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Clinical Problem Solving
August 2014

Unusual Presentation of a Laryngeal Mass

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, New York Presbyterian Columbia and Cornell, New York
  • 2Joint Residency Program, New York Presbyterian and Cornell, New York
JAMA Otolaryngol Head Neck Surg. 2014;140(8):781-782. doi:10.1001/jamaoto.2014.1204

A woman in her 50s with a history of hypertension and chronic back pain presented to the emergency department. She had been discovered unresponsive in bed, was apneic, and was intubated in the field. She had experienced multiple episodes of emesis. At presentation, a computed tomographic (CT) scan demonstrated diffuse subarachnoid hemorrhage, intraventricular hemorrhage, and communicating hydrocephalus with tonsillar and central herniation. She received mannitol and an emergent extraventricular drain. During her hospital stay, a cerebral aneurysm was successfully treated by an endovascular route. She required a tracheostomy and percutaneous gastrostomy tube placement. Twenty-eight days after her tracheostomy, a flexible endoscopic evaluation of swallowing with sensory testing (FEESST) revealed a submucosal mass. The mass did not fully obstruct the airway, and the patient tolerated a Passy-Muir valve with no respiratory distress. The primary team administered dexamethasone sodium phosphate and consulted the otolaryngology service. On examination, her vital signs were within normal limits, she was nonverbal but in no acute distress, her breathing unlabored and silent, with no stridor or stertor. Passing a flexible fiber-optic laryngoscope confirmed the presence of an apparent submucosal mass that either originated from the epiglottis or deep to a severely edematous right aryepiglottic (AE) fold or arytenoid, or completely obstructed the vocal cords from view. The mass did not respond to steroids. A CT scan of the neck with intravenous contrast was performed (Figure, A). The mass was nonenhancing. Subsequently, a retrospective review of a magnetic resonance imaging (MRI) examination demonstrated the mass compressed by the endotracheal catheter (Figure, B).

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