FREDERIC B.ASKINMDWILLIAM H.WESTRAMD
A 63-YEAR-OLD woman was referred to the ear, nose, and throat department with a 2-month history of intermittent hoarseness. No other signs were present, and no further symptoms could be identified on specific questioning. The medical and surgical history was noncontributory. A complete general examination and an examination of the ear, nose, and throat were performed. Indirect laryngoscopy revealed supraglottic spasm during phonation. The findings of the rest of the examination were normal, as were those of routine chest radiography. A diagnosis of functional dysphonia was made, and speech therapy was started. After 2 months of follow-up, the patient complained of an irritable dry cough of 2 weeks' duration. The hoarseness had improved, however. Clinical examination again did not reveal any additional signs, and the cough was attributed to a possible viral respiratory tract infection. The patient was then unavailable for follow-up for 6 months after the initial consultation, when she presented to the pulmonary physicians with persistent cough attacks, progressive dyspnea, chest pain, and audible inspiratory and expiratory stridor. The findings of the ear, nose, and throat examination were still normal. Auscultation revealed localized wheezing on the left side that was most pronounced in the third intercostal space parasternally. Treatment with nebulized epinephrine was successful in temporarily alleviating the severe dyspnea. A chest x-ray film (Figure 1) was obtained, and a rigid bronchoscopy was performed with the patient under general anesthesia (Figure 2). The tracheal and left bronchial lumina were markedly reduced by the presence of hyperplastic tissue. A carbon dioxide laser was used to increase the lumen and at the same time obtain tissue for histologic analysis (Figure 3).
Knappe MV, Schneider JW, Gregor RT. Pathologic Quiz Case 2. Arch Otolaryngol Head Neck Surg. 1998;124(4):469-471. doi:10.1001/archotol.124.4.468