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LARYNX PATHOLOGIES

Dr. Avinash Gupta

Dept. of Radio Diagnosis

15th June 2012

Laryngeal cysts originate from the minor salivary glands

within the mucosa of the larynx. They may therefore be seen

anywhere within the larynx. Diagnosis of a salivary gland cyst

may be suspected clinically and imaging usually confirms the diagnosis.

On CT, cysts demonstrate a low attenuation values (0-20

HU) and they show no enhancement after injection of contrast material.

On MR, the cysts display a high signal intensity on T2weighted images and variable signal intensities on TI-weighted images owing to the variable protein content.

LARYNGEAL CYST

Laryngoceles occur as a result of elongation and dilatations of the saccule (laryngeal appendix) of the laryngeal ventricle. A laryngocele often forms due to obstruction of the laryngeal saccule(laryngeal appendix) where it opens into the laryngeal ventricle.

Sometimes a small cancer located near the neck of the saccule may be responsible and thus becomes clinically manifest.

Laryngoceles are found in 2% of healthy individuals and

in 18% of patients with carcinoma of the larynx.

LARYNGOCOELE

Laryngoceles may contain air or fluid. In the latter case they are also referred to as saccular cyst or laryngeal mucocele.

An internal laryngocele extends superiorly in the paraglottic space and appears endoscopically as a submucosal supraglottic mass.

If the laryngocele extends through the thyrohyoid membrane into the soft tissues of the neck, it is termed an external laryngocele

LARYNGOCOELE

Contrast-enhanced TlW SE MR image in a dyspneic 45-year-old man shows a large, airfilled structure with thin, smooth, enhancing walls (arrow) located in the supraglottic larynx. characteristic of an internal laryngocele

Contrast-enhanced CT image in a severely dyspneic 4-day-old boy shows a large, fluid-filled structure (calipter) with thin, smooth walls located in the supraglottic larynx, characteristic of an internal congenital laryngeal mucocele.

Contrast-enhanced CT images at the supraglottic level show a flUid-filled dilated laryngeal saccule (arrow) extending through the thyrohyoidmembrane into the soft tissues of the neck (dashed arrow). There is slight enhancement of the walls of the fluid-filled structure (mucocele and pyocele).

Contrast-enhanced T1W FSE MR images at the supraglottic level show an air-filled laryngocele (arrows) extending through the thyrohyoid membrane into thesoft tissues of the neck (dashed arrows).

Thyroglossal duct cysts arise from the thyroglossal duct

remnant. The infrahyoid thyroglossal duct cyst is typically seen anterior to the larynx within or beneath the strap muscles.

It is located in the midline or slightly off the midline. Occasionally. the cyst can bulge over the notch of the thyroid cartilage into the preepiglottic fat space .

The paraglottic space is spared as opposed to the case with laryngoceles which usually extend into the paraglottic space.

THYROGLOSSAL CYST

Contrastenhanced CT images at the level of the hyoid bone (a) and at the upper supraglottic level (b) showing a midline cystic lesion (arrows). without enhancing walls. xtending into the pre-epiglottic space at the level of the thyroid notch (dashed arrow).

Laryngotracheitis or croup is an infection that occurs in the age group 3 months to 3 years and is caused by a parainfluenza virus.

The onset is gradual with several days of upper and lower respiratory tract symptoms followed by the development of a classic barking cough and stridor.

The mucosal swelling is most significant in the subglottic area. where airway narrowing causes the gradual airway tapering described as the "wine bottle" when visualized on plain films.

LARYNGOTRACHEITIS

Epiglottitis or supraglottitis occurs in a slightly older age

group and is caused by Haemophilus influenza type B.

Diffuse thickening of the epiglottis and supraglottic larynx is typically seen on plain films. Because total airway obstruction may occur very rapidly, necessitating emergency tracheostomy.

Patients with epiglottitis should always be investigated in the emergency room.

EPIGLOTTITIS

Wegener granulomatosis is a necrotizing vasculitis that

causes inflammatory lesions. usually granulomas or areas of

necrosis in the respiratory tract and kidney.

It can involve the larynx. However. usually other areas of the head and neck, such as the orbits and the paranasal sinuses, are involved as well. Nevertheless. laryngeal involvement may be the initial presentation of Wegener granulomatosis.

Clinically. the laryngeal lesions may be superficial or may present as submucosal masses, most often in the subglottic region

WEGENER’S GRANULOMATOSIS

Contrast-enhanced CT of the larynx and trachea reveals circumferential. slightly irregular soft-tissue thickening at the subglottic region (arrow). as well as at thelevel of the cervical trachea (dashed arrow). Note irregular contours of the cricoid posteriorly (arrowhead) and tracheal ring laterally (black stealth arrow).

