A 77-year-old man presents with a six-week history of hoarseness and left ear pain when swallowing. He has a history of smoking 15 cigarettes per day for most of his adult life and recent alcohol abuse. Examination shows a mass on his left vocal cord that is not mobile. Given his symptoms and risk factors, the most likely diagnosis is squamous cell carcinoma of the larynx. He requires micro-laryngoscopy and biopsy of the abnormal vocal cord as well as a full examination to investigate and stage the cancer. As treatment involves a multidisciplinary team, specialists from ENT, oncology, pathology, and others should be involved in his care.

2. CASE STUDY 1
A 77 years-old man, and smoker of 15
cigarettes a day for most of his adult life,
presents to his Doctor complaining of
hoarse voice for the last six weeks, he also
c/o of left earache, particularly on
swallowing. He has had a problem with
alcohol abuse in recent years. Indirect
laryngoscopy shows a mass arising from
the left vocal cord, which is not mobile.
The neck, chest and abdomen are normal.

3. 1.What is the most likely diagnosis?
2.How should the patient be
investigated?
3.List the other agencies/specialties
which should be involved with this
case

4. Comments
1.Squamous cell carcinoma of the larynx
must be considered in any patient who
has a hoarse voice for more than three
weeks. In this case the patients smoking
history and referred otalgia are highly
suggestive of this diagnosis.

5. 2.The patient must have a micro-
laryngoscopy and biopsy of the abnormal
vocal cord. In addition full panendoscopy
should be performed in order to exclude a
second, smoking induced primary tumor.
A pre-operative chest x-ray should be
performed in order to exclude a
carcinoma of the lung. It is important to
examine the neck to pick up any
metastatic tumor deposits.

6. 3.In addition to the ENT surgeon, the head
and neck team (multidisciplinary team)
should include a histopathologist,
radiologist, maxillofacial surgeon, plastic
and reconstructive surgeon,
oncologist/radiotherapist, speech
therapist, physiotherapist, dietician, head
and neck community nurse, social worker
and alcohol dependence worker.

7. CASE STUDY 2
A twenty six years old teacher
presented to the ENT surgeon c/o of
recurrent attacks of sore throat and
dysphonia examination confirms the
fact that she is quite hoarse and her
vocal cords have “swellings”
bilaterally.

8.  What is the most likely diagnosis?
 What should be he first line of
treatment?
 Does surgery have a role to play in
this condition?

9. COMMENTS
1. She has singer‘s nodules.
2. In the majority of cases the nodules will
resolve with a course of speech therapy.
3.In those cases which fail to resolve after
speech therapy, surgery may be required
in order to remove the nodules, taking
care to cause as little disruption as
possible to the coverings of the vocal fold
in order to preserve the mucosal wave.