Laryngeal carcinoma imaging with recent advances

1. LARYNGEAL CARCINOMA
IMAGING
PRESENTER-SHAURYA
MODERATOR- D.BHUYAN

2. INTRODUCTION
Cancers of the larynx constitute about 25% of all head and neck malignancies, 90% of these
being squamous cell carcinomas (SCC).
• Majority of these SCCs are readily identified at endoscopy,However Integration of
endoscopic findings with cross-sectional imaging helps to assess the submucosal and
loco-regional extent of the SCC improves the T staging accuracy.
• Imaging also provides information about the nodal disease, systemic metastases, any
synchronous tumors and recurrent disease.

3. HEADINGS FOR DISCUSSION
2)CROSS SECTIONAL IMAGING
1)ANATOMY INCLUDING EMBRYOLOGY
3)BRIEF INTRODUCTION OF CANCER
AND DIAGNOSTIC APPROACH
5)STAGING 4)INDIVIDUAL CARCINOMA IMAGING
6)MANAGEMENT
7)RECENT ADVANCES
AND CASE DISCUSSION

4. ANATOMICAL OVERVIEW
The larynx is a 5-7 cm long structure.
Its upper boundary starts at the tip of the epiglottis,
opposite the 3rd to 4th cervical vertebra, and lower end
at the lower border of the cricoid cartilage opposite the
6th cervical vertebra.
• Laryngeal skeleton is made of 6 cartilages and is
suspended from the hyoid bone by the medial and
lateral thyrohyoid membrane

5. IMPORTANT DIMENSIONS OF LARYNX
MALE FEMALE
AVERAGE LENGTH 44mm 36mm
TRANSVERSE DIAMETER 43mm 41mm
AP DIAMETER 36mm 26mm
VOCAL CORD LENGTH-CHILD 8mm 6mm
VOCAL CORD LENGTH-ADULT 17-23mm 15-19mm

6. PEDIATRIC V/S ADULT LARYNX
PEDIATRIC ADULT
SIZE Small Doubled that of Paediatric group.
LUMINAL SHAPE Conical/funnel shaped Cylindrical shaped
POSITION C1-C2(superiorly placed) Straighter
and less oblique
C3-C6
EPIGLOTTIS Omega Leaf shaped
THYROID Flat Shield like
ARYTENOID Large Small
MUCOSA AND SUBMUCOSA Lax Adherent
NARROWEST PORTION Subglottis Glottis
SOFTNESS AND SENSITIVITY Soft and more sensitive to spasm

7. VASCULAR SUPPLY
• The superior laryngeal artery arises from the superior
thyroid artery, a branch of the external carotid artery
and supplies the upper half of larynx.
• The inferior laryngeal artery arises from the inferior
thyroid artery, itself a branch of the thyrocervical
supplying the lower half of larynx.

8. • Venous drainage is by the superior and
inferior laryngeal veins.
• The superior laryngeal vein drains to the
internal jugular vein via the superior thyroid
vein
• whereas the inferior laryngeal vein drains
to the left brachiocephalic vein via the
inferior thyroid vein.

9. LYMPHATIC DRAINAGE
• SUPRAGLOTTIC AREA
• Superior lymphatics drain to the upper deep cervical nodes,
•
• GLOTIC AREA ( VOCAL FOLDS) is devoid of lymphatics.
• INFRA GLOTTIC AREA
• Drain to the pretracheal lymph nodes , paratracheal nodes
laterally and then to the deep cervical and superior
mediastinal nodes.
• DELPHIAN NODE
• A midline prelaryngeal lymph node, indicative of metastasis
from thyroid or laryngeal carcinoma.

10. NERVE SUPPLY
• Superior laryngeal nerve(4th branchial arch)
• 1) Internal branch (sensory) – areas above the glottis
• 2) Motor – Cricothyroid muscle
• Inferior (recurrent) laryngeal nerve(6th branchial arch)
- Motor – all intrinsic laryngeal muscles of same side
(except cricothyroid) and interarytenoid muscle of both sides
-Sensory – areas below the glottis

11. • During 4th wk, the tracheo-bronchial diverticulum appears in the ventral wall of primitive pharynx, just below
hypobrachial eminence. It is bounded by the hypobranchial eminence and laterally by sixth branchial arches.
• The groove gradually deepens,and the septum separates the laryngotracheal tube from the pharynx and
oesophagus which fuses caudally leaving a slit like aperture cranially.
• The process of this fusion starts caudally and extend cranially.
• The cranial end of tube forms larynx & trachea and the caudal end of tube forms bronchi & lungs
• Supraglottis is developed from buccopharngeal anlage(3rd and 4th branchial arch)and hence has extensive
lymphatic drainage.
EMBRYOLOGICAL CONSIDERATIONS

13. SKELETAL FRAMEWORK
• Laryngeal frame work consists of :
• Cartilages
• Joints
• Ligaments
• Membranes
• Muscles
• Mucous membrane
• Hyoid Bone

14. HYOID BONE
• The hyoid bone is suspended from the skull base via the stylohyoid
ligaments.
• It is an U-shaped bone with Body 2 lesser horns (cornua) 2 greater
horns (cornua)
Attachments include –
Middle constrictor muscle and the stylohyoid ligament attach to the
lesser cornu.
The hyoglossus muscles attach to the greater cornu.

15. CARTILAGES OF LARYNX
EPIGLOTTIS
• Oblong leaf shaped cartilage
• 2 surfaces—Lingual and Laryngeal
• Attached by thyroepiglottic ligament and hyoepiglottic ligament
• The inferior aspect is called petiole attaching it to thyroid lamina
• Grossly this cartilage has multiple perforations resembling a mesh so
epiglottic cartilage is not a major barrier to tumor spread.

16. THYROID CARTILAGE
• The upper limit of fusion of the two laminae forms the
superior thyroid notch,
Posterior border of each lamina extends upward and
downward to form the superior and inferior cornua.
• The superior horns are anchored to the hyoid bone; both
inferior horns articulate with the cricoid cartilage
• To the posterior surfaces of the thyroid laminae attaches the
2 vestibular ligaments,and the 2 vocal ligaments.

