Cricoid chondrosarcoma presenting as breathy dysphonia.

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A 49-year-old real estate salesman presented with a 13-month history of breathy dysphonia. His symptoms arose following an upper respiratory tract infection, and his voice quality had steadily deteriorated ever since. He reported occasional coughing while drinking water, but no other dysphagia or dyspnea. The initial evaluation shortly after the onset of his symptoms had yielded a diagnosis of reflux laryngitis, but appropriate treatment did not alleviate his symptoms. A later evaluation identified glottic insufficiency, which was attributed to vocal fold paresis based on laryngoscopy.

Peroral Strobovideolaryngoscopy in our office confirmed the glottic insufficiency. Examination also revealed ventricular fold hyperfunction on the side that failed to adduct normally, a finding that suggested intact neuromuscular function (figure 1, A). On closer inspection, a smooth subepithelial mass was noted just underneath the posterior glottic bar (figure 1, B). Examination with a flexible endoscope confirmed this observation.

Computed tomography (CT) of the neck demonstrated a well-demarcated lyric lesion on the posterior lamina of the cricoid cartilage that measured approximately 1.4 x 2 cm (figure 2). A clinical diagnosis of cricoid chondrosarcoma was made on the basis of the typical laryngoscopic and radiographic appearance.

Laryngeal chondrosarcomas are rare, typically low-grade cartilaginous tumors that usually present with hoarseness and dyspnea. (1,2) Most chondrosarcomas involve the posterior aspect of the cricoid cartilage. (1,2) Their presence there may lead to an expansion of the circumference of the laryngeal inlet, lateral displacement of the arytenoid cartilages, and consequent glottic insufficiency. (3) If a chondrosarcoma is diagnosed while it is still small, it may be amenable to conservative surgery; several different procedures have been recommended, depending on the location and extent of the tumor. (3,4) The goal is excision with maximum preservation of laryngeal function.

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In our patient's case, the size of the tumor required compromise of the left cricoarytenoid joint. Its proximity to the contralateral cricoarytenoid joint made the patency of the laryngeal airway after resection uncertain. Nevertheless, the patient underwent temporary tracheostomy and partial cricoidectomy with laryngeal stenting at another center. He remained tracheostomy-dependent some 6 months after surgery, having failed decannulation twice because of airway distress.

This case underscores the importance of meticulous laryngoscopic evaluation and illustrates the difficulties in judging suitability for partial resection of the cricoid cartilage.

References

(1.) Rinaldo A, Howard DJ, Ferlito A. Laryngeal chondrosarcoma: A 24-year experience at the Royal National Throat, Nose and Ear Hospital. Acta Otolaryngol 2000;120(6):680-8.

(2.) Thompson LD, Gannon FH. Chondrosarcoma of the larynx: A clinicopathologic study of 111 cases with a review of the literature. Am J Surg Pathol 2002;26(7):836-51.

(3.) Koufman JA, Cohen JT, Gupta S, Postma GN. Cricoid chondrosarcoma presenting as arytenoid hypertelorism. Laryngoscope 2004; 114(9):1529-32.

(4.) Cohen IT, Postma GN, Gupta S, Koufman JA. Hemicricoidectomy as the primary diagnosis and treatment for cricoid chondrosarcomas. Laryngoscope 2003;113(10):1817-19.

Scott Rickert, MD; Robert Buckmire, MD; Lucian Sulica, MD

From the Department of Otorhinolaryngology, Weill Medical College of Cornell University, New York City (Dr. Rickert and Dr. Sulica), and the Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill (Dr. Buckmire).