A 55-year-old man presents to his physician with hoarseness for 3 weeks. He has not had a recent episode of straining his voice. After a thorough history and physical exam, the most appropriate next step would be which of the following?
d. Radiograph of the neck
e. Reassurance of the patient
The most correct answer is b, direct laryngoscopy.
The differential diagnosis for hoarseness is lengthy when there is laryngeal involvement. These range from simple self-resolving infectious processes causing laryngitis through nodules, papillomas, carcinoma in situ, and then laryngeal carcinoma. The vigilant clinician will want to inspect the area directly before deciding whether antibiotics, standard or advanced imaging, bronchoscopy, an invasive biopsy procedure, or pain palliation with reassurance is appropriate.
A 35-year-old woman presents to her primary care physician with hoarseness of 7 days' duration. Physical examination of the patient reveals a solitary soft berry-shaped nodule in the larynx on the true vocal chord. Which of the following is the most accurate prognosis for this woman's complaint?
a. The lesion will likely recur regardless of treatment.
b. This carcinoma often spreads from the true chords to other laryngeal sites.
c. The nodule shows no correlation with human papilloma virus infection.
d. Biopsy will show that the nodule is covered with respiratory mucosa.
e. This nodule is benign with virtually no malignant potential.
The most correct answer is e, benign without malignant potential.
This woman's laryngeal papilloma is characteristically solitary and positioned to produce hoarseness but its likelihood for regrowth after excision and its metastatic potential are both very low. If biopsied it would show squamous epithelium overlying fibrovascular cores. If not already established, the woman should be tested for papilloma virus infection, since this papilloma has a high association rate with HPV types 6 and 11.
A 12-year-old boy who emigrated with his paternal uncle from sub-Saharan Africa 6 weeks earlier presents today with a mass in his nasopharynx. Biopsy shows an undifferentiated tumor with large epithelial cells admixed with lymphocytes; nucleoli are prominent, but cell borders are indistinct. Which of the following most accurately describes this boy's tumor?
a. It has no known association with Epstein-Barr virus infection.
b. This tumor subtype is highly sensitive to radiation therapy.
c. Such malignancies are strongly keratin-negative by immunohistochemistry.
d. Left untreated, this subtype uniformly has a very poor outcome.
e. This tumor type grows very rapidly and occurs only in North America.
The most correct answer is b, highly sensitive to radiation therapy.
Undifferentiated nasopharyngeal carcinomas of the type in this youth lack the striking keratin outer layer that is the dominant histological finding among the well-differentiated tumors in the U.S. population; despite the lack of a keratin layer, the cells make keratin and would show positive immunohistochemical staining for keratin, as is typical of squamous cell carcinomas in general. They do show strong association with EBV infection and are the predominant tumor subtype among individuals who have grown up in Asia or Africa. With radiation treatment, to which undifferentiated carcinomas are susceptible, the prognosis for non-recurrence in this young man is quite good.