Male patient, 58 years-old, with history of arterial hypertension, type II diabetes mellitus and active smoking habits. He was admitted to the emergency department (ED) with worsening dysphagia for 3 months. Diagnostic rigid laryngoscopy in the ED revealed a mass in the right vocal cord with extension to the homolateral arytenoid, right larynx hemiparesis and acceptable glottic inlet. Later the patient underwent a first biopsy of the lesion through a suspension microlaryngoscopy, and no difficulty regarding airway management was documented in this intervention (Cormack-Lehane grade I laryngoscopy). Histologic examination revealed a polymorphic inflammatory process as part of a fungal infection and the patient complied with two weeks of treatment with fluconazole. 
Due to maintenance of complaints the patient underwent a second biopsy four weeks after the initial intervention. At our pre-operative evaluation, the patient reported worsening of dysphonia and dyspnoea since the first time and we decided to manage the situation as a predictably difficult airway. Fiberoptic intubation was chosen as the first-line approach and was conducted under sedation with remifentanil 0,1 ug kg-1min-1 and topic analgesia of the naso and oropharynx with lidocaine 10% spray. This approach allowed visualization of the glottis with an extensive mass spreading from the right glottic inlet to the supra and infra-glottic regions with important narrowing of the glottic opening. Intubation was achieved with a microlaryngoscopy 5mm cuffed tube. Pathologic analysis of this biopsy confirmed the diagnosis of verrucous carcinoma of the larynx. 

09 / When dysphonia speaks for itself: reconsidering the airway plan despite a previous grade I laryngoscopy