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Case Studies in the Larynx Non-SCC Pathology

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Presentation on theme: "Case Studies in the Larynx Non-SCC Pathology"— Presentation transcript:

1 Case Studies in the Larynx Non-SCC Pathology
Nicholas S. Pierson, MD University of Utah Neuroradiology 12th Intensive Interactive Head and Neck Imaging Conference 1

2 Objectives Case based review of key laryngeal diagnoses and imaging characteristics Dispel the myth that “the only thing that happens in the larynx is SCC” Provide appropriate differential diagnoses Introduce some uncommon pathologies of the larynx Ledbetter- showing supraglottic squam Wiggins- covering squam and staging extensively

3 Case 1 49 year old male Progressive difficulty breathing
Globus sensation 30 pack year smoking history

4 Exophytic polypoid lesion arising from the left true cord

5 Easy to mystake for vocal folds, key is to note more tissue than is typically seen abnormal morphology on axial

6 Different patient with a similar finding, showing a smooth exophytic lesion arysing from the vocal fold Epiglottis, arytenoids, pyriform sinus, cords

7 DDX Polyp Nodule Polypoid degeneration Squamous papilloma SCC

8 Vocal Cord Polyp Small exophytic growth from the true cord
Usually solitary Present with hoarseness, breathiness, vocal fatigue, decreased vocal range Proposed causes: vocal abuse, GERD, nasosinusitis, irritants Path: polyp

9 Companion Case 1a Vocal Cord Nodule

10 Case 2 75 year old male with hoarseness Obvious mass on laryngoscopy
Abnormality found incidentally on imaging 10 years prior Refused treatment at the time

11 Hypo to muscle, expansile, calcs

12 T1 T1 FS Post Het enhancement, t2 hyper, t1 iso/hypo to muscle T2 FS

13 DDX Chondroid lesion: Chondroma\sarcoma Other sarcomas
Inflammatory cartilaginous processes such as relapsing polychondritis SSC Rare lesions: Carcinoid, paraganglioma, giant cell tumors Mets/Myeloma

14 Low Grade Chondrosarcoma
Expansile mass within laryngeal cartilage Cricoid most common Can contain calcified matrix, ring-like or popcorn Difficult to exclude SCC in non-calcified lesions Present with dysphagia, dysphonia, or stridor

15 Companion Case 2a: 67 year old male
Incidental lesion seen on MRI C-spine Asymptomatic

16 Expansile, calcs low density

17 Companion Case 2b: 39 year old male Difficulty breathing

18 Giant Cell Tumor

19 Case 3: 64 year old male History of multiple myeloma and right inguinal melanoma Metastatic workup

20 T2 FS T1 T1 FS Post Multiple Myeloma

21 Companion Case 3a: 76 year old male History of multiple myeloma

22 Multiple Myeloma

23 Companion Case 3b: 71 year old male History of prostate cancer

24

25 Companion Case 3c: Pitfall
74 year old male with skull base lesion Surgical debulking of the left skull base and orbit many years prior Dysphonia, dysphagia

26 Teflon Granuloma

27 Vocal Cord Medialization Pitfall
Some patients who have primary malignancies develop vocal cord paralysis Some of these patients undergo vocal cord medialization These have variable appearances and can look mass like Can also be hot on PET

28 Case 4 55 year old male with dysphagia Fluctuant neck mass
Changes in size and tenderness Occasional copious secretions

29 T2 FS

30 DDX Laryngocele Other cystic neck masses Lateral hypopharyngeal pouch
Thyroglossal duct cyst Branchial cleft cyst 2 and 4 Lateral hypopharyngeal pouch Abscess Vallecular cyst Cystic nodal mass

31 External (mixed) Laryngocel
Paraglottic/Supraglottic Extend through the thyrohyoid membrane Circumscribed, thin walled, may contain fluid or air Present as neck mass in low submandibular space

32 Laryngocele Types Internal/Simple: confined to paraglottic space
External/Mixed: internal and external components Pyolaryngocele: superinfection Secondary: Glottic or inferior supraglottic mass obstructs laryngeal ventricle

33 Companion Case 4b 88 year old female with papillary thyroid cancer and lung cancer 70 year history of ~5 cigarettes per day Hoarseness CT STN as part of workup

34 Right air filled, confined to the to the paraglottic space,
Left fluid filled Start thinking internal laryngocele

35 SCC with Secondary Laryngocele
Wasn’t initially described and found at larungoscopy Glottic and subglottic mass: SCC Secondary 15% SCC with Secondary Laryngocele

