CASE REPORT

Dr. Junaid Shahzad

Post-graduate Resident

Otolaryngology Department

Capital Hospital, Islamabad

CASE PRESENTATION

PATIENT PROFILE Name: XYZ Age: 62 Gender:Female Residence: Islamabad Profession: Housewife

PRESENTING COMPLAINTS Patient presented to OPD in OCTOBER

2013 with history of DYSPHAGIA- 4 months

HISTORY OF PRESENTING COMPLAINTS Patient was in normal state of health till 4

months back,when she experienced dysphagia for solids which progressed slowly and for the last one month she had dysphagia for liquids as well.

There are no alleviating factors Dysphagia was also associated with pain

(odynophagia) during swallowing. This was also associated with weight loss. There is no history of voice change and

breathlessness or otalgia. No history of cough or recurrent chest

infection.

PAST HISTORY Patient was a known hypertensive since

the past decade, but not compliant on medication.

PERSONAL HISTORY Patient was a housewife. She has 3 children,2 daughters and 1

son, all married. She lives with her son and daughter in

law.

DRUG HISTORY Patient has been taking anti

hypertensive medications off and on since the past 10 years.

Sone times takes medications for heartburn.

No history of SMOKING or ADDICTION

SOCIAL HISTORY Belongs to a low socioeconomic back

groung.

GENERAL PHYSICAL EXAMINATION An old lady sitting on bed, well oriented

in time,place and person. Jaundice Clubbing NAD Cyanosis

GPE:BP: 50/90 mmHgTEMP: AfebrileR/R: 18/minPULSE: 80/min

ENT EXAMINATION

EAR EXAMINATION:External ear unremarkableTympanic membranes intact bilaterally with

normal landmarks.Hearing test OK

NOSE:Septum, turbinates and nasal mucosa

appeared normal.Normal patency

THROAT: Lips, tongue, cheek mucosa, palate, floor of

mouth, gums, teeth, pillars, tonsills and PPW – Normal.

Tongue mobility, Gag reflex, cough reflex and palatal movements were normal

Laryngeal crepitus was present Videolaryngoscopy: Revealed

Epiglottis, Vallecular, Py. Sinuses, aryepiglottic fold, vocal cords, PPW all appear normal

Exophytic growth post cricoid area. Vocal cords mobile.

NECK NODES: No neck nodes palpable

SYSTEMIC EXAMINATION

CVS: S1+S2 audible in all four areas

RESP: Normal vesicular breathing

GIT:NAD

CNS:

LAB INVESTIGATIONS Hb: 11.9g/dl Na: 138mmol/l K: 3.6mmol/l Cl: 92mmol/l Urea:22mg/dl Creatinine:0.8mg/dl

DIAGNOSTIC INVESTIGATION: DIRECT LARYNGOSCOPY AND

OESOPHAGOSCOPY:

Exophytic growth involving post cricoid region and extending to BOTH Pyriform Sinuses,and Vallecula.

Sample taken by punch biopsy, sent for Histopathology.

Glottis and subglottis clear.

HISTOPATHOLOGY:

POORLY DIFFERTIATED NON KERATINIZING SQUAMOUS CELL CARCINOMA

IMMUNOHISTOCHEMISTRY:P-63- Positive.

RADIOLOGICAL INVESTIGATIONS CT SCAN NECK AND CHEST WITH

CONTRAST:

Obliteration and stenosis oropharyngeal cavity with effacement of vallecula and pyriform sinuses.

Enlarged lymph nodes in bilateral parapharyngeal spaces and Carotid spaces.

Non specific nodule in right middle lobe adjacent to mediastinal pleura.

DIAGNOSIS

Poorly differentiated Non keratinizing Squamous Cell Carcinoma Hypopharynx.

STAGE: T2 N2C M1

TREATMENT SENT TO N.O.R.I for

CHEMOTHERAPY/RADIOTHERAPY. RADIOTHERAPY

13 Cycles 39 Gy completted SUPPORTIVE

Magic mouth washTab chymoral forte BDSyp Mucain 2tsf tdsSyp Brufen 2tsf x tds

FOLLOW UP Monthly follow up maintained. AT 5 months follow up:

VIDEOLARYNGOSCOPY: Normal.

DIRECT LARYNGOSCOPY/OESOPHAGOSCOPY: Normal.

CT SCAN NECK AND CHEST WITH CONTRAST: Normal.

THANK YOU