imaging in laryngeal malignancy

1. Imaging in laryngeal
malignancy
Presenter:Dr Rutvij modh

2. • Introduction
• Anatomy
• Imaging

3. Introduction
• Cancers of the larynx constitute about 25% of all head and neck
malignancies. They commonly present in adults between 50 and 70 years and
show a strong male predominance.
• Over 90% of these cancers are squamous cell carcinomas (SCC). Tobacco
smoking and alcohol consumption are important risk factors for laryngeal
SCC. Patients with laryngeal SCC have a higher risk for synchronous
malignancies arising from the lung and upper aerodigestive tract.

4. • Majority of these SCCs are readily identified at endoscopy. Integration
of endoscopic findings with cross-sectional imaging to assess the
submucosal and loco-regional extent of the SCC improves the T
staging accuracy and influences the treatment decisions in these
patients.
• Imaging also provides information about the nodal disease, systemic
metastases, any synchronous tumors and recurrent disease.

5. • Laryngeal carcinoma is a relatively rare disease, but with a high
morbidity and mortality, that typically affects men over 50 years of
age with a history of tobacco and alcohol use; the association with a
second primary pulmonary tumor is frequent.
• The symptoms, often manifesting late, include hoarseness/dysphonia,
sore throat, dyspnea, dysphagia/odynophagia and/or a neck mass.
The symptoms, often manifesting late, include hoarseness/dysphonia,
sore throat, dyspnea and a neck mass.

6. Anatomy

7. LARYNX
SITUATION AND EXTEND
• Adult male- Extends from 3rd to 6th cervical vertebra.
• In children and adult females it lies at a higher level.
CARTILAGES OF LARYNX
• 3 Unpaired:- Thyroid, Cricoid, Epiglottic cartilages.
• 3Paired:- Arytenoid, Corniculate, Cuneiform.

8. THYROID CARTILAGE
• Largest of laryngeal cartilages.
• ‘V’ shaped.
• Right & left laminae.
• Angle between 2 laminae in males
is 90˚ and in females is 120˚.

10. THYROID CARTILAGE
• Superior cornu connected with greater cornu of hyoid (by thyrohyoid
ligament).
• Inferior cornu articulates with cricoid cartilage (cricothyroid joint).
• Oblique line:- Inf. constrictor, pretracheal fascia, sternothyroid and
thyrohyoid attached.

11. CRICOID CARTILAGE
• Signet ring shaped.
• Encircles larynx below
thyroid cartilage.
• Foundation of larynx.
• Only complete ring.
• Lower margin of cricoid
represents lower margin
of larynx.

12. EPIGLOTTIC CARTILAGE
• Most superior limit of larynx.
• Projects behind the hyoid bone &
tongue.
• Has multiple perforations, thus
not a major barrier to tumour
spread.
• Lower end is attached to angle
between the 2 laminae of the
thyroid cartilage.
• Primary supports:- hypoepiglottic
& thyroepiglottic ligaments

13. ARYTENOIDS
• Pyramid-shaped cartilages.
• Location:- upper border of
laminae of cricoid cartilage.
• Apex articulates with
corniculate.
• Base with cricoid laminae.

14. ARYTENOIDS
• 2 processes.
• Muscular process:- to which cricoarytenoid muscles are attached.
• Vocal process:- to which vocal ligaments are attached.

15. ARYTENOIDS
• Because of its characteristic shape and position it can help localize
ventricles on axial scanning.
• The upper margin of the arytenoid is at the level of false cord just
above ventricle.
• Vocal process is at the level true cord just below the ventricle.

16. Corniculate & Cuneiforms
Corniculate
• 2 small conical nodules.
• Articulate with the apex of
arytenoid.
• Lie in the posterior part of
aryepiglottic fold.
• May not be distinguished
in imaging studies.

17. Cuneiforms
• Rod-shaped cartilages.
• Lateral and cranial to corniculate, buried in AE folds.
• Almost never visualized in sectional imaging.
Corniculate & Cuneiforms

18. Histology & Ossification of Laryngeal Cartilages
• Thyroid, cricoid and basal parts of arytenoids are
hyaline cartilages.
• They may ossify after 25 yrs.
• Epiglottis, Corniculate & Cuneiform are elastic
cartilages.
• They do not ossify.

19. Histology & Ossification of Laryngeal Cartilages
• The first regions of the laryngeal cartilages to ossify are along the
lines of attachment of muscles.
• Cartilages are resistant to tumor invasion, while bones are not.
• Thus areas of ossified cartilage are more prone to direct tumor
invasion.

