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CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 69-72  

An elderly smoker with hoarseness of voice and hemoptysis


Department of Respiratory Medicine, A. J. Institute of Medical Sciences, Mangalore, Karnataka, India

Date of Submission05-Nov-2019
Date of Decision30-Apr-2020
Date of Acceptance25-Jun-2020
Date of Web Publication22-Jan-2021

Correspondence Address:
Vishnu Sharma Moleyar
Department of Respiratory Medicine, A. J. Institute of Medical Sciences, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_295_19

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  Abstract 


Hoarseness of voice with hemoptysis in an elderly smoker can occur due to malignancy in the upper respiratory tract or intrathoracic lesion. When ear, nose, and throat examination is normal in such a patient, the lesion is most likely to be intrathoracic. In this case-based discussion, we discuss regarding how to evaluate a patient with hoarseness of voice with hemoptysis. We report an unusual case for hoarseness of voice with hemoptysis in an elderly smoker.

Keywords: Aortic aneurysm, evaluation, hemoptysis, hoarseness of voice, symptoms


How to cite this article:
Moleyar VS, Bali A. An elderly smoker with hoarseness of voice and hemoptysis. Med J DY Patil Vidyapeeth 2021;14:69-72

How to cite this URL:
Moleyar VS, Bali A. An elderly smoker with hoarseness of voice and hemoptysis. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Feb 27];14:69-72. Available from: https://www.mjdrdypv.org/text.asp?2021/14/1/69/307675




  History Top


A 79-year-old male, chronic smoker with 24 pack-years smoking was admitted with hoarseness of voice and mild recurrent hemoptysis for the past 6 months. He had cough with scanty mucoid sputum. He had no history of breathlessness, stridor, chest pain, fever, or weight loss. He had no cardiac symptoms and neck swelling. He had systemic hypertension for past 10 years and was on amlodipine 5 mg daily for the past 10 years. He had no history of diabetes mellitus, history of chest trauma, and other significant illnesses in the past. He had no other addictions/substance abuse.

Question 1: Which of the following is LEAST LIKELY to cause hoarseness of voice with recurrent hemoptysis?

  1. Laryngeal cancer
  2. Bronchogenic carcinoma
  3. Vocal cord nodule
  4. Tuberculosis of the upper respiratory tract
  5. Granulomatosis with polyangiitis.


Answer: 3. Vocal cord nodule is a benign lesion usually presents with change in voice. Hemoptysis is not a symptom in vocal cord nodule.[1]

Question 2: What is the next step in the evaluation of a patient with hoarseness of voice?

  1. Indirect laryngoscopic examination
  2. Bronchoscopy
  3. Computed tomography (CT) scan of the neck
  4. Chest X-ray
  5. CT scan of the neck and thorax.


Answer: 1. The next step in evaluation in a patient with hoarseness of voice with recurrent hemoptysis is laryngoscopic examination.[2] This will delineate local cause, if any, for the symptoms by direct visualization of the vocal cords and surrounding structures.

Ear, nose, and throat examination: the left vocal cord was immobile. No other abnormality was detected.

Question 3: Which of the following is the MOST COMMON cause for vocal cord paralysis in adults?

  1. Surgical complication
  2. Infection
  3. Intrathoracic neoplasm
  4. Central nervous system (CNS) tumors
  5. Prolonged intubation.


Answer: 3. The most common cause for vocal cord paralysis in adults is intrathoracic neoplasm.[3]

Question 4: Which of the following is the MOST COMMON malignancy causing vocal cord paralysis?

  1. Esophageal carcinoma
  2. Bronchogenic carcinoma
  3. Lymphoma
  4. Thyroid carcinoma
  5. Mediastinal teratoma.


Answer: 2. Many intrathoracic lesions can cause vocal cord paralysis. Majority of these are malignant lesions. The most common intrathoracic malignancy causing vocal cord paralysis is bronchogenic carcinoma.[3]

[TAG:2]Causes for Vocal Cord Paralysis[3][/TAG:2]

Neoplasm: 33.4%:

  • Fifty-nine percent of these are lung primaries (bronchogenic carcinoma)
  • Trauma (including surgery): 31.5%
  • Idiopathic: 15.5%
  • Medical/inflammatory: 13.2%
  • CNS causes: 6.4%.


