morning and this is the larynx and
we'll talk about a little bit about
technique normal anatomy and common
pathology so these are the things that
we're going to cover so a technique
standpoint the right now currently I
think all of us are using some type of
multi detector imaging at least at our
institution we're using 0.625
acquisitions we're looking approximately
2.5 millimeters with a one point two
five millimeter overlap we always have
contrast on our laryngeal CTs
approximately 100 CC's we're using a
dual phase where we give 50 cc's then
wait and then we give another bolus of
contrast and and part of that is with
multi detector CT it takes about eight
seconds to do a CT if you have a
64-slice CT and when MDCT first came out
with 64 slices now you have 320 s
everybody was getting CTA s on all their
neck CT so we had to throttle back a
little bit so that's why we use the dual
phase we don't use a quiet respirations
and the various laryngeal maneuvers I
know when I was a resident and we had
when the first file CT's in the
countries we looked at valsalva is
reverse reverse valsalva so on and so
forth but we do everything with quiet
respiration every all of our studies now
get sagittal and coronal reformats I
think it's so much easier to now I
remember the good old days where it used
to take a couple hours to get these
reformats and then they'd be printed on
the hard copy and so on and so forth but
obviously now it just takes just a
couple seconds to do the reformats
and it certainly helps when we're
looking at various spread patterns just
a nice example here this was a laryngocele
we'll have more to say about that but on
the coronal images we can see very
nicely the internal component laryngocele
going through the thyrohyoid
membrane and then the Cystic component
extending outside of the thyrohyoid
membrane so there's your if you will
complex laryngocele you can
perform laryngeal MR on 1.5 or 3t this
is performed on the 3t waited on the 3t
waited mr I have to admit at our
institution and all my prior
institutions we do a lot more CT than we
do MR in general I think in the u.s. we
do a little bit
or CT than MR in Europe my colleagues do
a lot more mr from my standpoint either
one is fine it' s just that when I look
at a step when I look at a modality I
want to see if we do a hundred patients
what percent of those hundred patients
are going to have diagnostic quality
studies especially if you have an
advanced laryngeal carcinoma the patient
swallows they move their head a little
bit even if it's the last 10 seconds of
that 2 minute acquisition you know whole
thing's degraded and it's certainly at
3t the motion artifact is a little bit
more exacerbated so that's why we use a
little bit more CT I mean just takes
literally just 20 seconds to do a neck
CT one of the things again like I
learned before radiologically oftentimes
the imaging manifestations are protein
for many of these pathologies there's a
squamous cell carcinoma and that's
actually tuberculosis path proven and
this could easily be a squamous cell
carcinoma this on the other hand is a
densely enhancing mass and just this
just happens to be a sub mucosal
paraganglioma so an unusual case you can
see that this has a different appearance
compared to the more run-of-the-mill
squamous cell carcinoma so this can tip
you off that you're dealing with a more
of a highly vascular lesion so let's
talk about anatomy anatomy anatomy
anatomy I think one of the common themes
as dr. Sol mentioned anatomy is key I
know many of you know in my position the
anatomy for both medical schools is
still under radiology and I know dr.
