Larynx and hypopharynx

The clinical value of DCE-MRI for differentiating secondary laryngeal cartilage lesions

To explore the value of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in the assessment of laryngeal cartilage lesions. In this study, 3 groups of cases were selected, including 16 cases benign lesions of the laryngopharynx as the benign group, 17 cases malignant lesions of laryngopharynx as the malignant group and 23 healthy adults as the control group. Conventional magnetic resonance imaging and DCE-MRI were performed with a 3.0 T MR scanner. cutoff, sensitivity, specificity and area under the curve values were calculated via receiver operating characteristic curve analysis based on the pathologic findings of surgically resected specimens. There were significant differences in the values of the volume transfer constant (Ktrans), the rate constant between the extravascular extracellular space and blood plasma (Kep) and The extravascular extracellular space fractional volume (Ve) between the control, benign and malignant groups (P < .005). Among the 3 groups, the malignant group had the highest Ktrans and Ve values (0.8681 ± 0.3034 and 0.6186 ± 0.2405, respectively), and the benign group had the highest Kep value (2.445 ± 0.7346). The cutoff points of the Ktrans, Kep, and Ve values of the control, benign and malignant groups were 0.39, 1.261, and 0.195; 0.471, 0.964, and 0.235; and 0.706, 2.005, and 0.659, respectively. The Ktrans, Kep, and Ve values obtained via DCE-MRI may enable differentiating laryngeal cartilage lesions. DCE-MRI can be used to evaluate laryngeal cartilage lesions accurately and quantitatively.

Does CT help in predicting preepiglottic space invasion in laryngeal carcinoma?

OBJECTIVE

Evaluating preepiglottic space involvement in laryngeal cancer by CT may lead misinterpretation. We sought to understand the causes of misinterpretation in evaluating the preepiglottic space by CT and assessed the effects of misinterpretation in treatment plans of patients with laryngeal squamous cell carcinomas.

METHODS

Specimen histopathology reports of 102 (99 male, 3 female) patients who underwent total or partial laryngectomy due to supraglottic and/or transglottic laryngeal carcinoma were reviewed. Neck CTs were also re-assessed for preepiglottic space involvement by three radiologists. The initial surgical treatment choices were re-examined according to the current radiological evaluation in combination with pathological results of the specimens and physical examination findings in the patients. Interobserver agreement regarding image interpretation was based on a kappa analysis.

RESULTS

The interclass correlation coefficient in predicting preepiglottic space invasion was 0.74; this was considered 'good.' Among the three radiologists, sensitivity, specificity, accuracy of CT in detecting preepiglottic space involvement were 86-93%, 75-93%, and 77-93%, respectively, while the negative and positive predictive values were 97-98% and 38-50%, respectively. Given the previous treatments applied, false-positive diagnoses for PES involvement resulted in overtreatment in 2.9% of cases. False-negative diagnoses of PES involvement (1.9% of cases) did not result in any undertreatment.

CONCLUSIONS

Although CT is a practical and inexpensive imaging tool for evaluating laryngeal carcinomas, the PPV of CT in assessing preepiglottic space invasion, especially in advanced tumors, is low and may lead to overtreatment.

The "forgotten zone": acquired disorders of the trachea in adults

The upper airway is generally defined as the air passage segment that extends between the naso- or oropharynx and the carina. The longest segment of the upper airway—the trachea—begins at the inferior portion of the larynx and extends to the branch point of the main carina. The trachea has the potential to be a “forgotten zone” in differential diagnoses, as pathological processes involving this portion may not receive prominent clinical consideration in disorders presenting with respiratory symptoms and signs. Unlike the oropharynx, this anatomical area is beyond visualization on routine inspection; unlike the mediastinum and lung fields, it is a potential “blind spot” on initial, plain radiographic examination of the chest. Nonetheless, the adult trachea is affected by a number of primary disorders and is also a target organ of a variety of systemic diseases. This review will focus on both primary and systemic diseases involving the adult trachea with specific attention to their clinical manifestations and diagnostic hallmarks.

