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Progressive Hoarseness and Laryngeal Obstruction in an Elderly Man

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

An otherwise healthy man in his 60s presented to a tertiary otolaryngology clinic reporting a 1-year medical history of progressively worsening hoarseness and dyspnea. He denied any history of dysphagia, odynophagia, fevers, unintentional weight loss, cough, or reflux symptoms. There was no prior history of smoking, head and neck surgeries, or radiation exposure. He was treated for asthma with inhaled steroids by his primary care physician without improvement in symptoms. On physical examination, the patient was stridulous and considerably hoarse. His neck examination was unremarkable. Subsequent videostroboscopy revealed severe laryngeal mucosal edema, most significant in the false vocal folds, interarytenoid, and postcricoid regions (Figure 1A). There was right true vocal fold immobility with compensatory squeeze of the false vocal folds and an absent mucosal wave. Computed tomographic (CT) scan of the neck with contrast showed irregularity along the free edges of the true vocal folds but no evidence of a neoplasm or cervical lymphadenopathy. The patient underwent urgent direct laryngoscopy with biopsy, which showed edematous, irregular, friable laryngeal mucosa with significant airway narrowing. Laryngeal biopsy findings are shown in Figure 1, B and C.

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B. Blastomycosis

A hematoxylin-eosin stain was initially performed, which showed multiple epithelioid histiocytes and giant cells with a background of lymphocytes and necrosis, consistent with necrotizing granulomatous inflammation (Figure 1B). Acid-fast bacteria stain results were negative. A Grocott methenamine silver stain demonstrated broad-based budding yeast engulfed by multinucleated giant cells (Figure 1C). Findings were most consistent with blastomycosis, which was confirmed with polymerase chain reaction (PCR) testing. Given the concerns for airway obstruction, the patient underwent tracheotomy at time of direct laryngoscopy. He also required a gastrostomy tube owing to aspiration seen on modified barium swallow study (MBSS).

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Article Information

Corresponding Author: Kenneth W. Altman, MD, PhD, Department of Otolaryngology–Head and Neck Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA 17822 (kaltman@geisinger.edu).

Published Online: August 4, 2022. doi:10.1001/jamaoto.2022.1945

Conflict of Interest Disclosures: Dr Altman reported consultant and speaker fees from Merck and Vindico for medical education and CME activities related to best practice in chronic cough, personal fees from AXDEV for consulting in a marketing study supported by Merck, uncompensated work from Lyra Site PI in a clinical trial, and personal fees from Medscape for speaking in a CME program supported by Merck outside the submitted work. No other disclosures were reported.

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

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