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Dav id J. D iSan tis , M .D .

D enn is M . B alfe , M .D .

R icha rd E . H ayden , M .D .

S tuart S . Sag el, M .D .

D onald Session s, M .D .

Jo seph K . T . L ee , M .D .

The N eck a fte r To ta l La ryngec tom y:

C T S tudy1

Com pu ted tom ograph ic scan s in 23 pa-

tien ts who had undergone to ta l laryng ec-

tom y were analyzed retrosp ectiv ely to

d eterm ine norm al postoperativ e appea r-

ance and to eva luate th e ro le o f C T in as-

.5 sessing recurren t n eop la sm . N in e pa tien ts

w ithou t c lin ica l ev id ence o f recu rrence

illu stra ted th e no rm a l po stoperative

changes: a round or ovo id neopharynx

connecting th e base of th e tongue w ith

th e cerv ica l esophagu s and in tac t fa t

p lanes su rround ing th e neopharynx , n eu -

4. rovascu lar bund les , and sterno cle idom as-

to id m uscles. In th e 12 patien ts w ith re -

cu rren t n eop lasm , the C T m an ifesta tion s

in cluded m asses invo lv ing th e in terna l

jugu la r lym ph node cha in (ad jacen t to th e

neopharynx , n eurovascu lar bund les, o r

sternoc le idom asto id m uscles) , tra cheos -

tom y site , o r paratrachea l reg ion . R ecur-

ren ce wa s m im icked on CT in tw o pa -

tien ts , on e w ith an ab scess and one w ith

m etastases from an adenoca rc inom a of

unknow n pr im ary site. In e ight patien ts,

a d istended neopharyngea l lum en co rre -la ted w ith ben ign or m alignan t s tr ictu re.

CT supp lem en ted phy sica l exam ina tio n

-4 -V and ind irec t m irror exam ination , p rov id -

ing data regard ing presen ce and exten t of

recu rren t tum or and a id ing in p lann ing

th e m ode and scope of th erapy .

Index term s: L arynx , com puted tom og rap hy ,

271 .1211 #{149}arynx , n eo p lasm s, 27 1 .3 7 #{149}arynx ,

su rgery #{149} eck , com puted tom og raphy

Radiology 1984; 153: 713-717

* 1 F rom the M allinckro d t Inst itu te o f R adio log y

(D .J .D ., D .M .B ., S .S .S ., J .K .T .L .) and the D epartm en t o f

O tola ryn gology (R .E .H ., D .S .), W ash ing ton U niversity

S choo l o f M ed ic ine , S t. L ou is , M O . R ece ived M arch 22 ,

1 984 ; accep ted M ay 17 , 1984 .

#{176}RSNA ,1984 ht

C LIN ICA L eva lua tion of pa tien ts fo llow in g to ta l lary ngec tom y (TL )

frequen tly is d ifficu lt. Pa lpa tion is lim ited by po stsu rg ical

scar rin g an d rad ia tio n fib ro sis, w h ile ind irec t m irro r exam ina tion fa ils

to eva lua te the m ore caud al p ortions of the ph arynx . E ven esopha-

go scopy an d b iopsy m ay fa il to de tec t tum or recu rrence (1 ).

R ad iograph ic stud ies m ay prov ide h e lp in eva lua ting these pa tien ts .

B arium exam ina tion a ids in defin ing fis tu las , stric tu res, and tum or

recurren ce invo lv ing the ph arynx and esophagu s (2 ); it can no t,

how ever, ad equa tely assess lym ph node en largem en t on ex trano da l

tum or sp read . W hile no t focus ing on po stla ryngec tom y pa tien ts, re -

cen t rep orts h av e dem ons tra ted the u tility o f po stopera tive neck

com puted tom ograph y (CT ) fo r assessm en t o f tum or recurrence (3 -5 ),

sim ila r to its es tab lished ro le in p rim ary la ry ngea l m alignancy (6 , 7 ).

C onsequen tly , w e h ave correla ted pos tla ry ngec tom y CT find ings

w ith c lin ica l, su rg ica l, and p atho lo g ic da ta in 23 pa tien ts , in o rd er to

d iffe ren tia te the norm al from the pa tho log ic pos to pera tive C T ap-

pearance .

SURG ICAL CONSIDERAT IO NS

Tota l laryngec tom y is perfo rm ed for la ryng ea l neop lasm s tha t,

because of s ize on loca tion , a re no t am enab le to conserva tion surgery .

