Case Report
An 80-year-old healthy male with no history of tobacco or alcohol use
presented to an otolaryngologist for throat pain, fever, right otalgia
and right maxillary sinus tenderness. He had previously been identified
with a germline BRCA2 mutation in the course of successful management of
intraductal breast carcinoma, prostatic adenocarcinoma and pancreatic
adenocarcinoma. His initial physical exam was normal, and he was
empirically treated for bacterial sinusitis. On follow up, the patient
had improvement of initial symptoms but had developed a non-productive
cough. His exam at that time was remarkable for a small pharyngeal
ulcer, and anti-gastroesophageal reflux therapy was started.
Subsequently the patient underwent CT larynx without contrast by his
Oncologist for additional workup of fatigue in the context of ongoing
otalgia, sinus tenderness and cough. This imaging revealed an asymmetric
soft tissue prominence at the larynx with thickening along the adjacent
right hypopharynx, a 1.3 cm lymph node and fat stranding at the right
carotid space. Laryngopharyngitis was diagnosed based on repeat exam and
review of imaging. A primary care physician then obtained a non-contrast
MRI for new headaches incidentally identifying a transglottic mass
invading thyroid cartilage with encasement of the right carotid, and a
1.6 cm right level IIA lymph node (figure 1). The patient was referred
to our tertiary care center for concern of hypopharyngeal malignancy.
Evaluation with flexible fiberoptic laryngoscopy revealed a mass at the
right pharyngeal wall extending to the right pyriform sinus (figure 2).
Ultrasound-guided needle biopsy was attempted twice revealing acute
inflammation and keratinized squamous cell epithelium of the right
piriform sinus, respectively. Biopsy of the right level II lymph node
showed chronic lymphocytic leukemia. A biopsy of the right piriform
sinus under general anesthesia was then completed revealing
well-differentiated keratinizing squamous cell carcinoma.
A diagnostic PET/CT showed an FDG-avid soft tissue mass centered on the
right piriform sinus with extension into the right parapharyngeal soft
tissues, thyroid cartilage, and prevertebral space to the level of the
cricoid cartilage. Chemoradiation (using weekly carboplatin and
paclitaxel) was successfully completed for the stage IVa (cT4b, cN0, M0)
disease. A twelve-week post-chemoradiation PET/CT revealed complete
resolution of cancer and the patient remained disease-free at most
recent 3-year follow up.