1.
Diseases of the Larynx
• Traumatic
• Congenital
• Inflammatory
• Infectious
• Granulomatous
• Mucosal
• Neoplastic
Dr Ahmed Esawy

2.
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

3.
•Squamous cell
carcinoma is mucosal
disease
Dr Ahmed Esawy

4.
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

5.
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

6.
• Supraglottic 60 %-70 % lymphatic spread 30 %
• glottic 25 %-35 % lymphatic spread 1 %
• subglottic 5 % lymphatic spread 30 %
Dr Ahmed Esawy

7.
Sqaumous CCA
• Prognosis:
–Stage dependent
• T1,T2: >80% 5 yrs survival
• T3: 50-60%
• T4: < 40%
• N+: reduce prognosis by half
Dr Ahmed Esawy

8.
Barium swallow
Delineate site and extent of the massDr Ahmed Esawy

9.
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

10.
Supraglottic carcinoma
• 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

11.
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

12.
Suprglottic tumour to widen thyroaryteniod gap and invade piriform sinus posteriorly
Dr Ahmed Esawy

13.
Supraglottic carcinoma
Dr Ahmed Esawy

14.
Coronal construction for craniocaudal invasion and paraglottic extention
Axial CT for lymph nodes
Dr Ahmed Esawy

15.
Supraglottic carcinoma
Dr Ahmed Esawy

16.
• 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.

17.
• 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).

18.
• 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.

19.
Supraglottic mass extending to thyriod cartilage

20.
Coronal T1Tumour invasion
of PGS

21.
• 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.

22.
• 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).

23.
• 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).

24.
Supraglottic tumour with paraglottic spread into the lateral edge of the true cord
Dr Ahmed Esawy

25.
Supraglottic carcinoma extending around the ventricle into the lateral cord
Dr Ahmed Esawy

26.
Supraglottic tumour without cartilage invasionDr Ahmed Esawy

27.
Tumour involving the cartilage Dr Ahmed Esawy

28.
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

29.
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

30.
Sqaumous CCA (TNM
staging)
T: primary tumor
Tx Cannot be staged
T0 No evidence of tumor
Tis Carcinoma in situ
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

31.
Anterior commissure invasion (less than 1-2 mm normally)
Posterior two third of cord intact
Dr Ahmed Esawy

32.
Involve entire length of right cord ,
Medial displament of aryteniod
Anterior commissure invasion
Thyriod cartilage destructionDr Ahmed Esawy

33.
right cord carcinoma
Laryngeal vantricle
Aryteniod cartilage
Anterior commissure invasion
Dr Ahmed Esawy

34.
Glottic carcinoma
Dr Ahmed Esawy

35.
Glottic carcinoma
Dr Ahmed Esawy

36.
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

37.
•Anterior commissure not
more than 1mm
Dr Ahmed Esawy

38.
• 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

39.
• 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.

40.
• 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.

41.
• 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.

42.
• 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.

43.
PET
Increase FDG activity

44.
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

45.
Vocal cord lesion with subglottic extention
Tumour within the ring of criciod cartilage Note the intact fat planes (arrowhead)
Dr Ahmed Esawy

46.
Tumour of the anterior commissure extending
Dr Ahmed Esawy

47.
• Anterior spread jeopardizes the anterior
commissure
• Posterior spread threatens the posterior
commissure,
Dr Ahmed Esawy

48.
• 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.

49.
• 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).

50.
• Assessment of cord mobility is
essential for cancer staging
Dr Ahmed Esawy

51.
• 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

52.
• Glottic carcinoma.
• nodular irregularity of the true
vocal cords (white arrows).
• The lesion is slightly hyperdense.
• Benign polyps may have an
identical appearance.

53.
• 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

54.
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

55.
Sqaumous CCA (TNM staging)
T: primary tumor
Tx Cannot be staged
T0 No evidence of tumor
Tis Carcinoma in situ
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

56.
Subglottic Carcinoma
Dr Ahmed Esawy

57.
Subglottic Carcinoma
• 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

58.
• 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

59.
Carcinoma right true vocal cords with subglottic extension
Destruction of thyriod
Sclerosis of the right aryteniod as well as criciod
Dr Ahmed Esawy

60.
• 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.

61.
• 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).

62.
• 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

63.
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

64.
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

65.
• PYRIFORM SINUS CARCINOMA
Dr Ahmed Esawy

66.
• 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).

67.
• 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).

68.
• 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.

69.
• 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).

70.
• Hypopharyngeal carcinoma. CT demonstrates a large hypopharyngeal
carcinoma (arrowheads) that has grown posteriorly to involve the
retropharyngeal space.

71.
Non-Squamous Cell
Neoplasms of the
Larynx
Dr Ahmed Esawy

72.
lipoma
Homogenous non-enhancing lesion Of fat density seen at the level of right
Aryepiglottic fold with intact mucous memberne
Dr Ahmed Esawy

73.
• 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

74.
NHL
CT+C show bilateral large submucosal lesions

75.
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.

76.
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.

77.
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 phlebolithsDr Ahmed Esawy

78.
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).

79.
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

80.
• Features differentiating
chondrosarcoma from cancer
include the generally
• older age at diagnosis,
• absence of smoking history,
• predominately calcified tumor matrix
Dr Ahmed Esawy

81.
Chondriod lesion of criciod cartilage
Dr Ahmed Esawy

82.
Chondrosarcoma : axial CT : tumour expands the thyriod lamina
B: note siplled density within the cartilage
Dr Ahmed Esawy

83.
• 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.

84.
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).

85.
CHONDROMA
OF CRICIOD
CARTILAGE
Dr Ahmed Esawy

86.
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

87.
Laryngeal
plasmacytoma
epiglottic tumorDr Ahmed Esawy

88.
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

89.
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

90.
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);

91.
Adenocarcinoma glottic
Dr Ahmed Esawy

92.
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).

93.
Metastasis from melanotic
melanoma left aryepiglottic fold
Dr Ahmed Esawy

94.
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

95.
Metastasis from amelanotic
melanoma
Dr Ahmed Esawy

96.
Granular Cell
Tumors of the
Subglottic Region
• Axial CT scan at level of subglottis shows
enhancing mass (arrows) that extends Into strap
muscles.