Radiological imaging of the laryngeal diseases

Dr/ ABD ALLAH NAZEER. MD.

Supraglottis.Lingual and laryngeal surfaces of the epiglottis.Arytenoid fold.Arytenoid cartilages.False vocal folds.Ventricle.

Glottis.-True vocal cord.- Anterior commissure.- Posterior commissure.-Upper border: Floor of ventricle.-Lower border: 1 cm below apex of ventricle.

Subglottis.Upper border: Lower limits of glottis.Lower border: Inferior rim of cricoid cartilage.

Congenital disorders of the Larynx.Laryngomalacia-Most common congenital anomaly of the larynx-characterized by partial or complete collapse of thesupraglottic structures on inspiration.It is the most common cause of congenital stridor, accountingfor 60% of all casesMales 2x > female

LaryngomalaciaEtiology: Unknowntheories: GERD, Immature neuromuscular control

Immature neuromuscular control may be responsible for thearytenoid prolapse observed in laryngomalacia, although anincrease in the incidence of laryngomalacia does not occur inpremature infants who have classic hypotonicity.

Endoscopic view

Vocal Fold ParalysisEpidemiologyVocal fold paralysis is the second most common congenitalanomaly of the larynx, accounting for 15-20% of all cases.No gender difference exists in the prevalence of this anomaly.Up to 45% of patients have other, coexisting airway pathology,and so a formal microlaryngoscopy and bronchoscopy is essential.

Bilateral TVC Paralysis:Etiologyusually idiopathic. may also occur secondary to central neuromuscular immaturity.lesions in the central nervous system, including Arnold-Chiari malformation, hydrocephalus or myelomeningocele, Birth trauma that causes excessive strain to the cervical spine may cause transient bilateral vocal fold paralysis lasting 6-9 months.Clinical presentationBilateral vocal fold paralysis manifests as an inspiratory stridor at rest that worsens upon agitation in children with near-normal phonation and progressive airway obstruction.Aspiration is common with bilateral vocal fold paralysis, often resulting in recurrent chest infections and a failure to thrive.

Unilateral TVC ParalysisEtiologyusually idiopathic.Lesions in the mediastinum, such as tumors or vascular malformations, Iatrogenic injury to the left recurrent laryngeal nerve can occur during surgery for cardiovascular anomaliesClinical presentation:Unilateral TVC paralysis may manifest during the first few weeks of life, or it may go unnoticed. The most common symptoms are a hoarse, breathy cry that is aggravated by agitation. Feeding difficulties and aspiration may also occur.

Left vocal Fold Paralysis.

Vocal Fold Paralysis.

Bilateral Vocal Cord Paralysis

Congenital Subglottic StenosisEpidemiologyis the third most common congenital anomaly of the larynx, accounting for 15% of all cases.This condition is the most common laryngeal anomaly that requires tracheotomy in infants.Males affected 2x > as females.

EtiologyIncomplete recanalization of the laryngotracheal tube during the third month of gestation leads to different degrees of congenital subglottic stenosis, with complete laryngeal atresia being the extreme form

Classification CSS can be classified into 2 types.1) Membranous CSS is the result of circumferential submucosal hypertrophy with excess fibrous connective tissue and mucus glands. This type is the most common and mild form of congenital subglottic stenosis.

2) Cartilaginous CSS results from an abnormal shape of thecricoid cartilage. The cartilage usually narrows laterally but may also develop generalized thickening or excessively large anterior or posterior laminae.While the lumen at the midportion of the cricoid cartilage is normally elliptical, In some infants with congenital subglottic stenosis, an elliptical cricoid is present with a transverse diameter that is significantly smaller than the anteroposterior diameter,

CSS defined as:-term infant = lumen diameter is < 4 mm-preterm infant = lumen diameter < than 3 mm.The stenosis is then graded:grade I = less than 50% obstruction;grade II = 52% to 70% obstruction;grade III = 71% to 99% obstruction;grade IV = no detectable lumen.

Idiopathic subglottic stenosis.

Subglottic HemangiomaEpidemiologySubglottic hemangiomas account for 1.5% of all congenital anomalies of the larynx.Females are affected 2x > males. Etiology and pathogenesis: Subglottic hemangiomas develop as a result of a vascularmalformation derived from the mesenchymal rests of vasoactive tissue in the subglottis.