Question 5: What is the next step in the evaluation of this patient?

  1. Bronchoscopy
  2. CT scan of the neck
  3. Chest X-ray
  4. CT scan of the neck and thorax
  5. Spirometry.


Answer: 3. Hemoptysis with hoarseness of voice with normal indirect laryngoscopic examination indicates that the lesion is intrathoracic. Hence, the next step in the evaluation of this patient is chest X-ray. The cause for hoarseness of voice is recurrent laryngeal nerve palsy. Left recurrent laryngeal nerve palsy is more common in intrathoracic lesions due to long intrathoracic course of the nerve [Figure 1].
Figure 1: Chest X-ray posteroanterior view showing aortic dilatation

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Chest X-ray shows mediastinal widening.

Question 6: What is the next investigation?

  1. Thoracic ultrasound
  2. Bronchoscopy
  3. Contrast-enhanced CT (CECT) of the thorax
  4. Fluoroscopy
  5. Thoracoscopy.


Answer: 3. Since intrathoracic lesion is suspected to be the cause for his symptoms, CECT of the thorax is the next investigation of choice. CECT will identify the site and extent of the lesion.

Question7: What is the diagnosis from CT scan? [Figure 2], [Figure 3] and [Figure 4]
sFigure 2: Computed tomography scan coronal section image showing leaking aortic aneurysm with left-sided small hemothorax

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Figure 3: Computed tomography scan sagittal section image showing an aortic aneurysm

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Figure 4: Computed tomography scan axial section image showing an aortic aneurysm

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  1. Bronchogenic carcinoma with small left-sided pleural effusion
  2. Left lower lobe pneumonia with pleural effusion
  3. Leaking aortic aneurysm with small left-sided hemothorax
  4. Aneurysm of the left ventricle with small left-sided pleural effusion
  5. Mediastinal mass with small left-sided pleural effusion.


Answer: 3. Final diagnosis: Leaking aortic aneurysm with small left-sided hemothorax.

Question 8: Which is a RARE symptom in thoracic aortic aneurysm?

  1. Chronic cough
  2. Chest pain
  3. Hoarseness of voice
  4. Back pain
  5. Hemoptysis.


Answer: 5. If the aneurysm erodes into a bronchus leading to aortobronchial fistula, hemoptysis can occur.[4] This is very rare and can be fatal. Compression over a bronchus can lead to chronic cough. Acute severe chest pain may indicate aortic dissection which can occur as a complication in aortic aneurysm. Compression of the recurrent laryngeal nerve can lead to hoarseness of voice.[4] Compression over the vertebra by the aneurysm can lead to back pain.

Question 9: What is the MOST LIKELY cause for hemoptysis in aortic aneurysm in this patient?

  1. Leaking aortic aneurysm (aortobronchial fistula)
  2. Erosion by bronchogenic carcinoma
  3. Aortic dissection
  4. Bronchiectasis due to compression of adjacent bronchus
  5. Pulmonary embolism.


Answer: 1. CT scan does not show any evidence of other lung pathology or pulmonary embolism. Hence, the most likely cause for hemoptysis in this patient is leaking aortic aneurysm.

Question 10: Which of the following is the MOST COMMON cause for descending thoracic aortic aneurysm?

  1. Cystic medial degeneration
  2. Marfan's syndrome
  3. Family history of thoracic aortic aneurysm
  4. Atherosclerosis
  5. Syphilis.


Answer: 4. All of the above are risk factors for developing a descending thoracic aneurysm, but the most common cause is atherosclerosis.[5]

Question 11: Which is a WRONG statement regarding thoracic aortic aneurysm?

