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EN4.40-44 | Larynx Voice and Airway — PBL Case

CLINICAL SETTING

It is Monday morning at the ENT OPD of a district hospital in Lucknow. Dr Ananya Srivastava, a final-year resident, is seeing her first patient of the week — Mr Ramesh Verma, a 54-year-old male farmer and occasional bidi smoker who has come in with his wife. Mr Verma speaks in a low, rough whisper. His wife explains that his voice changed about four months ago and has been getting progressively worse. He initially thought it was a 'cold' and tried home remedies. Three weeks ago he noticed a lump on the left side of his neck. He has also had some difficulty swallowing solids over the past three weeks, and his wife says he has lost about 5 kg over the past two months. On examination: Mr Verma looks thin. There is a firm, non-tender, 3 × 2 cm lymph node in the left upper deep cervical region. He has no stridor at rest. His voice is severely hoarse.

Trigger 1: The Laryngoscopy Dilemma

Dr Ananya performs indirect laryngoscopy. She sees an ulceroproliferative growth on the left true vocal cord — the cord is fixed (immobile). The right cord appears normal. The subglottis is clear. On reviewing the patient's history, she notes he first developed hoarseness 4 months ago. He saw a general practitioner 6 weeks after onset, who prescribed antibiotics and steam inhalation. He improved briefly, then worsened. No laryngoscopy was performed at that visit. His wife asks: 'Doctor, would he have been cured if they had checked earlier?'

DISCUSSION POINTS

  • At what duration of hoarseness should laryngoscopy have been performed, and what does this threshold represent clinically? Was the GP's management at 6 weeks appropriate?
  • The left vocal cord is fixed (immobile). What does cord fixation indicate about disease extent, and what anatomical structure(s) has the tumour likely involved to produce this finding?
  • Compare Mr Verma's presentation with a patient who presents with dysphagia, referred otalgia, and neck nodes but NO hoarseness. What subsite does the second patient likely have, and why does the symptom pattern differ so markedly from Mr Verma's?
  • How would you answer the wife's question — 'Would he have been cured if they had checked earlier?' — in a way that is honest, compassionate, and does not unfairly blame the GP without complete information?
Click to reveal Trigger 2: Investigation, Staging and the MDT (discuss previous trigger first!)

Trigger 2: Investigation, Staging and the MDT

Microlaryngoscopy and biopsy confirm squamous cell carcinoma of the left true vocal cord. The histology report: moderately differentiated SCC, margins not assessable (punch biopsy). CT scan of the neck and chest shows: 3.5 cm endolaryngeal mass with extension through the thyroid cartilage, 3 × 2 cm left level II node (no contralateral nodes), no distant metastases. Lung fields clear. Dr Ananya presents the case to the weekly multidisciplinary tumour board. The radiation oncologist and the head-and-neck surgeon are present. The staging is discussed. The family is waiting outside.

DISCUSSION POINTS

  • Using the clinical and CT findings (left vocal cord lesion with thyroid cartilage invasion, single ipsilateral node <3 cm, no distant disease), assign the T, N and M stage for this patient. What is the overall clinical stage?
  • The MDT is debating between total laryngectomy (+ left neck dissection) and concurrent chemoradiotherapy (larynx preservation). What are the key oncological and quality-of-life factors that inform this choice for a T4a N1 M0 glottic carcinoma?
  • If this same node presentation (N1, left level II) were in a patient with a supraglottic primary, what is the biological explanation for why supraglottic tumours metastasise to cervical nodes earlier than glottic tumours of equivalent T-stage?
  • Dr Ananya must explain the diagnosis and treatment options to Mr Verma and his wife. He is likely to lose his voice after total laryngectomy. How should she structure this conversation — what principles of informed consent and compassionate communication apply?
Click to reveal Trigger 3: Airway Emergency and Tracheostomy Care (discuss previous trigger first!)

Trigger 3: Airway Emergency and Tracheostomy Care

Mr Verma is listed for total laryngectomy + left selective neck dissection. During the pre-operative assessment, the anaesthetist notes that his stridor has increased over the past week, with biphasic stridor now audible at rest. The airway is assessed as potentially difficult. On Day 1 post-operatively, Mr Verma has a permanent tracheostomy (laryngectomy stoma). On Day 3, a ward nurse notices he is in respiratory distress — his tracheostomy tube appears blocked and he cannot speak or signal clearly. The registrar on call is managing another emergency.

