This document provides information on various laryngeal pathologies that can be diagnosed using imaging techniques like CT and MRI. It discusses laryngeal cysts, laryngoceles, thyroglossal cysts, laryngotracheitis, epiglottitis, Wegener's granulomatosis, laryngeal stenosis, vascular malformations, vocal cord paralysis, laryngeal trauma, squamous cell carcinoma, supraglottic carcinoma, glottic carcinoma, transglottic carcinoma, subglottic carcinoma, atypical squamous cell carcinomas, hemangiomas and more. Imaging findings that help diagnose and characterize these conditions are also described.

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LARYNX
PATHOLOGIES
Dr. Avinash Gupta
Dept. of Radio Diagnosis
15th June 2012

2. Laryngeal cysts originate from the minor salivary glands
within the mucosa of the larynx. They may therefore be seen
anywhere within the larynx. Diagnosis of a salivary gland cyst
may be suspected clinically and imaging usually confirms the
diagnosis.
On CT, cysts demonstrate a low attenuation values (0-20
HU) and they show no enhancement after injection of contrast
material.
On MR, the cysts display a high signal intensity on
T2weighted images and variable signal intensities on TI-
weighted images owing to the variable protein content.
LARYNGEAL CYST

3. Laryngoceles occur as a result of elongation and dilatations of the
saccule (laryngeal appendix) of the laryngeal ventricle. A
laryngocele often forms due to obstruction of the laryngeal
saccule(laryngeal appendix) where it opens into the laryngeal
ventricle.
Sometimes a small cancer located near the neck of the saccule may
be responsible and thus becomes clinically manifest.
Laryngoceles are found in 2% of healthy individuals and
in 18% of patients with carcinoma of the larynx.
LARYNGOCOELE

4. Laryngoceles may contain air or fluid. In the latter case they are also
referred to as saccular cyst or laryngeal mucocele.
An internal laryngocele extends superiorly in the paraglottic space
and appears endoscopically as a submucosal supraglottic mass.
If the laryngocele extends through the thyrohyoid membrane into
the soft tissues of the neck, it is termed an external laryngocele
LARYNGOCOELE

6. Contrast-enhanced TlW SE MR image in a dyspneic 45-year-old man
shows a large, airfilled structure with thin, smooth, enhancing walls
(arrow) located in the supraglottic larynx. characteristic of an internal
laryngocele

7. Contrast-enhanced CT image in a severely dyspneic 4-day-old boy shows
a large, fluid-filled structure (calipter) with thin, smooth walls located in
the supraglottic larynx, characteristic of an internal congenital laryngeal
mucocele.

8. Contrast-enhanced CT images at the supraglottic level show a flUid-filled
dilated laryngeal saccule (arrow) extending through the thyrohyoid
membrane into the soft tissues of the neck (dashed arrow). There is slight
enhancement of the walls of the fluid-filled structure (mucocele and pyocele).

9. Contrast-enhanced T1W FSE MR images at the supraglottic level show an air-
filled laryngocele (arrows) extending through the thyrohyoid membrane into
the
soft tissues of the neck (dashed arrows).

10. Thyroglossal duct cysts arise from the thyroglossal duct
remnant. The infrahyoid thyroglossal duct cyst is typically seen
anterior to the larynx within or beneath the strap muscles.
It is located in the midline or slightly off the midline. Occasionally.
the cyst can bulge over the notch of the thyroid cartilage into the
preepiglottic fat space .
The paraglottic space is spared as opposed to the case with
laryngoceles which usually extend into the paraglottic space.
THYROGLOSSAL CYST

11. Contrastenhanced CT images at the level of the hyoid bone (a) and at the
upper supraglottic level (b) showing a midline cystic lesion (arrows).
without enhancing walls. xtending into the pre-epiglottic space at the level
of the thyroid notch (dashed arrow).

12. Laryngotracheitis or croup is an infection that occurs in the age
group 3 months to 3 years and is caused by a parainfluenza virus.
The onset is gradual with several days of upper and lower
respiratory tract symptoms followed by the development of a
classic barking cough and stridor.
The mucosal swelling is most significant in the subglottic area.
where airway narrowing causes the gradual airway tapering
described as the "wine bottle" when visualized on plain films.
LARYNGOTRACHEITIS

14. Epiglottitis or supraglottitis occurs in a slightly older age
group and is caused by Haemophilus influenza type B.
Diffuse thickening of the epiglottis and supraglottic larynx is
typically seen on plain films. Because total airway obstruction
may occur very rapidly, necessitating emergency
tracheostomy.
Patients with epiglottitis should always be investigated in the
emergency room.
EPIGLOTTITIS

16. Wegener granulomatosis is a necrotizing vasculitis that
causes inflammatory lesions. usually granulomas or areas of
necrosis in the respiratory tract and kidney.
It can involve the larynx. However. usually other areas of the head
and neck, such as the orbits and the paranasal sinuses, are involved
as well. Nevertheless. laryngeal involvement may be the initial
presentation of Wegener granulomatosis.
Clinically. the laryngeal lesions may be superficial or may present as
submucosal masses, most often in the subglottic region
WEGENER’S
GRANULOMATOSIS

17. Contrast-enhanced CT of the larynx and trachea reveals circumferential.
slightly irregular soft-tissue thickening at the subglottic region (arrow). as well
as at the
level of the cervical trachea (dashed arrow). Note irregular contours of the
cricoid posteriorly (arrowhead) and tracheal ring laterally (black stealth arrow).