poach and set that up and I think as
usual he was way ahead of his times and
so so much of what we do in radiology is
anatomy and I'm gonna spend a fair
amount of time going over the anatomy
because you know when we talk about the
anatomy of the larynx it's almost like a
word salad
it's aryepiglottic folds thyroepiglottic
ligament cricothyroid cartilage thyroid
9 muscles and I can go on and on and
just confuse that living daylights out
of you and you know it always confused
me when I was a resident till I had you
know I'm not the smartest tool in the
shed but one day my 20 watt light bulb
went off and I had my Eureka moment and
that was that all of these structures in
the larynx
all these muscles and all the membranes
are named after
cartilaginous and bony framework of the
of the larynx so you know this is what
structure right here some and somebody's
yell about we're all friends here unless
you're from Ohio State okay that's a
that's a joke not really but I had to
say it's a joke otherwise I could get in
trouble no so anyway this is what here
there's your epiglottis so the
epiglottis is an anterior and midline
structure and what cartilage are we
looking at right here that's the
arytenoid cartilage right and this is
actually the core niculae cartilage we
try to ignore that when it almost looks
like the sorting hat from Harry Potter
but if you look at the fold of tissue
that runs from the arytenoid cartilage to
the epiglottis and this is referred to
as what the aryepiglottic fold that's
where it gets its name from
so the epiglottis is an anterior midline
structure and the aryepiglottic fold is
a pair of midline structure when you
look in what the surgeon sees here's the
epiglottis anteriorly
and here's the aryepiglottic folds are
para midline structures by the way what
structure is located here that's a sack
like saddle structures here it's the
piriform sinus exactly right so if you
have this fold of tissue that goes from
the epiglottis to the tongue base again
think Greek roots what would you call
this midline fold that runs from the the
epiglottis to the tongue base so it's
the median glosso epiglottis hold now
what about the muscles that run from the
thyroid cartilage to the arytenoid
cartilage what would you call those
muscles take a wild guess
those are the thyroarytenoid muscles
what do you call the ligament that runs
from the highway bone to the epiglottis
that's the hyoid epiglottis ligament see
there's nothing fancy about it you just
have to remember that the cartilage of
the layer of the excuse me all these
structures are named after the carlage bony framework so if you
remember the hyoid bone and the
epiglottis
there's your higher epiglottic ligament if
you remember the original cartilage and
the epiglottis there's your Aryepiglottic fold if you remember the thyroid
cartilage and the arytenoid cartilage that's your thyroarytenoid
muscles if you remember the cricoid
cartilage and the arytenoid cartilage
this is your cricoarytenoid ligaments
and so on and so forth so if you
understand that that I think everything
else makes a lot of sense so let's go
ahead and step through the anatomy
anatomy anatomy and talk about the
various primary sites so as I mentioned
the epiglottis is an anterior and it's a
midline structure as seen here on this
illustration and here's a schematic
illustration of an epiglottis carcinoma
remember the epiglottis is an anterior
midline structures so clinically this is
an epiglottis carcinoma seen at
endoscopy its anterior and this is what
we see radiologically so how do we
determine that well as I mentioned
before it's pretty simple you just look
anterior midline and there's your
epiglottis carcinoma its anterior and
its midline the aryepiglottic folds a
pyramid line structure and it runs from
the original cartilage to the lateral
aspect of the epiglottis so this is what
the clinicians see at endoscopy and this
is what we see radiologically here's our
epiglottis anterior midline here's our
aryepiglottic folds this polypoid
carcinoma involving the right area
epiglottis fold here's a normal area
epiglottal cold on the left side on the
CT scan what structure is here anybody
anterior midline
if you don't shout out I'm gonna start
calling on people all right so there's
anterior you think I'm joking right I
know a lot of people in this room from
the last ten years so and funny how no
one makes eye contact now after I said
that that's okay so here's the
epiglottis right Kevin there's anterior
midline structures right so there's the
epiglottis on the left hand side there's
a normal area epiglottis old and here's
a piriform sinus on the contralateral
side we can see that the aryepiglottic
fold
contains this mass so there's our