DISCUSSION POINTS

  • The stridor is biphasic. Using the principle of stridor phase localisation, explain what anatomical level is obstructed and why — correlating this with the known glottic tumour location.
  • The anaesthetist is considering an awake fibreoptic intubation before induction, with a plan for immediate tracheostomy if intubation fails. Compare this to the scenario where a patient with acute laryngeal trauma arrives in casualty requiring emergency surgical airway: (a) which procedure is correct for the emergency and why? (b) identify the exact anatomical landmark used for each — the cricothyroid membrane vs the 2nd-3rd tracheal rings.
  • On day 3, the duty nurse finds Mr Verma in respiratory distress with a blocked tracheostomy tube. You are the intern on call. List the bedside actions in order: starting with the inner cannula, through to escalation if simple measures fail.
  • Mr Verma's family asks whether he will 'breathe normally' and 'be able to speak again' after a total laryngectomy. What does post-laryngectomy rehabilitation involve — specifically regarding tracheoesophageal speech, electrolarynx, and stoma care? Frame your answer for a junior doctor explaining to a family.

Group Task Assignments

Group 1: Diagnostic Pathway and Staging

  • Draw the clinical decision pathway from 'hoarseness >3 weeks' to definitive histological diagnosis — include every step (laryngoscopy type, biopsy technique, staging investigations) and the clinical rationale for the sequence
  • Apply TNM staging to Mr Verma's case using the 8th edition AJCC criteria. Identify what would change the stage from T4a to T4b.
  • Prepare a 3-minute verbal summary of Mr Verma's case as you would present it to the MDT — include referral reason, key findings, staging and your recommendation

Competencies: EN4.40, EN4.42

Group 2: Glottic vs Supraglottic Carcinoma — A Comparative Study

  • Construct a comparison table (glottic vs supraglottic): subsite anatomy, presenting symptoms, lymphatic drainage, typical nodal stage at first presentation, prognosis, preferred treatment for T1-T2 disease
  • Explain the biological basis for the prognostic difference: why does glottic SCC T1 have a ~90% 5-year survival while supraglottic T1 has ~70%?
  • Propose a public health message for a rural health worker explaining why a smoker's hoarseness lasting more than 3 weeks must be referred urgently — frame it in simple terms that a ASHA worker could convey to a patient

Competencies: EN4.42

Group 3: Stridor — Assessment and Emergency Management

  • Construct the differential diagnosis of stridor by age group (neonate, 6 months–3 years, adult) and by phase (inspiratory, biphasic, expiratory) — produce a structured table
  • For Mr Verma's pre-operative worsening stridor (biphasic, at rest), design the anaesthetic airway management plan: awake technique options, standby surgical airway, post-induction contingency
  • Write a protocol card (one A5 page) for ward staff on 'Acute stridor in a post-laryngectomy patient' — to be placed in the ENT ward emergency folder

Competencies: EN4.43, EN4.44

Group 4: Tracheostomy Technique, Care and Complications

  • Produce a step-by-step illustrated description of the surgical tracheostomy technique — landmark, skin incision, tracheal entry level (2nd-3rd ring), tube insertion and securing
  • Compare tracheostomy and cricothyroidotomy across six dimensions: indication (elective vs emergency), anatomical landmark, tracheal/cartilage level, tube size, conversion, and complications
  • Write the ward instruction sheet for a newly placed tracheostomy: include tube-change schedule, inner cannula cleaning frequency, humidification requirements, emergency equipment at bedside, and tube dislodgement protocol by day (fresh <7d vs mature >7d)

Competencies: EN4.44

Group 5: Patient Communication and Rehabilitation

  • Role-play (then write): How would you explain to Mr Verma and his wife, in simple language, that he requires a total laryngectomy and will lose his natural voice? Include: what the surgery involves, breathing changes, the three modes of alaryngeal speech, and available support
  • Research the alaryngeal communication options (tracheoesophageal speech/voice prosthesis, electrolarynx, oesophageal speech) — produce a table comparing mechanism, intelligibility, cost, and availability in India
  • Identify the Communicator and Professional competencies tested in this case. Write a reflective note (100 words) on the ethical obligation to disclose prognosis honestly while preserving hope — referencing the wife's question in Trigger 1

Competencies: EN4.40, EN4.42

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [EN4.40] What is the clinical threshold for laryngoscopy in a patient with hoarseness? What features in the history and examination raise the suspicion of malignancy vs a benign cause?
  2. [EN4.40] Describe the course of the left and right recurrent laryngeal nerves. Why is left vocal cord palsy more common with thoracic pathology?
  3. [EN4.41] What are the clinical and laryngoscopic features that distinguish vocal cord nodules, polyps, and Reinke's oedema? What is the primary treatment for each?
  4. [EN4.42] Compare the clinical presentation, lymphatic behaviour, staging considerations, and prognosis of glottic carcinoma vs supraglottic carcinoma. What is the T-stage significance of vocal cord fixation?
  5. [EN4.43] What does the phase of stridor (inspiratory, biphasic, expiratory) indicate about the level of airway obstruction? Construct a differential diagnosis of stridor by age group.
  6. [EN4.44] Describe the indications, anatomical landmarks, tracheal entry level, and complications of tracheostomy. How does this differ from cricothyroidotomy in indication and technique?
  7. [EN4.44] What are the principles of post-tracheostomy care? How do you manage an acute blocked tracheostomy tube, and how does management differ between a fresh (<7 days) and a mature stoma?