[Pretherapeutic and posttherapeutic laryngeal imaging]

Cross-sectional imaging with CT, MRI and more recently PET CT plays an indispensable complementary role to endoscopy in the pretherapeutic diagnostic and staging of laryngeal neoplasms and in the evaluation of the operated or irradiated larynx. Adequate interpretation of the CT, PET CT and MR images requires a thorough knowledge of the patterns of submucosal spread and familiarity with the diagnostic signs of neoplastic invasion as seen with each modality. In addition, one should be aware of the implications of imaging for staging and treatment. Both CT and MR imaging are highly sensitive for the detection of neoplastic invasion of the preepiglottic and paraglottic spaces, subglottic region and cartilage. The high negative predictive value of both CT and MRI allows a relatively reliable exclusion of neoplasm cartilage invasion. The specificity of both CT and MRI is, however, moderately high and both methods may, therefore, overestimate the extent of tumor spread. However, recent investigations have shown that the specificity of MRI may be significantly improved by using new diagnostic criteria which allow differentiation of tumor from peritumoral inflammation in many instances. Both cross-sectional imaging methods also significantly improve the pretherapeutic staging accuracy of laryngeal tumors if used in addition to clinical examination and endoscopic biopsy. In the presence of a submucosal mass, CT and MRI play a key role for the diagnosis, as they may characterize the lesion, reliably depict its submucosal extent and guide the endoscopist to perform deep biopsies which allow the definitive histological diagnosis. Cross-sectional imaging also plays a key role in the evaluation of laryngoceles, recurrent laryngeal nerve paralysis and fractures.

[Imaging of larynx: diagnostic value of computed tomography and magnetic resonance imaging]

Computed tomography (CT) and magnetic resonance imaging (MRI) are enabling more precise diagnosis and treatment planning in patiensts with diseases of the larynx. The aim of this article is to describe the role of these methods in assessment of the laringeal diseases and key local anatomic characteristics important for spread of the disease. CT and MRI have a valuable contribution to the staging of the tumors due to the possibility to show the relationship to the ventricular complex, involvement of the subumucosal spaces, defining craniocaudal and anterposterior extension, laringeal cartilage invasion, as well as regional lymph node metastases.

[MR diagnostic value in assessing laryngeal tumor]

AIMS

To evaluate diagnostic accuracy of pretreatment surgical magnetic resonance images (MRI) in assessment of patients with tumors of the larynx.

MATERIALS AND METHODS

The study included 12 patients, 11 men and 1 women, age 61,4 years. All patients underwent laryngeal endoscopy and biopsy followed by MRI. The biopsy confirmed that all patient had squamous-cell carcinoma. The MRI images were evaluated for presence in supraglottic, glottic or subglottic region, invasion of submucosal space, cartilage, extension to extralaryngeal tissue, presence of regional lymph nodes in regions I to VII. Imaging data were compared to surgical findings.

RESULTS

In 11 patients (92%) the tumor was supraglottic and glotic region and in 1 (8%) subglottic. None of them had tumor only in one region. Paraglottic ivasion was seen in 9 (75%) and preepiglottic in 2 (50%) patients. Paraglottic and preepiglotic invasion in the same time was seen in 3 (25%) patients. 7 (58%) patients had normal vocal cord mobility, 3 (25%) mobility was unilateral and 2 (17%) had no vocal cord mobility. Cartilage invasion has not been seen in present study. All patients had billateral limphadenopathy region II-IV. Extension to extralaryngeal tissue was absent. These findings were confirmed on surgery with high diagnostic accuracy.

CONCLUSION

MRI has been shown to be a reliable method for presurgical assessment of patients with tumor of the larynx.