20. LARYNGEAL JOINTS
• True synovial joints and subject to diseases that may
afflict such joints.
• Cricothyroid joint:- permits rotatory movements around
a transverse axis and gliding movements.
• Cricoarytenoid joint:- permits rotatory movements
around a vertical axis and gliding movements.

21. Ligaments & Membranes of Larynx
THYROHYOID membrane and ligaments
• Connects thyroid cartilage to hyoid
bone.
• Median & lateral parts are thickened to
form ligament.
• Membrane is pierced by internal
laryngeal nerves and superior laryngeal
vessels.

22. Ligaments & Membranes of Larynx
INTRINSIC LIGAMENTS
Quadrangular membrane
• Extends from arytenoid to epiglottis.
• Lower free border forms vestibular fold.
• Upper border forms the support of aryeppiglottic fold.

23. CONUS ELASTICUS (Cricovocal membrane)
• Arises from the arch of cricoid
cartilage.
• Ends in the free edge of vocal
cord as a thickened elastic
band, Vocal ligament.

24. Hyoepiglottic ligament
• It is an elastic band connecting
the anterior surface of
the epiglottis to the upper border
of the body of the hyoid bone.

25. Thyroepiglottic ligament
• It connects the long and narrow
attached part or stem of
the epiglottis to the angle formed
by the two lamina of the thyroid
cartilage, a short distance below
the superior thyroid notch.

26. CAVITY OF LARYNX
• Extends from inlet of larynx to
cricoid.
• Upper fold – Vestibular fold
(False cord).
• Lower fold – Vocal fold (True
cord).
• Axially oriented parallel
structures situated along
cranio-caudal axis.
• Rima vestibuli
• Rima glottidis

27. RIMA GLOTTIDIS
• Narrowest part of laryngeal cavity.
• The rima glottidis is the opening
between the true vocal cords and
the arytenoid cartilages of the larynx.
• It is normally subdivided into two parts:
that between the arytenoid cartilages is
called the intercartilaginous part, and
that between the vocal folds the
intermembranous part or glottis vocalis.

28. Rima vestibuli
• It is the interval between the false vocal cords or vestibular folds.

29. Vocal Cord & Vocal ligament
• True cord converge anteriorly
to thyroid cartilage.
• Vocal ligament:- is a thin
fibrous band within the free
margin of true cord from
arytenoid to anterior
commissure.
• Aryepiglottic fold:- from
lateral margin of epiglottis to
arytenoid.

30. Sinus or Ventricle Of Larynx
• Fusiform cleft between vestibular and vocal folds.
• The anterior part of sinus prolonged upwards as diverticulum called Saccule
or appendix of larynx.
• Contains mucous glands, helps in the lubrication of vocal folds.
• Dilatation of saccule causes a supraglottic cyst called laryngocele.

31. Spaces of Larynx
PREEPIGLOTTIC SPACE
• Anterior space between ventral surface of epiglottis and
anterior boundary of larynx.
• The cranial limit of this space is thyrohyoid ligament.
• The caudal limit of this space is thyroepiglottic ligament.
• Filled with fat and has rich lymphatic network.

32. Spaces of Larynx
PARAGLOTTIC SPACE
• Represents deeper soft tissue of lateral wall of larynx.
• Bounded medially by, conus elasticus and laterally by thyroid
cartilage.
• Paraglottic region at the level of false cord is almost entirely
composed of fat.
• At the level of true cord, transverse arytenoid muscle fills the space.

33. Spaces of Larynx
PYRIFORM SINUS
• Mucosa-lined recess of hypopharynx.
• Between thyroid cartilage and aryepiglottic fold.
• Small amount of fat present just deep to the
mucosa.

34. REGIONS OF LARYNX
• Larynx is subdivided by 2 horizontal axial plane.
• One extends through apex of 2 ventricles.
• Other is 1 cm caudal to first plane.
• Supraglottic larynx – Cranial to first plane.
• Glottis is the region between 2 planes.
• Subglottis is between lower plane and
caudal margin of cricoid.

35. Supraglottic space
• The supraglottis extends from the epiglottis and laryngeal surface of
the aryepiglottic folds, through the laryngeal ventricle, and inferiorly
to the superior surface of the true vocal cords. It includes the
epiglottis, laryngeal surface of the aryepiglottic folds, arytenoids, and
false vocal cords.
• Supraglottic larynx subdivided into supra and infrahyoid regions.
• This subdivision is by Hyoepiglottic ligament.