17. CRICOID CARTILAGE
• Shaped like a signet ring.
• The cricoid lamina has 2 superior facets– articulate with the arytenoid
cartilages and lower lateral facets with the thyroid cartilage.
• The lower border of the cricoid cartilage is joined to the first tracheal
ring by cricotracheal ligament.
• Arising from the arch of the cricoid cartilage anteriorly are the
cricothyroid muscles and lateral to it the bilateral posterior
cricoarytenoid muscles.

18. ARYTENOID CARTILAGES
• Almost pyramidal in shape
• Base has 2 processes: vocal ligament is attached
anteromedialy and Laterally projecting Muscular process –
lateral and posterior cricoarytenoid muscles are attached
• The apex of the arytenoid cartilage supports the
corniculate cartilage
• Attached to Anterolateral surface –thyroarytenoid muscle,
the vestibular ligament and Posterior surface — Transverse
and oblique arytenoid muscles

19. OTHER CARTILAGES
• CORNICULATE CARTILAGES ( OF SANTORINI )
• CUNEIFORM CARTILAGES (OF WRISBERG)
• TRITIATE CARTILAGE :an occasional cartilage
located in thyrohyoid membrane

20. LARYNGEAL MEMBRANES
• THYROHYOID MEMBRANE :
• It thickens anteriorly, forming the median thyrohyoid ligament and
thickened posterior margin is called the lateral thyrohyoid ligament
• THE CRICOTRACHEAL MEMBRANE : connects the most superior
tracheal cartilage with the inferior border of the cricoid cartilage

21. INTRINSIC MEMBRANES
CONUS ELASTICUS(CRICOVOCAL LIGAMENT)
• Conus Elasticus connects the cricoid cartilage with the thyroid and
arytenoid cartilages.
• Having 2 parts- 1 .Medial cricothyroid ligament
2. Lateral cricothyroid membranes
• Its free borders form the vocal ligaments

22. QUADRANGULAR MEMBRANE
• Extends from the sides of the epiglottic cartilage anteriorly
to the anterolateral surface of the arytenoid cartilage
• It forms the aryepiglottic fold superiorly and ventricular
ligament inferiorly.
• it forms the medial wall of the piriform recess.

23. LIGAMENTS & FOLDS OF LARYNX
• 1. EPIGLOTTIC LIGAMENTS AND FOLDS
• Hyoepiglottic ligament
• Thyroepiglottic ligament
• Median glossoepiglottic ligament
• Lateral glossoepiglottic or pharyngoepiglottic fold, attached
between the base of the epiglottic cartilage and the
pharyngeal wall at the root of the tongue

24. 2.ARYEPIGLOTTIC FOLDS
3. VESTIBULAR FOLDS (FALSE VOCAL CORDS). Attached in front to the thyroid cartilage
and behind to the anterolateral surfaces of the arytenoid cartilages.
The vestibular ligaments are separated from true cord by laryngeal ventricles.
They Overlap the true vocal folds just prior to a cough or sneeze — reinforcing the
resistance offered by the true vocal folds against the internal expiratory pressures

25. 4.VOCAL LIGAMENTS, VOCAL CORDS, AND VOCAL
FOLDS
• The thickened, upper edges of the conus are the vocal ligaments or vocal cords.
• Extend from the thyroid anteriorly to the apices of the arytenoid cartilages.
• Histologically 5 layers: LAYER 1: is the squamous epithelial lining.
• LAYER 2,3,4: composed of loose fibers and matrix
• LAYER 5: formed by the vocalis muscle
• Vocalis muscle represent medial fibres of thyro arytenoid muscle.
• At the anterior most portion of the vocal fold a mass of collagenous tissue is present--known as Broyle's
ligament which is devoid of perichondrium.

26. RIMA GLOTTIDES AND RIMA VESTIBULI
• The space between the true vocal is known as
the rima glottides.
• It is Subdivided into 2 parts, 2/5 –
intercartilaginous part (interarytenoid space),
and 3/5 — the intermembranous part
Rima vestibuli is the space between two vestibular folds.

27. LARYNGEAL MUCOSA
• It is mostly of the respiratory type called ciliated columnar epithelium
• Certain areas of the larynx covered with stratified squamous epithelium are-, dorsal
epiglottic surfaces, the ventral half of the aryepiglottic folds, and the vocal cords.
• Mucous glands are found at the posterior surface of the epiglottis, aryepiglottic fold,
and laryngeal appendices.

28. ANATOMICAL LARYNGEAL SPACES
• VESTIBULE:Pyramid -shaped space extends from the laryngeal aditus to the false vocal cords.
• LARYNGEAL VENTRICLES (sinuses of Morgagni): These are diverticula of the interval between
the false and true vocal cords.
The anterior end of the ventricle may possess an additional external expansion, the laryngeal saccule or
appendix
• SUBGLOTTIC (INFRAGLOTTIC) SPACE :From the glottis to the inferior border of the cricoid
cartilage

29. LARYNGEAL SUBDIVISIONS
• Larynx is divided into 3 parts by False ,True vocal
cords and ventricle
• On axial images, the superior margin of the Laryngeal
cavity is defined by a section through the apex of the
arytenoids, the false cords and the fat-filled
paraglottic spaces deep to the false cords.

30. INTRINSIC MUSCLES
• Adjust tension in the vocal ligaments
•
• Abductors Tensors
• Posterior cricoarytenoid Cricothyroid
• Adductors
Openers of inlet : Thyroepiglottic
Closers of inlet: Interarytenoid

31. CROSS SECTIONAL ANATOMY

32. ANTERIOR AND POSTERIOR COMMISSURE
• The anterior commissure is the midline
anterior meeting point of the true vocal cords.
• It comprises of the anterior cord, the anterior
junction of the two vocal cords, the thyroid
cartilage and the Broyle’s ligament.
• The posterior commissure is the mucosal
surface on the anterior surface of the cricoid
cartilage between the arytenoid cartilages.

33. POTENTIAL TISSUE SPACES
PARAGLOTTIC SPACES ( TUCKER’S SPACE)
• Located deep to mucosal surface
of false and true vocal cords.
• At the level of the supraglottic
larynx, the PGS is filled with fat.
Below the ventricle the TAM fills
the region.
• The PGS is continuous with the
extralaryngeal soft tissues
between the thyroid and cricoid
cartilages anterolaterally

34. PRE-EPIGLOTTIC SPACE ( BOAYER’S SPACE)
• The pre-epiglottic space
(PES) is a fat-filled space,
rich in lymphatics.
• The pre-epiglottic space
forms an inverted pyramid,
continuous with the
superior portion of the
paraglottic space deep to
the quadrangular
membrane.

