larynx imaging 3rd part laryngeal neoplasm ct mri dr ahmed esawy

Diseases of the Larynx

• Traumatic

• Congenital

• Inflammatory

• Infectious

• Granulomatous

• Mucosal

• Neoplastic Dr Ahmed Esawy

Neoplasms of the Larynx

Benign Malignant

Papilloma Squamous Cell Ca

Minor S.G. tumors Neuroendocrine (e.g.

carcinoid, melanoma)

Granular cell tumor Chodrosarcoma

Chondroma Rhabdomyosarcoma

Hemangioma Lymphoma

Paraganglioma

Dr Ahmed Esawy

• Squamous cell

carcinoma is mucosal

disease

Dr Ahmed Esawy

Squamous cell carcinoma

• 90 % of all laryngeal neoplasm

• Mucosal / accessible to direct visualzation

• Imaging

• site of mass

• local extent (PES/PGS,subglottic,ant commissure)

• deep extent / extralaryngeal spread

• cartilage invasion (sclerosis of aryteniod suggest invasion)

• MRI detect fat invasion

• non palpable nodes

• secondary VS primary

• prebiopsy aviods confusion

Dr Ahmed Esawy

Spread:

• Direct to the adjacent areas of the larynx and extralarynx

• Lymphatic to the deep cervical LNs:

• Supraglottic to upper deep cervical LNs

• Glottic has no lymphatic drainage (eraly glottic cancer doesn’t spread to LNs) except after spread to the adjacent areas.

• Subglottic to the lower cervical LNs.

Dr Ahmed Esawy

• Supraglottic 60 %-70 % lymphatic spread 30 %

• glottic 25 %-35 % lymphatic spread 1 %

• subglottic 5 % lymphatic spread 30 %

Dr Ahmed Esawy

Sqaumous CCA

• Prognosis:

–Stage dependent

• T1,T2: >80% 5 yrs survival

• T3: 50-60%

• T4: < 40%

• N+: reduce prognosis by half

Dr Ahmed Esawy

Barium swallow

Delineate site and extent of the mass Dr Ahmed Esawy

Supraglottic carcinoma

• Includes : epiglottis

• FVC

• AE folds

• aryteniod cartilage

• Most arise from base of epiglottis and FVC

• Extention : preepiglottic space

• BOT

• piriform sinuses

• anterior commissure

Dr Ahmed Esawy


• More aggressive in direct extention

and nodal metastases

• 50 % present with nodes

• Often asymptomatic longer than

glottic tumours

• Overall survival rate 75 %

Dr Ahmed Esawy

Sqaumous CCA (TNM

staging)

T: primary tumor

Tx Cannot be staged

T0 No evidence of tumor

Tis Carcinoma in situ

Supraglottis

T1 Tumor confined to one subsite of larynx; normal mobility

(i.e., ventricular bands; arytenoids; epiglottis)

T2 Involving more than one subsite (supraglottis or glottis;

normal mobility)

T3 Linked to larynx with fixation or extension to involve

postcricoid, medial pyriform, or preepiglottic space

T4 Tumor invasion of cartilage or tissue beyond larynx

Dr Ahmed Esawy

Suprglottic tumour to widen thyroaryteniod gap and invade piriform sinus posteriorly

Dr Ahmed Esawy


Dr Ahmed Esawy

Coronal construction for craniocaudal invasion and paraglottic extention

Axial CT for lymph nodes

Dr Ahmed Esawy


Dr Ahmed Esawy

• Supraglottic squamous cell carcinoma. Enhanced CT (A) demonstrates a large necrotic epiglottic mass (arrows) completely filling the preepiglottic space and compromising the airway. Image (B) more caudal to previous slice reveals markedly thickened epiglottis and aryepiglottic folds (arrows) infiltrated with tumor.

• Supraglottic squamous cell carcinoma. Enhanced CT (A) demonstrates a large necrotic epiglottic mass (arrows) completely filling the preepiglottic space and compromising the airway. Image (B) more caudal to previous slice reveals markedly thickened epiglottis and aryepiglottic folds (arrows) infiltrated with tumor. A metastatic lymph node is also identified (asterisk).

