Report of a rare case of vocal fold carcinoma that was obscured by a prominent vocal fold polyp.

From the Department of Otolaryngology (Dr. Soylu, Dr. Aydogan, Dr. Ozsahinoglu) and the Department of Pathology (Dr. Tunali), Cukurova University Medical Faculty, Adana, Turkey.

Reprint requests: Levent Soylu, MD, Cukurova Universitesi Tip Fakultesi, Kulak Burun Bogaz Anabilimdali, Balcali, Adana, Turkey, 01330. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Abstract

We report the case of a 56-year-old man who was evaluated for hoarseness. Telescopic and fiberoptic examination revealed a huge, pedunculated polyp that obscured the vocal folds. Upon further examination, microlaryngoscopy revealed a coexisting superficial irregular lesion on the upper surface of the left vocal fold, which was identified as a microinvasive carcinoma. This unusual presentation emphasizes the importance of a microlaryngoscopic examination.

Introduction

A laryngeal carcinoma accompanied by a synchronous vocal polyp is rare. A review of the English-language literature during the past 20 years did not find any such case.

We report an unusual case of a patient with an early glottic carcinoma that was not recognized during the office examination because it was obscured by a huge pedunculated vocal polyp.

Case report

A 56-year-old man had a 4-month history of hoarseness when he came to our clinic in March 1995. His primary care physician had diagnosed a vocal fold polyp and advised surgery, but the patient applied for a second opinion. He denied any history of weight loss, odynophagia, or hemoptysis, but he had been a heavy smoker for the previous 20 years. Indirect mirror laryngoscopy together with rigid and fiberoptic laryngoscopy showed a huge, yellow, pedunculated polyp that obscured the vocal folds. There was no palpable cervical lymphadenopathy.

Microlaryngoscopy under general anesthesia revealed that the pedunculated polyp had originated in the inferomedial surface of the middle third of the left vocal fold (figure 1). Interestingly, when the surgeon pushed the polyp down to the subglottic space to look for its origin, he discovered another vegetative lesion on the upper surface of the left vocal fold (figure 2). The vegetative lesion did not involve the anterior commissure or laryngeal ventricle. After excision of the polyp, a biopsy was performed on the anterior aspect of the suspected malignancy.

The histopathology report identified a polyp on the left vocal fold and a carcinoma in situ. There was pleomorphism, dyskeratosis, anisocytosis, and atypical mitotic figures within the cells of the superficial layers of stratified squamous epithelium. One month later, the smaller lesion was stripped in another center, and the histopathology report identified a moderately differentiated epidermoid carcinoma at the posterior aspect and a carcinoma in situ at the anterior aspect of the left vocal fold. The patient was staged as T1N0M0, and he received 50 Gy of radiotherapy in 16 fractions over 22 days. On followup 8 months later, the patient was still free of disease.

Discussion

Vocal fold polyps are a common cause of dysphonia and are generally attributed to smoking. [1] The patient described here was a heavy smoker, and he complained of dysphonia. Interestingly, our patient also had a concomitant carcinoma in the same vocal fold, which is most unusual. The incidence of a concomitant early glottic carcinoma and a vocal fold polyp is unknown. Our review of the English-language literature did not reveal the exact incidence of this synchronicity. We also reviewed the charts of 1,063 cases of vocal fold nodules and polyps that were treated surgically at our institution over the previous 23 years, and could not find a similar case.

Patients with malignancies of the vocal folds have the same symptoms as patients with vocal fold polyps. [2,3] Therefore, symptoms that should lead us to suspect a malignancy in the glottic area in this patient were instead attributed to the huge vocal fold polyp. Even microlaryngoscopy did not reveal the carcinoma in the left vocal fold until the pedunculated polyp was moved inferiorly. When it was, the vegetative lesion that was not identified during the office examination was recognized easily.

On the basis of this experience, we believe that the otolaryngologist should maintain a high index of suspicion for early laryngeal cancer, especially in older men who have a history of heavy smoking, even in the presence a benign pathology, such as the vocal fold polyp described in this case.

References

(1.) Bastian RW. Benign mucosal and saccular disorders; benign laryngeal tumors. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head and Neck Surgery. Vol. 3, 2nd ed. St. Louis: Mosby Year Book, 1993:1897-924.

(2.) Scott PS, Schaefer SD. Disorders of laryngeal function. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL, eds. Otolaryngology. Vol. 3, 3rd ed. Philadelphia: W.B. Saunders, 1991:2257-72.

(3.) Bailey BJ. Early glottic carcinoma. In: Bailey BJ, Johnson JT, Kohut RI, et al, eds. Head and Neck Surgery-Otolaryngology. Vol. 2, 1st ed. Philadelphia: J.B. Lippincott, 1993;1313-33.