Abstract
We present the unique opportunity to correlate videostroboscopic findings with histologic examination. An immunocompromised patient with hoarseness because of ulcerative lesions of both vocal folds of uncertain cause died within a few weeks of initial presentation, and the larynx was donated for postmortem examination. Relevant history, as well as endoscopic and histopathologic findings, is presented.
1
Case report
A 57-year-old male presented with a 5-day history of worsening hoarseness. He had undergone stem cell transplantation for Hodgkin lymphoma approximately 2 years ago, and he had been recently diagnosed with graft-vs-host disease for which he was taking high-dose prednisone. The patient had no complaints of dysphagia, odynophagia, shortness of breath, and/or pain, although he had recently been evaluated for cough at another facility.
A complete head and neck examination revealed no focal abnormalities. Endoscopic laryngeal examination revealed bilateral exudative lesions restricted to the membranous vocal folds, extending from the anterior commissure to the vocal processes ( Fig. 1 , left). Videostroboscopy revealed marked glottic insufficiency during phonation. The mucosal wave was entirely absent bilaterally. Brush biopsies of the lesions were taken under topical anesthesia and sent for both cytologic examination and culture. The patient was prescribed levofloxacin, fluconazole, and esomeprazole. Cytologic examination revealed squamous and respiratory epithelium with inflammatory cells. Stenotrophomonas maltophilia sensitive to levofloxacin grew in culture. A sputum culture obtained before this evaluation had also grown out this organism.
After 4 weeks of treatment, the patient returned with no improvement in voice. Endoscopic examination of the vocal folds revealed resolution of exudate with residual ulceration of the vocal folds, similar in extent to the original lesions ( Fig. 1 ). Under stroboscopic light, mucosal wave was absent over the area of ulceration, consistent with the impression of deepithelialization of the vocal folds. Significant glottic insufficiency persisted. As all purulence had resolved, no further antibiotic therapy was prescribed. Injection augmentation was considered but deferred given the patient’s poor overall condition. A few weeks after this visit, the patient died of complications related to his immunocompromised status and graft-vs-host disease. Before his death, the patient expressed, in writing, that his larynx should be donated for postmortem examination.
The larynx was fixed in formalin, and multiple coronal sections were taken through the true vocal folds. As shown in Fig. 2 , histologic examination revealed ulceration of the true vocal fold, with loss of epithelium and a lymphohistiocytic infiltrate, including multinucleated giant cells, extending into skeletal muscle. The presence of regenerating muscle fibers and focal reepithelialization suggest injury resolution. All fungal stains had negative results.