• Supraglottic carcinoma. Enhanced CT demonstrates a soft-tissue attenuation mass (m) arising from the epiglottis and encroaching on the preepiglottic (black arrow) and paralaryngeal (double black arrows) spaces and right aryepiglottic fold (white arrow). Metastatic lymph nodes (asterisks) are also evident.

Supraglottic mass extending to thyriod cartilage

Coronal T1Tumour invasion

of PGS

• Supraglottic carcinoma. Large predominantly hypodense anterior epiglottic mass (arrows) fills the preepiglottic space at the level of the hyoid bone (H). The airway (white asterisk) is compressed by the lesion.

• Supraglottic carcinoma. Tumor thickens the left side of the epiglottis and

extends into the paralaryngeal space and left aryepiglottic fold (arrows);

normal right aryepiglottic fold (arrowhead).

• Localized false vocal cord tumor. Carcinoma involving the left false vocal cord (white arrows) obliterates the normal low-attenuation paralaryngeal space and bulges into the airway; normal right paralaryngeal space (arrowheads).

Supraglottic tumour with paraglottic spread into the lateral edge of the true cord

Dr Ahmed Esawy

Supraglottic carcinoma extending around the ventricle into the lateral cord

Dr Ahmed Esawy

Supraglottic tumour without cartilage invasion Dr Ahmed Esawy

Tumour involving the cartilage Dr Ahmed Esawy

Glottic carcinoma

• Involving : TVC

• anterior commissure

• posterior commissure

• 60-75% laryngeal carcinomas

• Present early with hoarsness

• Nodal META late

• 5 yr survival 85-90 % early

• 25-55 % late Dr Ahmed Esawy

Patterns of tumor invasion:

• anterior extension into anterior commissure

– >1 mm thickness of anterior commissure

– invasion of contralateral vocal cord via anterior commissure

• posterior extension to arytenoid cartilage, posterior commissure, cricoarytenoid joint

• subglottic extension – tumor >5 mm inferior to level of vocal cords

• deep lateral extension into paralaryngeal space

• Prognosis:T1 carcinoma rarely metastasizes (2%) due to absence of lymphatics within true vocal cords

Dr Ahmed Esawy

Sqaumous CCA (TNM

staging)

T: primary tumor

Tx Cannot be staged



Glottis

T1 Tumor limited to vocal cords, normal mobility T1a

one

cord T1b both cords

T2 Extension to supraglottis and/or subglottis; may be

impaired cord mobility

T3 Limited to larynx with cord fixation

T4 Extension beyond larynx or into cartilage

Dr Ahmed Esawy

Anterior commissure invasion (less than 1-2 mm normally)

Posterior two third of cord intact Dr Ahmed Esawy

Involve entire length of right cord ,

Medial displament of aryteniod

Anterior commissure invasion

Thyriod cartilage destruction Dr Ahmed Esawy

right cord carcinoma

Laryngeal vantricle

Aryteniod cartilage

Anterior commissure invasion Dr Ahmed Esawy

Glottic carcinoma

Dr Ahmed Esawy

Transglottic Carcinoma

• transglottic tumors exceeding 2 cm

in diameter frequently involve the

cartilage. The extent of these lesions

may not be fully appreciated

clinically due to submucosal spread

Dr Ahmed Esawy

• Anterior commissure not

more than 1mm

Dr Ahmed Esawy

• Carcinoma of the right true vocal cord with thyroid cartilage destruction. Mass involving the right true vocal cord invades the anterior commissure and destroys the right thyroid lamina (black arrowheads), and extends into the adjacent soft tissues (white arrowheads). Cortical thinning of the posterior aspect of the left thyroid lamina (arrows) is a normal variation and should not be interpreted as cartilage destruction

• Transglottic carcinoma, arytenoid cartilage involvement. CT scan shows a mass in the left vocal cord that extends to the thyroid cartilage (asterisk) and the left arytenoid cartilage (arrowhead). The mass escapes into the neck through the thyroarytenoid space (arrows). The left arytenoid cartilage is sclerotic compared to its companion on the right. This extensive mass also involved the supraglottic region.

• Transglottic carcinoma with cartilage invasion. CT scan reveals a soft-tissue mass (white arrows) thickening the mucosa and projecting into the airway at the level of the cricoid cartilage. This mass had spread from a glottic site and descended to the inferior margin of the cricoid cartilage. Note the cricoid sclerosis (arrowheads) and destruction with marrow replacement by tumor (black arrow) that marked the cartilage invasion.