Imaging of the larynx and hypopharynx

The purpose of this article is to review currently used imaging protocols for the evaluation of pathologic conditions of the larynx and hypopharynx, to describe key anatomic structures in the larynx and hypopharynx that are relevant to tumor spread and to discuss the clinical role of Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and PET CT in the pretherapeutic workup and posttherapeutic follow-up of patients with squamous cell carcinoma of this region. A detailed discussion of the characteristic neoplastic submucosal invasion patterns, including extension to the preepiglottic space, paraglottic space and laryngeal cartilages and the implications of imaging for tumor staging and treatment planning is provided. The present article also reviews less common tumors of this region, such as chondrosarcoma, lymphoma, minor salivary gland tumors and lipoma. As the majority of non-neoplastic conditions do not require imaging the role of CT and MRI is discussed in some particular situations, such as to delineate cysts and laryngoceles, abscess formation in inflammatory conditions, to evaluate laryngeal and hypopharyngeal involvement in granulomatous and autoimmune diseases, and to evaluate the extent of laryngeal fractures due to severe blunt trauma.

Hypopharyngeal cancer

Hypopharyngeal cancers are usually squamous cell carcinomas (SCCs) that has the worst prognosis among the head and neck cancers. Overall, 5-year survival rate remains poor despite recent improvements in diagnostic imaging, radiation and chemotherapy, and improved surgical techniques. Hypopharyngeal cancers tend to present with advanced primary disease, and nodal metastasis is highly likely. The most important features determining prognosis are the size and extent of local spread of the primary carcinoma and the extent of involvement of regional lymph nodes. Distant metastasis at presentation is more common in hypopharyngeal cancers than in other head and neck cancers. Poor survival rate is partly due to emergence of second primary cancers but also to development of distant metastasis. Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) remain the mainstay of initial radiological evaluation of hypopharyngeal cancer. Imaging usually results in upstaging of the tumor at presentation. Meticulous evaluation of the extent of the primary tumor with attention to spread to the subsites of the hypopharynx, larynx, and cartilage invasion are necessary for accurate staging. After surgery and radiation therapy, it is difficult with CT and MR to differentiate residual and recurrent tumor from edema and scarring. Fluorine 18-fluoro-deoxy-glucose -positron emission tomography (FDG-PET) has high sensitivity in detection of occult, residual, and recurrent tumors but has low specificity. Combined PET and CT increase specificity and are increasingly being used to image posttreatment cases. Other newer imaging modalities such as diffusion-weighted imaging (DWI), MR spectroscopy, and MRI with superparamagnetic iron oxide (SPIO) contrast agent are reported to be useful and should be used more widely in difficult cases.

[Imaging diagnostics of the pharynx and larynx]

The pharynx and larynx represent very sophisticated regions and may be involved in a diverse range of pathologic conditions. Evaluation of the head and neck has developed significantly with the establishment of CT and MRI as they provide true insights into the endoscopically blind areas as well as depth of tumor infiltration, its submucosal growth and contralateral involvement, cartilage invasion, bone marrow invasion, and nonpalpable adenopathy. Inflammations in the head and neck region are only exceptionally imaged with CT or MRI; indications are the diagnosis of retrotonsillar and parapharyngeal abscesses and ensuing complications. The different imaging modalities of malignant pharyngeal and laryngeal tumors and their differential diagnosis are presented in this paper.

Airway Problems Caused by Hypogonadism in Male Patients Undergoing Neurosurgery

Unanticipated difficult endotracheal intubations can pose challenges for the anesthesiologist. Risks include airway injury, hypoxemia, and death. There is intubation difficulty in various conditions including Downs syndrome, achondroplasia, acromegaly, and dwarfism. We describe difficulty in intubating the trachea with an appropriate sized endotracheal tube in two young male patients with hypogonadism presenting for neurosurgical procedures under general anesthesia. We discuss the role of hypogonadism and the effects of gonadotropin hormones on pubertal laryngeal growth in male patients.

Cross-sectional imaging combined with 3D-MR angiography (3D-MRA): diagnostic tool for preoperative vascular assessment of head and neck tumors

BACKGROUND

Head and neck cancer accounts for 5% of all malignancies worldwide. The presence of lymph node metastases and vascular infiltration influence patient outcome. This prospective study describes the preoperative morphologic assessment of the vascular status of patients with head and neck tumors by means of high spatial resolution and extended coverage of the arterial and venous system reaching from the supra-aortic region to the skull base.