35. REINKE’S SPACE
• It is the Sub mucosal space between mucosa and vocalis
muscle .
• Rienke space edema can cause vocal cord thickening
mimicking vocal cord invasion.

36. Sagittal section showing the epiglottis, valleculae, and base
of the tongue. Preepiglottic space is hyperintense
secondary to fat
. Coronal section

37. Axial T1-weighted slice of the
larynx showing the thyroid
cartilage (T), arytenoid (a), and
the thyroarytenoid muscle (M).
Axial slice (slightly lower than
Image 1) showing the cricoid
cartilage.
T1-weighted axial slice above Image
1 showing the epiglottis (arrow) and
the vallecula, the hypointense area
just anterior to the epiglottis

38. BRIEF INTRODUCTION TO LARYNGEAL CARCINOMA
• Majority of neoplasms are SCCs arising from the anterior third of the true cord along its
free margin.
• Verrucous carcinoma,Papillary SCC, adenocarcinoma, sarcomas, and lymphoma (vividly
enhancing bulky supraglottic mass) make up a small percentage of other tumors in this
region
• Verrucous carcinoma is an exophytic slow-growing variant of squamous cell carcinoma
having a typical exophytic “warty” appearance at direct inspection.

39. RISK FACTORS
Cigarette smoking
Tobacco chewing
Alcohol
Human Papilloma Virus 16 &18
Chronic Gastric Reflux
• Occupational exposures
• Prior history of head and neck irradiation
• Genetics/ Risk factors :Aneuploidy

40. NATURAL HISTORY
• Glottic carcinomas are the most common accounting for 59% with M:F ratio 4:1.
• Supraglottic tumors are more aggressive with -Direct extension into pre-epiglottic space, lateral
hypopharnyx, glossoepiglottic fold, and tongue base
-Lymph node metastasis
Glottic tumors grow slower and tend to metastasize late owing to a paucity of lymphatic drainage
• True subglottic tumors are uncommon and most are extensions of glottic tumors

41. SYMPTOMS
POINTERS TO DISEASE EXTENT
• Symptoms are more common in Glottic carcinoma than other tumours unless advanced.
• Hoarseness - Most common symptom
• Hemoptysis supraglottic tumors
• DysphoniaTVC/glottic lesions
• Airway Obstruction insidious subglottic tumors

42. APPROACH TO DIAGNOSIS OF LARYNGEAL CARCINOMA
Clinical
• Clinical examination followed by endoscopy is always the first step in T staging of laryngeal SCC.
• Small and superficial mucosal tumors may not be appreciated at CT or MRI and hence, it is
mandatory that an endoscopy is done prior to any imaging study
Layngoscopy- Indirect,Direct and Micro laryngoscopy(with aid of microscope)
Fibreoptic laryngoscopy and Video Stroboscopy

43. ENDOSCOPY
• Laryngoscopy
• Assessment of the lesion and mucosa surrounding the primary site
• Degree of alteration of mobility of the true vocal cord and arytenoid
cartilage
• Fiberoptic exam to look for: contour, colour, vibration, cord mobility,
lesions.
• Stroboscopic video laryngoscopy to look for subtle irregularities:
vibration, periodicity, cord closure

44. OPTICAL COHERENCE TOMOGRAPHY
• OCT uses near infrared light waves
combined with interferometry to produce
high-resolution images of larynx by
measuring backreflected light
• Allow visualization of thickness of
epithelium, basement membrane, and
lamina propria of vocal cord
Useful for diagnosis of hyperplasia, early
stage keratosis of vocal fold and helps in
detecting early stage carcinoma of vocal
cord
T2 squamous cell carcinoma of the left vocal fold; demonstrating
normal epithelium with an intact basement membrane on the right of the
image and loss of the basement membrane on the left.

45. RADIOLOGICAL DIAGNOSIS
• To know about the tumor extent (limitations of endoscopy)
• CT or MRI radiological criteria used for tumor involvement,include asymmetric soft tissue prominence or
thickening,abnormal contrast enhancement, a bulky mass, obliteration of the normal fat planes and spaces, or a
combination of these.
• MRI: - Better for differentiating high-density tumor vs fat in the preepiglottic space and Soft tissue invasion
• CT: cartilage destruction ,If cartilage invasion is imperative to be ruled out, MRI seems to be superior to CT
• PET-CT: -Residual disease and Recurrence

46. IMAGING PROTOCOLS
CT
• Evaluation of laryngeal SCC requires a contrast CT study of the neck using a multidectector CT (MDCT),
following the injection of an iodinated contrast agent (total dose 35-40 g).
• Axial scanning is performed from the skull base to the aortic arch with the acquisition plane parallel to the
plane of hyoid bone, to obtain scans parallel to the true vocal cords.
• The raw axial image is then reconstructed with a section thickness as little as 0.75 mm to obtain sagittal
and coronal reformatted images.
• A 512 × 512 matrix is used with a small field of view (FOV) between 16 and 20 cm. All images are reviewed
in soft-tissue and bone windows.

47. TISSUE CHARACTERIZATION
• False vocal cords, aryepiglottic folds, pre and para- epiglottic spaces are fat containing – hence
appear hypoattenuating
• Tumour on CT appears isodense.
• Ossified cartilages appear hyperdense in outer and inner cortex with a hypodense central area
• On Post-contrast there is no enhancement of mucosal surface of larynx.

48. E-PHONATION
• Indications
• Phonation is indicated when the true and false vocal cords are not clearly depicted
• Method
• This maneuver is performed by having the patient say “e” uniformly for at least 10 seconds
• Results
• With phonation,the true and false vocal cords are adducted and ventricles are filled with air and
allows accurate determination of the location of a supraglottic tumor or a glottic tumor.

49. Axial CT scan shows a tumor of the anterior
commissure However, the true and false vocal cords are
poorly seen, so the local extent of the tumor remains
undefined
phonation shows the right laryngeal ventricle The
tumor is located solely below the ventricle; therefore,
involvement of the supraglottic structures is ruled out.

50. MODIFIED VALSALVA MANEUVER
• Indications
• The modified Valsalva maneuver is to correctly evaluate the location and extent of a hypopharyngeal
tumor due to apposition of mucosal surfaces
• Method
• Expiration is performed against the resistance of pursed lips or a pursed nose
• Results
• The major effects of the modified Valsalva maneuver are to open the glottis and to distend the
laryngeal vestibule and piriform sinuses .