DiagnosisWhen the diagnosis is unclear, perform biopsy of the lesion with caution because of the risk of significant hemorrhage.Plain radiographs of the neck may show an asymmetric narrowing of the subglottis, which may aid in establishing the diagnosis prior to endoscopy.

Contrast-enhancing airway infantile hemangioma in posterior subglottis.

Enormous extent infantile hemangiomas can reach. Arrows indicate large component in the neck that includes airway infantile hemangiomas.

Hemangioma in posterior subglottis

Congenital Laryngeal WebsEpidemiologyLaryngeal webs are rare congenital anomalies of the larynx.Etiology and pathogenesisIncomplete recanalization of the laryngotracheal tube during the third month of gestation leads to different degrees of laryngeal webs.The most common site of development of laryngeal webs is at the level of the vocal folds anteriorly, although they may occur in the posterior interarytenoid or in the subglottic or supraglottic area.Clinical presentationLaryngeal webs may manifest with symptoms ranging from mild dysphonia to significant airway obstruction, depending on the size of the web.Stridor is rare except in patients who have a posterior interarytenoid web.A third of children with laryngeal webs have anomalies of the respiratory tract,most commonly subglottic stenosis.

Posterior WebsDiagnosis is made at the time of DL with palpation of the interarytenoid area. Posterior webs may be associated with subglottic stenosis.

Anterior WebsAnterior congenital laryngeal webs are also rare anomalies that, if severe, are diagnosed in the neonatal period after an investigation for the source of aphonia and stridor.

Congenital Laryngeal Atresia, Cysts, and Lymphangioma.

Laryngeal atresia is the most rare and most devastating of the congenital anomalies of the larynx. Only a few studies report documented survivors of such lesions. Etiology and pathogenesisFailure of recanalization of the laryngotracheal tube during the third month of gestation leads to laryngeal atresia.Clinical presentationLaryngeal atresia manifests as an acute airway obstruction in the newborn immediately after clamping the umbilical cord. Examination reveals a neonate with severe respiratory distress marked by strong respiratory efforts and inability to inhale air or cry

Laryngeal CystsEpidemiologyLaryngeal cysts are uncommon congenital anomalies of the larynx. Congenital saccular cysts represent 25% of all laryngeal cysts. Etiology and pathogenesisObstruction of the laryngeal saccule orifice in the ventricle leads to retention of mucus, which causes saccular cysts. Ductal cysts arise from blockage of submucosal mucus glands. These cysts can occur in the vallecula, subglottis, or vocal cords. They are common in the subglottis after prolonged intubation because of irritation and blockage of submucosal glands.

Lateral saccular laryngeal cyst.

Laryngeal LymphangiomaEpidemiologyLaryngeal lymphangiomas are rare congenital anomalies of the larynx. Half the cases are diagnosed in the neonatal period, and 75% are diagnosed by age 1 year. Etiology and pathogenesisLymphangiomas originate from lymphatic vessel malformations.Clinical presentationIndividuals with laryngeal lymphangioma may be asymptomatic or may present with significant airway obstruction when the lesions attain a large size. Upper respiratory tract infections may precipitate symptoms by causing a rapid increase in the size of these lesions. DiagnosisEndoscopy is the procedure of choice for aiding in the diagnosis of laryngeal lymphangiomas.

Lymphangioma at the left vallecula.

Inflammatory Disorders of Larynx.

Classification:

A. Acute infection B. Chronic infection

Acute simple laryngitis Chronic laryngitis

Acute epiglottitis Tuberculosis

Viral LTB Scleroma

Bacterial LTB Candidiasis

Spasmodic croup Sarcoidosis

C. Laryngeal edema

D. Laryngo-pharyngeal reflux disease (LPRD)

Acute (simple) Laryngitis.

Etiology

Viral infection (common cold)

Vocal abuse

Allergy / smoking / environmental pollution

Gastro esophageal reflux disease

Thermal / chemical burn due to inhalation

Use of asthma inhalers

Laryngeal trauma (endotracheal intubation)

Undue physical or psychological stress

Acute laryngitis.

Acute tuberculous laryngitis.

Acute tuberculous laryngitis.

Acute Epiglottitis.