carcinoma and look what it's doing to
the piriform sinus it's actually
pinching it off important to remember
this when we talk about vocal cord
palsies because the in vocal cord
palsies the ipsilateral piriform sinus
is going to be dilated conceptually this
is the hardest one for me and this is
the false vocal cord and and a tough
structure but this is the way that I
conceptualize it the aryepiglottic folds
down and eventually the inferior
flexion of the aryepiglottic fold
attaches to the top of the arytenoid
cartilage so when I'm looking at a CT
scan what I tend to look for is the top
of the arytenoid cartilage so on the
schematic illustration here's the false
vocal cord the black area here is the
laryngeal ventricle and this is the true
vocal cord so on our schematic
illustration this inferior flexion of
the aryepiglottic folds is indicative of
the false vocal cord here is a black
area the laryngeal ventricle and there's
our true vocal cord so when we look at a
CT scan clinically here was a vocal cord
carcinoma and there are two structures
here on the CT scan that tells me that
we're at the level of the false vocal
cord one is that we're looking at the
top of the arytenoid cartilage so if you
see the top of the arytenoid
cartilage that tells me we're at the
level of the false vocal cord secondly
with a leap of faith sometimes you'll
see this strip of tissue on the left
hand side and that's the lateral
thyroarytenoid muscle so those two
structures indicate that we're at the
level of the false vocal cord sometimes
I have a hard time seeing the lateral
Thyroarytenoid muscle especially as
we come more dose conscious sometimes we
just don't have the MA that we did 15
years ago before we really started being
concerned with the dose restrictions
that we currently are under so this
tissue is this muscle is not as
consistent if you will but by the same
token we can always see the top of the
arytenoid cartilage so when I see this I
am pretty comfortable we're at the level
of the false vocal cord the true vocal
cord is very easy very very simple to
see because the true vocal cord is
located that cricoarytenoid
joints so when we see the cricoarytenoid
joint we know we're at the level of the
true vocal cord so here's a schematic
illustration of a true vocal cord
carcinoma there's our written oyd
cartilage there's our cricoid cartilage
cricoarytenoid joint and here we can see
the typical spread patterns of a true
vocal cord carcinoma here's a Veruca
carcinoma involving the right --true
vocal cord and this is what we see on CT
scan so there's our cricoid cartilage
there's our original cartilage
cricoarytenoid joint and here
our true vocal cord carcinoma in this
particulars case a true vocal cord
carcinoma is extending all the way
anterior to this specific location at
the true vocal cord its anterior and
this is the anterior commissure
conversely this is the posterior
commissure so in this case here's a true
vocal cord carcinoma we know it has to
be cricoarytenoid join growing
anteriorly all the way to the anterior
commissure the foundation of the larynx
is the cricoid cartilage so I think of
the the cricoid cartilage analogous to
the foundation of our house if we don't
have a foundation of our house
everything is going to collapse and the
cricoid cartilage is the signet ring
which the way I conceptualize things
holds a whole laryngeal framework intact
if there was no cricoid cartilage our
larynx is going to end up by our thyroid
our thyroid gland so the cricoid
cartilage is very important but this
really constitutes the subglottis
so everywhere that we see the cricoid
cartilage that's essentially where the
sub glottis is located so this is a
pathologic specimen of a primary
subglottic carcinoma and then way we
know we're at the level of the
subglottis as we've looked for the
signet ring of the cricoid cartilage it
literally looks like a big Oh a big big
oh and there should just be just this
thin thin rim of mucosa as is seen here
so if you will this is a normal
appearing cricoid cartilage this is a
normal mucosa overlying the cricoid
cartilage but instead of seeing this
thickness in this large subglottic
carcinoma we can see this
circumferential thickening of the
subglottis and this is the typical
appearance of a subglottic carcinoma
these tip as they get larger they tend
to be circumferential and because they
tend to present later as opposed to a
true vocal cord carcinoma they're
oftentimes associated with fairly
extensive erosion of the cartilages in
this case both the cricoid cartilage is
eroded and the thyroid cartilage is
eroded so we'll talk about you know
various other tumors what I've done so
far is gone over the technique and the
anatomy
