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

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Presentation on theme: "Case Studies in the Larynx Non-SCC Pathology Nicholas S. Pierson, MD University of Utah Neuroradiology 12 th Intensive Interactive Head and Neck Imaging."— Presentation transcript:

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

2 Case based review of key laryngeal diagnoses and imaging characteristicsCase based review of key laryngeal diagnoses and imaging characteristics Dispel the myth that the only thing that happens in the larynx is SCCDispel the myth that the only thing that happens in the larynx is SCC Provide appropriate differential diagnosesProvide appropriate differential diagnoses Introduce some uncommon pathologies of the larynxIntroduce some uncommon pathologies of the larynx Objectives

3 49 year old male49 year old male Progressive difficulty breathingProgressive difficulty breathing Globus sensationGlobus sensation 30 pack year smoking history30 pack year smoking history Case 1

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7 PolypPolyp NoduleNodule Polypoid degenerationPolypoid degeneration Squamous papillomaSquamous papilloma SCCSCC DDX

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

9 Companion Case 1a Vocal Cord Nodule Vocal Cord Nodule

10 75 year old male with hoarseness75 year old male with hoarseness Obvious mass on laryngoscopyObvious mass on laryngoscopy Abnormality found incidentally on imaging 10 years priorAbnormality found incidentally on imaging 10 years prior Refused treatment at the timeRefused treatment at the time Case 2

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12 T1 T2 FS T1 FS Post

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

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

15 67 year old male67 year old male Incidental lesion seen on MRI C-spineIncidental lesion seen on MRI C-spine AsymptomaticAsymptomatic Companion Case 2a:

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17 39 year old male39 year old male Difficulty breathingDifficulty breathing Companion Case 2b:

18 Giant Cell Tumor

19 64 year old male64 year old male History of multiple myeloma and right inguinal melanomaHistory of multiple myeloma and right inguinal melanoma Metastatic workupMetastatic workup Case 3:

20 Multiple Myeloma Multiple Myeloma T2 FST1T1 FS Post

21 76 year old male76 year old male History of multiple myelomaHistory of multiple myeloma Companion Case 3a:

22 Multiple Myeloma Multiple Myeloma

23 71 year old male71 year old male History of prostate cancerHistory of prostate cancer Companion Case 3b:

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25 74 year old male with skull base lesion74 year old male with skull base lesion Surgical debulking of the left skull base and orbit many years priorSurgical debulking of the left skull base and orbit many years prior Dysphonia, dysphagiaDysphonia, dysphagia Companion Case 3c: Pitfall

26 Teflon Granuloma Teflon Granuloma

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

28 55 year old male with dysphagia55 year old male with dysphagia Fluctuant neck massFluctuant neck mass Changes in size and tendernessChanges in size and tenderness Occasional copious secretionsOccasional copious secretions Case 4

29 T2 FS

30 LaryngoceleLaryngocele Other cystic neck massesOther cystic neck masses Thyroglossal duct cystThyroglossal duct cyst Branchial cleft cyst 2 and 4Branchial cleft cyst 2 and 4 Lateral hypopharyngeal pouchLateral hypopharyngeal pouch AbscessAbscess Vallecular cystVallecular cyst Cystic nodal massCystic nodal mass DDX

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

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

33 88 year old female with papillary thyroid cancer and lung cancer88 year old female with papillary thyroid cancer and lung cancer 70 year history of ~5 cigarettes per day70 year history of ~5 cigarettes per day HoarsenessHoarseness CT STN as part of workupCT STN as part of workup Companion Case 4b

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35 SCC with Secondary Laryngocele

36 34 year old mixed martial artist34 year old mixed martial artist 2 days following tournament2 days following tournament Throat injury with progressive pain and difficulty breathingThroat injury with progressive pain and difficulty breathing Case 5

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38 8/20138/2012

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

40 Equestrian injuryEquestrian injury Companion Case 5a

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42 38 year old female38 year old female 8 weeks of hoarseness8 weeks of hoarseness Case 6

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45 T1 Post T1 Post T2

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

47 Extensive DDX: Injury to CN10 or RLN anywhere from medulla to AP windowExtensive DDX: Injury to CN10 or RLN anywhere from medulla to AP window Trauma, neoplasm, idiopathic, strokeTrauma, neoplasm, idiopathic, stroke Checklist: Medulla, Jugular foramen, carotid space, TE grove, mediastinumChecklist: Medulla, Jugular foramen, carotid space, TE grove, mediastinum Vocal Cord Paralysis

48 73 year old male73 year old male Extensive smoking historyExtensive smoking history HoarsenessHoarseness Companion Case 6a

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50 43 year old male43 year old male Acute Horners syndrome and nystagmusAcute Horners syndrome and nystagmus Companion Case 6b

51 Lateral Medullary Syndrome DTI Flair FS

52 33 year old woman33 year old woman Progressive, worsening shortness of breathProgressive, worsening shortness of breath Case 7

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56 IatrogenicIatrogenic Post traumaticPost traumatic Thyroid mass/mass effec tThyroid mass/mass effec t Idiopathic/congenitalIdiopathic/congenital RP, WegenersRP, Wegeners Amyloid, SarcoidAmyloid, Sarcoid SchwannomaSchwannoma Vascular rings/slingsVascular rings/slings SCCSCC DDX: Subglottic Stenosis

57 Craniotomy for traumatic brain injury 10 years ago

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

59 44 year old female44 year old female DysphagiaDysphagia Case 8

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62 T1 FS +C T1 FS +C T2

63 ParagangliomaParaganglioma SchwannomaSchwannoma Vasoformative lesionVasoformative lesion MetastasisMetastasis HemangiopericytomaHemangiopericytoma DDX

64 Rare, well-circumscribed, enhancing, prominent flow voidsRare, well-circumscribed, enhancing, prominent flow voids Most common in supraglottis in the region of the aryepiglottic foldMost common in supraglottis in the region of the aryepiglottic fold Paired paraganglia arise from RLNPaired paraganglia arise from RLN Similar to carotid body tumorSimilar to carotid body tumor Symptom is primarily mass effectSymptom is primarily mass effect 3:1 F:M, mean age 44 years old3:1 F:M, mean age 44 years old Paraganglioma

65 63 year old female63 year old female Dysphagia, dysphoniaDysphagia, dysphonia Difficulty breathihngDifficulty breathihng Companion Case 8a

66 Vasoformative Lesion

67 35 year old female35 year old female Dysphagia, dysphoniaDysphagia, dysphonia Companion Case 8b

68 Schwannoma PrePost

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

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

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

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