In g en eral, tho se tum ors th at invad e the laryngea l can tilages, ex tend

sub g lo ttica lly abou t the crico id cartilage , o r cause vo ca l co rd fixa tion

are best m an ag ed by th is typ e of su rgery . T um ors tha t recu r a fte rconserva tion su rgery or rad ia tion therapy a lso are trea ted by to ta l

la ryngec tomy.

A fte r a low co lla r- ty pe inc ision and tn ach eo stom y, th e hy o id bo ne

is severed from th e sup nahyo id m u scu la tu re (F ig . la) . T he thyro id and

cn ico .id ca rtilages a re severed from the ir phary ngea l m uscu la r at-

tachm ents (F ig . ib ). T he inc ision is ex tended to encom pass the hyo id

bon e, ep ig lo ttis, anyep ig lo ttic fo ld s, pyn ifo rm fossae , thy ro id and

crico id cartilages, and true and fa lse vo ca l co rds . Th e resu ltan t an te rio r

phary ngea l defec t is c lo sed in lay ers: an inn er one of p haryng ea l

m ucosa ; a seco nd one com prising a v ariab le am ount o f cn icoph aryn-

g eu s and pharyng ea l co nstric to r m uscu la tu re ; an d an ou te rm os t layer

o f pen iphary ngea l co nnec tiv e tis su e. A con ical passagew ay ex tend ing

from the base of th e to ngue to the pro x im al esoph agus is fo rm ed , and

is te rm ed the n eo pharyn x (F ig . ic) (2 ) .

PAT IENTS AND M ETHODS

Review of the records from our institu tio n from 1980-1983 y ie ld ed 24 CT

stud ies o f the n eck in 23 pa tien ts w ho had undergon e to tal la ryngec tom y,

e ith er as prim a ry therapy for la ryn gea l c arcinom a or after fa i led rad iatio n

o r con servation surgery . T he popu lation inc lud ed 19 m en and fo ur w om en

w ith a m ean ag e of 6 4 yea rs. Tw enty p atie n ts had had rad iation th erapy as

w ell, and four had underg one u n ila te ra l rad ical neck d issec tion .

O f th e 23 pa tien ts , I 6 w ere re fe rred fo r C T eva lua tion because o f suspec ted

tum o r recu rrence , usu a lly because of sugg estive bu t incon c lu sive c lin ica l

eva lua tion s o n bec ause o f dysph agia . The exam ination w as requ ested to assess

ex ten t o f d is ease in tw o p atien ts w ith do cum en ted recurrenc e. F iv e asym p-

tom atic v o lu n teers w ere included a s a co ntro l g roup to def ine th e norm a l

pos to pera tive CT app earance .


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b.

‘4

I

-

Figu re 1

71 4 #{149}Radio logy Dec ember 1984

C.

///

II I

a and b . F ron tal (a) an d lateral (b ) dep ic tion s of the to tal lary ng ectom y procedure. Ii = hyo id b one ; m thy roh yo id m em brane; f = thyro id

car t i lage; c = c ric oid car tila ge; e ep ig lo t t is .

C. F orm a tion o f th e neo ph ary nx us ing m ucosal and m u scu lar la yers. ,i = neopharynx .

Genera lly , h ig h- reso lu t ion CT stu d ie s

w ere perfo rm ed w ith the pa tien t sup in e

and the neck ex tend ed ; scans w ere ob ta ined

from the ram i of the m andib le th rou gh the

upp er thorax to inc lude th e tracheos tom y

s ite . In tw o case s, the reg io n of th e tra ch e-

o stom y w as the a rea of clin ica l c onc ern , so

m ore cep halad lev els w ere n ot im aged .

Images w ere obtain ed using a 3-5 -secon dscan tim e , at 5 -m m inte rva ls w ith 5 -mm

collim a tion . In tra ven ou s con tra st m a ter ia l

w as adm in is tere d a t the d iscre tio n o f the

m on ito ring rad io log ist .

In the five n orm al vo lun tee rs, po sto per -

a tive fo llow -u p ran ged from 3.5 m onth s to

3 y ears w ith a m ean o f 1 8 m onth s. C lin ic al

fo llow -up after the C T scan in th is g rou p

averaged 4 m onth s. S ince gre ater than 9 0%

o f la ryn geal tum o r recu rren ces oc cur w ith in

2 years o f su rge ry or rad iat ion th erapy (8) ,

an d since the c lin ica l exam ina tio ns in these

asym ptom a tic pa tien ts rem ain ed u nre -

m ark ab le , they w ere th ought to define the

n orm al po sto pera tiv e ap pea ran ce. Th e re -

m ain ing 18 patien ts un derw en t op en bi-

opsy (12 c ase s), neck d issect ion (3 ca ses ),

p haryng oe sop hag oscop y (2 cases), o r en-

doscop ic b iopsy (1 case).