and when I went over the Anatomy I've
implicitly gone over the typical
radiological features of squamous cell
carcinoma they tend to be very bland as
I mentioned before the larynx is in the
visceral space so anytime you perform
the endoscopy everything that you see
including the mucosa over the larynx is
in the visceral space now what are some
other tumors that we have to consider in
the differential diagnosis and what I
hope to do isn't just instead of going
through all the tumors and by the end of
the talk you say they all look like
everything else which is possible that's
impossible but sometimes there are some
differentiating features that can tell
us that this indeed is a different type
of tumor than our standard
run-of-the-mill squamous cell carcinoma
so here's an example of a leash that's
involving the larynx is primarily
located to the cricoid cartilage so
anybody want to take a guess of what
this is when we do the bone algorithms
we can see that it's not a primarily
mucosal it's submucosa son really
limited to the cricoarytenoid joint and
if if and I never saw this as a resin
maybe that's why I didn't go into
musculoskeletal if I told you that there
were rings and circles here then what
would the diagnosis be anybody
chondrosarcoma exactly right and a
counter sarcomas are actually not
uncommon in the learn say typically
percent as a sub mucosal mass the the
surgeons tell me that tend to be fairly
rock-hard when they go down and they and
they look at the mass is that where my
surgeon the audience there you guys is
that true or not or am i making that up
I trust you guys so anything are you
guys out there correct or incorrect yes
or no may be all right no one's saying
anything okay the second another common
tumor involving the larynx is if it's
not squamous cell carcinoma when you're
looking at a mucosal tumor and they
could also be submucosa but in general
their mucosal lesions these tend to be
the various minor salivary gland tumors
and the most common are going to be the
Mucoepidermoid carcinomas and
adenoid cystic carcinoma of the
malignant variety so this is just an
example of a malignant minor salivary
gland tumor in this case that this was
adenoids
- carcinoma but unfortunately the
radiological appearance is very similar
but on the other hand from a statistical
standpoint one two and three when you
see a malignancy involving the mucosa is
going to be squamous cell carcinoma
another example of a minor salivary
gland tumor this in fact was a Mucoepidermoid carcinoma this was involving
the subglottis and unfortunately the
radiological appearance is
indistinguishable from squamous cell
carcinoma in this case so we just have
to add it to our differential diagnosis
but on the other hand this was kind of
an interesting case this was actually a
benign minor salivary gland tumor this
was a pleomorphic adenoma that was
involved in the larynx and this was a
gradient echo image in this case it was
very very high signal on t2 so if we see
a solid tumor that's high signal on to
involving the larynx that is not the
typical finding of squamous cell
carcinoma but in fact this was a
pleomorphic adenoma so in fact if we
transpose us into the parotid gland then
we could easily say that this was a Pleomorphic adenoma involving the parotid
gland in this particular case it just
happened to be in the larynx now this
was a sort of a tumor that's localized
to the larynx this is a granular cell
tumor and you know we published on this
a few years ago and it does have I would
say a characteristic spread pattern you
know a lot of the granular cell tumors
are never imaged there they tend to be
smaller lesions the surgeons tell me
they can go in there and and resect it
fairly easily but sometimes what happens
with granular cell tumors when they get
to imaging it's almost like the tip of
the iceberg phenomena so the surgeons
will go in and they'll shave off and
resect the granular cell carcinoma the
granular cell tumor and then the patient
recurs and they'll go back and and and
resect it again and it oftentimes the
patients will come back for multiple
receptions well they'll be able to get
the endo laryngeal component but in
those granular cell tumors that have
multiple recurrences these tumors tend
if you will to have a deeper if you want
to use a term endophytic is fine but
they have this
spread so the pot by the time they hit
imaging these tumors have a substantial
submucosal component to it and you know
like I said if it was a squamous cell
carcinoma the patients would have
clearly presented but the fact that
they've had multiple shavings and you
have this appearance this really I think
is due to incomplete resection and
unbeknownst to the surgeon a very deep
