?
What are the presenting features in Supraglottic, Glottic and Subglottic growth?
🔬 Clinical Examination Findings
- General & Systemic Examination: Normal.
- Oral Cavity & Oropharynx: Normal, except for nicotine stains on teeth.
- Neck Examination: Laryngeal crepitus is present. No palpable neck nodes.
- Nose, PNS, & Ear Examination: Normal.
Indirect Laryngoscopy (IDL) Findings
- Location: A pinkish, proliferative growth was seen involving the posterior two-thirds of the right true vocal cord.
- Surface: Irregular.
- Mobility: The vocal cord was mobile.
- Extent: The anterior commissure was not involved. The glottic chink was adequate.
What are the hidden areas in larynx on Indirect Laryngoscopy?
What is fixed Vocal Cord?
What is fixed Hemilarynx?
What are the causes of Immobile Vocal cord in CA Glottis?
What are the differences between vocal cord fixity and vocal cord paralysis?
What is a Transglottic growth?
What is Laryngeal crepitus? What is Bocca's sign?
📝 Case Summary
A 60 year old male (Smoker and alcoholic) was brought to OPD with complaint of change in voice since last 4 months. Change in voice is insidious in onset, gradually progressive in nature, hoarse in nature, constant throughout the day, no aggravating or relieving factors, a/w dry cough. On examination, there is a pinkish proliferative growth seen involving posterior 2/3rd of Right Vocal cord. Surface is irregular. Vocal cord is mobile. Anterior commissure not involved. Growth is moving along with vocal cord side to side. Glottic chink is adequate.
🩺 Provisional Diagnosis
Based on the history and clinical findings, the provisional diagnosis is:
Malignancy of the larynx, subsite glottis. Clinical Staging: T1a N0 Mx, Stage 1.
Why this format?
- Malignancy of larynx: We suspect cancer, but histopathology (biopsy) is needed to confirm the type (e.g., squamous cell carcinoma).
- Subsite glottis: The tumor is located on the true vocal cord (glottis).
- T1a: Tumor is limited to one vocal cord with normal mobility.
- N0: No clinically palpable neck nodes.
- Mx: Metastasis has not yet been assessed.
- Stage 1: This combination of T, N, and M falls into Stage 1.
Points in Favor of the Diagnosis
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Demographics: Elderly male (60 years old).
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Symptoms: Progressive hoarseness of short duration (4 months) is highly suspicious for malignancy.
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Risk Factors: Chronic heavy smoker and alcoholic, which have a synergistic effect on carcinogenesis.
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Clinical Findings: A proliferative growth with an irregular surface on the vocal cord is a classic appearance of a malignant tumor.
Ruling Out the Differential Diagnoses
| Differential Diagnosis | Why It Was Ruled Out |
|---|---|
| Solitary Papilloma | Usually affects younger adults and favors the anterior vocal cord. |
| TB Laryngitis | No systemic symptoms (fever, weight loss). Typically presents with voice weakness and odynophagia. IDL shows a "mouse-nibbled" appearance, not a proliferative mass. |
| Vocal Polyp / Nodule | Associated with vocal abuse. Polyps are typically smooth and pedunculated; nodules are bilateral and symmetric at the junction of the anterior 1/3 and posterior 2/3. |
| Reinke's Edema | Typically bilateral, gelatinous, translucent swelling along the entire cord, not a localized proliferative mass. |
| Chronic Laryngitis | Presents as diffuse redness and swelling, not a discrete mass. Hoarseness is typically not rapidly progressive. |
🔬 In-Depth: Laryngeal Carcinoma
What are the different endoscopic features of TB laryngitis?
Why is posterior part of larynx involved more commonly in TB Larynx?
What is the Most common site of CA Larynx?
What are the Subsites of Larynx?
What is the pattern of spread of carcinoma of supraglottis, glottis and subglottis?
- Prognosis by Site: Glottic cancers have the best prognosis because they cause early symptoms (hoarseness) and have sparse lymphatic drainage, leading to early detection and low rates of metastasis. Subglottic cancers have the worst prognosis due to their silent nature and early spread.
What are the Natural Barriers for Spread of CA Larynx?
What is the % of Neck Node involvement in different subsites of CA Larynx?
Key Anatomical Spaces for Tumor Spread:
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Pre-epiglottic Space: A fatty space anterior to the epiglottis. Invasion here is a sign of advanced disease.
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Paraglottic Space: A space lateral to the vocal cords. Invasion leads to vocal cord fixation.
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Broyle's Ligament: Attaches the vocal ligament to the thyroid cartilage at the anterior commissure. This area lacks a protective perichondrium, making it a direct pathway for cartilage invasion.
What are the boundaries of Pre epiglottic space?
What are the boundaries of Paraglottic space?
What is Reinke's space?
TNM Staging for Glottic Carcinoma (AJCC 8th Ed.)
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T1: Tumor limited to vocal cord(s) with normal mobility.
- T1a: One cord involved.
- T1b: Both cords involved.
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T2: Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.
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T3: Tumor limited to the larynx with vocal cord fixation, and/or invasion of paraglottic space, and/or minor thyroid cartilage erosion.
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T4a: Tumor invades through the thyroid cartilage and/or invades extra-laryngeal tissues (e.g., trachea, strap muscles, thyroid gland).
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T4b: Very advanced disease invading prevertebral space, mediastinal structures, or encasing the carotid artery.
🏨 Management Plan
Management always consists of two parts: Investigation and Treatment.
1. Investigations
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Routine Blood Investigations: For surgical fitness.
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Sputum for AFB: To rule out tuberculosis.
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Video Laryngoscopy / Stroboscopy: To visualize the growth in detail. Stroboscopy assesses the mucosal wave, which is absent or reduced over a malignant lesion. This is crucial for evaluating early glottic cancers.
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Direct Laryngoscopy and Biopsy (GOLD STANDARD): This is mandatory. It is performed under general anesthesia for three purposes:
- To obtain a tissue sample for histopathological confirmation.
- To accurately assess the full extent of the tumor (including hidden areas like the ventricle and subglottis).
- To confirm the mobility of the vocal cords.
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Contrast-Enhanced CT (CECT) of the Neck: Done before biopsy to avoid inflammatory artifacts. It helps to:
- Assess for cartilage invasion and extra-laryngeal spread.
- Evaluate the pre-epiglottic and paraglottic spaces.
- Detect metastatic lymph nodes.
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CT Chest: To screen for distant metastasis (most commonly to the lungs) and synchronous primary lung tumors.
What are the features of Malignant lymph node?
2. Treatment - Radiotherapy
What are the different treatment options according to staging of Glottic Carcinoma?
What are the factors deciding the treatment choice?
What is the dose of Radiotherapy given?
What are the Contraindications of Radiotherapy?
What are the Advantages and Disadvantages of Radiotherapy?
What are the Complications of Radiotherapy?
What are Radiosensitizers?
What is IMRT?
What is IGRT?
What is the ELS Classification of Cordectomy for Glottic CA?
Prognosis
Prognosis is primarily determined by the stage of the disease.
- 5-Year Survival for Glottic Cancer:
- Stage I (T1): ~85-95%
- Stage II (T2): ~70-85%
- Stage III: ~50-65%
- Stage IV: ~30-40%
Given our patient's T1aN0 (Stage I) disease, his prognosis with appropriate treatment is excellent.
What are the different prognostic factors in Carcinoma larynx?
📝 All the topics and questions mentioned in this post are explained in detail in my ENT notes - built for exam success and clinical understanding. Get full access by purchasing the notes.