51. Axial CT scan obtained during quiet respiration
shows that the mucosal surfaces of the left
piriform sinus are apposed
During the modified Valsalva maneuver shows
tumoral thickening of the lateral wall of the left
piriform sinus

52. MRI
• Compared with CT, MRI allow better analysis of potential cartilage invasion
• Coronal and Axial T1 and Sagittal T2 sequences are used.Axial plane is parallel to vocal cords and
coronal plane perpendicular to the defined axial plane.Contrast enhanced T1 sequences are used.
TSE gives excellent information along with T2W.
• Fat suppression may be used both on T1 and T2W, for better appreciation of the higher signal
intensity coming from abnormal soft tissues that may be bordered by fat
• Neck surface coil is preferred with a section thickness of 4 mm and an interslice gap of 0-1 mm

53. • Sagittal images show the epiglottis, valleculae, and base of
the tongue well. It can also demonstrate the relationship
between the tumor and the anterior commissure.
• coronal view evaluates transglottic spread.
• Axial images, allows assessment of cartilaginous erosion.

54. TISSUE CHARACTERIZATION
• Hypopharyngeal and laryngeal mucosa show low to intermediate SI on T1WI, higher SI on
T2WI and significant post-contrast enhancement
• Muscular tissue and vocal cords show intermediate SI on T1 and T2WI, with no post-contrast
enhancement
• Fat containing structures as expected show high SI on T1 and T2W.
• Tumor, is dark or intermediate on T1W and is relatively brighter on T2W and enhances after
gadolinium(Becker criteria).Enhancement is homogenous in case of glottic carcinoma and
heterogenous in case of subglottic carcinoma.

55. MODALITY OF CHOICE?
• The choice of imaging modality is subject to the availability
of the CT or MR scanner and the expertise in interpretation
of the scans.
• Also the ability of the patient to tolerate an MR examination
and increased cost for MR is an additional disadvantage.
• The lack of ionizing radiation, greater inter-tissue contrast,
and multiplanar imaging are advantages of MRI over CT, but
long acquisition times limited the spatial resolution that
could be achieved.
• Motion artifact is a significant problem CT avoids this by
using fast imaging.

56. • Although speed of imaging is always an advantage of CT,
some have recommended using multiple excitations on
the T1W.
• This gives shorter imaging times but averages out some
of the motion.
• CT is the preferred imaging method for evaluating
laryngeal SCC and MRI is used as a complementary
problem-solving tool when CT does not provide all the
information .

57. USG
• High-frequency ultrasonography is used to evaluate the involvement of cervical lymph nodes,
soft tissues and thyroid but rarely to evaluate the tumour itself, mainly because of the calcified
thyroid cartilages and the air within the laryngeal cavities.
• Acoustic windows include the thyrohyoid membrane, cricothyroid membrane and superior and
middle parts of the bilateral lamina of thyroid, where the structure had less calcification .
• Bilateral hyperechoic ventricular bands and hypoechoic vocal cords with echoic fringes are
regarded as landmarks

58. a) Ventricular bands appear
hyperechoic. Paraglottic space
manifests as a hyperechoic layer of
fatty tissue.
b) The vocal cords (v) adducted is
shown during breath-holding
c)Vocal cords are symmetrically
abducted during breath-relaxing.

59. IMAGING EVALUATIONS
• Imaging evaluations included shape, margin, echogenicity and vascularity of the tumour on
ultrasonography images.
• Pathology includes formation of nodule, a mass or a thickened change.
• on Invasion of paraglottic space the linear hyperechoic fatty layer is interrupted by a
hypoechoic tumour and the interruption of hyperechoic lines in case of cartilage erosion.

60. Through the right thyroid cartilage, a tumour (T) is detected
in the right vocal cord and anterior commissure
Cartilage erosion

61. PLAIN RADIOGRAPH
a, vallecula;
b, hyoid bone;
c, epiglottis;
d, pre-epiglottic space;
e, ventricle
f, arytenoid;
g, cricoid; and
h, thyroid cartilage.
The best plain film view is given by the lateral
projection with the pharynx and larynx clear of
the cervical spine.
It helps to rule out subglottic airway
narrowing,epiglottitis and other conditions

62. BARIUM PHARYNGOGRAPHY
• Laryngeal abnormalities can cause dysphagia, odynophagia, and Globus sensation as a
result, barium examination of the upper GIT remains a common primary diagnostic tool
• The motility and pliability of the pharyngeal wall and the mucosal surfaces are assessed.
Tumor infiltration causes lack of pliability or distensibility, as well as mucosal irregularity.

63. The lateral wall of the piriform sinus demarcates the lateral margin of the hypopharynx. The entire bulk of the
larynx pressing on the anterior pharynx creates a coated mucosal surface known as the “postcricoid line”

64. Marked enlargement of the epiglottis
as well as surface nodularity,
particularly on its posterior surface
Mass in the right piriform sinus
displacing the right aryepiglottic
fold superomedially
Lateral image show a round mass
filling the right piriform sinus.

65. PET CT
• (18F-FDG PET-CT) has become an important diagnostic tool for evaluation of laryngeal
carcinoma.
• Limitations include complex anatomy of this region and the small size of the anatomical
structures, as well as the physiological uptake of 18F-FDG in normal organs
• Primary tumour assessment
• Distant metastasis assessment : The most common sites are lungs, bone
and liver

66. • Cervical lymph node assessment
• There is superiority of PET-CT.,however, small lymph node lesions may be missed , and that inflamed
lymph nodes may take up the tracer.
• Second primary tumour assessment
• Second primary tumours are more frequent in the head and neck region, oesophagus and lungs
• Treatment response assessment

67. • Prognostic significance of pre-treatment PET-CT
• various pre-treatment prognostic parameters including SUVmax and SUV mean. metabolic tumour
volume (MTV) and total lesion glycolysis (TLG).
• Maximum standardized uptake value (>10 g/mL) of the primary tumor, metabolic total volume (>20
cm3), total lesion glycolysis (>70 g), and uptake pattern (ring-shaped)carries bad prognosis.
• Radiotherapy planning
• Post-therapy follow-up

69. PET-CT shows intense 18F-FDG
uptake of the primary tumour. In
addition, a round solid
pulmonary nodule with high 18F-
FDG uptake is evident in the
apical segment of the lower lobe
of the right lung, suggesting a
metastatic lesion .

