ENT Cancer PE (e.g., Oral Cancer, Lymphoma)

Subjective:
Chief Complaint:
Follow-up for persistent right vocal cord paresis, intermittent coughing, and aspiration symptoms.

History of Present Illness:
Margaret Ellis, a 64-year-old female, presents for reassessment and laryngoscopy. She has a history of right vocal cord paresis, which has been stable. She reports intermittent coughing, particularly when drinking liquids, and occasional aspiration symptoms. She uses a chin tuck maneuver to reduce aspiration. She denies any throat pain or hemoptysis. Imaging studies, including a PET scan in November 2023, showed no FDG uptake in the neck. Previous flexible video nasopharyngoscopy revealed right vocal cord paresis with complete glottic closure on phonation and no laryngeal lesions. She has declined procedural interventions such as medialization injection or thyroplasty in the past. She is under the care of a respirologist for pulmonary nodules, with a follow-up CT scan planned. She has no history of pneumonia and reports stable voice quality. She has a history of hypertension and has undergone an oophorectomy. She is also being monitored for a probable meningioma.

Past Medical History:
The patient has a documented history of right vocal cord paresis, hypertension, pulmonary nodules under respirology care, and a probable meningioma under neurosurgical evaluation. She has also been diagnosed with dyslipidemia and pre-diabetes. There is no history of pneumonia. She has not required antibiotics prior to dental procedures. The patient has demonstrated compliance with specialist follow-up, including respirology and neurosurgery consultations, and has declined procedural interventions for her vocal cord paresis after discussion of risks and benefits. She has attended scheduled imaging and specialist appointments as recommended.

Past Surgical History:
The patient has a history of oophorectomy. No additional surgical procedures have been documented.

Social History:
The patient is a care aide by occupation. She has a history of tobacco use. There is no reported use of vaping products.

The Review of Systems:
The patient reports intermittent coughing, particularly when drinking liquids, and occasional aspiration symptoms. She describes using a chin tuck maneuver to reduce aspiration. She denies problems eating, choking on liquids, throat pain, hemoptysis, breathing issues, and stress causing chest tightness. She expresses concern regarding her persistent symptoms and is seeking reassurance that there is no worsening of her condition. She hopes to avoid procedural interventions and prefers conservative management at this time.

Current Medications:
The patient is currently taking mometasone, atenolol, and omega-3 supplements. She has not required antibiotics prior to dental procedures.

Allergies:
The patient has a documented allergy to dust.

Objective:
Physical Examination:
General:
- Facial expression: well
- Facial symmetry: symmetrical

Neck:
- Palpate for lymph nodes:
  - Size: normal
  - Shape: normal
  - Mobility: mobile
  - Consistency: soft
  - Tenderness: non-tender
- Palpate the trachea: midline
- Detect carotid bulb: normal

Mouth:
- Oral inspection:
  - Lips: normal
  - Oral mucosa: normal
  - Tongue: normal
  - Condition of teeth and gingivae: normal
  - Examine the tonsils, pharyngeal wall, palate, tongue surfaces, and buccal cavities: normal

No cervical adenopathy. No metal implants. No pacemaker.

Test Results:
Flexible video nasopharyngoscopy demonstrated right vocal cord paresis with complete glottic closure on phonation and no laryngeal lesions. Positron emission tomography scan performed in November 2023 revealed no fluorodeoxyglucose uptake in the neck. Computed tomography of the chest identified multiple stable pulmonary nodules, with a stellate subsolid nodule in the left lower lobe mildly increased in size to 8 x 11 millimeters compared to the previous measurement of 7 x 9 millimeters. Two ground-glass density nodules in the left upper lobe remained unchanged at up to 10 millimeters. A right lung apex subsolid nodule measured 4 millimeters and was stable. No new pulmonary nodules were identified. There were no pleural effusions. No suspicious osseous lesions were observed. No mediastinal, hilar, or axillary lymphadenopathy was present. Imaging did not identify a causative lesion. No concerning mucosal pathology was seen. No lymphadenopathy was detected. Spirometry performed on June 11, 2025, showed a forced expiratory volume in one second to forced vital capacity ratio of 0.69, forced expiratory volume in one second of 1.75 liters (80% predicted), forced vital capacity of 2.53 liters (92% predicted), and no bronchodilator response.

Assessment:
Problem:

1. Right vocal cord paralysis with stable function and no evidence of malignant transformation.
2. Intermittent aspiration symptoms with liquids, managed with compensatory strategies.
3. No evidence of laryngeal mass or mucosal lesion on recent examination.
4. No history of pneumonia or hemoptysis.

Differential Diagnosis:
1. Idiopathic right vocal cord paralysis.
2. Neural injury or neuropathy affecting the right recurrent laryngeal nerve.
3. Remote sequelae of prior surgical intervention or trauma (not specified in this encounter).
4. Neoplastic process is considered unlikely given stable imaging and negative biopsy findings.

Plan:

• Right Vocal Cord Paresis  
• The patient continues to experience intermittent coughing, particularly with liquids, and occasional aspiration symptoms. The patient has declined procedural interventions such as medialization injection or thyroplasty. Advised that if symptoms worsen or become intolerable, referral for a procedure to improve glottic closure remains an option.  
• Pulmonary Nodules  
• Instructed the patient to follow up with her respirologist, Dr. Andrew Lin, regarding the results of her recent computed tomography scan of the chest and to inquire about the timing of the next scan. Advised the patient to contact Dr. Lin's office to discuss the computed tomography results and ensure timely follow-up after her scheduled lung function test on November 2.