PATIENTS AND METHODS

Cross-sectional imaging combined with contrast-enhanced 3D-maximum intensity projection MR angiography (3D-MRA) was applied using a dedicated head and neck coil with a 4-channel panorama array system interface to assess vascular involvement in patients with suspected head and neck cancer. 32 patients underwent preoperative assessment by magnetic resonance imaging (MRI). The results were then correlated with surgical and histological findings.

RESULTS

3 of the 32 patients (9%) demonstrated involvement of the arterial system. In 2 of these 3 cases, MRA correctly predicted the arterial status, while in 1 case it gave a false negative result. 11 of the 32 patients (34%) presented with involvement of the venous system. 10 cases showed complete concordance between the findings of the MR venography and the intraoperative status, while in 1 case a false negative result was produced.

CONCLUSION

In patients with suspected head and neck tumors, 3D-MRA in combination with cross sectional imaging is a valuable diagnostic tool for the detection of vascular involvement.

Diagnostic evaluation of magnetic resonance imaging with turbo inversion recovery sequence in head and neck tumors

The clinical outcome of patients with head and neck cancer depends on many factors such as tumor size, metastatic involvement and angioarchitecture of the tumor. The correct staging of tumor extension, presence of cervical lymph node metastases and evaluation of vascular infiltration are essential diagnostic steps before treatment. The aim of this study was to evaluate the accuracy of turbo inversion recovery magnitude (TIRM) magnetic resonance imaging (MRI) in the diagnosis of head and neck tumors with special attention to tumor size and tumor spread according to the current TNM classification. TIRM sequence with short T1 relaxation and long TE (echo time) improves imaging contrast because of the increased T1-weighting and the inherent fat suppression. In a prospective clinical study, 32 patients underwent preoperative MRI. Diagnosis was confirmed histologically in all cases. Scanning was performed on a 1.0-T unit applying TIRM as well as T1- and T2-weighted turbo spin echo (TSE) sequences. In all sequences, tumor size was overestimated due to reactive inflammatory changes surrounding the tumor tissue. The least overestimation was documented on TIRM and post-contrast T1 TSE. The highest values of relative tumor signal intensities were obtained in TIRM (3.5+/-0.9) and T2 TSE (3.5+/-0.8) followed by post-contrast T1 TSE (1.6+/-0.7) and pre-contrast T1 TSE (1.2+/-0.3). Due to the inherent fat suppression, tumor delineation was most obvious in TIRM. In patients with suspected cancer of the head and neck, TIRM should be considered as a standard and a diagnostically relevant sequence in the MRI staging protocol.

CT and MR imaging for detecting neoplastic invasion of esophageal inlet

AIM: Direct neoplastic invasion of esophageal inlet is an uncommon but significant sequela of advanced head and neck carcinomas. The aim of this study was to seek an optimal CT or MRI criterion for determining the neoplastic esophageal inlet involvement in order to help tumor staging and surgical planning.

METHODS: CT and MRI of 78 head and neck tumor cases were investigated retrospectively. At the level of the esophageal inlet on axial CT and MRI scans, the distance between the posterior aspect of cricoid cartilage and the anterior aspect of vertebra (d-CV) was measured by two senior radiologists who were unaware of clinical findings. Then, according to pathologic evidence and follow-up findings, these patients were divided into patient group, including 32 cases with neoplastic invasion of esophageal inlet and control group, including 46 cases without neoplastic esophageal inlet involvement. The statistical difference based on d-CV between the two groups was determined. The optimal criterion of d-CV on CT or MRI was assessed and its accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were evaluated respectively.

RESULTS: In control group, d-CV at the esophageal inlet level was 0.94±0.15 cm on axial CT and 0.91±0.18 cm on axial MRI, whereas in patient group, d-CV was 1.24±0.32 cm on CT and 1.31±0.36 cm on MRI. There was a statistical significance in d-CV between the two groups on CT and MRI modalities (P<0.01). d-CV greater than 1.0 cm was the typical feature of neoplastic invasion of the esophageal inlet with 73% sensitivity, 83% specificity, 79% accuracy, 76% PPV, 80% NPV on CT and 84% sensitivity, 77% specificity, 80% accuracy, 70% PPV, 88% NPV on MRI respectively.

