Dr Sunila BHMS,MD(Hom)
Email : firstname.lastname@example.org
Admission No: 1317 Date of Admission: 26/ 03/ 05
1. Hoarseness of voice (5 months)
- Hoarseness with obstructed feeling in throat
- No pain in throat
- No dysphagia
- Hoarseness < evening
2. Redness of left eye (1 month)
- No itching
- No pain
- No lachrymation
- There is sand sensation in left eye.
- Dimness of vision for distant objects
History of presenting complaint
Complaint started 5 months back. He took allopathic treatment with radiotherapy.
No relevant complaints in the past
No similar complaint among the family members
Born and brought up at Mankavu. He has the habit of smoking started at the age of 20. One packet of cigarettes a day and he is still continuing the habit.
- Appetite : Good; Desires pungent food
- Thirst : Good
- Bowels : Regular
- Urine : No complaints
- Sweat : N
- Sleep : Good
- Thermal reaction : Not specific
Pulse Rate: 68/ minute Respiratory Rate: 20/ minute
BP: 110/ 70mm of Hg Temperature : 98.6ºF
- Moderately built and nourished
- Pallor present
- No cyanosis, No icterus.
- No clubbing, No lymphadenopathy and No pedal oedema.
O/E: Oral cavity and Oropharynx
- Lips (N) Tongue (N)
- Gums (N) Pillars (N) Tonsils (N)
Internal Larynx Examination
There is an ulceroproliferative growth involving the anterior commissures and anterior ⅔ of medial borders and superior surface of (L) vocal cord.
Vocal cords mobile B/L
No neck node
Carotid palpable (B/L)
Impression : Carcinoma Larynx T2 N0 M0
Squamous cell Carcinoma- moderately differentiated
Examination of Respiratory system
Examination of Upper Respiratory tract
- No congestion of nasal mucosa, no deviation of nasal septum& no nasal polyp
- Uvula centrally placed & no tonsillar enlargement.
Examination of lower Respiratory tract
- Trachea appears to be centrally placed
- Chest wall bilaterally symmetrical
- No kyphosis, scoliosis or lordosis; no prominent vessels and visible pulsations.
No palpable swelling; Trachea centrally placed; Apex beat palpable.
Normal lung resonance
No wheeze heard
Examination of Central Nervous system
Examination of higher mental functions
Patient is conscious, intelligent, normal behaviour, past and present memory present, orientation of time, place and person present, no hallucination, delusion, illusion and speech normal.
Examination of Cranial nerves
No anosmia, parosmia and hallucination of smell.
There is no obstruction on the field of vision
Oculomotor Nerve, Trochlear Nerve, Abducens
Ocular movements are within normal limits, no nystagmus. Pupil reacts to light.
Sensation over face is intact; corneal and conjunctival reflexes intact.
Jaw jerk present
Eye closure, frowning, raising the eye brow present
Can blow, whistle and show the teeth
No impairment of hearing
Glosopharyngeal Nerves and Vagus
Gag reflex present
Uvula centrally placed
Hypoglossal Nerve Can move tongue in all directions
Sensory System: With in normal limit
Examination of motor System: Within normal limits
Signs of meningeal irritation: No signs of meningeal irritation
Analysis of symptoms
|Symptoms of disease||Symptoms of patient|
|Hoarseness of voice||Desires pungent things|
|Hoarseness of voice< evening|
Evaluation of symptoms
|Physical generals||Particulars||Common symptoms|
|Desires pungent things||Redness of left eye||Hoarseness of voice|
Totality of Symptoms
- 1. Patient desires pungent things
- 2. Hoarseness of voice
- 3. Hoarseness of voice < Evening
- 4. Redness of left eye
- 5. Ca larynx
|Desires pungent things||+|
|Hoarseness of voice||+|
|Carcinoma of larynx||+||+||+|
|Redness of left eye||+||+||+|
Predominant Miasm: Syphilis
- STOMACH, DESIRE pungent things.
- LARYNX AND TRACHEA VOICE hoarseness.
- LARYNX AND TRACHEA VOICE hoarseness evening.
- LARYNX AND TRACHEA CANCER larynx.
- EYE REDNESS canthi.
- Phosphorous- 9/3 Hepar sulph- 6/3
- Carbo veg- 8/3 Causticum- 6/2
- Graphitis- 6/3 Calcarea carb-
- 26-3-05 Calcarea Carb 200/2 dose
- 27-3-05 Sac lac 2 dose (Hoarseness slightly relieved)
- 28-4-05 Calc carb 200/2 dose
- 15-5-05 Sac lac 2 dose (Patient has symptomatic relief and discharged)
Tumors of the larynx
Benign tumours of the larynx are extremely rare and squamous carcinoma of the larynx predominates over all others, being responsible for more than 90% of tumours within the larynx. It is the commonest head and neck cancer and almost always occurs in the elderly male smokers. The squamous epithelium of the vocal folds and the respiratory epithelium of the supraglottis undergo dysplastic change stimulated by cigarette smoking and other factors. The incidence of laryngeal cancer in three compartments- supraglottis, glottis and subglottis, varies around the world; the glottis is generally the commonest site followed by the supraglottis. True carcinomas of the subglottis are very rare and most are a consequence of inferior spread from the glottis.
The frequent glottic origin means that patients almost always present with hoarseness. This is of great importance because if a diagnosis can be made while the tumour is in the first stage. I.e. confined to only one vocal fold, these cancers have more than a 5 year disease-free cure rate when treated with radiotherapy alone. The cure rate drops dramatically once the lymphatically rich supraglottis or subglottis is involved, owing to spread to neck nodes. The appearance of more than one neck gland halves the overall prognosis of the patient.