RESULTS

R etrosp ec tive ana lys is o f the po st-

la ryng ec tom y C T scans defined th ree

pa tien t g roup s: (I) those w ith n orm al

pos topera tive exam in a tion s; (II) pa -

tien ts w ith recu rren t tum or dem on-

s tra ted by CT ; (III ) p atien ts w ith CT

find ings m im ick ing tum or recur-

rence .

N orm al P ostoperativ e

Examina t ion s

In n ine pa tien ts th ere w as no s ig n

of tum or recu rrence ; th is g roup in -

c luded the f iv e asym ptom atic vo lun -

teens . In the vo lun tee rs , since no la -

ryn geal la ndm arks rem ained to act as

a gu ide , th ree leve ls hav e been chosen

to illu stra te the norm al pos to pera tive

appearance . T he m ost cep ha lad leve l is

a t the base of the ton gue , fo llow ed by

a m id neck leve l 2 -3 cm m ore caud a lly

and a low erm os t leve l a t the tracheos-

tom e, usua lly 3 -4 cm m ore caud a l.

Th e neophary nx is su tu red an ten i-

o rly to the base of the tongu e (F ig . 2a ).

It ap peared as a roun d or o vo id so f t-

tis su e m ass jus t ven tra l to the verteb ra l

body , o ften con ta in ing a sm all am oun t

o f a ir w ith in its lum en . In each of the

vo lun tee rs , sm alle r a ir co llec tio ns w ere

presen t ven tro la te ra l to the m ain neo-pharyn gea l lum en , rep resen tin g sm all

anas tom otic d iv er ticu la frequen tly

seen o n barium stud ies (2 ). W h ile the

fa t p lanes abo u t the v en tral on la te ra l

asp ects o f the n eo pharyn x w ere often

ind istinc t, no m asses abu tted th e neo-

ph arynx . T he fa t p lanes abo u t the

neunovascu la r bu nd les rem ain ed d is -

tin ct in fou r o f the five vo lun tee rs . In

on e case , a sm all a rea of con tac t be -

tw een the caro tid a rte ry an d neoph ar-

yn x in te rrup ted th e o therw ise in tac t fat

p lane . S im ila rly , the fa t p lanes sun-

roun d ing the s ten noc le id om asto id

m uscles rem ained in tac t in fo ur o f the

five vo lun tee rs . In o ne pa tien t the fa t

p lane d eep to th e righ t s te rn oc leido -

m asto id w as ob lite ra ted due to a partia l

neck d issec tion on tha t side (F ig . 2b).

Tw o to 4 cen tim ete rs m ore cauda lly

in the m id neck , the n eo pharyn x as-

sum ed a m ore roun ded configu ra tion

(F ig . 2c ). A lth ough th e fa t p lan es abou t

the neoph arynx w ere prese rved , the fa t

w as often som ew hat h igh er than non-

m al in a ttenu ation va lu e , p robab ly

secon dary to pos tsu rg ica l fib rosis . T he

fa t p lanes abou t th e neunov ascu lan

bund les an d the s tenn oc le idom as to id

m usc les w ere again prese rved .

A t th e leve l o f the tracheos tom e, the

re la tio nsh ip o f the trachea , eso phagus ,

neun ovascu la r bund les , and s te rn o-

c le id om asto id m usc les rem ained un -

a ltered (F ig . 2d). A lth ough no fran k

m ass w as p resen t, th e fa t p lan e be-

tw een the dorsa l asp ec t o f the s terno-

c le id om asto id m uscle and the neuno-

vascu lar bun d le w as ind istinc t in the

no rm al vo lun tee rs .