36. Glottis
• Glottis extends from upper surface of true cord to a line 1 cm below
the level of ventricle.
• The glottis consists of the true vocal cords and the anterior and
posterior commissures.

37. Subglottis
• The subglottis extends from the inferior surface of the true vocal
cords to the inferior aspect of the cricoid cartilage; this region is
difficult to visualize at otolaryngologic examination.

38. MUSCLES OF LARYNX
THYROARYTENOID MUSCLE
• To the radiologist, most imp
muscle is Thyroarytenoid
because it is a landmark in
defining the level of true cord.
• TAM – most of the bulk of the
cord.

39. MUSCLES OF LARYNX
THYROARYTENOID
• Stretches from arytenoid to thyroid cartilage, paralleling vocal ligament.
• 2 belly
• Medial belly, vocalis.
• Lateral belly forms main bulk.

40. MUSCLES OF LARYNX
POSTERIOR CRICOARYTENOID MUSCLES
• Stretches from the cricoid to muscular
process of arytenoid.
• Totally responsible for abduction of true cord.
• Frequently identified on CT and MRI
CRICOTHYROID MUSCLE
• Only intrinsic muscle lying on the external aspect.
• Lateral cricoarytenoid, Interarytenoids, Aryepiglotticus
and Thyroepiglotticus.

41. NERVE SUPPLY OF LARYNX
Motor supply:-
• All intrinsic laryngeal muscles of larynx are supplied by recurrent
laryngeal nerve except cricothyroid.
Sensory supply:-
• Internal laryngeal nerve above the vocal fold.
• Below recurrent laryngeal nerve.

42. LYMPHATIC DRAINAGE
• The lymphatics of supraglottic larynx drain through thyrohyoid
membrane to upper jugular ..
• Subglottic lymphatics drain through cricothyroid membrane to
pretracheal and Para tracheal LN.
• Submucosa of true cord has no lymphatics.
• Preepiglottic and paraglottic spaces are rich in lymphatics, tumour
infiltrations common.

43. LYMPHATIC DRAINAGE
DELPHIAN .
• Anterior to cricothyroid membrane.
• Enlargment of this node:- an early feature of presence of subglottic
tumours.

44. .
Lingual Tonsil
.
.
.
.

45. .
Internal Jugular Vein
External Jugular
Vein
Sternocleidomastoid
Muscle
Epiglottis
(Free Margin)
.
.
.
.

46. .
.
.
.

47. Submandibular
Gland
Glossoepiglottic Fold
Pharyngoepiglottic Fold
Splenius Capitus
Muscle
SemispinalisCapitus
Muscle Semispinalis
cervicisMuscle
Multifidus
Muscle
.
.
.
.
.

48. Vallecula
Nuchal Ligament
.
.
.
.
.

49. Hypopharynx
.
.
.
.
.

50. .
Genioglossus
Muscle
Mylohyoid
Muscle
Sublingual
Gland
.
.
.
.

51. Aryepiglottic Fold
.
.
.
.
.

52. Piriform Sinus
Epiglottis
(Body)
Hyoid
.
.
.
.
.

53. .
Fat in preepiglottic
space
Laryngeal inlet
Mylohyoid and
Geniohyoid
muscles
Paralaryngeal
(Paraglottic) Space
.
.
.
.

54. Thyrohyoid,
Sternohyoid,
Omohyoid Muscles
Hypoepiglottic Ligament
.
.
.
.
.

55. .
.
.
.

56. .
.
.
.

57. .
.
.
.

58. Anterior Belly of
Digastric Muscle
.
.
.
.
.

59. Superior Cornu
of Thyroid Cart.
Laryngeal
Vestibule
Vestibular Fold
(False Vocal Cord)
.
.
.
.
.

60. .
.
.
.

61. True Vocal
Cord
Anterior
Commisure
(Thyroid Cart.)
Arytenoid
Cartilage
Glottis
Cricoid
Cartilage Cricopharyngeus
Muscle
.
.
.
.
.

62. Laryngeal tumors
• Squamous cell carcinoma (SCC) – >90%
•Non-squamous cell carcinoma (NSCC) – 2 -5%.
Chodrosarcoma ,Rhabdomyosarcoma
Lymphoma

63. CT
• This is obtained by using a small Field Of View (FOV) (18 cm), thin
overlapping sections (0.5-1 mm), a low pitch (about 1) and adequate
mAs/kVp (around 500/120, respectively).
• Patients are examined in the supine position, with the neck slightly
hyperextended (the imaging plane should be parallel to the vocal
cords) and the shoulders lowered as much as possible, preventing any
asymmetry; they should be instructed to breathe shallowly (to keep
the vocal cords open) and to avoid swallowing/ coughing.