18. Tuberculosis with laryngeal involvement in a 37-year-old woman presenting
in the emergency room with cough. hemoptysis. and severe dyspnea. a CT
of the
neck reveals a large bilateral laryngeal mass involving both false cords
(arrows). ventricles. and paraglottic spaces. radiologically indistingUishable
from squamous cell carcinoma.

19. AMYLOIDOSIS - Contrast-enhanced CT of the neck reveals
circumferential soft-tissue thickening at the subglottic region with areas of
increased enhancement (arrow). Note the presence of enhancing cervical

20. Laryngeal stenosis and tracheal stenosis may be congenital
or may be the sequelae of previous trauma or surgery.
Typically, a circumferential narrowing may occur. The length
of such a stenosis is best assessed on coronal 2D
reconstructions from volumetric data sets
LARYNGEAL STENOSIS

21. Contrast-enhanced axial image at the subglottic level shows massive
circumferential thickening of the subglottic soft tissues

22. Vascular malformations are classified on the basis of the
predominant type of anomalous vessel, into capillary. venous. and
lymphatic malformations.
Dyspnea and stridor are the most common presenting symptoms.
Venous malformations are seen in adults and may present as an
isolated localized lesion in the supraglottic larynx or may be
associated with extensive cervicofacial angiodysplasia .
Males are affected more often than females.
VASCULAR
MALFORMATION

23. Arterial malformations are high-flow malformations. They
include arteriovenous malformations and fistulae.
At imaging. enlarged tOrtuous arteries and draining veins
are seen. The arterial components of these lesions appear
as flow voids on MR imaging.
CONT’D

24. Venous malformation in a 58-year.-old man presenting with hoarseness.
CT image at the supraglottic level demonstrates strong enhancement of a
large mass involving the right false cord (arrowhead). Small arrowheads
point to the aryepiglonic folds

25. Contrast-enhanced CT image demonstrates cervicofacial angiodysplasia
with involvement of the floor of the mouth (large arrowhead).
right aryepiglottic fold (small arrowhead). and submandibular space (arrows).
Phleboliths are indicated by the curved arrow.

26. Vocal cord paralysis can be categorized as superior
laryngeal nerve deficit, recurrent laryngeal nerve deficit, Or
total vagal nerve deficit. Paralysis of the recurrent laryngeal
nerve is the most common type of vocal Cord paralysis.
The CT and MRI features of recurrent laryngeal nerve
paralysis are explained by atrophy of the thyroarytenoid
muscle and include an enlarged ventricle, ipsilateral
enlargement of the piriform sinus, paramedian position,
and decreased size and/or fatty infiltration of the true vocal
cord.
VOCAL CORD PARALYSIS

27. Contrast-enhanced CT scan at the level of the aryepiglottic folds (a), false cords
(b), and undersurface of the true vocal cords (c) demonstrates a wide left piriform
sinus
(arrowhead), a paramedian position of the left false cord with a widened
laryngeal ventricle (arrow), and decreased density of the left vocal cord
corresponding to fatty infiltration. These findings indicate paralysis of the left
recurrent laryngeal nerve.

28. Severe blunt injuries of the larynx are relatively uncommon
and are most often due to motor vehicle accidents when the
larynx and upper trachea are crushed against the spine.
Laryngeal contusion usually responds to conservative
measures such as voice rest and head elevation, whereas
laryngeal fractures with dislocation of fragments of cartilage
are best repaired surgically within the first 24 hours.
LARYNGEAL TRAUMA

29. Patterns of laryngeal injury observed on imaging studies
include submucosal hematoma, dislocation of joints, fractures
of the laryngeal cartilages, and avulsion of the epiglottis.
Dislocation of the cricoarytenoid joint may occur with minor
trauma and is straightforward to diagnose owing to the
abnormal position of the arytenoid relative to the cricoid
cartilage
CONT’D

30. Axial CT images (a-c) and coronal 2D reconstruction from volumetric data
set (d) show a shattered thyroid cartilage (arrows) with posterior
displacement of fragments resulting in airway narrowing. The cricoid
cartilage is also fractured (dashed arrows) and there is lateral luxation of
the fractured right

31.  Squamous cell carcinoma of the larynx is primarily related
to cigarette smoking.
 The male to female ratio for laryngeal cancer is
approximately 10 : 1
 The attenuation values of squamous cell carcinoma on CT
scans and its signal characteristics on unenhanced and
contrast-enhanced MR images are very similar to those of
normal mucosa
SQUAMOUS CELL
CARCINOMA

34.  Tumors originating from the laryngeal surface of the
epiglottis (ventral supraglottic carcinomas) may be
subdivided into tumors arising from the suprahyoid or free
margin of the epiglottis, and tumors arising from the infra
hyoid or fixed portion of the epiglottis.
The degree of preepiglottic space involvement by tumor may
also affect the outcome of definitive radiation therapy in
supraglottic squamous cell carcinoma.
SUPRAGLOTTIC CA

35. Axial contrast-enhanced CT image in the patient shows an enhancing
tumor mass as it invades the preepiglottic space (arrow).

