Hoarseness and Cough in a 67-Year-Old Woman

A 67-year-old white woman presented with an approximately 1-month history of hoarseness and nonproductive cough. She had quit smoking 20 years earlier and denied chest pain and dysphagia. She was referred to an otorhinolaryngologist for further assessment. A computed tomography (CT) scan of the neck and chest was then requested. Contrast-enhanced CT images of the neck and chest are displayed (Figures ​(Figures11–4). In addition, a positron emission tomography scan (not shown) revealed increased uptake in the aorticopulmonary window lymph node and the left lung nodule. Figure 1 Axial postcontrast CT image demonstrates an enlarged lymph node complex (arrow)in the aorticopulmonary window. Figure 4 Axial CT image just inferior to the dilated laryngeal ventricle demonstrates the reduced size of the left thyroarytenoid muscle, or true vocal cord, with decreased density (arrow). A thoracic surgeon was consulted for fiber-optic bronchoscopy and mediastinoscopy. On bronchoscopic evaluation, only mild atrophy of the bronchial mucosa with no endobronchial mass was visualized. Further examination with a mediastinoscope revealed a solid and immobile lymph node complex in the aorticopulmonary window. Multiple biopsies of this lymph node complex were obtained. What is the most likely diagnosis? DIAGNOSIS: Left vocal cord paralysis secondary to malignant invasion of the left recurrent laryngeal nerve within the mediastinum. Pathology of the lymph node specimen revealed poorly differentiated large-cell carcinoma consistent with lung origin. The patient did well postoperatively and will follow up with an oncologist to discuss treatment options.