  1. Larger the size greater the chance for rupture in aortic aneurysm
  2. More common in elderly males
  3. Smokers have higher risk to develop aneurysm
  4. Chronic obstructive pulmonary disease (COPD) is a risk factor for aortic aneurysm
  5. Majority of aortic aneurysms are symptomatic.


Answer: 4. COPD is not a risk factor for developing aortic aneurysm.

Question 12: Which is NOT a risk factor for developing aortic artery aneurysm?

  1. Infections
  2. Hypertension
  3. Family history of aortic artery aneurysm
  4. History of coronary artery disease
  5. Pulmonary tuberculosis.


Answer: 5. Pulmonary tuberculosis does not lead to the development of aortic artery aneurysm.

Question 13: Which of the following is a WRONG statement regarding aortic aneurysm?

  1. Atherosclerosis is the most important risk factor
  2. May be associated with abdominal artery aneurysm
  3. Predisposes for aortic dissection
  4. All aneurysms should be treated surgically
  5. Can present with chest pain.


Answer 4. There are specific indications for surgical treatment in aortic aneurysm.[5]

Question 14: Which of the following may NOT require surgery in aortic artery aneurysm?

  1. Size <5.5–6 centimeters (cm)
  2. Acute symptoms due to aneurysm
  3. Aneurysm growth rate more than 0.5 cm over a period of 6 months to –1 year
  4. Presence of genetic disorders or familial history of thoracic aneurysms
  5. Ruptured aneurysm.


Answer: 1. The risk of rupture is low when size of the aortic aneurysm is <5.5–6 cm.[5] Hence, they can be managed conservatively with medical treatment and regular follow-up.

Question 15: Which of the following investigation is NOT useful in evaluating aortic aneurysm?

  1. CT angiogram
  2. Aortogram
  3. Echocardiography
  4. Thoracic ultrasound
  5. CECT scan of the thorax.


Answer 4. Thoracic ultrasound has not useful in the evaluation of aortic aneurysm.

Question 16: What is the most serious complication of aortic aneurysm?

  1. Dyspnea due to the compression of adjacent bronchus
  2. Rupture and massive hemorrhage
  3. Aortic dissection
  4. Bronchiectasis due to compression of adjacent bronchus
  5. Thromboembolism.


Answer: 2. Rupture and massive hemorrhage is the most serious complication of aortic aneurysm. It can lead to rapid deterioration and death within a few minutes due to massive blood loss.

In view of symptoms, the patient was advised surgical intervention. However, the patient and relatives refused surgery. Hence, medical management was continued with control of hypertension and symptomatic medication for cough with antitussive.


  Medical Management of Aortic Aneurysm Top


Regular monitoring of the aneurysm by CT or magnetic resonance imaging scans should be done every 6 months. Rigorous blood pressure control with medications as uncontrolled hypertension will lead to a rapid increase in size and increase the risk rupture of the aneurysm.[5] Smoking cessation should be advised in all patients. Underlying cause/modifiable risk factors should be treated wherever feasible.


  Learning Points Top


Aortic artery aneurysm can present with a variety of respiratory symptoms. Whenever there is a mass in chest X-ray on the left side which appears to be radiologically benign, consider aortic artery aneurysm as one of the differential diagnoses.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Johns MM. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck Surg 2003;11:456-61.  Back to cited text no. 1
    
2.
Hoffman HT, Porter K, Karnell LH, Cooper JS, Weber RS, Langer CJ, et al. Laryngeal cancer in the United States: Changes in demographics, patterns of care, and survival. Laryngoscope 2006;116:1-3.  Back to cited text no. 2
    
3.
Richardson BE, Bastian RW. Clinical evaluation of vocal fold paralysis. Otolaryngol Clin North Am 2004;37:45-58.  Back to cited text no. 3
    
4.
Elefteriades JA. Thoracic aortic aneurysm: Reading the enemy's playbook. Yale J Biol Med 2008;81:175-86.  Back to cited text no. 4
    
5.
Booher AM, Eagle KA. Diagnosis and management issues in thoracic aortic aneurysm. Am Heart J 2011;162:38-460.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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