Tuberculosis with laryngeal involvement in a 37-year-old woman presentingin the emergency room with cough. hemoptysis. and severe dyspnea. a CT of theneck reveals a large bilateral laryngeal mass involving both false cords (arrows). ventricles. and paraglottic spaces. radiologically indistingUishablefrom squamous cell carcinoma.

AMYLOIDOSIS - Contrast-enhanced CT of the neck reveals circumferential soft-tissue thickening at the subglottic region with areas of increased enhancement (arrow). Note the presence of enhancing cervical neck nodes bilaterally (thin arrows).

Laryngeal stenosis and tracheal stenosis may be congenital or may be the sequelae of previous trauma or surgery.

Typically, a circumferential narrowing may occur. The length of such a stenosis is best assessed on coronal 2D reconstructions from volumetric data sets

LARYNGEAL STENOSIS

Contrast-enhanced axial image at the subglottic level shows massivecircumferential thickening of the subglottic soft tissues

Vascular malformations are classified on the basis of the predominant type of anomalous vessel, into capillary. venous. and lymphatic malformations.

Dyspnea and stridor are the most common presenting symptoms.

Venous malformations are seen in adults and may present as an isolated localized lesion in the supraglottic larynx or may be associated with extensive cervicofacial angiodysplasia .

Males are affected more often than females.

VASCULAR MALFORMATION

Arterial malformations are high-flow malformations. They include arteriovenous malformations and fistulae.

At imaging. enlarged tOrtuous arteries and draining veins are seen. The arterial components of these lesions appear as flow voids on MR imaging.

CONT’D

Venous malformation in a 58-year.-old man presenting with hoarseness. CT image at the supraglottic level demonstrates strong enhancement of a large mass involving the right false cord (arrowhead). Small arrowheads point to the aryepiglonic folds

Contrast-enhanced CT image demonstrates cervicofacial angiodysplasiawith involvement of the floor of the mouth (large arrowhead).right aryepiglottic fold (small arrowhead). and submandibular space (arrows).Phleboliths are indicated by the curved arrow.

Vocal cord paralysis can be categorized as superior laryngeal nerve deficit, recurrent laryngeal nerve deficit, Or total vagal nerve deficit. Paralysis of the recurrent laryngeal nerve is the most common type of vocal Cord paralysis.

The CT and MRI features of recurrent laryngeal nerve paralysis are explained by atrophy of the thyroarytenoidmuscle and include an enlarged ventricle, ipsilateralenlargement of the piriform sinus, paramedian position, and decreased size and/or fatty infiltration of the true vocal cord.

VOCAL CORD PARALYSIS

Contrast-enhanced CT scan at the level of the aryepiglottic folds (a), false cords (b), and undersurface of the true vocal cords (c) demonstrates a wide left piriformsinus(arrowhead), a paramedian position of the left false cord with a widened laryngeal ventricle (arrow), and decreased density of the left vocal cord corresponding to fatty infiltration. These findings indicate paralysis of the left recurrent laryngeal nerve.

Severe blunt injuries of the larynx are relatively uncommon and are most often due to motor vehicle accidents when the larynx and upper trachea are crushed against the spine.

Laryngeal contusion usually responds to conservative measures such as voice rest and head elevation, whereas laryngeal fractures with dislocation of fragments of cartilage are best repaired surgically within the first 24 hours.

LARYNGEAL TRAUMA

Patterns of laryngeal injury observed on imaging studies include submucosal hematoma, dislocation of joints, fractures of the laryngeal cartilages, and avulsion of the epiglottis.

Dislocation of the cricoarytenoid joint may occur with minor trauma and is straightforward to diagnose owing to the abnormal position of the arytenoid relative to the cricoid cartilage

CONT’D

Axial CT images (a-c) and coronal 2D reconstruction from volumetric data set (d) show a shattered thyroid cartilage (arrows) with posterior displacement of fragments resulting in airway narrowing. The cricoid cartilage is also fractured (dashed arrows) and there is lateral luxation of the fractured rightarytenoid cartilage (thin Arrow).

Squamous cell carcinoma of the larynx is primarily related to cigarette smoking.

The male to female ratio for laryngeal cancer is approximately 10 : 1

The attenuation values of squamous cell carcinoma on CT scans and its signal characteristics on unenhanced and contrast-enhanced MR images are very similar to those of normal mucosa

SQUAMOUS CELL CARCINOMA

Tumors originating from the laryngeal surface of the epiglottis (ventral supraglottic carcinomas) may be subdivided into tumors arising from the suprahyoid or free margin of the epiglottis, and tumors arising from the infra hyoid or fixed portion of the epiglottis.