70. INDIVIDUAL CARCINOMAS
SUPRAGLOTTIC SCC
Supraglottic SCC may arise in the anterior compartment (epiglottis) or the postero-lateral compartment
(aryepiglottic fold and false cords).
• A.EPIGLOTTIC SCC
• These are anterior midline cancers that primarily invade into the pre-epiglottic space.
• The primary sign of PES invasion at imaging is replacement of the normal fat by abnormal enhancing
soft tissue

71. Axial contrast CT image
shows a lobulated enhancing epiglottic
mass filling the preepiglottic space
Axial contrast CT image in another patient shows the epiglottic
mass filling the right vallecula Enlarged necrotic deep cervical
node level II on the right side

72. SPREAD

73. B. ARYEPIGLOTTIC FOLD (AE FOLD) SCC
These cancers present as exophytic or infiltrative masses.
Supraglottic carcinoma not reaching the level of the ventricle or true fold.
Axial plane. Tumor (T) of supraglottis/aryepiglottic fold. N, metastatic node.

74. SPREAD
• They expand the AE fold and spread into the PGS. They may spread further anteriorly
into the PES or posteriorly to invade the piriform sinus

75. C. FALSE CORD SCC
• More extensive tumor may destroy
the thyroid cartilage and spread
transglottically into the glottis and
subglottis.
Axial contrast CT section
through the false cords shows a mass within the
right false cord and the right PGS

76. Submucosal spread into the PGS, destruction of the thyroid cartilage and spread
transglottically into the glottis and subglottis.
SPREAD

77. GLOTTIC SCC
• Glottic SCCs commonly arise from the
anterior half of the vocal cord and
spread into the anterior commissure
• Anterior commissural disease is seen
on CT or MRI as soft tissue thickening
of more than 1-2 mm.
Axial contrast CT image shows a glottis mass
in the left true cord reaching the anterior commissure

78. SPREAD

79. SUBGLOTTIC SCC
• Lymph node metastases are
common and affect the pre and
paratracheal nodes
• Hence,the neck CT should be
extended to include the superior
mediastinum.
• Subglottic cancer is diagnosed if
any tissue thickening is noted
between the airway and the cricoid
ring
Axial contrast CT image through the
subglottis shows a smooth well-defined enhancing
mass on the right side reaching anteriorly just below
the anterior commissure

80. SPREAD
• The tumour may spread causing
invasion of the cricoids, trachea and
the cervical esophagus with
extralaryngeal spread.
Axial CT image shows a circumferential
subglottic mass with destruction of the cricoid
and the thyroid cartilages and extralaryngeal
spread of tumor

81. TRANSGLOTTIC SPREAD
Laryngeal SCC encroaching on both, the glottis
and supraglottis, with or without subglottic
component and when the site of origin is
unclear, is termed as transglottic extension
• This tumor spread is frequently through the
PGS and is frequently accompanied by
metastatic lymphadenopathy.
Sagittal line diagram shows a large
supraglottic mass (red colour) spanning the glottis and
the subglottis

82. Coronal CT shows the entire
extent of transglottic mass spreading along the right
paraglottic space.The left paraglottic fat space is normal
• Coronal images are particularly helpful in
assessing transglottic extension of tumor
• Transglottic cancer precludes primary
radiation or partial laryngectomy

83. ADVANCED TRANSGLOTTIC SPREAD
mass in the supraglottis invading the
preepiglottic ,paraglottic space . Widened thyroarytenoid gap. subglottic extension

84. WEAK POINTS FOR THE SPREAD OF LARYNGEAL CANCER
• Broyle’s ligament has no perichondrium.
• Fenestrations within the infrahyoid epiglottis
• The thyrohyoid membrane through the superior laryngeal neurovascular bundle,cricothyroid
membrane,and through inferior pharyngeal constrictor.
• At anterior commissure ,the cartilage is prone to invasion at this site because the internal
perichondrium is deficient and the external perichondrium is thinner

85. TNM DEFINITIONS AJCC 8TH ED
Primary tumor (T)
• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ

86. • Supraglottic SCC
• T1: limited to one subsite of supraglottis, with normal vocal cord mobility:
• T2: invades mucosa of more than one adjacent area, with normal vocal cord mobility:
• subsite of supraglottis,Glottis,region outside supraglottis, e.g., base of tongue,vallecula
T3: limited to larynx with vocal cord fixation and/or invasion of any of the following:
• inner cortex of thyroid,Paraglottic space,Preepiglottic space,Postcricoid area

87. • Glottis
• T1: limited to Vocal cords with normal vocal cord mobility (may involve anterior or posterior
commissure)
• T1a: limited to one vocal cord
• T1b: involves both vocal cords
• T2: extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility
• T3: limited to larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner
cortex of thyroid cartilage

88. • Subglottic SCC
• T1: limited to subglottis
• T2: extends to vocal cord(s) with normal or impaired vocal cord mobility (no cord fixation)
• T3: limited to larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner
cortex of thyroid cartilage

89. • T4: moderately or very advanced
• T4a: moderately advanced local disease:
• invades through outer cortex of thyroid cartilage
• invades cricoid
• invades tissues beyond the larynx (e.g., trachea)
• T4b: very advanced local disease:
• invades the mediastinum
• invades the prevertebral space
• encases the carotid artery

90. REGIONAL LYMPH NODES (N)
• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis in a single ipsilateral lymph node
• N2a: Metastasis in a single ipsilateral node > 3 cm but ≤ 6 cm
• N2b: Metastasis in multiple ipsilateral nodes ≤ 6 cm
• N2c: Metastasis in bilateral or contralateral nodes ≤ 6 cm
N3: Metastasis in a lymph node > 6 cm

91. DISTANT METASTASIS (M)
• MX- Distant metastasis cannot be assessed
• M0- No distant metastasis
• M1- Distant metastasis

92. TREATMENT OPTIONS
• Functional/Organ Preservation
• Surgical (Partial resections)
• Non- Surgical (Chemo radiation)
• Other Aspects
• Management of nodal disease
• Post operative Radiation
• Palliation Chemoradiation
Partial resections
Supraglottic Partial Laryngectomy
Extended supraglottic partial laryngectomy
Three –quarters partial laryngectomy
Vocal cord stripping
Cordectomy
LASER resection
Vertical Partial
Supracricoid partial Laryngectomy
Near Total Laryngectomy
Supraglottic carcinoma
Premalignant lesions
Glottic carcinoma

93. PARAMETERS INFLUENCING TREATMENT OPTIONS
• Important parameters that influence the treatment strategies involve the T
staging,Nodal status and metastatic
• Also,the patient conditions influence the treatment options.
• Important parameters for T-staging include tumor in the laryngeal submucosal
spaces, spread across the commissures, cartilage invasion, transglottic, deep
subglottic and extralaryngeal extension.