• Transglottic carcinoma. Enhanced transaxial T1-weighted MR image (A) reveals a large supraglottic soft-tissue mass (arrowheads) that invades the left paralaryngeal space, the left thyroid cartilage lamina, and paralaryngeal muscles (arrow). Sagittal T1-weighted image (B) demonstrates the full extent of tumor (arrowheads) as it infiltrates to the level of the true cords.

PET

Increase FDG activity

Transglottic tumour : the tumour follows(arroe) the paraglottic space around The

ventricle widening the cord at the tumour infiltration .arrowhead represent The

approximate level of the ventricle

Dr Ahmed Esawy

Vocal cord lesion with subglottic extention

Tumour within the ring of criciod cartilage Note the intact fat planes (arrowhead) Dr Ahmed Esawy

Tumour of the anterior commissure extending

Dr Ahmed Esawy

• Anterior spread jeopardizes the anterior

commissure

• Posterior spread threatens the posterior

commissure,

Dr Ahmed Esawy

• Carcinoma left true vocal cord. Enhanced CT in a patient with a clinically fixed left true vocal cord. An enhancing mass (arrowheads) of the anterior left true cord extends laterally into the paraglottic space to the thyroid cartilage and anteriorly to involve the anterior commissure (arrow). The anterior right true cord is also involved. The thyroid cartilage is intact and not invaded by tumor. P, laryngeal prominence.

• Carcinoma true vocal cord, with involvement of anterior and posterior commissures. Left true vocal cord tumor extends posteromedially over the arytenoid cartilage toward the posterior commissure (arrows) and anteriorly across the anterior commissure (arrowhead).

• Assessment of cord mobility is

essential for cancer staging

Dr Ahmed Esawy

• T1 lesions imaging may demonstrate no abnormality or may show subtle asymmetry of the cords

• Causes for a false positive diagnosis of carcinoma include benign polyps and granulomatous disease

Dr Ahmed Esawy

• Glottic carcinoma.

• nodular irregularity of the true vocal cords (white arrows).

• The lesion is slightly hyperdense.

• Benign polyps may have an identical appearance.

• Glottic tumors may extend superiorly

to involve the paralaryngeal space

and supraglottis or inferiorly to

involve the subglottis

• Inferior extension greater than 8 to 9

mm anteriorly and 5 to 6 mm

posteriorly usually requires total

laryngectomy Dr Ahmed Esawy

Subglottic Carcinoma

• Incidence:5% of all laryngeal cancers

• Inferior glottis to inferior criciod

• late detection due to minimal symptomatology

• Prognosis:poor due to early metastases to cervical lymph nodes (in 25% at presentation) 5y {40 %

Dr Ahmed Esawy

Sqaumous CCA (TNM staging)

T: primary tumor

Tx Cannot be staged



Extension beyond larynx or into cartilage

Subglottis

T1 Tumor limited to subglottis

T2 Extension to vocal cord; mobility may be impaired

T3 Limited to larynx with cord fixation

T4 Extension beyond larynx or into cartilage Dr Ahmed Esawy


Dr Ahmed Esawy


• More commonly, subglottic tumors represent extensions from the glottic region or pyriform sinus

• Subglottic extension from glottic primary cancer is usually associated with cord fixation

• Patients often present with dyspnea, stridor, and pain; over 40% have cervical lymphadenopathy at initial examination

Dr Ahmed Esawy

• the cricoid cartilage must be intact

for successful conservative surgery.

Almost 50% of subglottic carcinomas

have cricoid or thyroid cartilage

invasion at clinical presentation

Dr Ahmed Esawy

Carcinoma right true vocal cords with subglottic extension

Destruction of thyriod

Sclerosis of the right aryteniod as well as criciod

Dr Ahmed Esawy

• Carcinoma true vocal cords with subglottic extension. Enhanced CT (A) demonstrates thickening of the anterior commissure (arrow) by a mass involving both true vocal cords.