64. • Good vascular enhancement/lymph node delineation can be obtained
in the arterial or venous/"early" interstitial phase (the latter being
more often used), but adequate tumor enhancement requires a
longer waiting period because it relies on both hypervascularization
and interstitial leakage of contrast ("late“ interstitial phase).

65. Staging of Carcinoma of Larynx
• T stage: Supraglottic Tumors
• T1 Limited to one subsite (structure)
• T2 Involvement of more than one
subsites or extension outside
• supraglottis (vallecula, base of tongue,
piriform sinus). Vocal
• cords not fixed.
• T3 Limited to larynx with fixed vocal
cords
• Any extension to pre-epiglottic space
or postcricoid
• T4 Invasion through thyroid cartilage
or involvement of soft tissues
• of neck, esophagus, thyroid
T stage: Glottic Tumors
T1 Limited to one (T1a) or both (T1b) vocal cords. Mobile vocal
cords
T2 Extension to supraglottic or subglottis, impaired vocal cord
mobility
T3 Limited to larynx with fixed vocal cords
T4 Invasion through thyroid cartilage or other neck structures
(pharynx, trachea, esophagus, thyroid)
T stage: Subglottic Tumors
T1 Limited to subglottis
T2 Involvement of vocal cords, not fixed
T3 Limited to larynx, vocal cords fixed
T4 Involvement through thyroid or cricoid cartilages, other neck
structures

66. • N stage
• N1 Ipsilateral lymph node up to 3 cm
• N2 Lymph node 3-6 cm (ipsilateral single or multiple), Any
• contralateral
• N3 Lymph node more than 6 cm
• M stage
• M0 No distant metastases
• M1 Distant metastases
• Stage Grouping
• Stage 1 T1, N0
• Stage 2 T2, N0
• Stage 3 Up to T3 or N1
• Stage 4 T4 or N2 (4a), N3 (4b) and M1 (4c)

67. Supraglottic Tumors
• These may arise from any muscosal surface of the supraglottic larynx but
epiglottis is the most common site of origin. Early tumors of epiglottis are
often seen on imaging as midline, well-defined enhancing nodules.
• With further spread, epiglottic tumors may spread superiorly to vallecula
and base of tongue and laterally to aryepiglottic folds, false vocal cords and
paralaryngeal fat deep to false vocal cords.
• Anterior extension of epiglottic tumors involves fat in pre-epiglottic space

68. • Any supraglottic carcinoma can directly extend to glottis and involve
true vocal cords. The glottic involvement may be anteriorly to anterior
commisure or posteriorly to involve cricoarytenoid joint; the later
results in fixity of the cord.
• Further inferior spread to subglottis however, is prevented till late by
conus elasticus.

69. • In supraglottic carcinoma, deep extension beneath the mucosa is
underestimated clinically and can be detected only on imaging.
• Important submucosal spaces that need to be evaluated on imaging include
pre-epiglottic space anterior to epiglottis and paralaryngeal spaces lateral to
aryepiglottic folds and false cords.
• These spaces normally contain fat and hence tumor invasion of these spaces
can be seen as partial or complete obliteration of fat.

72. Spread:
PES (Pre-epiglottic space)
Vallecula
base of tongue
PGS (Paraglottic space)
PES glottis or subglottis

73. Glottic Carcinoma
• True vocal cords are the most common site of laryngeal carcinoma.
• Most glottis carcinoma arise along the anterior free margin of the
true vocal cords. Small lesions result in thickening of the vocal cord on
imaging and large lesions may be seen as bulky masses.

74. • With anterior spread, glottis carcinoma readily involves anterior
commissure. From here, it may spread to contralateral vocal cord or
extend along tendon of the anterior commissure to thyroid cartilage
where this tendon is attached. This results in early thyroid cartilage
invasion.

75. • Glottic carcinoma may also arise at the commissure. Posterior
extension of the glottis carcinoma involves interarytenoid region
(posterior commissure) and crico-arytenoid joint. Glottic carcinoma
superiorly spread to ventricle and false vocal cords.
• It may also extend inferiorly to subglottic region, although it is
relatively uncommon

79. Subglottic Carcinoma
• Carcinoma primarily arising at subglottic larynx is rare and most are
extensions of glottic or supraglottic carcinomas.
• Primary subglottic carcinoma is seen as circumferential mucosal
thickening of the subglottis.
• Because of the close proximity, cricoid cartilage invasion occurs early.
It may also spread superiorly to involve glottis.