94. T-STAGING PARAMETERS USED FOR PROGNOSIS OF DISEASE
Cartilage invasion
• Cartilage invasion is considered a contraindication to the standard hemilaryngectomies and
RT.
• Thyroid cartilage invasion is usually considered a contraindication to the supraglottic
laryngectomy. Whereas,Involvement of the epiglottic cartilage is not a contraindication.
• Minor involvement of the thyroid cartilage is not a contraindication.
• invasion of cricoid is considered contraindication for vertical laryngectomy

95. • Tumour tends to invade ossified cartilage rather than nonossified cartilage.Invasion of
ossified cartilage shows loss of bone density and loss of medullary fat density.
• The nonossified part of the cartilage can have approximately the same appearance as tumor
on CT .
• If there is bright signal on the T1W, that part of the cartilage is normal ossified
cartilage,tumor and nonossified cartilage are usually intermediate or dark.
• On fat suppression T2W sequences reveals normal cartilage dark and abnormal cartilage
higher signal. cartilage does not enhance with gadolinium, whereas tumor invading cartilage
does enhance to some extent

96. High signal of fat in ossified cartilage (OC on T1). OC and NOC have low
signal on fat-suppressed T2 MRI.
On T1 post contrast OC nor
NOC not enhance

97. • Edema, fibrosis, and even red marrow have been described with this similar pattern.
• Edema of the cartilage presumably means that tumor is close and, at least the
perichondrium has been invaded.
• The CT criteria of cartilage invasion include sclerosis, erosion, lysis and extralaryngeal spread.
• Sclerosis has low specificity (may be caused by peritumoral inflammation),Whereas erosion
and lysis are highly specific.

98. Edema same signal as tumour on T1 More signal intensity on T2 FS, More enhancement on
Post Gad

99. PRETREATMENT TUMOR VOLUME
• An increasing volume of the primary tumor correlates with an increasing rate
of local failure.
• Supraglottic cancers with pretreatment CT volume of ≤6 ml and glottic cancers
with volumes <3.5 ml have shown better results.
• Abnormal signal intensity of laryngeal cartilages at MRI correlates with poor
prognosis after radiation therapy if the tumor volume >5 ml.

100. VOCAL CORD FIXATION
• Mobility of Vocal cord is the single most important factor to decide choice of treatment
• In the supraglottic carcinomas, the cause of fixation is tumor invasion in the arytenoid
eminence and the second most frequent cause is extensive involvement of the TAM.
• In the glottic carcinomas, fixation of the ipsilateral vocal fold results from an extensive
invasion into the TAM
• It results also from invasion into the interarytenoid ,C/L arytenoid and cricoarytenoid joint.

101. NODAL FACTORS(N STAGING)
Nodal staging is the most accurate prognostic factor for SCC.
A axial diameter more than 10mm, a necrotic node and a node with indistinct spiculated margins are
the accepted radiological criteria to diagnose malignant nodes
• The overall accuracy of PET-CT in identifying nodal disease is higher than that of CT alone.
However most of nodes are <7 mm in diameter and PET-CT is not useful in evaluating these nodes.
• Currently, USG with FNAC is the most accurate method for evaluating metastatic disease in
subcentimeteric size nodes.

102. SYSTEMIC METASTASES (M STAGING)
• The single most frequent site for distant metastases in laryngeal SCC is the
lung, followed by bones and the abdomen.
• While a chest radiograph may suffice in patients with early cancer, a contrast
CT of the chest or whole body PET-CT is recommended in patients with
advanced laryngeal SCC.

103. POST-OPERATIVE IMAGING AFTER SURGERY
SUPRAGLOTTIC TUMORS
• The voice-sparing surgical option for supraglottic scc is the supraglottic laryngectomy which removes
supraglottis plus the upper third of the thyroid cartilage followed by thyrohyoidopexy.
• An extended supraglottic laryngectomy includes the additional resection of one arytenoid cartilage,
base of tongue , or the piriform sinus
• A three-quarters laryngectomy is performed when a supraglottic tumor extends to the glottis, true
vocal cord and arytenoid cartilage are resected .

104. Absence of the epiglottis neovestibule and thyroidhyoidopexy
CT FINDINGS AFTER SUPRAGLOTTIC LARYNGECTOMY

105. CONTRAINDICATIONS FOR SUPRAGLOTTIC
LARYNGECTOMY
• Tumor crossing the ventricle is the primary contraindication.
• Tumor extension onto the cricoid cartilage or thyroid cartilage invasion
• Bilateral arytenoid involvement or Arytenoid fixation
• Extension onto the glottis or impaired vocal cord mobility
• Involvement of the apex of the piriform sinus or postcricoid region

106. GLOTTIC CARCINOMA
• Classic vertical hemi laryngectomy is performed which removes the true cord the laryngeal ventricle
and false cord, and a small anterior portion of the contralateral cord.
• CT scans obtained after vertical partial laryngectomy shows-A vertical defect in the thyroid lamina
• Arytenoid cartilage on the involved side may or may not be depicted
• Last, the excised true vocal cord and a small portion of the contralateral cord are replaced by dense
scar tissue, called as pseudocord, with absence of normal paraglottic fat.
• In addition, preepiglottic space shows less fat, no aryepiglottic fold, and an asymmetric neovestibule

107. CT FINDINGS AFTER VERTICAL PARTIAL LARYNGECTOMY
Absence of the left aryepiglottic fold less
preepiglottic fat, and the neovestibule
pseudocord near the left inferior
thyroid cartilage
Anterior postsurgical defect
of the thyroid with sclerotic
border .

