Case Report

Supervisor :
Dr. Oscar Djauhari,Sp.THT-KL

Clerkship of Ear Nose Throat – Head and Neck Department

Regional Hospital R. Syamsudin SH, Sukabumi
University of Muhammadiyah Jakarta
Period 2018
1
 Patient’s Identity

• Name : Mr. AS
• Age : 64 years old
• Occupation : Retired from cement industry
(work for 20 years)
• Address : Kp. Buniwangi, Pelabuhan Ratu
• Gender : Man
• MR No : R000825xx
• Get in Hospital : June 18th, 2018
• Examination date : June 19th, 2018

2
 • A 64 years old man come to
Main Symptom hospital with horsness since 3
month ago

• Bad prolong cough for 5 month,

Additional weight loss for 20 kgs since this 6
Symptoms month, dysfagia since 3 month ago,
enlarged gland of the neck since 5
months before admissionss.

3
 History of Present Illness
• Patient came to the hospital with the complaint he has
hoarseness since 3 month ago. It happens progressively day
by day.
• He also complaint for Bad prolong cough for 5 month
• He also complaint for dysfagia since 3 month
• He also complaint for of weight loss up to 20 kg since this 6
month. Enlarged gland of the neck since 5 months before
admissionss.

4
 History of Past Illness
• The patient has no history of high blood
pressure, diabetes mellitus, coagulopathies,
mechanic or noise trauma, and infection of the
nose, ear and throat before.
• The patient never previously had similar
symptom as now.

5
 • History of tumor (-)
History of Family
• History of hypertension (-),
Illness diabetes (-), allergy (-)

History of Already got to the

primary care but not
Treatment cured

• Smoking behavior: since 20 years old (

45 years ago), in average 10
History of cigarettes/day. Just quit at 55 years
old, living in a shabby neighborhood,
Psychosocial the economic is very poor

6
 Physical Examination (Generalized Status)

General condition : Appear ill

• Vital sign:
– Blood pressure : 130/80 mmHg
– Heart rate : 82 beat per minute
– Respiratory rate : 20 beat per minute (tachypnea)
– Temperature : 36,9oC
• Nutritional status:
– Weight : 50 kg
– Height : 166 cm
– BMI : 18,18 kg/m2 (underweight)
7
 Physical Examination (Ears)
Auris Dextra:

• Auricle : normal
• External auditory canal:
– hyperemic (-), edema (-), mass (-), laceration (-), cerumen
(+)

 Retroauricular: normal, no deformities

• Tymphanic membrane:
– Intact, hyperemic (-), bulging (-), retracted (-), light reflex
normal
• Rinne test : (+), Weber Test : No Lateralization
8
 Physical Examination (Ears)
Auris sinistra:

• Auricle : normal
• External auditory canal:
– hyperemic (-), edema (-), mass (-), laceration (-), cerumen
(+)

 Retroauricular: normal, no deformities

• Tymphanic membrane:
– Intact, hyperemic (-), bulging (-), light reflex (+)
• Rinne test : (+), Weber Test : No Lateralization

9
 Physical Examination (Nose)
Anterior
Dextra Sinistra
Rhinoscopy
smooth, hyperemic (-) Mucosa smooth, hyperemic (-)
serous (+) Secret serous (+)
Inferior
eutrophy eutrophy
choncae
Deviation septum (-) Septum Deviation septum (-)
(-) Mass (-)

Air
Air passage normal Air passage normal
passage

10
 Physical Examination (Oropharynx)

Orofaring
Dextra Examination Sinistra
Mouth
smooth, hyperemic (-) Mucosa smooth, hyperemic (-)
dirty (-) Tongue dirty (-)
Calm, deformity (-) Palatum molle Calm, deformity (-)
Complete, caries (-) Teeth Complete, caries (-)
Deviasi (-) Uvula Deviasi (-)
Tonsil T1/T1

11
 Physical Examination (Oropharynx)

Calm Tonsil mucosa Calm

Smooth, granulated
Smooth, granulated (-)
(-)

(-) cripta (-)

(-) Detritus (-)
(-) Adhering (-)
Pharyng
Calm Mucosa Calm
(-) Granula (-)
(+) Post nasal drip (+) 12
Physical Examination (Nasopharynx)

13
 Physical Examination (Larynx)

Laryngopharyng (Indirect Laringoscopy)

Epiglotis

Plica ariepiglotica

Plica ventricularis

Plica vocalis

Rima glotis

14
 Physical Examination (Neck)

• Maxillofacial : symmetrical
• Neck : mass (+), enlarging lymph node
(+), left cervical lymph node under left ear, size
3x5cm, immobile, painless, consistency is hard,
firm border

15
 Eye Examination

• ODS : Eye movement good to every single

direction
• ODS : Diplopia binocular (-)

16
 Resume
• A 65 year-old-male patient came to hospital with
symptom horsness since 3 month ago, Bad prolong
cough for 5 month, weight loss for 20 kgs since
this 6 month, dysfagia since 3 month , a
palpable mass near the side of his neck since 5
months ago, In the physical examination:
• Laringopharing
• Glotis: Masa(+),Hiperemis, granul, easily
bleeding
• Lymph node: found an enlarging left cervical
lymph node, 3x5 cm, immobile, painless, and hard
in consistency

17
• Working
• Suspect Laringofaring
diagnosis:
carcinoma

• Differential
diagnosis:

18
 Additional Examination
• Laringoscopy
• Biopsy
• Laboratory
– Complete blood count (Hb, Ht, Leukocyte,
differential count, thrombocyte), kidney and liver
function
• Thorax x-ray for assest metastase

19
 Therapy
• Inpatient :
a) Radiotherapy
b) Surgery: conservative laryngeal
surgery or total laryngectomy
c) Combined therapy

20
 Prognosis
• Quo ad vitam : dubia
• Quo ad functionam : dubia ad malam
• Quo ad sanationam : dubia

21
22
Normal Larynx

23
 Normal vs. Cancerous

 Normal  Cancer (beginning

stage)

24
 Squamous
Ca of larynx

Normal larynx 25
• Aetiology
• Classification and staging
• Supraglottic, glottic and subglottic cancer
• Diagnosis
• Treatment
• Vocal rehabilitation

26
Aetiology

27
 Classification and staging

• TNM classification and staging

• Classification by AJCC

28
 TNM classification and staging

Helps to determine :
a) The extent
b) Treatment modalities
c) Prognosis

29
AJCC classification

30
SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK
LARYNX

 MOST COMMON NONCUTANEOUS SITE OF SCC IN THE

HEAD AND NECK
 SUPRAGLOTTIC: EMBRYOLOGICALLY DERIVED FROM
BUCCOPHARYNX
 GLOTTIC AND SUBGLOTTIC: DERIVED FROM
TRACHEOBRONCIAL TREE
 TNM CLASSIFICATION DEPENDS UPON VOCAL CORD
INVOLVEMENT AND TUMOR EXTENSION

31
 SQUAMOUS CELL CARCINOMA OF
THE HEAD AND NECK
STAGING

 AMERICAN JOINT COMMITTEE ON CANCER.

T = TUMOR SIZE

 T1 <2 CM DIAMETER
 T2 2-4 CM DIAMETER
 T3 >4 CM DIAMETER
 T4 >4 CM WITH INVASION OF
ADJACENT STRUCTURES

32
 SQUAMOUS CELL CARCINOMA OF
THE HEAD AND NECK
STAGING

 N = NODAL BASINS:
 N0 NO POSITIVE NODES
 N1 SINGLE NODE <3 CM DIAMETER
 N2 3-6 CM DIAMETER
 N3 >6 CM DIAMETER

 M = METASTATIC DISEASE
 M0 NO METASTASIS
 M1 METASTASIS

33
 SQUAMOUS CELL CARCINOMA OF
THE HEAD AND NECK
STAGING

 STAGE I T1N0M0
 STAGE II T2N0M0
 STAGE III T3N0M0, T1 or T2 or T3, N1 or M0
 STAGE IV T4N0 or N1, M0
ANY T, N2 or N3, M0
ANY T, ANY N, M1

34
 Supraglottic cancer
• Less frequent than glottic cancer
• Majority of lesions are seen on epiglottis, false cords,
aryepiglottic folds
• Spread: vallecula, base of the tongue, pyriform fossa
and even penetrate the thyroid
• Symptoms: often silent, may present with throat pain,
dysphagia and referred pain-ear, mass in the neck

35
 SQUAMOUS CELL CARCINOMA OF
THE HEAD AND NECK
LARYNX - SUPRAGLOTTIC

 STAGE I & II: RADIOTHERAPY (PRESERVES VOICE) OR

HEMILARYNGECTOMY
 LYMPHATIC SPREAD AS HIGH AS 50%
 LARYNGEAL SUSPENSION REQUIRED TO PREVENT
ASPIRATION AFTER HEMILARYNGECTOMY
 STAGE III & IV: LARYNGECTOMY
 FIVE YEAR SURVIVAL 37-57%

36
Supraglottic

37
 Glottic cancer
• Most common- 65%
• Spread: anteriorly- anterior commisure
posteriorly- vocal process and
arytenoid process
Upward- ventricle and false cord
Downward- Subglottic region
Symptoms: Hoarseness of voice, stridor

38
 SQUAMOUS CELL CARCINOMA OF
THE HEAD AND NECK
LARYNX - GLOTTIC

 TREATMENT: RADIOTHERAPY OR SURGERY

(HEMILARYNGECTOMY)
 LYMPH NODE METASTASIS 2% (LOW)
 FIVE YEAR SURVIVAL IN THE EARLY STAGES 90%
 STAGE III & IV: TOTAL LARYNGECTOMY

39
Glottic

40
 Subglottic cancer
• Lesions rare
• Spread: Anterior wall, to the opposite side
or downwards to the trachea
• May invade cricothyroid membrane,
thyroid gland and muscles of neck
• Symptoms: Stridor

41
 SQUAMOUS CELL CARCINOMA OF
THE HEAD AND NECK
LARYNX - SUBGLOTTIC

 RARE

 RADIOTHERAPY OR SURGERY

42
Subglottic

43
 Diagnosis
• History: any patient may present with:
..A sore throat that does not go away
..Dysphagia
..A change or hoarseness in voice
..Pain in the ear
..A lump in the neck

• Examination: done to find extra laryngeal spread of

disease and nodal metastasis

44
 Investigation
• Laryngoscopy:
indirect, direct or
micro

45
• Radiography
• CT
• Staining and biopsy

46
 Treatment

Depends upon:
a)The site of lesion
b)The extent of spread
c)Metastasis

47
Treatment maybe:
a) Radiotherapy
b) Surgery: conservative laryngeal
surgery or total laryngectomy
c) Combined therapy

48
49
50
 Rehabilitation

By the following methods:

A) Written language
B) Oesophageal speech

51