VOCAL CORD POLYP MASQUERADING BEHIND HEMOPTYSIS: A CASE REPORT OF CONCURRENT PULMONARY THROMBOEMBOLISM AND A DIFFICULT SUBGLOTTIC AIRWAY

Abstract

Background: Vocal cord polyps are often benign lesions associated with laryngeal hoarseness and are typically caused by capillary injuries due to phonotrauma. Recorded hemoptysis cases caused by vocal cord polyps are rare, making the occurrence that they are together with acute pulmonary embolism extremely unlikely. Case Presentation: A 71-year-old patient who is a heavy smoker (bidi-smoker, smoking index of 1000) with alcohol dependence and hypertension came to the clinic with complaints of having blood-stained sputum for last 10 days. According to the chest scan, the patient had visible wedge-shaped opacity in the area of the right lower lobe together with right side pleural effusion. Provided contrast-enhanced computed tomography revealed defect of filling in the right main pulmonary artery and its branches, in addition indicating the presence of the pulmonary infarction taking place in the right lower lobe and providing basis to make the diagnosis of pulmonary thromboembolism and anticoagulant was initiated. A Fibroptic bronchoscopy was performed as a part of evaluation. And, during this procedure, it was found a polyp-like structure located near the anterior area of the left vocal cord. The patient was subsequently scheduled for microlaryngeal surgery and polypectomy. Intraoperatively, visualization and removal of the lesion proved technically challenging. The use of the endotracheal tube made the surgical field obscure, prompting performing of tracheostomy. Following tracheostomy and combined rigid laryngoscopic and flexible bronchoscopic assessment, a polypoidal subglottic lesion with a stalk extending from the anterior commissural region of the left vocal cord was identified. Initial attempts using snare excision were unsuccessful and it was only possible to conduct piecemeal excision with using biopsy forceps with the help of flexible bronchoscope that has been inserted using rigid laryngoscope. The results of histopathology confirmed that the lesion was a polyp which consists of myxoid and edematous tissues, and presents fibrin deposition and widened blood vessels under layers of epithelium. Conclusion: This case demonstrates that hemoptysis among patients that are elderly smokers has at least a few different causes, besides that, a polyp that is situated near the anterior commissure with its subglottic processes causes a threat for the doctor during microlaryngeal surgery as it is impossible to perform surgery вtime without the patient’s tracheostomy.