Imminent Respiratory Collapse in Advanced Head and Neck Cancer: A Case Report and Discussion

Airway obstruction is a distressing and potentially life-threatening complication in patients with advanced head and neck cancers, particularly squamous cell carcinoma (SCC) of the pharynx. This case highlights the clinical, ethical, and interdisciplinary complexities involved in managing airway compromise in the context of progressive disease and limited treatment options. A 75-year-old man with recurrent SCC of the soft palate, nasopharynx, oropharynx, and hypopharynx, recently initiated on pembrolizumab and radiation therapy, presented with dysphagia, stridor, and intermittent tumor bleeding. Imaging revealed a large pharyngeal mass causing critical airway narrowing. Plans for tracheostomy to manage anticipated radiation-induced edema were aborted following the patient's acute neurological deterioration, with imaging confirming bilateral carotid artery occlusions and a new stroke. With poor prognosis and elevated risk of carotid blowout syndrome (CBS), further disease-directed treatments were deemed inappropriate. A multidisciplinary team, including palliative care, oncology, and ENT, facilitated a transition to comfort-focused care, emphasizing symptom control, airway management, and emotional support. The patient was transferred to inpatient hospice for end-of-life care. This case underscores the multifactorial nature of airway obstruction in advanced pharyngeal SCC, including tumor burden, treatment-related edema, and vascular complications. It highlights the importance of risk stratification for tracheostomy, especially in the setting of stroke, bleeding risk, and impending CBS. Symptom management was pivotal in maintaining comfort. Nonpharmacologic strategies and psychosocial-spiritual support further contributed to comprehensive end-of-life care. Individualized, multidisciplinary, and patient-centered approaches are essential when curative therapies are no longer appropriate in advanced head and neck cancer. Prioritizing comfort, clear communication, and integrative symptom management can optimize quality of life and support dignity at the end of life.