O f th e rem ain ing fou r pa tien ts in

th is g ro up , th ree w ere eva lu ated be-

cause of d ysp hag ia and one b ecause of

a ques tion ab le n eck m ass . T he pa tien ts

w ith dysphag ia d em onstra ted the ex-

pec ted pos topera tive CT ch anges;

how ever, the cepha lad p ortio n of the

neoph ary ng eal lum en w as d iste nd ed

w ith a ir. In each case , a ben ign s tric tu re



TABLE I: S ite o f R ecurren t T um or in 12

Patien ts

Site

N o. of

Patien ts

In tern al ju gu lar lym ph node s

(ad jac en t to neu rov ascu la r bun dle ,

neoph ary nx , or

ste rno cle idom asto id m usc le)

8

Pe ris tom al sof t t issue 3

Trachea 2

Mediast inum 2

N eck su bcutaneo us tis sue 2

b.

V olum e 153 N um ber 3 Rad io logy #{149} 15

o f the neo pha rynx w as d iagn osed b y

b arium exam in atio n and /on endoscop y

(F ig . 2e ). T h e pa tien t ev alu a ted fo r

question ab le neck m ass sh ow ed non -

m al pos topera tive ch an ges on CT , w ith

en dosco py and subseq uen t clin ica l

fo llow -up revealin g no tum o r recu r-

.1 rence.

Patien ts w ith R ecurren t Tum or

Tw elv e p atien ts had d ocum en ted

recu rren t on m eta sta tic neop la sm .

TA BLE I lis ts the site s in vo lved b y tum o r

and th e ir re la tive frequency . S eve ra l

pa tien ts h ad m ultip le site s o f invo lve -

m en t. M ost o ften (8 /12 ) , the tum o r w as

cen tered in th e in terna l jug u la r lym ph

node ch ain , effac ing th e n orm a l fa t

p lan es abo u t ad jacen t struc tu re s . In

each case, a m ass ob lite ra ted p a rt on all

o f the fa t p lane d eep to the ste rn oc lei-

dom asto id , on su rrou nd in g the neuro -

v ascu lar bu nd le (F ig . 3a and b). C on-

com itan t in filtrativ e en largem en t o f

the ste rnoc le idom as to id m usc le w as

presen t in f ive pa tien ts (F ig . 3c ). T um o ro b lite ra ted pa rt o r all o f the pen ineo -

pharyngea l fa t p lane in th ree instances

-‘-V (F ig . 3d ).

L ess frequ en t sites o f tum o r recu r-

rence in clu ded sub cu tan eo us m e ta sta-

ses ex terna l to the stennoc le idom as to id

m usc le (2 p atien ts ) an d pen is tom a l re -

cun rence (5 pa tien ts). In tw o stom a l

recu rrences , the tum o r w as m an ifes ted

as irregu la r th icken in g of the trach ea l

w a ll o r stom a l so ft tissu e, ex tend in g

in to the trachea l lum en (F ig . 3 e) , w h ile

the o th e r th ree h ad pen is tom a l m asses

ex tend in g deep to th e ste rn oc le ido -

m asto id m u sc le (F ig . 3 f) . Tw o o f th e

pa tien ts w ith s tom a-lev el recu rrences

. a lso h ad upp er m ed iastin al m e ta sta se s

tha t w ere no t c lin ically su spec ted (F ig .

3g ) .

In th ree pa tien ts in th is g roup , C T

dem onstrated the n eo phanyngea l

lum en to b e d is ten ded w ith a ir . B arium

exam in atio n resu lts w ere ava ilab le in

tw o o f these ; bo th dem on stra ted

m arked n arrow in g of the ce rv ica l

e sop hagu s, in o ne case d ue to b en ign

str ic tu re , and in the o the r ca se du e to

c ircum fe ren tial tum or recu rrence .

Figure 2

CT F ind ings M im ick ing

R ecurren t Tum or

Tw o pa tien ts had CT fin d ing s th a t

m im icked tum o r recu rrence . In o ne ,

in terna l ju gu la r lym ph ad en opa thy

o b lite ra ted the fa t p lan es abou t the

s ten noc le idom asto id m usc le and n eu-

n ovascu la r bun d le , a s in the G roup II

ca se s. B iop sy , how eve r , revea led m et-

a sta tic adenocanc inom a w ith no know n

a . N o rm al C T scan at base-o f-to ng ue leve l.

b = base of tong ue ; a in te rna l and ex-

tenn al caro tid a rte r ie s; v = jugu la r ve in ;

n = neopharynx lum en ; a rrow head neo-

pha ry ng ea l d iv erticu lum a t an as tom o sis

w ith ba se o f tong ue; s sternocleido-

m as to id m usc le .

b . A symm etry d ue to m od ifie d r igh t ne ck

dissect ion . N o te lo ss of the fat p lan e deep

to the righ t s tern ocleid om asto id m u scledue to lym ph nod e d issec tion . f pre -

served fat p lane deep to lef t s te rnoc le i-

dom asto id m usc le ( s) .

