H&N Imaging Larynx

CT Imaging Supine with Scanogram lateral 2-3 mm sections From the base of Parallel to the Quite breathing IV contrast injection 2D, 3D, virtual endoscopy Soft tissue window for all images Bone window [ cartilage invasion ] hyperextended neck

tongue to the trachea laryngeal ventricle

MR Imaging Head and neck coil Motion artifacts [ swallowing and Sagittal and axial T1 WIS T2 , PD WIS axial with fat Fat suppressed images before and 20 cm FOV 4mm slice thickness , MR angiography to show flow respiration ] suppression after contrast 192 X 256 matrix within the vessels

Neck anatomy Hyoid bone Thyroid cartilage Cricoid cartilage anterior midline below the mandible anterior midline below the hyoid bone ring below the thyroid cartilage

Muscles

Trapezius Sternomastoid Platyzma Digastric Omohyoid

Landmark

Neck anatomy Muscles connecting the anterior aspects of hyoid, thyroid cartilage and sternum They are thin and flat difficult to be distinguished radiographically. Thyroihyoid Omohyoid superior belly Sternohyoid Sternothyroid Strap muscles

Anatomic data The false cords are thick folds of mucous membrane parallel to the vocal cords The false cords are filled with fat The true cords are fibrous and divide the larynx into supra and infra glottic regions The space between the true and false cords is called laryngeal ventricle

Laryngeocele Congenital laryngeoceles are rare Stationed in Egypt 1829 by Larrey, Napoleons surgeon in- chief Shouting and voice abuse lead to laryngeoceles A dilated laryngeal saccule Three types: Internal 40% : Cyst inside the larynx External laryngeoceles 26% : Extend through the thyrohyoid membrane at the point of the superior laryngeal nerve and vessels Mixed laryngeoceles 44% : cyst on both sides of the thyroid membrane

Laryngeocele 3 Types

Air filled sac (J) arises from the ventricle and

Air filled sac (H) lies outside the larynx

Internal (J) and external (H) sacs communicating

Laryngeocele Bilateral lesions in 23% Infection 10%

Laryngeal cancer associated with laryngeoceles in 15% About 50% of laryngeoceles detected by plain X ray contain cancer

Laryngeocele X ray : Air filled lesion = External Internal type needs barium diverticulum will fill with barium CT : Sac filled with air or fluid Air fluid level = infection Fluid and mass = carcinoma or mixed type swallow DD pharyngeal

Laryngeal cancer Almost all tumors are squamous cell carcinomas Supraglottic 60%- 70% lymphatic spread 30% Glottic 25%- 35% lymphatic spread 1% Subglottic 5% lymphatic spread 30%

Role of imaging CT MRI Delineating the site and extent of the mass Show invasion of PES, PGS, subglottic extension and anterior commissure invasion

CT detects sclerosis of the arytenoid cartilage suggestive of tumor invasion MRI Superior in detection of the fat and cartilage involvement Other imaging Barium FDGmodalities Conventional radiographs swallow PET fused with CT

Role of imaging Barium swallow Delineating the site and extent of the mass Can not show invasion of PES, PGS, subglottic extension and anterior commissure invasion

Supraglottic carcinoma Radiologist Role Tumor Tumor Anterior commissure Cartilage invasion

size extension into Pre- epiglottic space Paraglottic space

Laryngeal cancer Supraglottic carcinoma Squamous cell carcinoma 90% of all laryngeal and hypopharyngeal cancer

Epiglottic lesions invade the peri - epiglottic space Tumors originating from the false cord, Aryepiglottic fold or laryngeal ventricle invade the paraglottic space The 1ry sign of invasion is obliteration of fat in these spaces Lymphatic spread to the superior jugular lymph nodes

Thickening and enhancement of the infrahyoid epiglottis, with infiltration of the preepiglottic space. Downward tumor extension into the aryepiglottic fold . More inferiorly there is tumor infiltration of the left false vocal cord .Tumor soft tissue is seen just above the level of the anterior commissure as well as above the level of the true vocal cord . Sclerosis of left thyroid cartilage

Supraglottic carcinoma

The tumor mass extends throughout the left paraglottic space, abutting and slightly displacing downwards the upper margin of the true vocal cord. Tumor thickening of the infrahyoid epiglottis extending down to the level just above the anterior commissure.

Supraglottic carcinoma Squamous cell carcinoma of the right false vocal cord.

Small infiltrating lesion in the right paraglottic space, at the level of the false vocal cords; the lesion extends into the lower part of preepiglottic space. Coronal reformatting showed the enhancing tumor in the right false vocal cord just above the normal true vocal cord (asterisk)

Radiologist Role Very important for supraglottic laryngectomy Midline sagittal T1 WIs The distance between the tumor and anterior commissure Invasion of PES Tumor free margin

Coronal T1 WIs Tumor invasion of the PGS Laryngeal cancer Glottic carcinoma

Glottic cancer with anterior commissure invasion. The anterior commissure (C) should be less than 1- to 2-mm thick. This lesion extends across midline to the contralateral left side vocal cord.

The patient may still be a candidate for a vertical hemilaryngectomy, because the posterior two thirds of the contralateral true vocal cord are still intact.

Total laryngectomy Extensive tumor of the larynx or hypo pharynx Cartilage invasion or subglottic extension After failed radiotherapy Local recurrence after partial laryngectomy Radiation induced chondro -necrosis

Removal of the whole larynx , pyriform sinuses ,strap muscles and hyoid bone

Horizontal supra glottic laryngectomy

 Localized lesions above the ventricle Involvement of the pre epiglottic space is not a contraindication Removal of the upper half of the larynx including the epiglottis, pre epiglottic space , aryepiglottic folds , false cord ,part of the thyroid cartilage and one arytenoids cartilage if involved

Vertical hemi

-laryngectomy Tumors limited to the true cord

Contraindicated if there is involvement of : False cord Ventricle Thyroid cartilage

Supra - cricoid laryngectomy with crico -hyoidopexy Advanced supra glottic cancer invading the glottis Contraindicated if there is involvement of : Subglottic region Cricoid cartilage Removal of the true and false cords , the epiglottis , pre epiglottic space , para glottic space , the thyroid cartilage and one arytenoids cartilage if involved

Laryngeal tumors with characteristic imaging features Hemangioma 2-5% of all laryngeal tumors

 Infantile and adult types Strong enhancement by CT, MR Phlepoli in cavernous type Strong hyper intensity in T2 WIs DD Paraganglioma, vascular deposits

Chondroma Chondrosarcoma 200 cases reported Males 50- 70 years Common from thyroid cartilage Lobulated locally Intratumoral suggestive

old cricoid cartilage (70%), (30%) invasive mass calcifications are highly

Very high signal in T2 WIs [ Hyaline cartilage with high water contents ] Both lesions can not be differentiated on imaging

Lipoma Liposarcoma 80 cases reported Rare in the larynx Usually extend from the 25% multiple Commonly Supraglottic Mobile tumor may lead Typical appearance on Fat suppressed MR images are diagnostic

pharynx

to death CT, MRI