• Carcinoma true vocal cords with subglottic extension. Enhanced CT

• (B) The mass descends into the subglottic region and perforates the cricothyroid membrane and inferior thyroid cartilage to invade the soft tissues of the neck (black arrowheads). Portions of the mass are hypodense due to necrosis. The airway (asterisk) is markedly narrowed. Prior radiation therapy has caused skin thickening (white arrowheads).

• no measurable soft tissue thickness should be demonstrated between the cricoid cartilage and the airway. Any soft tissue thickening or exophytic tissue should be considered carcinoma

Dr Ahmed Esawy

Special Issues in Cancer of the

Larynx and Hypopharynx

• The laryngeal cartilage integrity is an important feature of cancer staging. The presence of cartilage invasion implies a T4 lesion, which precludes conservative surgery .

• Moreover, irradiation of invaded cartilage may predispose to perichondritis and cartilage necrosis

• The thyroid cartilage is most commonly affected. Sites of invasion

Dr Ahmed Esawy

Hypopharynx carcinoma

• Most commonly from pyriform sinuses

• Involvment : piriform sinus apex

• postcriciod region

• esophageal verge

• larynx

• 50-78 % present with nodes

• Often present late

Dr Ahmed Esawy

• PYRIFORM SINUS CARCINOMA

Dr Ahmed Esawy

• Pyriform sinus carcinoma. Dense soft-tissue mass (arrowheads) partially effacing right pyriform sinus and infiltrating paralaryngeal space on enhanced CT. The mass approaches the right carotid artery (C) but does not involve the vessel. Normal left pyriform sinus (asterisk), normal left paralaryngeal space (p).

• A. Pyriform sinus carcinoma, with thyroid cartilage destruction and extralaryngeal extension. A: On T1-weighted MR image, a large hypointense tumor (t) is seen in the region of the right pyriform sinus. Fat within the medullary cavity in the posterior portion of the left thyroid lamina (small arrows) is high in signal intensity, whereas the right thyroid lamina is destroyed and its medullary cavity is replaced by low-intensity tumor (arrowheads). Distinction between the tumor and strap muscles is poor. Tumor abuts carotid artery (c) but does not involve its wall; internal jugular vein (J).

• B. Pyriform sinus carcinoma, with thyroid cartilage destruction and extralaryngeal extension. B: On T2-weighted image, the extralaryngeal extension of hyperintense tumor (large arrow) and the strap muscles (S) are better delineated. Contrast between the tumor and fat within the paralaryngeal space is decreased. C, carotid artery; J, jugular vein; SCM, sternocleidomastoid muscle.

• B. Pyriform sinus hypopharyngeal squamous cell carcinoma.

• a large hypopharyngeal mass (small arrowheads) extending posterolaterally to abut the left carotid artery (c) and displacing the barium filled hypopharynx to the right (arrows). A small left jugular lymph node is noted (large arrowhead).

• Hypopharyngeal carcinoma. CT demonstrates a large hypopharyngeal

carcinoma (arrowheads) that has grown posteriorly to involve the

retropharyngeal space.

Non-Squamous Cell

Neoplasms of the

Larynx

Dr Ahmed Esawy

lipoma

Homogenous non-enhancing lesion Of fat density seen at the level of right

Aryepiglottic fold with intact mucous memberne Dr Ahmed Esawy

• Lymphoma hypopharynx. A predominately submucosal right pyriform sinus mass (black asterisk) invades the preepiglottic and right paralaryngeal spaces (arrowheads) with effacement of the right pyriform sinus. Biopsy confirmed a diffuse large B-cell lymphoma. Left pyriform sinus (white asterisk).

• Multiple lesion suggest NHL

NHL

CT+C show bilateral large submucosal lesions

Infantile

hemangioma subglottic

2 month girl

Dr Ahmed Esawy

Axial contrast material-enhanced CT scan demonstrates

a strongly enhancing subglottic soft-tissue mass

(arrowhead), characteristic of infantile heniangioma

Axial T2

high signal

Coronal contrast-enhanced Ti-weighted MR image demonstrates

involvement of the subglottis (small arrowheads) and cerncal trachea

(large arrowheads). Arrow indicates the right laryngeal ventricle.

Supraglottic

hemangioma

58 y man

• hoarseness.

• (a) Axial CT scan obtained at the supraglottic level demonstrates

• a large, strongly enhancing mass involving the right false vocal cord (arrowhead). Arrows indicate the aryepiglottic folds.