Synonym: Acute Supraglottitis

Supraglottic laryngitis

Definition: Rapidly developing inflammation of epiglottis &

adjacent tissues, due to bacterial infection, may cause life-

threatening airway obstruction

Causative agents: Haemophilus influenzae type b (Hib),

Streptococcus pyogenes, Streptococcus pneumoniae,

Staphylococcus aureus

X-ray soft tissue neck

Red arrow = enlarged epiglottisYellow arrow = thickened ary-epiglottic folds.

Laryngo-Tracheo-Bronchitis (LTB).

Plain X-ray soft tissue neck, AP view

a. Church steeple or pencil-point sign: squared

appearance of subglottic area replaced by cone shaped

narrowing just below vocal cords

b. Ballooning of hypopharynx

Church Steeple sign.

Chronic Laryngitis.

Definition: Chronic non-specific inflammation

causing irreversible changes of laryngeal mucosa

Etiology of chronic laryngitis:

Viral infection (common cold)

Vocal abuse

Allergy / smoking / environmental pollution

Gastro esophageal reflux disease

Thermal / chemical burn due to inhalation

Laryngeal trauma (endotracheal intubation)

Undue physical or psychological stress

Chronic Laryngitis.

Reinke’s edema.

Accumulation of fluid in Reinke’s space

Synonyms: Bilateral diffuse polyposis, Smoker’s polyps, Polypoid corditis,

Polypoid degeneration of vocal cords, Localized hypertrophic laryngitis

10% of benign laryngeal lesions

Reinke’s space

Etiology

Irritants: tobacco smoke, dry air, dust, alcohol

Laryngeal allergy

Infection: chronic sinusitis

Idiopathic

Edema limited to superior surface of vocal cord due to

dense fibrous attachment to conus elasticus on under

surface of vocal cord.

Angio-neurotic edema.Recurring attacks of swelling of face, larynx & extremities caused by edema due to vasodilatation & increased capillary permeabilityTypes: Allergic: swelling with itching, laryngeal edema & bronchospasm Hereditary: Non-pruritic swelling + laryngeal edema + recurrent abdominal pain with vomiting & diarrhea

Laryngeal Tuberculosis.

Commonly associated with pulmonary TB

Posterior commissure arytenoids, vocal cords, ventricular bands & epiglottis mainly affected

Method of spread:

Bronchogenic: contact of larynx with sputum containing tubercular bacilli

Hematogenous

Laryngo-pharyngeal reflux disease (LPRD).

GERD vs. LPRD

Symptoms of LPRD.

Hoarseness

Persistent clearing of throat

Difficulty in swallowing food

Breathing difficulties or choking episodes

Annoying cough after eating

Sticking sensation or lump in throat

Heartburn & indigestion absent

LaryngocoeleA laryngocoele refers to a dilatation of the laryngeal ventricular saccule.

Sub typesThree laryngocoele sub-types are described:internal - the dilated ventricular saccule is confined to the paralaryngeal space ( 40%),external - the saccule herniates through the thyrohyoid membrane, and the superficial portion is dilated ( 25%), and mixed - with dilated internal and external components ( 45%).Laryngocoele is usually acquired rather than congenital. Risk factors include raised intralaryngeal pressure secondary to excessive cough or playing blowing instruments or due to an obstructing lesion such as tumour, and the finding of a laryngocoele should prompt a search for an underlying laryngeal carcinoma obstructing the orifice of the laryngeal ventricle Radiographic features: CTTypically seen as a well defined, air or fluid filled lesion related to the paraglottic space, which has continuity with the laryngeal ventricle. The extent will obviously depend on sub type.Attenuation characteristics may vary depending on laryngocoele content (e.g. air, fluid, mucus etc).

Two cases of internal laryngocele

External laryngocele

External laryngocele

Mixed laryngocele.

Polyps are benign lesions of the larynx, occurring mostly in adult males, that are usually located on the phonating margin (edge) of the vocal folds and prevent the vocal folds from meeting in the midline. Polyps can interfere with voice production and may produce a hoarse, breathy voice that tires easily. These may respond to conservative medical therapy and intensive speech therapy. If the lesion fails to respond, meticulous microsurgery may be indicated. One of the cofactors in the cause of these lesions may be laryngeal reflux disease.