CONCLUSION: Except for other CT and MR imaging features of neoplastic invasion of esophageal inlet, d-CV greater than 1.0 cm is an optimal adjunct criterion for esophageal inlet invasion by advanced head and neck carcinomas.

Laryngeal imaging

Knowing the surgical options for treating laryngeal carcinomas and the factors that are used to select patients for radiation therapy leads to a more valuable and relevant interpretation of neck scans in patients with laryngeal tumors. Critical factors include tumor volume; cartilaginous invasion; spread across supraglottic-glottic-subglottic boundaries; infiltration of preepiglottic, paraglottic, and pharyngeal planes; and nodal disease. MR imaging offers greater sensitivity to cartilaginous invasion than CT but shows a higher rate of false-positive studies. Direct coronal MR imaging is often valuable in assessing these issues.

Imaging of the hypopharynx and cervical esophagus

Cross-sectional imaging with CT and MR imaging plays a crucial role in the evaluationof cancers of the hypopharynx and cervical esophagus. Clinical examination, includingendoscopy, often fails to detect the full extent of this tumor as it has high propensity togrow in submucosal fashion. Detailed description of the cross-sectional anatomy and ofthe tumor growth pattern will aid in the detection and evaluation of the full extent of thelesion. Post-treatment imaging findings are addressed.

Enhanced four-detector row computed tomography imaging of laryngeal and hypopharyngeal cancers

PURPOSE

Four-detector row computed tomography (4D CT) enables imaging of the larynx and hypopharynx with high temporal resolution and rapid reformatting of coronal planes. The aim of our study was to assess the usefulness of postcontrast biphasic 4D CT in diagnosing tumor extent.

METHODS

Forty-seven patients with laryngeal or hypopharyngeal cancer were investigated using 4D CT. Two radiologists retrospectively evaluated transverse and reformatted coronal images in both the early and late phases.

RESULTS

Images in the late phase were superior to those in the early phase in the conspicuity of the depicted lesions. The coronal images facilitated assessment of the craniocaudal extension of tumors and obliteration of the paraglottic space. The maximal diameter of tumors tended to be larger on the coronal image than on the transverse image.

CONCLUSIONS

Images in the late phase were more informative than images in the early phase to demonstrate tumor extension. Reformatted coronal imaging was useful in evaluating craniocaudal extension.

Imaging in laryngeal cancer: computed tomography, magnetic resonance imaging, positron emission tomography

Imaging modalities have become increasingly significant in the treatment of laryngeal cancer. The ability of CT and MR imaging to reveal pathologic conditions that are undetectable by palpation or endoscopy has led to the development of several imaging-based systems of anatomic classification and tumor staging. This article provides an up-to-date review of the radiographic evaluation of the normal neck and information for both the radiologist and clinician treating the patient with laryngeal cancer. Technical considerations, imaging-based staging systems, and the radiographic characteristics of laryngeal cancer in various regions of the neck are discussed.

Laryngeal imaging

Knowing the surgical options for treating laryngeal carcinomas and the factors that are used to select patients for radiation therapy leads to a more comprehensive interpretation of neck scans in patients with laryngeal tumors (Table 6). Critical factors include tumor volume; cartilaginous invasion; spread across supraglottic-glottic-subglottic [table: see text] boundaries; infiltration of preepiglottic, paraglottic, and pharyngeal planes; and nodal disease. MR imaging offers greater sensitivity to cartilaginous invasion than CT but leads to a high rate of false-positive studies, which decreases its overall accuracy. Thin-section CT with multiplanar capability is competitive with direct coronal MR scanning and benefits from high specificity and submillimeter section thickness, if multidetector units are employed. Overall, the head and neck radiologist plays an invaluable role in assessing the extent of disease and therefore influences the appropriate selection from the available treatment options.

