Hemoptysis Case 3

A 53-year-old man consults a physician because he has begun coughing up sputum tinged with fresh blood. He does not initially report any other symptoms to his physician. When his physician comments on his hoarseness and cough, the patient discounts these symptoms and attributes them to his long smoking history. He cannot say when they began or became worse.

Q 1
The chronic hoarseness suggests dysfunction of which of the following?
/ A. Palate
/ B. Pharynx
/ C. Tongue
/ D. Trachea
/ E. Vocal cords

Q 2
Laryngoscopy reveal a fungating tumor of the larynx that is located between the false and true vocal cords. This tumor is in which of the following sites?
/ A. Aryepiglottic fold
/ B. Infraglottic compartment
/ C. Piriform recess
/ D. Supraglottic compartment
/ E. Ventricle

Q 3
Biopsy of the mass demonstrates a malignancy. Which of the following is the most likely diagnosis?
/ A. Adenocarcinoma
/ B. Lymphoma
/ C. Oat cell carcinoma
/ D. Sarcoma
/ E. Squamous cell carcinoma

Q 4
In addition to smoking, which of the following is an accepted risk factor for this patient's tumor?
/ A. Alcohol use
/ B. Cocaine use
/ C. Coffee use
/ D. Marijuana use
/ E. Tea use

Q 5
The patient returns to clinic three weeks after receiving the news that his cancer is inoperable. His wife reports that he has been more withdrawn, eating and sleeping poorly and "just seems to have lost all hope." On examination, the patient moves very little, never makes eye contact, and admits to "some" depressed mood, Ioss of appetite, and sleep disruption. Which of the following symptoms is of most concern regarding his risk of suicide?
/ A. Decreased appetite
/ B. Decreased energy
/ C. Diminished concentration
/ D. Guilty and worthless feelings
/ E. Hopelessness

Q 6
Some patients present with hoarseness due to a tumor at the lung apex that involves a nerve that is a branch of which of the following?
/ A. Accessory nerve
/ B. Glossopharyngeal nerve
/ C. Hypoglossal nerve
/ D. Phrenic nerve
/ E. Vagus nerve

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Hemoptysis Case 3 Answers
A1
The correct answer is E. Hoarseness specifically suggests dysfunction of the vocal cords, which produce the sounds that are then articulated to speech with the pharynx (choice B), palate (choice A), tongue (choice C), teeth, and lips. While vocal cord dysfunction is specifically suggested by hoarseness, the anatomic lesion may or may not be present at the level of the vocal cords. Vocal paralysis may be the result of local tumor or trauma, intracranial lesions affecting the nucleus ambiguus or its supranuclear tracts, and lesions at the base of the skull, neck, or upper portion of the thorax that involve either the vagus nerve or the recurrent laryngeal nerves.
Air from the trachea (choice D) passes into the larynx to reach the vocal cords, but tracheal dysfunction does not produce hoarseness.

A2
The correct answer is E. The interior of the larynx is divided into 3 compartments: the supraglottic compartment (choice D) above the false vocal cords, the ventricle between the false and true vocal cords, and the infraglottic compartment (choice B) below the true vocal cords.
The aryepiglottic fold (choice A) is the upper free border of the quadrangular membrane found in the supraglottic compartment.
The piriform recess (choice C) lies behind the thyroid laminae and the lateral wall of the supraglottic compartment.

A3

The correct answer is E. The epithelial lining of the larynx is squamous epithelium, and the vast majority of cancers of the larynx are squamous cell carcinomas. Squamous cell carcinoma can present with hoarseness, cough, hemoptysis, or difficulty swallowing. If the symptoms develop insidiously (as in the case), the patient may not seek medical attention until late in the course. While very small laryngeal cancers can be treated successfully with surgery and/or radiation, larger ones are much more problematic, in large part because complete resection of the cancer and any lymph node metastases can be difficult to impossible to perform without compromising the many vital neck structures. Patients treated with partial laryngectomy may retain some speech ability. Patients treated with total laryngectomy can often learn to speak again using esophageal speech (gradual belching of air through the pharyngoesophageal junction), a tracheoesophageal fistula (one way valve between the trachea and the esophagus which makes a sound when air is forced across it), or an electrolarynx (sound source held against the neck). With all three techniques, the sound produced is then turned into articulation by the patient's pharynx, palate, tongue, teeth, and lips. The other tumors listed in the choices are very uncommon in the larynx.

A4
The correct answer is A. The only two risk factors that you will need to associate with laryngeal carcinoma are smoking and alcohol use. Cocaine (choice B), coffee (choice C), and tea (choice E) have not been linked to laryngeal cancer.
Marijuana (choice D) has been suggested as a risk factor for oral cancer in a few cases, but a causal association has not been established.

A5
The correct answer is E. Hopelessness is an ominous sign and is associated with a higher risk for suicide.
Decreased appetite (choice A), decreased energy (choice B), and diminished concentration (choice C) are symptoms indicating the presence of a major depressive episode, or are the result of the medical illness.
Guilty and worthless feelings (choice D) are symptoms of depression. They do not predict risk for suicide.

A6
The correct answer is E. The larynx has complex innervation. The vocal cords and most of the area of the larynx below them are supplied by the recurrent laryngeal nerve, which is a branch of the vagus nerve that passes beneath the subclavian artery before returning to the neck to innervate the larynx. From above the larynx, the superior laryngeal nerve arises from the vagus and divides into the internal laryngeal nerve and the external laryngeal nerve. The innervation above the vocal cords is by the internal laryngeal branch of the vagus nerve. The cricothyroid muscle (the only muscle of the larynx not supplied by the recurrent laryngeal nerve) is supplied by the external laryngeal branch of the superior laryngeal, which also branches off the vagus, but which contains motor fibers originally derived from the accessory nerve (choice A).
The glossopharyngeal nerve (choice B) supplies the pharynx.
The hypoglossal nerve (choice C) supplies the tongue.
The phrenic nerve (choice D) supplies the diaphragm.