Nodules are calluses on the vocal folds that occur with improper voice use or overuse. They are most common in children and females. They prevent the vocal folds from meeting in the midline and thus produce an hourglass deformity on closure resulting in a raspy, breathy voice. Most times these will respond to appropriate speech therapy.

Vocal cord polyp.

Anterior laryngeal polyp (black arrow) and (b) the lesion seen on an ultrasonogram.

Laryngeal nodule.

Benign tumour of the larynx

Benign laryngeal tumors include juvenile papillomas, hemangiomas, fibromas, chondromas, myxomas, and neurofibromas. They may appear in any part of the larynx. Symptoms include hoarseness, breathy voice, dyspnea, aspiration, dysphagia, pain, otalgia (pain referred to the ear), and hemoptysis. Diagnosis is based on direct or indirect visualization of the larynx, supplemented by CT

Benign laryngeal tumors.

Solitary fibrous tumor of the larynx

Adult laryngeal hemangioma.

Laryngeal schwannoma

Laryngeal schwannoma.

Adult rhabdomyoma

Pleomorphic lipoma at the left pyriform fossa.

The Laryngeal Lipoma.

Leiomyoma.

Paraganglioma

Paraganglioma.

Vallecular cyst.

Cancer larynx.About 90-95 % of laryngeal malignancies are squamous cell carcinoma with various degree of differentiation. Squamous cell subtypes include keratinizing and non keratinizing and well differentiated to poorly differentiated grade.The rest 5-10% of lesions include verrucous carcinoma, spindle cell carcinoma, malignant salivary gland and sarcomas.Glottic (59% > Supraglottic (40%) > Subglottic (1%).

Smoking contributes to cancer development by causing mutations or changes in genes, impairing clearance of carcinogens from the respiratory tract, and decreasing the body's immune response.

Signs and Symptoms of Laryngeal CancerSigns and symptoms of laryngeal cancer include: progressive or persistent hoarseness, difficulty swallowing, persistent sore throat or pain with swallowing, difficulty breathing, pain in the ear, or a lump in the neck. Anyone with these signs or symptoms should be evaluated by an Otolaryngologist (Ear, Nose and Throat Doctor). This is particularly important for people with risk factors for laryngeal cancer.

Supraglottic carcinomas.

supraglottic carcinoma.

Supraglottic carcinoma.

Supraglottic carcinoma.

Supraglottic carcinoma.

Glottic carcinoma.

Glottic tumor with infiltration of paraglottic space on the right side.

T4 glottic tumor with infiltration of thyroid cartilage on the left side.

Transglottic carcinoma.

Transglottic carcinoma.

Transglottic carcinoma.

Transglottic carcinoma.

Transglottic carcinoma.

Subglottic carcinoma.

Subglottic carcinoma.

Tumor extension to subglottis region.

Hypopharyngeal carcinoma.

The malignant lymphomas are divided in Hodgkin disease and non-Hodgkin lymphomas (NHL). Lymphomas primary to the larynx are mainly NHL and are predominantly located in the supraglottic region, as this area of the larynx contains follicular lymphoid tissue. Among the subtypes of the NHL, the diffuse large B-cell and the mucosa-associated lymphoid tissue (MALT)- type marginal zone B-cell lymphomas are the most commonly found primary laryngeal hematopoietic neoplasms. Other types of lymphomas, such as T- or natural killer (NK)-cell lymphomas, are rarely reported. The presenting symptoms and signs include dysphagia, dysphonia dyspnea, and cervical lymphadenopathy. The indirect laryngoscopy usually reveals a polypoid submucosal supraglottic mass, nonulcerated, without these characteristics to be specific.

Laryngeal lymphoma. Axial CT scan demonstrates moderate uniform enhancement of a right false vocal cord mass (asterisk) with involvement of both the right aryepiglottic fold and the right pyriform sinus (black arrow). Note the normal configuration of the left aryepiglottic fold (white arrow), which is indistinguishable on the right.

Large submucosal tumor of the subglottic region. (B) CT scan: axial plane. Regression of the subglottic tumor after the chemotherapy.

Chondrosarcoma of the cricoid cartilage.

Sarcomas of the larynx are rare neoplasms that constitute less than 1% of laryngeal malignancies.

Chondrosarcoma of larynx.

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