Not an ordinary sore throat

It was a busy Saturday morning surgery. The patient was a 52 year old Menorcan waiter whom I knew vaguely, having seen him a few times when his marriage was in trouble. His new partner made the call at about 10 30 am when there were still 15 patients to see and three visits in the book. He had been down to the surgery the previous afternoon with a sore throat without a cough, and had been prescribed penicillin by one of my partners. His girlfriend said that he was no better and was having trouble breathing. I asked if he could come down to the surgery, to which the reply was: “No, he finds it very difficult to get down the stairs.” I thought it best to speak directly to the patient.

He apparently had a slight sore throat, but was not wheezy, and could talk normally with no obvious breathing problem. There was no history of asthma or allergy, and he said that he felt fine in bed but could really not get down the stairs; he even found it an effort to get to the lavatory. Somewhat reluctantly I said that I would visit after surgery.

He looked fine lying in bed, and conversed easily with no dyspnoea or stridor. “I'm sorry to call you out, Doctor, but I cannot get down the stairs.”

Impatiently, I asked him to sit up so that I could look in his throat and examine his chest.

“I can't, Doctor.”

“Of course you can,” I said, firmly helping him upright, at which moment he choked and gasped, and threw himself back flat on the bed. I asked him to try again and the same thing happened. He seemed to be unable to breathe in the vertical position but was fine lying flat.

I examined him flat on the bed: the pharynx was a little red, but there was no quinsy or obvious swelling, and no cervical lymphadenopathy. He had a slight temperature. The lungs were clear and there was no asymmetry in expansion. He could breathe equally well lying on the right or the left, or on his back.

Finally, taking him seriously, I asked if he had any problems in the past with his throat, and the reply was that when he was a child he had had some throat polyps removed.

I gave him some steroids and arranged to admit him, with a provisional anatomical diagnosis, and with strict instructions to the ambulance crew to keep him flat when going down the stairs. The ear, nose, and throat registrar had said: “Send him in—it sounds absolutely fascinating.”

Initial laryngoscopy proved difficult, but after 48 hours of steroids and antibiotics he had his posterior laryngeal polyp excised—arising from the arytenoids. Results of histology were benign.

The usual response to laryngeal obstruction—usually caused by epiglottic or pharyngeal swelling—is to sit up and forward. This man had significant laryngeal obstruction from a posterior polyp, which flopped in and out of the glottic opening as he changed position from horizontal to vertical and back again.

The image of my patient's reaction to “iatrogenic” laryngeal obstruction when I forced him into the vertical position to examine him will certainly live with me for a long time.