spread so when I see something like this
and it's not squamous cell carcinoma
carcinoma that I do start thinking
granular cell tumors and this is the
classic appearance of a subglottic
hemangioma I think we're all know what
age group this comes in that's a younger
kids oftentimes they don't get image the
surgeons will just go when the pediatric
otolaryngologist can go in there and
resect it and oftentimes they don't come
to imaging however when they do come to
imaging here's a typical densely
enhancing lesion involving the larynx
now some surgeons may we're sectors
because it is a hemangioma they have a
proliferative phase and an involuting phase and if there's no significant
compression to the airway then some
pediatric otolaryngologist will just
feel comfortable following it in this
particular case a nice example here of
the subglottic hemangioma again it's
below the level of the true vocal cord
so it's involved in the subglottis
remember at the love of the cricoid
cartilage we can't see the cricoid
cartilage why because in a kid the
cricoid is know pacified but if we look
for that a shape structure we know we're
at the level of the subglottis and we
can see the pretty typical appearance of
the dense enhancement of a subglottic
hemangioma well what about the various
infections and in inflammatory processes
well one of the more common things that
occur in the larynx is Wegener's
granulomatosis and Wegener's as a
granulomatous vasculitis it's probably
immune related there's a classic form
where you have necrotizing granulomas of
the upper and lower respiratory tracts
it's also a systemic vasculitis that can
result in focal necrotizing glomerulitis
now when it's in the larynx
webinars typically involves the lair
in the region of the subglottis and
again it causes a narrowing or stenosis
and people usually present with sore
throat laryngitis or the fevers and the
alpha or arthrologist and this is an
endoscopic view of Wegener's
granulomatosis and this is what we see
radio radiologically and unfortunately
this looks just like a squamous cell
carcinoma now the granular cell tumors
well it would expect to have a little
bit more extension into the anterior
neck but this circumferential
involvement involving the subglottis the
differential is going to be squamous
cell number one minor salivary gland
number two but if the surgeons tell you
they do not see a mucosal leash and the
biopsies were all negative force a tumor
then we have to consider Wegener's
granulomatosis and this is two examples
of pathologically proven Wegner's notice
on this case we don't have the smooth O
shaped appearance but we can see this
irregularity involving the mucosa of the
larynx so think Wegener's granulomatosis
another example here non-contrast
t1-weighted contrast-enhanced
t1-weighted image this is way too much
enhancement involving the subglottis
again it should be very thin and very
fine enhancement and but instead we have
this very thick enhancement of the sub
glottis the other thing that we have to
think about too when we see wetness is
sarcoid so sarcoidosis can have the
exact same appearance as Wagner so when
I see this I think I always say you know
Wegner sarcoid so back when I was taking
my boards and I saw something weird in
the abdomen you know I would say TB
sarcoid lymphoma I don't know if they
still teach the residents that but TB
sarcoid lymphoma so when the larynx I
think about sarcoid Wagner's and
especially if the patient is from India
or South America I always throw in
tuberculosis as well too so those are
the three things that I combined if it's
not squamous cell carcinoma here is an
example of an unusual case here's a
laryngeal abscess that's involving the
free margin of the epiglottis so we have
a suprahyoid and an infra Hired
component the epiglottis we refer to
this area right at the top as the
suprahyoid
or particularly the free Marge in the
epiglottis and there's our laryngeal
abscess if we have a diffuse
inflammation involving the supraglottic
larynx and this is what's referred to as
a supraglottitis in the kids this would
sometimes is epiglottitis but in the
adult some people refer to this as an
adult form of epiglottitis again I kind
of use this with a little trepidation
because it's not fully accepted but in
general you could think of supraglottitis is somewhat akin to an epic alot
Titus so what does it look like well
they can be extraordinarily severe and
and quite scary to look at if you will
because it's a pretty severe infection
there's a diffuse enlargement of the era
of the epiglottis diffuse swelling of
the aryepiglottic folds and the false
vocal cords here we can see diffuse
enhancement and often times you'll have
obliteration of the pre epiglottis and
