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An Unexplained Lost Voice

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 64-year-old man presented to the otolaryngology clinic with hoarseness of voice for 3 weeks associated with intermittent dry cough. He had no medical history or family history of cancer and was not a smoker. In the absence of other suggestive symptoms, as well as a normal physical examination that did not reveal any enlarged cervical lymph nodes or oropharyngeal or neck mass and an unremarkable nasoendoscopic examination, a diagnosis of laryngopharyngeal reflux was made. The patient was advised to try conservative management with dietary advice and proton pump inhibitors, and a clinical review was scheduled in 6 weeks. The patient only returned 3 months later when his hoarseness became worse. Repeat nasoendoscopy now showed left vocal cord palsy in the paramedian position. In the absence of a history of trauma and associated neurological or systemic symptoms, the main concern was an underlying tumor that impinged on the vagus nerve at various points or its recurrent branch. Results of a computed tomographic (CT) scan showed an ill-defined soft tissue mass, which was likely nodal disease, at the left supraclavicular (Figure 1), as well as the prevertebral and paravertebral region, which partially encased the left common carotid, left subclavian, and left vertebral arteries. This was along the expected course of the left recurrent laryngeal nerve and likely accounted for the left vocal cord palsy. However, the primary site of disease remained unclear. A fused positron emission tomography with CT (PET/CT) scan with fluorodeoxyglucose (FDG) tracer was then performed.

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B. Metastatic colon cancer

The PET/CT scan showed an intensely FDG-avid sigmoid lesion (Figure 2A) with associated intensely FDG-avid superior rectal and left common iliac adenopathy (Figure 2B) and FDG-avid soft tissue in the left supraclavicular fossa and aortopulmonary window (Figure 2C). Because metastasis of sigmoid colon cancer to the prevertebral and paravertebral lymph nodes resulting in recurrent laryngeal nerve palsy is highly unusual, a radiologically guided core biopsy of the left supraclavicular mass was performed. Histology as well as immunophenotype analysis confirmed that the tumor originated from the lower gastrointestinal tract. Flexible sigmoidoscopy showed a large stenosing sigmoid tumor, and histologic findings from biopsies were concordant with adenocarcinoma. In view of the imminently obstructing tumor, the patient underwent laparoscopic Hartmann surgery to avert a clinical crisis of intestinal obstruction during chemotherapy.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Ker-Kan Tan, PhD, MBBS, Division of Colorectal Surgery, Department of Surgery, National University Hospital, 1E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore, Singapore 119228 (surtkk@nus.edu.sg)

Published Online: February 10, 2022. doi:10.1001/jamaoto.2021.4280

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Puxeddu  R , Pelagatti  CL , Ambu  R .  Colon adenocarcinoma metastatic to the larynx.   Eur Arch Otorhinolaryngol. 1997;254(7):353-355. doi:10.1007/BF02630729PubMedGoogle ScholarCrossref
2.
Minami  S , Inoue  K , Irie  J ,  et al.  Metastasis of colon cancer to the thyroid and cervical lymph nodes: a case report.   Surg Case Rep. 2016;2(1):108. doi:10.1186/s40792-016-0237-3PubMedGoogle ScholarCrossref
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Amante  MA , Real  IO , Bermudez  G .  Thyroid metastasis from rectal adenocarcinoma.   BMJ Case Rep. 2018;2018:bcr2018225549. doi:10.1136/bcr-2018-225549PubMedGoogle Scholar
4.
Stachler  RJ , Francis  DO , Schwartz  SR ,  et al.  Clinical practice guideline: hoarseness (dysphonia) (update).   Otolaryngol Head Neck Surg. 2018;158(suppl 1):S1-S42. doi:10.1177/0194599817751030PubMedGoogle Scholar
5.
Stinnett  S , Chmielewska  M , Akst  LM .  Update on management of hoarseness.   Med Clin North Am. 2018;102(6):1027-1040. doi:10.1016/j.mcna.2018.06.005PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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