36 Case 5 34 year old mixed martial artist 2 days following tournament
Throat injury with progressive pain and difficulty breathing

37 Fracture of thyroid cartilage with bayonet apposition
Edema in strap muscles Paraglottic fat and arepiglottic fold edema/hematoma, airway narrowing

38 8/2013 8/2012 Normal last year, same tournament last year complex facial bone fracture

39 Thyroid Cartilage Fracture
Can be caused by any trauma involving neck: blunt, hanging, penetrating Include cartilages in search pattern Important to exclude to avoid airway compromise When present evaluate surrounding soft tissue and airway May be a subtle finding

40 Companion Case 5a Equestrian injury

41 Wiggins showed Quickly review, can be dramatic, thyroid cart, gland, chricoid

42 Case 6 38 year old female 8 weeks of hoarseness

43 Ballooning of the laryngeal ventricle: sail sign
Enlarged pyrigorm sinus and medially displaced aryepiglottic fold

44 Permiative destructive skull base lesion at the jugular foramen
Enhancement

45 T1 T2 T1 Post T1 Post Salt: hemorage, slow flow T! Pepper; flow voids
9,10, 11, 12 Intens enhancement T1 Post T1 Post

46 Vocal Cord Paralysis Sail sign- ballooned ventricle
Medial rotation of arytenoid Medialized aryepiglottic fold Enlarged pyriform sinus

47 Vocal Cord Paralysis Extensive DDX: Injury to CN10 or RLN anywhere from medulla to AP window Trauma, neoplasm, idiopathic, stroke Checklist: Medulla, Jugular foramen, carotid space, TE grove, mediastinum Right: jugular foramen, clavicle, recurs around right subclavian Left: jug foramen, mediastinum, recurs around AP window medial to ligimentum arteriosum Recurrent ascends in TE groove

48 Companion Case 6a 73 year old male Extensive smoking history
Hoarseness

49

50 Companion Case 6b 43 year old male
Acute Horner’s syndrome and nystagmus

51 Lateral Medullary Syndrome
Flair FS DTI Vert dissection Stroke DDX of medulary lesion, cav mall, mets, demyelenating, Injury to the nucleas ambiguos is the localizing lesion Wallenburg- nystagmus from vestibular nuclei and horners from descending sympathetic fibers Wiggins shows a TE groove lesion of thyroid Lateral Medullary Syndrome

52 Case 7 33 year old woman Progressive, worsening shortness of breath

53 Green Arrow = irregular narrowing of subglottic larynx
Yellow Arrow = too much soft tissue at laryngo-tracheal junction

54 Green Arrows = Focal, concentric subglottic narrowing. No mass seen.

55

56 DDX: Subglottic Stenosis
Iatrogenic Post traumatic Thyroid mass/mass effect Idiopathic/congenital RP, Wegener’s Amyloid, Sarcoid Schwannoma Vascular rings/slings SCC

57 Craniotomy for traumatic brain injury 10 years ago

58 Iatrogenic Subglottic Stenosis
Most common intrinsic cause, ~90% Hx of prolonged intubation Pressure necrosis Describe level and length Is the cricoid involved?

59 Case 8 44 year old female Dysphagia

60

61

62 T1 T2 T1 FS +C T1 FS +C

63 DDX Paraganglioma Schwannoma Vasoformative lesion Metastasis
Hemangiopericytoma

64 Paraganglioma Rare, well-circumscribed, enhancing, prominent flow voids Most common in supraglottis in the region of the aryepiglottic fold Paired paraganglia arise from RLN Similar to carotid body tumor Symptom is primarily mass effect 3:1 F:M, mean age 44 years old

65 Companion Case 8a 63 year old female Dysphagia, dysphonia
Difficulty breathihng

66 Hemangioma Phlebs, bright on T2, ehance Vasoformative Lesion

67 Companion Case 8b 35 year old female Dysphagia, dysphonia

68 Pre Post Koonts showed. Just to remind Schwannoma

69 Conclusion Discussed part of the spectrum of non-SCC pathology of the larynx Covered differential diagnoses of potentially encountered lesions Reviewed some less common lesions of the larynx included in their differentials Additional pathology to consider

70 Case Studies in the Larynx Non-SCC Pathology
Nicholas S. Pierson, MD University of Utah Neuroradiology 12th Intensive Interactive Head and Neck Imaging Conference 1

71

72 Companion Case 3d: Mimic
Incidental findings in 2 different patients Low density foci in the thyroid cartilage Recently described as “benign tumor like lesions” and “pseudo-lesions”

73 Two different patients


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