Extensive cervicofacial angiodysplasia with

laryngeal involvement

cervicofacial angiodysplasia with involvement of the floor of the mouth (large

arrowhead), right aryepiglottic fold (small arrowhead), and submandibular space

(straight arrows). Curved arrow indicates phleboliths Dr Ahmed Esawy

AIDS-related laryngeal Kaposi sarcoma 24 y man

• Axial contrast-enhanced CT scan obtained at the supraglottic

level demonstrates a relatively strongly enhancing mass

involving the right false vocal cord (arrowhead).

Cartilage-derived lesions

• are rare and account for less than 10% of laryngeal submucosal lesions

• Chondrosarcomas

• Chondromas

• Chondrometaplasia is a benign condition in which nodules of cartilage arise in the laryngeal soft tissues

• Approximately 80% of these lesions arise in the cricoid cartilage, followed in frequency by the thyroid cartilage. Lesions in virtually all patients demonstrate coarse or stippled calcifications

Dr Ahmed Esawy

• Features differentiating

chondrosarcoma from cancer

include the generally

• older age at diagnosis,

• absence of smoking history,

• predominately calcified tumor matrix

Dr Ahmed Esawy

Chondriod lesion of criciod cartilage

Dr Ahmed Esawy

Chondrosarcoma : axial CT : tumour expands the thyriod lamina

B: note siplled density within the cartilage

Dr Ahmed Esawy

• Chondrosarcoma of the cricoid cartilage. CT demonstrates stippled calcification (arrowheads) within a large mass (small arrows) arising from the cricoid cartilage and extending into the extralaryngeal tissues. The thyroid cartilage (large arrows) is displaced anteriorly and to the left.

Chondrosarcoma of the cricoid cartilage

• Axial contrast-enhanced CT scan shows a large, hypoattenuating mass with coarse

calcifications, characteristic of chondrosarcoma.

• The mass arises from the cricoid cartilage and leads to significant airway obstruction (arrow).

CHONDROMA

OF CRICIOD

CARTILAGE

Dr Ahmed Esawy

Chondrosarcoma

of the

thyroid cartilage

Dr Ahmed Esawy

T1 lobulated, low-signal-intensity mass

arising from the right thyroid lamina

(arrowheads)

T2 tumor mass with very high

signal intensity, indicating high water content

Laryngeal

plasmacytoma

epiglottic tumor Dr Ahmed Esawy

Plasma cell

granuloma

epiglottis • L-shaped tumor mass with low

signal intensity involving the epiglottis (arrowhead) as well as the base of the tongue (arrow).

• the tumor with strong, homogeneous enhancement without evidence of large necrotic areas or gross ulceration (arrowheads).

Dr Ahmed Esawy

Adenoid

cystic carcinoma

• large primary subglottic tumor extending beyond the larynx (arrowheads) and invading the cricoid cartilage (*). No cervical lymph node metastases were seen at CT.

subglottic

tumor

Mucoepidermoid carcinoma subglottic

• Axial contrast-enhanced CT scan obtained at the level of the subglottis demonstrates a left-sided mass (arrowhead) with invasion of the cricoid cartilage (arrows);

Adenocarcinoma glottic

Dr Ahmed Esawy

Lipoma right aryepiglottic fold

• Axial contrast-enhanced CT scan obtained at the supraglottic level shows

a homogeneous, nonenhancing lesion isoattenuating to fat at the level of the right aryepiglottic fold (arrowhead).

Metastasis from melanotic

melanoma left aryepiglottic fold

Dr Ahmed Esawy

Metastases

• to the larynx usually occur in the terminal

stages of widely disseminated malignancy.

• Primary tumors include

• melanoma (30%),

• renal carcinoma (15%),

• lung carcinoma (10%),

• breast carcinoma (10%),

• prostate carcinoma (5%) (99).

Dr Ahmed Esawy

Metastasis from amelanotic

melanoma

Dr Ahmed Esawy

Granular Cell

Tumors of the

Subglottic Region

• Axial CT scan at level of subglottis shows enhancing mass (arrows) that extends Into strap muscles.

larynx imaging 3rd part laryngeal neoplasm ct mri dr ahmed esawy

Health & Medicine