TNM Classification of Laryngeal Cancer
- T - Primary Tumour
- T x - Primary tumour cannot be assessed.
- To - No evidence of primary tumour
- T is - Carcinoma in site
- T1 – Tumour limited to one sub site of supraglottis, with normal vocal cord mobility.
- T2 – Tumour invades more than one sub site of supraglottis, with normal vocal cord mobility
- T3 – Tumour limited to larynx with vocal cord fixation and/ or invades post cricoid area, medial wall of piriform sincit or pre-epiglottic tissues.
- T4 – Tumour invades through thyroid cartilage and/ or extends to other tissues beyond the larynx, e.g. to oropharynx, soft tissues of neck.
- T1 – Tumour limited to vocal cords, (may involve anterior or posterior commissures) with normal mobility
- T1a- Tumour limited to one vocal cord
- T1b- Tumour involves both vocal cords
- T2 – Tumour extends to supraglottis and/ or with impaired vocal cord mobility
- T3 – Tumour limited to larynx with vocal cord fixation.
- T4 – Tumour invades through thyroid cartilage and/ or extends to other tissues beyond the larynx; e.g. to oropharynx, soft tissues of the neck.
- T1 – Tumour limited to subglottis
- T2 – Tumour extends to vocal cord(s) with normal or impaired mobility.
- T3 – Tumour limited to the larynx with vocal cord fixation
- T4 – Tumour invades through cricoid or thyroid cartilage and/ or extends to other tissues beyond the larynx; e.g. to oropharynx, soft tissues of the neck.
- N – Regional lymph nodes
- M – Distant metastasis
- Stage 0 T is No Mo
- Stage I T1 No Mo
- Stage II T2 No Mo-
- Stage III T1 N1 Mo
- T2 N1 Mo
- T3 No, N1 Mo
- Stage IV T4 No, N1 Mo
- Any T No, N1 Mo
- Any T Any N M1
Direct laryngoscopy, together with Hopkins rod examination allows precise determination of the extent tumours and biopsy confirms an exact histology. CT and MRI scanning give further details of the extent of larger tumours and suspicious nodal involvement within the neck which may not be determined on clinical examination.
Early supraglottis and glottis tumours are optimally treated with mega voltage radiotherapy. Five-year cure for Stages I & II are approximately 90 and 70% respectively, and the patient has an excellent voice following this type of treatment. If modern mega voltage radiotherapy is not available then early tumours may be excised by endoscopic laser surgery or open partial laryngeal surgery. With early bilateral supraglottic tumours a horizontal laryngectomy may be undertaken excising the supraglottic growth and the remainder of the glottis. The subglottic part of the larynx is then stitched tongue base to provide continuity. In most patients undergoing partial laryngeal surgery of this type the voice result is not satisfactory as that with radiotherapy.
Advanced Laryngeal Disease
Once the squamous carcinoma has caused fixation of the vocal fold or has infiltrated outside the larynx into adjacent such as thyroid gland and strap muscles, some form of subtotal or total laryngectomy is required to attempt to cure the disease. Total laryngectomy is frequently required when radiotherapy fails. Part or all of thyroid gland and associated parathyroid glands may also need to be removed depending on the extent of the disease, so patients after this type of radical surgery may require oral thyroxin and calcium supplement for the remainder of their lives. Laryngectomy patients must obviously avoid immersion in water as this would flow directly into their tracheal stoma.
1.Homoeopathic Medical Repertory by Robin Murphy
- Diseases, CANCER general
- Larynx, CANCER
- Larynx, Cancer: ars, con, phytolacca, ars-I, bell, carb-an, clem, hydr, iod, kreos, lach, morph, nit-ac, phos, sang, thuja
2. Repertory of Homeopathic Materia Medica- J.T. Kent : LARYNX AND TRACHAEA; CANCER, larynx: ars, nit-ac, phos, sang, thuja
3. Synthesis – Dr. Frederick Schroyens LARYNX AND TRACHEA, CANCER, larynx: arg-cy, ars, nit-ac, phos, sang, thuja
4. Synthetic Repertory : Cancerous affections +3 – Ars, Brom, carb-an, conium, Lycopodium, Nit-ac, phos, phytolacca, silicia
Indications of some important medicines in the treatment of carcinoma larynx
1) Ars alb: Unable to lie down. Fear of suffocation. Air passages constricted. Cough< after midnight, lying on back. Extreme prostration & anxiety.
2) Conium mac: Oppressed breathing, constriction & pain in chest. Expectoration only after long coughing. Dry cough; <evening & night; caused by dry spot in larynx with itching in chest & throat, when lying down.
3) Phytolacca: Aphonia. Difficult breathing. Tickling cough < at night. Decrease of weight.
4) Phosphorous: Hoarseness< evening. Larynx very painful. Tickling in larynx while speaking. Aphonia< evening with rawness. Cannot talk on account of pain in larynx
5) Argentum met: Chronic hoarseness & aphonia< from use of voice. Larynx is a special centre for this drug.
6) Causticum: Hoarseness with pain in chest; aphonia. Larynx sore. Difficulty of voice of singers & public speakers.
7) Carbo veg: Cough with itching in the larynx. Deep, rough voice failing on slight exertion. Hoarseness< evening, talking.
8) Calcarea carb: Painless hoarseness& bloody expectoration.
9) Bromium: Dry cough with hoarseness & burning pain behind sternum. Difficult & painful breathing.
- Synthesis Repertory by Fredericke Schroyens
- Homoeopathic medical repertory by Robin Murphy
- Repertory of Homoeopathic Materia Medica by J T Kent.
- Allen’s Key notes.
- Boericke’s Materia Medica
- Bailey & love’s short practice of surgery.