# Situation: A 60-year-old man who smokes and drinks alcohol daily undergoes total laryngectomy with a permanent tracheostoma for cancer of the larynx. Which symptom is the typical early warning sign of cancer arising on the vocal cords?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 60-year-old man who smokes and drinks alcohol daily undergoes total laryngectomy with a permanent tracheostoma for cancer of the larynx.

Which symptom is the typical early warning sign of cancer arising on the vocal cords?

## 보기

1. Pain referred to the ear
2. Difficulty swallowing
3. Persistent hoarseness **✔ 정답**
4. A painless neck mass

**정답: 3**

## 해설

Glottic (vocal cord) cancer changes the voice early, so hoarseness lasting more than 2 to 3 weeks, especially in a smoker, must be evaluated. The vocal cords have few lymphatics, so node spread is late. Referred ear pain, dysphagia, and a neck mass are later findings or typical of supraglottic tumors.

## 심화 해설

Why hoarseness is the earliest warning sign

Glottic cancers arise directly on the vocal cords, which are the vibrating edges of the larynx responsible for voice production. Even a small lesion on the cord surface disrupts the smooth mucosal wave and glottic closure, producing an immediate change in voice quality. Because the vocal cords participate in phonation with every spoken word, any structural alteration is expressed acoustically as hoarseness long before the tumor grows large enough to cause pain, airway obstruction, or visible neck swelling.

The vocal cords are also anatomically sparse in lymphatic channels. This means a tumor confined to the glottis tends to remain localized for a longer period, and regional lymph node metastasis is a late event. Consequently, a painless neck mass is not an early finding in glottic cancer. Key point! The early symptom is a voice change, not a lump.

Duration that should trigger evaluation

Hoarseness that persists beyond 2 to 3 weeks without an obvious benign explanation, especially in a patient with a significant smoking and alcohol history, requires laryngoscopic examination. The rationale is that simple inflammatory laryngitis typically resolves within this timeframe, whereas a malignant lesion will not. Persistent hoarseness in a smoker is laryngeal cancer until proven otherwise.

Why the other options are not early glottic signs

| Finding | Timing in glottic cancer | Explanation |
| --- | --- | --- |
| Referred ear pain (otalgia) | Late | Occurs when the tumor extends beyond the larynx and irritates sensory branches of the vagus nerve (Arnold nerve) shared with the ear canal |
| Difficulty swallowing (dysphagia) | Late or supraglottic | Glottic tumors do not impinge on the swallowing passage early; dysphagia suggests supraglottic or hypopharyngeal extension |
| Painless neck mass | Late | Reflects cervical lymph node metastasis, which is delayed because the vocal cords have sparse lymphatic drainage |

Clinical application for the nursing examinee

In a patient scheduled for total laryngectomy, the preoperative history often reveals that the earliest symptom was a change in voice that was initially dismissed. Watch out! Do not confuse the early presentation of glottic cancer with that of supraglottic cancer, which may first present with a sore throat, dysphagia, or a neck mass because the supraglottis has richer lymphatic supply and does not affect voice until later.

The assessment priority is to recognize that any adult with unexplained hoarseness lasting longer than 3 weeks warrants referral for visualization of the larynx. Early diagnosis of malignant laryngeal lesions improves the chance of curative, voice-preserving treatment and survival.

## 임상 시나리오

Persistent Hoarseness in a SmokerRed Flag for Glottic Cancer
Hoarseness lasting more than 2 to 3 weeks in a patient with smoking and alcohol history requires laryngoscopy to rule out vocal cord cancer.

Vocal cord lesions disrupt phonation early, producing voice change before pain, dysphagia, or neck mass appear.

CautionDo not attribute persistent hoarseness to benign laryngitis without visualization; glottic cancer is a diagnosis of exclusion in high-risk patients.

## 핵심 개념

- **Glottic cancer** — Cancer arising on the vocal cords, which changes voice early due to disruption of phonation.
- **Hoarseness** — A rough or breathy voice quality caused by impaired vocal cord vibration or closure.
- **Referred otalgia** — Ear pain perceived from a distant site, often a late sign of laryngeal tumor extension.
- **Lymphatic spread** — Spread of cancer via lymph channels; vocal cords have few lymphatics, so nodal metastasis is late.
- **Laryngoscopy** — Direct or indirect visualization of the larynx to evaluate persistent hoarseness or suspected lesions.

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