Concealed Transglottic Carcinoma Disguised as Neuralgia: Diagnostic Challenges and Insights

Significance Statement

Transglottic carcinoma was named by McGavran in 1961 and is characterized by tumor infiltration and expansion in paraglottic space. Due to the concealment of tumor site, early symptoms of transglottic carcinoma are not always obvious and can easily lead to misdiagnosis. We report a case of pharyngeal neuralgia, which was ultimately diagnosed as laryngocarcinoma, hoping to provide some reference value for colleagues.

A 51-year-old Chinese male sought medical attention from our otolaryngology department due to pharyngeal pain for 2 months. The patient had a hoarse voice 3 months ago, prior to our assessment when he underwent fibrolaryngoscopy examination in a primary medical institution indicated limited activity of the left vocal fold, and no obvious mass in the larynx (Figure 1A). His hoarseness improved after treatment with dexamethasone and methylcobalamin, and fiberoptic laryngoscopy result 2 weeks later showed no significant changes (Figure 1B). Subsequently, he developed left pharyngeal pain, described as intermittent “needle pricking pain.” No obvious abnormalities were observed on cranial MRI, mediastinal CT, trigeminal nerve CT, or head and neck CTA. Styloid CT indicates slight elongation of his left styloid process. Stroboscopic laryngoscopy examination indicated poor motion of the left vocal fold and fold-like changes in the supraglottic larynx, but no obvious mass was found (Figure 1C). He was suspected of having neuralgia and received treatment with carbamazepine, mecobalamin, prednisone, and omeprazole. However, the condition worsened to persistent stinging pain. He relied on diclofenac sodium and ibuprofen to relieve pharyngeal pain.

Figure 1.

(A and B) Fibrolaryngoscopy examination indicated limited activity of the left vocal fold and no obvious mass in the larynx. (C) Stroboscopic laryngoscopy examination indicated poor motion of the left vocal fold and fold-like changes in the supraglottic larynx, but no obvious mass was found. (D) Fibrolaryngoscopy examination revealed a mass in the left supraglottic region.

The patient sought medical attention from our otolaryngology department for further diagnosis and treatment. Physical examination showed no suspicious neck mass, and the patient had no obvious hoarseness. He had a history of alcohol drinking and smoking for 25 years, and denied any other medical or medication history. Fibrolaryngoscopy examination revealed a mass in the left supraglottic region (Figure 1D). Enhanced CT and PET-CT revealed a high probability of tumor in the left supraglottic and glottic regions, and lymph node metastasis in some cervical regions (Figure 2). He underwent a laryngeal biopsy, and pathological examination revealed poorly differentiated squamous cell carcinoma of the larynx (Figure 3). He subsequently underwent subtotal laryngectomy, left neck lymph node selective dissection, and tracheotomy. The postoperative pathological report revealed spindle cell squamous cell carcinoma of the larynx, and no lymph node metastasis was detected. He was diagnosed with laryngeal squamous cell carcinoma T3N0M0 and transferred to the oncology department for further treatment.

Figure 2.

PET-CT revealed a high possibility of tumors in the left supraglottic and glottic regions, and lymph node metastasis in some cervical regions.

Figure 3.

Pathological examination revealed poorly differentiated squamous cell carcinoma of the larynx.

Laryngeal squamous cell carcinoma originates from the epithelium of the laryngeal mucosa and is the second most common malignant tumor in head and neck region. ¹ Transglottic carcinoma usually originates from laryngeal ventricle and involves supraglottic and glottic regions. Tumor infiltrates and expands under the mucosa, extensively infiltrating the paraglottic space. ² Due to concealment of tumor site, early symptoms are not obvious, and laryngoscopy examinations may not reveal the tumor. When hoarseness occurs, vocal folds are often fixed, and when tumor expands into paraglottic space, pharyngeal pain may occur.

This case had delayed imaging examinations of larynx due to multiple laryngoscopic examination reports showing no mass. We suggest that when unexplained pharyngeal pain occurs, enhanced CT and MRI examinations should be considered, and if necessary, PET-CT or adequate biopsy should be performed. In addition, the possibility of metastasis in transglottic carcinoma is relatively high, and even if regional lymph node metastasis is not detected on examination or imaging, neck lymph node selective dissection is still recommended. ³