81. PET
Axial images with 18FDG and CT-coregistration: the tumor (g, arrow) and the lymphadenopathy (h, arrow)
are clearly visible as hyperaccumulating areas; two hyperaccumulating pulmonary lesions (i, arrows)
are also discovered in the right and left inferior lobe, respectively, suspicious for distant
metastases. Stage IVc

82. MRI
• Imaging MR imaging is also obtained with the patient supine and
during quiet respiration. Axial T2-weighted fast spin echo (FSE) and
T1-weighted FSE images are obtained with a scan orientation parallel
to the true vocal cords.
• Typical image parameters for a standard examination include a slice
thickness of 3 mm with a 1-mm inter-section gap. Additional axial fat-
saturated T1-weighted fast field echo (FFE) images after intravenous
administration of gadolinium chelates are obtained routinely.

83. Axial T1-weighted images before (c) and after (d) contrast injection: the tumor is better
visualized (heterogeneously enhancing) after contrast administration (d, arrow); the cricoid
cartilage shows minor post-contrast signal alteration (d, arrow head), but this finding is
not evident on unenhanced scans (c) and is more likely related to inflammation than
invasion. Stage cT1.

84. Imaging of Cervical Lymph Nodes
• Evaluation of cervical lymph nodes is important in patients with head
and neck carcinomas as it assesses the prognosis and help to select
the appropriate management.
• Imaging can indentify up to 20 percent of clinically silent metastatic
cervical lymph nodes and thus help to choose most appropriate
management.

87. Non-Squamous Cell Neoplasms of the Larynx
• Chondrosarcoma
• Chondrosarcomas are malignant cartilaginous tumours that account
for ~25% of all primary malignant bone tumours. They are most
commonly found in older patients within the long bones and can
arise de novo or secondary from an existing benign cartilaginous
neoplasm.
• On imaging, these tumours have ring-and-arc chondroid matrix
mineralisation with aggressive features such as lytic pattern, deep
endosteal scalloping and soft-tissue extension.

90. Rhabdomyosarcoma
• Rhabdomyosarcoma is the rare malignancy which can involve any part
of the body. About 30 percent of rhabdomyosarcoma occur in head
and neck with orbit and nasopharynx as the most common sites.
• These usually occur in young children but can also affect adolescents
and young adults.

91. • On imaging, nasopharyngeal rhabdomyosarcoma appear similar to
SCCA. These are seen as large aggressive locally infiltrating tumors
with variable contrast enhancement.
• Tumor extension to sinuses and skull base erosion are the common
findings

92. Lymphoma
• Both Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) can
involve cervical lymph nodes and imaging cannot differentiate
between nodes of HL and NHL.
• Lymphoma is the most common diagnosis in young patients
presenting with unilateral enlarged neck nodes.
• Extranodal lymphoma in head and neck is usually NHL and it is more
common in elderly. Waldeyer’s ring is the most common extranodal
site.

94. Post Radiotherapy Neck
• Radical (definitive) radiotherapy is the preferred treatment modality
for pharyngeal and laryngeal cancers and it involves delivery of high
radiation doses.
• Radiotherapy results in edema and fibrosis and it affects all areas of
pharynx, larynx and superficial soft tissues of the neck included in
radiation field.
• Acute affects of radiotherapy are characterized by inflammation,
increased capillary permeability of small vessels and lymphatics and
interstitial edema.

95. • After 4 to 6 months, there is sclerosis and fibrosis of the connective
tissues, obliteration of small vessels and lymphatics and resolution of
the edema. Degree of these changes depends on the total radiation
dose.

97. Postoperative Neck
• Variety of surgical procedures may be employed for the treatment of
pharyngeal tumors.
• Anatomical alterations and depend on type and extent of surgical
resection and this information should be available for interpretation
of post- operative scans.
• Postoperative pharyngeal wall is typically thin and smooth.
Myocutaneous flap reconstructions are seen as fatty, bulky areas.
• Neck dissection is a common procedure for the management of
cervical lymph nodes and exact postoperative appearance depends
on the type of neck dissection procedure

100. References
• DIAGNOSTIC RADIOLOGY Neuroradiology Including Head and Neck
Imaging; Manorama berry
• Laryngeal imaging David:2002; M. Yousem MD, Ralph P. Tufano MD
• Imaging in laryngeal cancers :2012; Varsha M Joshi, Vineet Wadhwa, Suresh
K Mukherji

101. THANK YOU