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Clinical Challenge
October 2016

An Unusual Laryngeal Mass Requiring Unusual Airway Management

Author Affiliations
  • 1University of Washington School of Medicine, Seattle
  • 2Department of Otolaryngology, University of Washington, Seattle
  • 3Department of Pathology, University of Washington, Seattle
JAMA Otolaryngol Head Neck Surg. 2016;142(10):1023-1024. doi:10.1001/jamaoto.2015.3356

A man in his 60s presented with positional shortness of breath and sensation of airway obstruction of 3 to 4 months’ duration, with acute increase in symptoms over 4 days. He described the need to cough to clear the airway, but coughing provided no relief. He noted some relief when bending at the waist or lying prone. Flexible fiber-optic laryngoscopy revealed a large, irregular pedunculated mass on the left anterior false vocal fold (Figure, A and B). The mass was seen to ball-valve in and out of the glottis with respiration. The position of the mass was discussed with the anesthesiology team, who felt comfortable performing prone intubation. Preparations for emergency tracheotomy were made. In the operating room, with the patient, the anesthesia unit performed flexible fiber-optic laryngoscopy and advanced the endotracheal tube into the trachea over the flexible bronchoscope. A video laryngoscope was used to ensure that advancing the tube would not shear the mass. The patient was turned supine, and microdirect laryngoscopy was performed. The mass originated from a stalk in the left anterior ventricle. It was removed with microscissors. Pathologic examination (Figure, C and D) revealed a 1.7 × 1.3 × 1.0-cm mass with a papillary-like architecture, expansion of the submucosa by benign mature adipose tissue, and variable amount of fibrous tissue. There was mild chronic submucosal inflammation without squamous epithelial proliferation.