An adult male patient presented to an Accident and Emergency Department with stridor, and was diagnosed clinically to have infective exacerbation of chronic obstructive pulmonary disease. A CT scan of his neck revealed a large mass occluding the laryngeal airway. A biopsy and subsequent histopathological analysis of this mass revealed no evidence of a malignancy. Despite this, a laryngectomy was undertaken and a large verrucous squamous cell carcinoma was confirmed. Case Report A 59 year old Caucasian male attended the Accident and Emergency Department at the University of Wales Hospital, Cardiff, complaining of severe and worsening shortness of breath, with a three month history of a chronic non productive cough and loss of appetite. One week prior to his emergency admission, he had been reviewed by his general medical practitioner regarding an acute onset of a productive cough which had resulted in the prescription of a course of amoxicillin.Despite an unremarkable medical history, he had smoked 20 cigarettes a day for most of his adult life, but had given up 4 months previously. The patient had also been suffering from hoarseness of the voice for 4 years, but this had not been investigated.On examination, the patient was tachypnoiec with stridor, and had such difficultly speaking that he was unable to finish sentences. Auscultation revealed poor air entry bilaterally with diffuse wheezes. Cardiovascular, abdominal and neurological examination was unremarkable.His initial oxygen saturation was 91% on air. Repeated arterial blood gas analysis displayed a pattern of deteriorating respiratory acidosis. His white blood cell was elevated at 13.1x109/l and his CRP was 64mg/l. The remaining haematological investigations were within normal range. A chest radiograph showed opacification peripherally in the left mid zone .A CT pulmonary angiogram showed infective consolidation of left upper and lower lobes and small airway disease of both lung bases, but no evidence of pulmonary embolism or malignancy.These clinical and radiological findings led to a diagnosis of infective exacerbation of chronic obstructive pulmonary disease.The patient deteriorated and was transferred to the Intensive Care Department where he was subsequently intubated. Intubation itself was straightforward. At this point, in light of the history of hoarseness of voice, an opinion was sought from the Ear Nose and Throat Department. As part of their assessment a CT scan of the neck was requested.A CT scan was undertaken using Niopam 300mg/l contrast given according to the 120/120 technique. This revealed an 11cm soft tissue mass extending from the nasopharynx to below the thyroid isthmus (Figures 3 and 4). This mass compromised the patient’s airway for all of its length and abutted the lateral and posterior walls of the pharynx. The loss of a clear tissue plane between the mass and the posterior oropharynx strongly suggested involvement (Figure 1). The soft tissue lesion extended posteriorly around the greater horn of the hyoid bone. There was also involvement of the strap muscles of the neck (Figure 2), as well as subcutaneous striations. The thyroid and cricoid cartilages showed altered texture suggesting involvement, and both the nasogastric and endotracheal tubes were displaced by the mass. No pathological cervical lymphadenopathy was observed, although ultrasound examination of the neck revealed a prominent, right side level II reactive node.In light of the clinical presentation, the radiological diagnosis was more suggestive of an infective aetiology, although malignancy could not be excluded.The patient underwent a tracheostomy and panendoscopy. Biopsies from the larynx, naso and oropharynx, revealed no infective elements or dysplasia, and no tissue diagnostic of malignancy, though some fragments of tissue showed papilloma-like architecture.The clinical and radiological findings were discussed extensively at both local and regional Head and Neck Multi Discipli
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