108. CONTRAINDICATIONS TO VERTICAL LARYNGECTOMY
• Tumor involving more than one third of the contralateral vocal cord
• Extension subglottically >10 mm anteriorly and >5 mm posterolaterally
• Thyroid cartilage invasion
• involvement of the cricoarytenoid joint, interarytenoid area, opposite
arytenoid, or rostrum of the cricoid is an absolute contraindication
• Vocal cord fixation.

109. SUPRACRICOID LARYNGECTOMY
• Supracricoid laryngectomy involves resection of the supracricoid structures followed by
cricohyoidopexy or cricohyoidoepiglottopexy.
• At least one but preferably both arytenoid cartilages are preserved.
Contraindications to supracricoid laryngectomy
Subglottic extension, Immobile arytenoid cartilage
Invasion of valleculae , base of tongue , posterior commissure or massively preepiglottic space.

110. CT FINDINGS AFTER SUPRACRICOID LARYNGECTOMY
Both arytenoid cartilages are visible , but the
thyroid cartilage is absent
cricoidhyoidopexy. The small notch in the left border of
the cricoid cartilage is a result of surgical manipulation.

111. NEAR TOTAL LARYNGECTOMY
• Pearson’s Near total laryngectomy includes resection of hyoid bone, vocal fold and take the
upper margin of the cricoid .
• Contralateral RLN, part of the thyroid lamina, arytenoid and a portion of the TAM are preserved
• From these structures, neolarynx. is constructed connecting the trachea to the pharynx
• On radiologic images, neolarynx appears as a circumferential soft-tissue structure
• Breathing is maintained through a permanent tracheostomy.

112. CT FINDINGS AFTER NEAR TOTAL LARYNGECTOMY
Remnants of thyroid lamina and
the arytenoid cartilage
Neolarynx seen as several concentric
soft-tissue layers
Tracheostomy tube

113. SUBGLOTTIC TUMOURS
• Only surgical option for subglottic ca is total laryngectomy which involves removal of the
hyoid bone,and whole of larynx and proximal trachea at least 1 cm beyond the tumor .
• The anterior wall of the hypopharynx is also removed.
• Contraindications to this type of surgery are metastasis and synchronous tumor.

114. CT FINDINGS AFTER TOTAL LARYNGECTOMY
• The anterior pharyngeal defect is closed with layers
of overlapping soft tissue and muscle to form
neopharynx, which extends from the tongue base to
the cervical esophagus.
• Here transverse tracheo-oesophagoplasty,is
performed for neolarynx A 'Neo-Epiglottis' is
constructed from the posterior tracheal wall and a
'Pseudo-Glottis' in the tracheo-oesophageal
partition wall with a valvular mechanism. Absence of the laryngeal framework and soft
tissues and of the thyroid isthmus.Neopharynx
is depicted as a concentrically layered soft-
tissue structure

115. REHABILITATION AFTER TOTAL LARYNGECTOMY
Airways and ventilation : Permanent Tracheostomy
• Voice restoration: For tracheoesophageal speech, a voice prosthesis is placed in the tracheo-oesophageal
puncture Eg-Blom-singer prosthesis,panje voice button.
others include - Electrolarynx. esophageal speech and larynx transplant
Oral feeding :Neopharynx is created
Smell and taste rehabilitation:"Polite Yawning" manoeuvre is created

116. NODAL DISSECTION
• Elective neck dissection of level II,III,IV nodal station are carried out for advanced supraglottic ca.
• Paratracheal nodes (level VI) should be dissected in cases of advanced subglottic cancer.
• Complete radical or functional neck dissections are almost never done.
• In more than 30% of supraglottic tumours, occult metastatic spread may occur into the contralateral
lymph nodes ,therefore contralateral elective neck dissection ”conditional dissection”is carried.

117. POST THERAPY IMAGING FOR RECURRENCE
• Surveillance is especially crucial in the first 2-3 years of treatment with best results within 2-3 months.
• A baseline pretreatment FDG PET CT is recommended to use for comparison at subsequent levels.
• Endoscopy remains the preferred method to diagnose mucosal recurrences
• on CT, focal areas of nodularity or soft tissue(>1cm) noted in the surgical bed,suggestive of recurrence.
• Treatment failure should be suspected if a 4-month CT scan demonstrates less than 50% reduction in
tumour size.

118. Post-treatment CT following
chemoradiation shows no obvious mass.
Post-treatment PET-CT shows an area of uptake
on the left side suggesting tumor recurrence

119. POST RADIATION CHANGES
• Post radiation changes includes edema, thickening and abnormal enhancement .
• Subtle reticulation or stranding of fat in the PES and the PGS is seen,causing increase in CT density
• The epiglottis, aryepiglottic folds and the arytenoids are swollen.
• Fragmentation, sclerosis lysis and dislocation of the cartilages may be seen suggesting the onset of
chondronecrosis.
• It can be differentiated form perichondritis in which there is progressive soft-tissue thickening
surrounding the cartilages associated with endolaryngeal focal tissue loss but no visible
cartilage alterations

120. Postradiation change showing the aryepiglottic
folds shows pronounced swelling .

121. BENIGN AND SUBMUCOSAL TUMORS
• Benign tumours include papilloma and plasmocytoma.
• The role of imaging in submucosal tumours is to confirm the mass, to determine the deep structures
involved,to guide for deep agressive biopsies,and to detect type of tumour.
Chondrosarcomas and chondromas arise from the cricoid followed by thyroid
This lesion usually shows coarse(popcorn)calcification and may compress the airways.
on MR,high signal intensity are noted on T2 corresponding to tumour matrix and low signal to stippled
calcification, With diffuse central or peripheral enhancement on T1W images

122. Adenoid Cystic Carcinoma. These arise in the minor
salivary glands of the subglottis and may show perineural
spread along RLN.
Hemangiomas, venous vascular malformations, and
paragangliomas enhance significantly on CECT scans.
Phlebolith are pathognomic for haemangioma and show
high signal intensity on T2 MR with inhomogenous contrast
enhancement on T1.Paraganglioma shows signal void on
T1 & T2.
• Other than these, soft tissue tumors including lipoma
do not have specific identifying characteristics. Chondrosarcoma of thyroid
cartilage causing its elevation

123. HYPOPHARYNGEAL TUMORS
The pyriform sinuses tumour may spread
submucosally into the posterior wall of the
hypopharynx, the postcricoid region, or the
aryepiglottic fold(medial wall)or invasion of thyroid
cartilage(lateral wall)
Postcricoid tumours may invade arytenoids and
posterior cricoid cartilage, causing vocal cord
paralysis and hoarseness.
A total laryngo-pharngectomy is most commonly
performed for post cricoid.
Tumor (T) of pyriform sinus protruding
through the thyroarytenoid gap and
invading the paraglottic space of
supraglottic larynx.