The degree of preepiglottic space involvement by tumor may also affect the outcome of definitive radiation therapy in supraglottic squamous cell carcinoma.

SUPRAGLOTTIC CA

Axial contrast-enhanced CT image in the patient shows an enhancing tumor mass as it invades the preepiglottic space (arrow).

Axial unenhanced TlW SE image obtained in the same patient at the same level shows a tumor mass with an intermediate signal intensity as it extends into the preepiglottic space (thick arrow). Note the high signal intensity of the noninvadedparaglottic space due tothe high content of fatty tissue (thin arrow). d Axial Gd-enhanced TlW SE image at the SAme level shows enhancement of the tumor mass invading the preepiglotticspace.

Glottic carcinoma typically arises from the anterior half of the true vocal cord.

Glottic carcinoma primarily spreads ventrally into the anterior commissure.

Once the tumor has reached the anterior commissure, it may easily spread into the supraglottis or subglottis.

MRI is more sensitive than CT in detecting these early lesions.

GLOTTIC CA

CT image does not demonstrate the tumor. MRI (T2W SE image) nicely demonstratesthe small tumor as an area of increased signal intensity (block arrow). Noinvasion of the anterior commissure (arrow).

Axial contrast-enhanced CT scan at the glottic level shows a left-sided mass invading the anterior commissure (arrow) and the right vocal cord. The tumor mass also abuts the thyroid cartilage. b CT scan. obtained at a lower level. shows tumor extension into the anterior subglottic region (arrow).

The term "trans glottic carcinoma" generally refers to tumors that involve both the glottis and supraglottis at the time of diagnosis.

Some authors restrict the term "transglottic“ to tumors that originate from the laryngeal ventricle and grow primarily submucosally into the paraglottic space.

TRANSGLOTTIC CA

Involvement of the subglottis by laryngeal cancer usually represents inferior spread of a glottic or supraglottic tumor rather than a primary tumor originating in the subglottis.

Diagnosis of primary subglottic cancers may be delayed as patients present relatively late in the disease process with symptoms such as stridor, hoarseness, dysphagia, or palpable low cervical lymph nodes.

SUBGLOTTIC CA

Contrast- enhanced CT at the subglottic level shows circumferential subglottic tumor (T) with destruction of the cricoid ring and invasion of paralaryngeal strap muscles (arrow).

ATYPICAL SQUAMOUS CELL CARCINOMAS

Axial T1 W SE image. A tumor mass (T) with low signal intensity invades the right aryepiglottic fold and the paraglottic fat (arrow). N - large metastatic lymph node. bAxial T2W FSE image. Slight increase in signal intensity within the tumormass and within the metastatic lymph node. c Contrast-enhanced. axialTlW SE image. Moderate homogeneous enhancement without Intratumaralnecrosis. Deep submucosal biopsy revealed undifferentiated carcinoma of nasopharyngeal type

SPINDLE CELL - Axial contrast-enhanced CT image demonstrates a polypoid mass with moderate inhomogenous enhancement attached to the mucosa by a thin stalk (arrow).

BASALOID CELL - T1WSE image. A tumor mass involves the right piriform sinus and the retrocricoarytenoid region (arrows) and cricoid cartilage. b T1Wcontrast-enhanced SE image. The tumor mass has a distinct lobulated enhancement pattern. The tumor lobules (arrows) display amoderate enhancement. while the stroma surrounding the tumor lobules enhances significantly

Hemangiomas are neoplastic conditions characterized by an increased proliferation and Turnover of endothelial cells. and typically display a rapid proliferation phase during the first year of life followed by an involution phase.

As opposed to hemangiomas. vascular malformations are not tumors but true congenital vascular anomalies with a normal proliferation rate of endothelial cells .

Hemangioma of the larynx occurs in children under the age of 6 months. and is twice as common in females.

HEMANGIOMAS

INFANTILE HEMANGIOMA - Axial contrast enhanced CT image demonstrates a subglottic soft-tissue mass with v ry strong enhancement after injection of contrast material (arrowhead). characteristic of an infantile hemangioma.b T2W SE MR image obtained in the same patient demonstrates th typical high signal intensity observed in these lesions (arrowhead). The cricoid ring is indicated by open arrows. c Coronal T1W contrast-enhanced image demonstrates involvement of the subglottis (small arrowheads) and cervical trachea (large arrowheads). Arrow points to the right laryngeal ventricle.

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