An Unusual Cause of Late Dysphagia After Head and Neck Radiation Therapy

Excerpt

A 72-year-old man presented to our clinic complaining of new-onset dysphagia, recent weight loss, a burning tongue sensation, and odynophagia that had begun two weeks earlier. His past history included a cT1N0 pulmonary adenocarcinoma treated by surgical resection in 2011 and an open partial laryngectomy plus adjuvant radiotherapy (RT) for a cT2N1 supraglottic squamous cell carcinoma in 2013. Subsequent oncological follow-up was negative. The only adverse effect reported was chronic xerostomia since the end of RT. He had always managed to eat both solids and liquids by mouth without the need for artificial nutrition and his medications included only pantoprazole PO 40 mg/day. No fever, headache, or a history of recent trauma were recorded at the time of our evaluation while a full neurological examination was unremarkable. The inspection of the oral cavity revealed a well-demarcated necrotic area of 4 × 3 cm on the left side of the mid-third of the tongue (Fig. 1, left). The remaining ear, nose, and throat inspection, including the fiberoptic evaluation of the upper aerodigestive tract, did not show other mucosal lesions. The motility of the two residual arytenoids was preserved without any evidence of endolaryngeal penetration or aspiration. We decided to hospitalize the patient, and an exclusively enteral nutrition was ensured through the placement of a nasogastric feeding tube (NGFT). Prophylactic antibiotic therapy (amoxicillin/clavulanic acid 1 g IV BID) and daily paracetamol (1 g IV TID) were prescribed. An incisional biopsy of the tongue and a computed tomography with angiography (CT) of the head and neck (Fig. 2) were then performed. What is the diagnosis?

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