C. N orm al m idneck leve l. n neopharynx ;

a c aro tid a rte ry ; v ju gu lar v ein ; s

ste rno cle idom as to id m uscle .

d . N orm a l trach eo stom e lev el. s = sterno-

c leidom as to id m usc le ; v = ju gu lar vein ;

a caro tid artery ; arrow head air in

esop hagea l lum en .

e. Bar ium ph ary ngogram , latera l v iew of

neopharynx . n dila ted prox im a l n eo-

ph ary ngeal lum en; a rrow head s ben ig n

stric tu re a t the neoph arynx-ce rv ica l

esop hagus junc tion .

prim ary site . In the secon d case , a pe r-

ineophary ngea l so ft-tissue m ass w as

tho ugh t to rep re sen t m e ta sta tic d isea se

(F ig . 4 ). A t su rge ry , h ow ev er , it w as

fo un d to be an abscess w ith n o fo cu s o f

ma l i g n an cy .

In bo th o f these pa tien ts , the neo-

p ha ryn gea l lum en w as d istend ed w ith

a ir (F ig . 4 ). B arium exam in atio n re -

v ea led str ic tu res o f the n eo ph aryn x or

ce rv ica l e soph ag us in b o th cases.



e.

g.

I

.4

Figure 3

71 6 #{149}Rad io logy D ecem ber 1984

a. N ecro tic in tern al ju gu lar lym ph nod e m eta stas is o b li tera tin g ad jac en t fa t

p lan es. N o te the rim o f con tra st enh an cem en t. in metastasis; s ste rno -

c leid om asto id m uscle ; z’ ju gu lar vein .

b. Large n ecro tic in tern al jugu lar lym ph nod e m e tastasis. In p ro spe ct, th is w as

m isin terpre ted as in te rna l ju gu lar vein throm bosis. A t surgery , the m ass w as

com pre ssin g a sm all pa ten t ju gu lar ve in . m me tastasis; c c aro tid ar tery ;

S = s ternoc leidom as to id m u scle; g su bm andib u la r g lan d ; neopharynx ;

1’ = in tern al ju gu lar v ein .

C. In filt ra tive en la rgem ent o f the sternoc leidom as to id m usc le . m neoplast ic

m a ss; s = sterno cleidom as to id m usc le; r sm alle r re cur ren t tum or ad jacen t

to th e neo ph ary nx (n ) .

d. T um or recurrence obliterating th e p erineo pha ryn geal fa t p lan es. A rrow

neoph ary nx lum en w ith n aso gas tric tub e; a rrow head la rge d ive rtic u lum

of the n eo pha ryn x , ex tend ing cau dally ; in tum o r surro un din g the neo-

pharynx .

e. T rach ea l tum or re cur ren ce a t tra cheostom e lev el. A rrow head re cu rren t

tum or ; = esophagus.

f. Tum o r recu rrence ad jacen t to the stern ocleid om asto id m usc le and n eo pha ryn x

at c eph alad a spe ct o f tracheo stom e . m m alig nan t m ass; s sternocleido-

m asto id m uscle ; z n eo pha ryn x .

g. M ed iast ina l tum or re cur ren ce. in = m alig nan t m a ss ad ja cen t to th e trachea .

DISCUSS ION

Symm etry of neck stru ctu res p ro -

v ides a co nven ien t sta r ting po in t in CTeva lua tio n afte r to ta l la ryn gec tom y .

C onsequ en tly , in pa tien ts w ho h av e

no t had a m odif ied o r rad ica l neck

d issec tion , fa t p lanes abo u t the neo-

pha ry nx , sterno cle idom asto id m usc les ,

and neurov ascu la r bu nd le s shou ld b e

essen tia lly p re se rved b ila tera lly . E x-

cep tion s, a s d efined by th e five no rm a l

v o lun tee rs , w e re b lu rrin g of the p en -

neo pha ryng ea l fa t p lanes a t the leve l

o f the base o f th e ton gue an d of th e fa t

p lan e be tw een th e ste rnoc le idom asto id

m u scle and th e neck v es sels a t the tra -

cheos tom e lev el. T he p en ineoph aryn -

g ea l fat m ost o ften had a h ighe r than

no rm al attenua tion v alue , w hich w e

asc r ibed to po stsu rg ica l ch an ge . O b -v io usly , a frank m ass in th ese reg ions

shou ld ra ise susp ic io n o f tum or recu r-

n en ce .

