An Unusual Case of Airway Obstruction: A Case Report

Aneesha Davis Karathra¹ https://orcid.org/0009-0004-8413-3819, Pramod Menon², Ajaykumar K Francis³

^1–3Department of Otorhinolaryngology, Government Medical College, Thrissur, Kerala, India

Corresponding Author: Aneesha Davis Karathra, Department of Otorhinolaryngology, Government Medical College, Thrissur, Kerala, India, Phone: +91 8281243875, e-mail: aneeshadavisk@gmail.com

Received: 06 January 2024; Accepted: 22 April 2024; Published on: 17 July 2024

ABSTRACT

We report a case of an 88-year-old female who presented to us with dysphagia, change in voice, and stridor, the diagnosis of which turned out to be primary laryngeal lymphoma. It is a rare condition, and repeated biopsies are needed in most of the cases. It has a very good response to radiotherapy and chemotherapy.

Keywords: Amyloidosis, B-cell non-Hodgkin lymphoma, Case report, Chondrosarcoma, Mucosa-associated lymphoid tissue, Neuroendocrine tumors

How to cite this article: Karathra AD, Menon P, Francis AK. An Unusual Case of Airway Obstruction: A Case Report. Int J Phonosurg Laryngol 2024;14(1):13–15.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

INTRODUCTION

When considering the incidence of malignancies that involve the head and neck, lymphoma is second only to squamous cell carcinoma. This level of frequency is attributable primarily to disease involving Waldeyer’s ring and cervical nodes. In contrast, primary disease arising in the larynx is unusual. Due to the scarcity of lymphoid tissue in the glottis, most primary lymphomas arise either in the supraglottis or subglottis. Non-Hodgkin lymphoma (NHL) with primary laryngeal presentation is very rare, constituting <1% of all primary laryngeal neoplasms. In a solitary laryngeal lymphoma, radiation therapy may be the sole therapeutic modality necessary to achieve an excellent prognosis.¹^,²

We are reporting this case in view of the diagnostic challenges we faced and the rarity of the condition.

CASE DESCRIPTION

An 88-year-old female presented with dysphagia for 3 months, a change in voice for 1 month, and breathing difficulty for 3 days. On general examination, stridor was present. Vitals were stable. Oral cavity, oropharynx, and neck examinations were normal. A video laryngoscopic examination was done, and it revealed edema over the left arytenoid, aryepiglottic fold (AEF) with pooling in left pyriform fossa (PFF) and left hemilarynx fixity (Fig. 1). Glottic space was critical. She underwent an emergency tracheostomy under local anesthesia. Contrast-enhanced computed tomography (CECT) scan of the neck was taken, and it showed a fairly defined enhancing soft tissue density lesion of size 2 × 3 × 6.5 cm in left PFF involving AEF, causing supraglottic luminal narrowing with extra laryngeal spread via a thyrohyoid membrane and paraglottic extension (Figs 2 and 3). Considering these clinical and radiological findings, a diagnosis of hypopharyngeal malignancy was made. For confirmation, the patient underwent direct laryngoscopy with biopsy from the supraglottis under general anesthesia (GA), and the specimen was sent for histopathological examination. As the report came out as stratified squamous epithelium with inflammatory infiltrates without any evidence of malignancy, video laryngoscopy (VLS) was repeated, which showed the same previous findings. This led us to repeat the biopsy under GA, but the histopathological report (HPR) report was still negative for malignancy. In view of the high clinical suspicion, we counseled the patient and bystanders for the next attempt, and a third biopsy under GA was done.

Fig. 1: Video laryngoscopy

Fig. 2: Contrast-enhanced computed tomography neck—section 1

Fig. 3: Contrast-enhanced computed tomography neck—section 2

This time, the HPR report came out as stratified squamous epithelium with a focal area of diffusely scattered atypical lymphoid cells (Fig. 4). Hence, immunohistochemistry (IHC) was done, and it showed a mild cluster of differentiation 3 (CD3) positivity and strong CD20 positivity (Figs 5 and 6), and this helped us to arrive at a diagnosis as B-cell NHL of the larynx. The patient was then referred to radiation oncology, and she took six cycles of chemotherapy with cyclophosphamide and prednisolone. VLS was done after a follow-up of 3 months and it showed complete resolution of the disease (Fig. 7). Hence, tracheostomy decannulation was done. The patient got symptomatically better, and now she is under regular follow-up.

Fig. 4: Histopathology slide—hematoxylin and eosin stain

Fig. 5: Immunohistochemistry—CD3

Fig. 6: Immunohistochemistry—CD20

Fig. 7: Follow-up of VLS

DISCUSSION

Non-Hodgkin lymphoma can occur in extranodal sites in 25% of the cases. NHL with primary laryngeal presentation is very rare, accounting for <1% of primary laryngeal neoplasms. It usually arises from the lymphoid collection of supraglottic lamina propria and ventricle. The most common symptoms are dysphonia and progressive airway obstruction. Usually, B-cell lineage is more common. Clinical and histological diagnosis is difficult most of the time. Repeated deep biopsies are needed for diagnosis. Around <35 cases have been reported in English literature so far.³ It has a very good response to radiotherapy and chemotherapy. It remains localized for a long duration and then disseminates to other extranodal sites. So, lifelong follow-up and periodic evaluation are mandatory. These lymphomas are predominant in males. Most of the primary low-grade non-Hodgkin’s malignant lymphomas belong to the mucosa-associated lymphoid tissue (MALT) type of lymphoma.⁴ Some cases of laryngeal lymphoma were associated with extranodal lymphomas elsewhere in the upper respiratory tract.⁵ Other differential diagnoses for laryngeal lymphoma are amyloidosis and chondrosarcoma.

CONCLUSION

Though primary laryngeal lymphoma is very rare, a high index of suspicion is needed when repeated biopsies are negative in laryngeal lesions. Histopathological examination has a very important role in aiding the diagnosis of such rare cases.

ORCID

Aneesha Davis Karathra https://orcid.org/0009-0004-8413-3819

REFERENCES

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