36. Axial unenhanced TlW SE image obtained in the same patient at the same level
shows a tumor mass with an intermediate signal intensity as it extends into the
preepiglottic space (thick arrow). Note the high signal intensity of the noninvaded
paraglottic space due to
the high content of fatty tissue (thin arrow). d Axial Gd-enhanced TlW SE image at
the SAme level shows enhancement of the tumor mass invading the preepiglottic
space.

37.  Glottic carcinoma typically arises from the anterior half of
the true vocal cord.
 Glottic carcinoma primarily spreads ventrally into the
anterior commissure.
 Once the tumor has reached the anterior commissure, it
may easily spread into the supraglottis or subglottis.
 MRI is more sensitive than CT in detecting these early
lesions.
GLOTTIC CA

38. CT image does not demonstrate the tumor. MRI (T2W SE image) nicely demonstrate
the small tumor as an area of increased signal intensity (block arrow). No
invasion of the anterior commissure (arrow).

39. Axial contrast-enhanced CT scan at the glottic level shows a left-sided mass
invading the anterior commissure (arrow) and the right vocal cord. The tumor
mass also abuts the thyroid cartilage. b CT scan. obtained at a lower level.
shows tumor extension into the anterior subglottic region (arrow).

40.  The term "trans glottic carcinoma" generally refers to
tumors that involve both the glottis and supraglottis at the
time of diagnosis.
 Some authors restrict the term "transglottic“ to tumors
that originate from the laryngeal ventricle and grow
primarily submucosally into the paraglottic space.
TRANSGLOTTIC CA

41.  Involvement of the subglottis by laryngeal cancer usually
represents inferior spread of a glottic or supraglottic tumor
rather than a primary tumor originating in the subglottis.
 Diagnosis of primary subglottic cancers may be delayed as
patients present relatively late in the disease process with
symptoms such as stridor, hoarseness, dysphagia, or
palpable low cervical lymph nodes.
SUBGLOTTIC CA

42. Contrast- enhanced CT at the subglottic level shows circumferential
subglottic tumor (T) with destruction of the cricoid ring and invasion of
paralaryngeal strap muscles (arrow).

43. ATYPICAL SQUAMOUS CELL
CARCINOMAS

44. Axial T1 W SE image. A tumor mass (T) with low signal intensity invades the right
aryepiglottic fold and the paraglottic fat (arrow). N - large metastatic lymph node.
b
Axial T2W FSE image. Slight increase in signal intensity within the tumor
mass and within the metastatic lymph node. c Contrast-enhanced. axial
TlW SE image. Moderate homogeneous enhancement without Intratumaral
necrosis. Deep submucosal biopsy revealed undifferentiated carcinoma of
nasopharyngeal type

45. SPINDLE CELL - Axial contrast-enhanced CT image demonstrates a
polypoid mass with moderate inhomogenous enhancement attached to the
mucosa by a thin stalk (arrow).

46. BASALOID CELL - T1WSE image. A tumor mass involves the right piriform sinus
and the retrocricoarytenoid region (arrows) and cricoid cartilage. b T1Wcontrast-
enhanced SE image. The tumor mass has a distinct lobulated enhancement pattern.
The tumor lobules (arrows) display a
moderate enhancement. while the stroma surrounding the tumor lobules enhances
significantly

47. Hemangiomas are neoplastic conditions characterized by an
increased proliferation and Turnover of endothelial cells. and
typically display a rapid proliferation phase during the first
year of life followed by an involution phase.
As opposed to hemangiomas. vascular malformations are not
tumors but true congenital vascular anomalies with a normal
proliferation rate of endothelial cells .
Hemangioma of the larynx occurs in children under the age
of 6 months. and is twice as common in females.
HEMANGIOMAS

48. INFANTILE HEMANGIOMA - Axial contrast enhanced CT image demonstrates a
subglottic soft-tissue mass with v ry strong enhancement after injection of contrast
material (arrowhead). characteristic of an infantile hemangioma.
b T2W SE MR image obtained in the same patient demonstrates th typical high
signal intensity observed in these lesions (arrowhead). The cricoid ring is indicated
by open arrows. c Coronal T1W contrast-enhanced image demonstrates involvement
of the subglottis (small arrowheads) and cervical trachea (large arrowheads). Arrow
points to the right laryngeal ventricle.

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