STWS Home Module Home  Head and Neck: Case #4 Print

Physical Exam

05/10/XX

Hoarseness; difficulty breathing for two weeks. No apparent lymphadenopathy.

   
X-Rays & Scans

05/10/XX

Upper GI: apparent mass extending to esophagus, otherwise unremarkable.

05/10/XX CXR: Lungs are clear. No evidence of disease.
   
Scopes 05/10/XX Direct laryngoscopy and biopsy of laryngeal mass. Findings: fungating mass on right posterior aryepiglottic fold, arytenoid cartilage and anterior half of esophageal inlet.
05/17/XX Total laryngectomy with bilateral neck dissection.
   
Laboratory

 

None
   
Operative Findings 05/17/XX No obvious residual unresected tumor.
   
Pathological Reports

05/10/XX

Biopsy of supraglottic mass: Squamous cell carcinoma with areas of necrosis.

05/17/XX Total laryngectomy: squamous cell carcinoma, moderately differentiated, penetrates esophagus approximately 2 cm, 0/39 right and left lymph nodes positive.
   
Treatment 05/17/XX
Surgery: Total laryngectomy and bilateral neck dissection
06/29/XX Radiation: began IMRT 63 Gy to head and neck

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