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A 66-year-old woman presented with progressive exertional dyspnoea, productive cough and dysphonia, particularly when singing; she also experienced a dry obstructed nose, sore mouth and mild dysphagia. She had previously been diagnosed with autoimmune disease affecting her eyes, nasal passages, oropharynx and oesophagus, for which she had received treatment with prednisolone and cyclophosphamide. Immunosuppression continued with azathioprine. She also suffered from aortic stenosis and hypothyroidism, which was treated with levothyroxine. No perinatal respiratory difficulties were known and she had never been intubated. Despite being a non-smoker, she had had frequent lower respiratory tract infections.
Physical examination showed no additional signs but chest radiography revealed ill-defined consolidation in the right upper lobe. Bronchoscopy was performed to exclude mycobacterial infection and showed an abnormal supraglottic region with a ring-like narrowing with scarring extending posteriorly from fused arytenoids through which the true vocal cords could be seen (fig 1). The laryngeal structures did not collapse with inspiration and movement of the true vocal cords was normal. No associated glottic or subglottic abnormalities were identified.
What is the abnormality at bronchoscopy and what are the differential diagnoses? What symptoms can arise?
See page 515.
This case was submitted by:
Competing interests: None.
Patient consent: Obtained.