Imaging of the hypopharynx and cervical esophagus

Cross-sectional imaging with CT and MR imaging plays a crucial role in the evaluation of cancers of the hypopharynx and cervical esophagus. Clinical examination, including endoscopy, often fails to detect the full extent of this tumor as it has high propensity to grow in submucosal fashion. Detailed description of the cross-sectional anatomy and of the tumor growth pattern will aid in the detection and evaluation of the full extent of the lesion. Post-treatment imaging findings are addressed.

Laryngeal crepitus: an aid to diagnosis in non-fatal strangulation

Examination of victims exposed to strangulation is well known in clinical forensic medicine. Not all cases show the objective signs to be found at the examination, e.g. petechial haemorrhages in the eyes and face as well as bruises and abrasions on the neck. In cases without objective signs especially, examination of the laryngeal crepitus might be an aid to diagnosis in strangulation. Laryngeal crepitus is felt by the examiner when the larynx is moved from side to side with a slight posterior pressure. When absent, it is a clinical sign of a mass in the retrolaryngeal space or hypopharynx, probably due to a laryngeal trauma. This paper describes three cases of strangulation where the clinical examinations showed a temporary absence of laryngeal crepitus.

Avaliação por tomografia computadorizada do envolvimento loco-regional do carcinoma espinocelular de corda vocal

No período de 1992 a 1998, foram avaliados, retrospectivamente, exames de tomografia computadorizada e prontuários de 22 pacientes com carcinoma espinocelular de corda vocal. Avaliou-se a concordância entre observadores para todos os casos e a acurácia e concordância entre os métodos para os casos operados, utilizando-se o índice kappa. A concordância foi excelente para o comprometimento tumoral das cartilagens tireóide, cricóide, extensão extralaríngea e estadiamento linfonodal; ótima para o envolvimento tumoral das cordas vocais, comissura posterior e espaço paraglótico; boa para o envolvimento tumoral da supraglote, subglote e estadiamento tumoral; regular para o envolvimento tumoral da comissura anterior e cartilagem aritenóide. A utilização simultânea da avaliação clínica e tomográfica para o estadiamento T obteve acurácia e concordância com achados patológicos de 89,47% e 84,9%, respectivamente, sendo superior à análise clínica isolada ou tomográfica. A acurácia e concordância patológica da tomografia computadorizada para o estadiamento N foi de 100%, sendo superior à avaliação clínica.

Laryngeal chondrosarcoma: a 24-year experience at the Royal National Throat, Nose and Ear Hospital

This paper presents a review of the experience of 12 patients with chondrosarcoma of the larynx treated at The Royal National Throat, Nose and Ear Hospital, London, over the last 24 years. This represents the largest European series and the third largest in the world. Chondrosarcoma is the most frequent non-epithelial malignant tumor of the larynx, with 83.3% of cases arising from the cricoid cartilage in our series. We have shown that deep wedge biopsy with a CO2 laser, aided by computerized tomography scanning, gives the most reliable diagnosis. Laryngeal chondrosarcoma is characterized by indolent growth, a potential for local recurrence and, infrequently, by metastases. The treatment details of our patients are discussed. Adequate partial resection is often successful and use of CO2 laser as the initial treatment in five of these cases is presented.

Neoplastic invasion of laryngeal cartilage: radiologic diagnosis and therapeutic implications

Cross-sectional imaging plays an indispensable complementary role to endoscopy in the pretherapeutic workup of laryngeal and hypopharyngeal cancer. Both computed tomography and magnetic resonance imaging are suitable for the detection of neoplastic cartilage invasion. Although MRI, due to its high negative predictive value, is now generally considered to be the most suitable imaging method for pretherapeutic evaluation of cartilage invasion CT continues to be commonly performed in many centers for practical reasons. Recent studies have shown that CT may yield acceptable sensitivity for neoplastic invasion of laryngeal cartilage if the diagnostic criteria are selected and combined appropriately. False positive results are inevitable with both CT and MRI because reactive inflammation may lead to overestimation of neoplastic cartilage invasion.