124. VOCAL CORD PARALYSIS
• Vocal cord paralysis can be due to
SLN deficit ,RLN deficit or total vagal
nerve deficit.
• The features of RLN paralysis includes
atrophy of TAM,PCA and include an
enlarged ventricle,ipsilateral
enlargement of the piriform sinus,
paramedian position of the true vocal
cord.
• In a patient with RLN of unknown
origin cross-sectional imaging should
be extended to the skull base and the
mediastinum. Axial and coronal contrast-enhanced T1W images show
atrophy of the right true VC ,enlargement of the ipsilateral
piriform sinus and right laryngeal ventricle

125. • Treatment may include injection of various
materials(Teflon) or even placement of fat to add
bulk to the paralyzed vocal fold
Radiodense VC injection displaces the true vocal fold medially.
The arytenoid is also slightly rotated
Several Prostheses (silicon)have been designed to reposition vocal cords
The dense
silicon
prosthesis is
“popped”
into a defect
cut through
the thyroid
cartilage(thyr
oplasty) and
left arytenoid
is pushed
medially

126. LARYNGOCELE
Laryngoceles are dilatations of the
saccule of the laryngeal ventricle due
to obstruction of the ventricle by
cancer located near the neck
• Laryngoceles may contain air or
fluid(saccular cyst) and may be
internal or external
On CT or MRI, a laryngocele presents
as a well-circumscribed, air- or fluid-
filled structure extending from the
laryngeal ventricle into the
paralaryngeal space (internal
laryngocele)
or through the thyrohyoid membrane
into the soft tissues of the
neck(external laryngocele)or mixed.
Internal larynocele causing a
submucosal bulge in the
supraglottic larynx.
Mixed laryngocele showing extension
through the thyrohyoid

127. RECENT ADVANCES IN IMAGING
MRI
• Dedicated coil in MRI consists of four identical loops to accommodate different neck sizes and to have a
high degree of isolation between elements to allow high acceleration and maintaining a high SNR
• In order to address movement artifacts, images are only obtained during exhalation
• Anterior-posterior phase encoding is used to reduce pulsatile artefact from flowing blood.
For TSE sequences, decreased slice thicknesses of 1 mm are chosen
.This results in maximum acceleration factor that results in artifact-free images,increased acceleration
and decreased time for scanning without causing unnecessary burden for the patients

128. EXTENDED MR SEQUENCES
Diffusion-Weighted Imaging (DWI) and Apparent Diffusion Coefficient (ADC)
Tumour on DWI appears hypointense and low ADC values on ADC maps
• cartilage edema on both DWI and ADC maps appears hyperintense
• Cartilage invasion appears hyperintense on DWI images but hypointense on ADC maps
• Thus,DWI can differentiate invasion from edema.

129. RECENT ADVANCES IN CT
Dual energy CT scan By two different energies we can differentiation
between tumour and non ossified cartilages.
Virtual laryngoscopy is a noninvasive technique providing visualization
of endolaryngeal surfaces and tumor extension by using CT scan.
Disadvantage includes limited mucosal resolution, also long time,and cost.
With a 64-channel multidetector row CT, imaging acquisition during
speech, swallowing, has become feasible.Diadvantage includes increased
radiation,and time.
supraglottic larynx carcinoma (arrows)

130. RECENT ADVANCES IN ENDOSCOPY
• Recent advances includes Narrow Band Imaging
Endoscopy,, Confocal Endomicroscopy, and Contact
endoscopy.
• Contact Endoscopy (CE) is capable of providing real time
and magnified images of cellular structure
• Narrow band imaging is used to penetrate the superficial
layer where it is absorbed by the capillary vessels in the
surface layer of mucosa.
Hypertrophic vessels in small vascular loops

131. RECENT ADVANCES IN ULTRASOUND
• Endolaryngeal high-frequency
ultrasound which includes 10-20 MHZ Usg placed
on the tip of endoluminal catheters .
• 360 degrees cross sections of the larynx were
obtained.
• All anatomical structures could be visualized up to a
depth of 2 cm.
Normal anatomy

132. CASE DISCUSSION
CASE 1
• A 48 year old male,presented
with history of
hemoptysis.History revealed
to be a chronic smoker.
• Laryngoscopy was done wich
revealed to be a supraglottic
ca.
• CECT was evaluated which
demonstrated tumour arising
from right aryepiglottic fold
but definite cartilage invasion
could not be confirmed.
• MR Contrast fat-suppressed
T1 image shows a mass
invading preepiglottic, right
paraglottic space with
Intracartilaginous signal
having similar intensity as
tumor.
• The tumour was staged to be
T4a due to cartilage invasion

133. CASE 2
• A 52 year old male ,chronic smoker,came with
hoarseness of voice since 5 years
• Layngoscopy was performed and now the
patient has come for CT evaluation
• Coronal CE-CT scan showing a transglottic
tumor spanning the right laryngeal ventricle,
involving the right false and true vocal cords,
and extending into the right paraglottic space
• The tumour was staged to be T3 due to
transglottic spread

134. CASE 3
• A 66 year old male
presented with dyspnoea
and stridor
• Coronal CT demonstrated
atrophy of the TAM on the
left side with ipsilateral
enlargement of the
ventricle
• Axial T1 image showed
PCA has atrophied on the
left side and is replaced by
fat .The PCA was normal on
opposite side
• The case was diagnosed to
be a case of Left RLN palsy

135. CONCLUSION
• Laryngeal SCC most commonly arising from the glottis.
• CT and MRI play a significant complementary role to clinical endoscopy in pretherapeutic staging.
• The checklist for reporting should include epicenter ,extent ,transglottic spread ,Pre-epiglottic and
paraglottic space , PC region and pyriform sinus, cartilage invasion, and Extralaryngeal spread including
nodal status.
• In addition, the radiologist also needs to be familiar with expected changes induced by surgical
resection and radiation therapy and with findings indicating recurrent disease.