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Clinical Challenge
September 2017

Nocturnal Dyspnea as a Result of a Hypopharyngeal Mass

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles
JAMA Otolaryngol Head Neck Surg. 2017;143(9):948-949. doi:10.1001/jamaoto.2016.4737

A man in his 60s presented with progressive onset of nocturnal dyspnea, dysphonia, dysphagia, and noisy breathing over the previous year. In addition, he reported a 22.7-kg weight loss. He also had a medical history significant for obstructive sleep apnea, gastroesophageal reflux disease with Barrett esophagitis, diabetes, and degenerative joint disease. Findings from his head and neck physical examination were normal except for the laryngeal examination. Laryngeal endoscopy revealed a large, well-mucosalized mass emanating from the left pyriform sinus, with mass effect on the larynx (Figure, A). The bilateral true vocal folds (TVFs) were visualized and were normal, but the full range of mobility of the left TVF could not be assessed owing to mass effect. A computed tomographic scan with contrast of the neck was obtained and revealed a 5 × 6-cm, nonenhancing, well-circumscribed laryngeal mass (Figure, B). The tumor was originating from the left pyriform sinus and did not appear to be locally invasive. Given these findings, the patient underwent direct laryngoscopy for transoral carbon dioxide laser–assisted excision without complications. Microscopic examination of the mass demonstrated polygonal cells with peripherally placed nuclei and eosinophilic cytoplasm containing cross-striations (Figure, C). Postoperatively, the patient reported improvement in dysphagia, voice quality, sleep, and breathing patterns.

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