R es idua l tum or a fte r to tal la ryng ec -

tom y for T -3 on T -4 lesio ns reported ly

is m anifest as loca l recurren ce ( in -

c lud ing stom a l recu rrence ) in 55% of

cases, and loca l n oda l d isea se in 65%

(7 ). In ou r stu dy , recu rren t tum or

g en era lly in vo lv ed th e in te rna l jugu lar

lym ph nodes (63% ), on the s tom al o n

pen istom a l reg ion (45% ). Th e absen ce

of cases o f recu rrence cen tered in the

neopha ry nx p ro bab ly ref lects se lectio n

b ia s , s ince cen tra l tum o r recu rrence

like ly w ould be obv iou s on barium

exam ina tion or m irro r ex am ina tion ,and thu s m ay no t be eva lua ted by

CT .

In th e 1 1 p a tien ts w ith tum or recu r-

nence , m asses effac ing th e fa t p lan es

abo u t the neopha ry nx , neunovascu lan

bund les, on stenno cle idom asto id m us-

des (o ften w ith in filtrativ e en la rge -

m en t o f the m usc le ) p rov id ed a re liab le

sig n of m e ta stases in vo lv ing the in -

tenna l jug u la r lym ph nodes. In v iew o f

the p rox im ity o f th ese no des to th e

neck vesse ls , w e now ro u tine ly use a

bo lus-dn ip techn ique of in trav en ous



Figu re 4

P erineo ph ary ngeal ab sces s m im ick ing a ne -

cro tic m e tastasis. a absc ess ; ii neopharynx

lum en , d is tend ed as a re su l t o f a d ista l stric-

tu re .

V olum e 153 N um ber 3 Radio logy #{149} 17

A t th e lev e l o f the tracheos tom e , in -

regu la r th icken in g o f the trach ea l w a ll

and pen istom a l so ft tissue , a lon g w ith

pe ritrach eal so ft-tissu e m asses, w e re

re liab le s igns of recurrence . The n e-

cess ity o f ob ta in in g scans a t an d be low

trach eostom y lev el w as bo rn e ou t b y

th e fiv e ins tan ces o f trachea l an d pe r-

is tom al tum o r, a s w e ll as b y the tw o

exam p les o f sup erio r m ed iastin al m e-

tas tases . In the la tte r c ircum stance , CT

obv ia ted attem p ts a t su rg ica l cu re an d

a ided in de linea tion o f rad iatio n th en -

apy porta ls .

In the tw o cases in w hich abscess and

m e ta sta tic adenoca rc inom a m im ick ed

tum or recu rrence , m asses w ere no ted

in the in te rn al jug u la r lym ph node or

p en ineop ha ry ngea l reg ions. E ven in

re tro spec t, n o d isting u ish in g fea tu re s

a llow ed d iffe ren tiatio n from m etasta tic

squam ou s-ce ll ca rc inom a . Clin ica l

h is to ry m ig h t a id in d iagn osing ab-

scess , w h ile b io psy w ou ld b e necessa ryto exc lude n onsq uam ous m eta sta se s.

W hile n o con tro lled tr ia l w ith com -

p an ison b arium exam ina tion s w as

don e, C T dem on stratio n of a d ilated

n eo ph aryn geal lum en w ithou t a sun -

rou nd in g m ass co rrela ted w ith b en ign

p osto pe ra tive str ic tu re in six pa tien ts .

This fin d ing m ay be im portan t in p a-

con trast enhan cem ent (4 ) in a ll pos t-

lary ngectom y p atie n ts , to as ses s vas-

cu lan in vasion be tter .

t ien ts w ith p ostop erative d ysp hag ia

bu t no dem onstrab le tum o r recu r-

rence.

In v iew of its ab ility to d is tin gu ish

norm al from patho lo g ic po stopera tive

ana tom y, as w ell as to assess the m ost

freq uen t site s o f recu rren t tum or, C T is

w e ll su ited to eva lua tion o f p atien ts

af te r to ta l la ryng ec tom y.

Dennis M . B alfe , M .D .

M a llin ck rod t Ins titu te of R adio log y

W ash ing ton U n ive rsity Sch ool o f M edicin e

51 0 South K ing sh ighw ay

S t. L ou is, M O 63110

References

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