the para glottic fat notice also there's
edema involving the retro pharyngeal
space and thickening and reticulation
and the platysma and the adjacent fat
and look what it's doing to the
submandibular gland it's actually
causing reticulation of the fat
surrounding the submandibular gland when
we talk about soft tissue infections of
the larynx this is primarily endo
laryngeal if you will so this is the
inflammation of the supraglottitis itself
but soft tissues infections can have
infections involving the skin over the
larynx so this is the erysipelas you can
have inflammations of the subcutaneous
tissues that's your cellulitis we will
talk a little bit about this disease
entity necrotizing fasciitis
and if involves some muscles it's a
Myositis now necrotizing fasciitis
everyone's heard of this obviously and
the lay public has heard of this too
because every six years or so there'll
be an article in the front page of the
New York Times or The Washington Post or
something giving the other name for
necrotizing fasciitis anybody remember
what that is it's a flesh-eating
bacteria right the old flesh-eating
bacteria so that's in in our
nomenclature we refer to this as
necrotizing fasciitis
how do we make the diagnosis of it in
the early stage of necrotizing fasciitis
it looks just like any other infection
you can see the reticulation of the fat
the obliteration of the normal fat
planes by intermediate soft tissue and
we can't do anything about it but what's
the finding here that tells you that
you're dealing with necrotizing
fasciitis it's the air exactly right so
if I told you that this patient had no
history of trauma and there was no
history of chemotherapy or radiation
therapy the patient did have a pretty
severe fever then that's the diagnosis
of necrotizing fasciitis if you do have
a patient that's had chemotherapy or
radiation therapy then all bets are off
because laryngeal or Condor necrosis can
develop air or gas following the
treatment and this can dissect along the
fascial planes so when you see something
when you see that air where it shouldn't
be the first thing you've got to ask
yourself is has the patient had any
trauma or on the other hand have they
had chemotherapy and radiation therapy
if they haven't then you have to start
thinking about neck we can also have
other ideologies involving the larynx
that are developmental and origin and
you know spend a couple of seconds to
get like yeah I guess what I've been
doing what I'm doing for 25 years and
some of the concepts that come naturally
to people I just I still it takes me a
while to get it so one of these things
is about the thyroid gland and I would
always get confused about lingual
thyroid and thyroglossal duct system so
on and so forth I'd always get but again
my 15 watt light bulb went on one day
and I thought I got it yeah I got it and
the way that I think about it is that
the thyroid gland has its normal descent
so it forms anybody remember where it
forms that remember in the name of the
foramen the foramen cecum right so the
foramen sit forms right at the tongue
base and we'll go over this a little bit
later but eventually ends up having a
relative descent where it ends up in the
anterior portion of your neck so
anywhere along that course it can leave
little driblets or droplets or little
footprints where it came from
and if you have thyroid tissue that is
left by the normal descent and that
thyroid tissue is essentially solid then
you have lingual thyroid but if you
leave that thyroid tissue and it still
has secretory elements where it starts
secreting fluid and it starts to blow up
like a water balloon
then you have a thyroglossal duct cyst so
again in my very simplistic way of
thinking of thing if you have a balloon
and then it's not blown up it's just
sitting there and it's all solid then
that's akin to lingual thyroid or
ectopic thyroid tissue but if you take
that balloon and you fill it up with
water then you have a thyroglossal
duct cyst so this is an example of a lingual
thyroid so this is at the level of the
frame and seek them this is a
contrast-enhanced CT scan we can see
this densely enhancing mass again you
look at this Wow could it be a pair of
ganglioma
could it be a hyper vascular minor
salivary gland tumor so on and so forth
it tips you off that you're right at the
level of the frame and cecum and when
you do a CT scan at the level of the
thyroid gland there's no thyroid tissue
whatsoever so this supports that you're
dealing with a lingual thyroid not a
thyroglossal duct system is a solid
enhancing lesion a lingual thyroid
another example here t2-weighted image
contrast and non contrast t1 contrast
enhanced t1 boy it looks just like
squamous cell carcinoma but on the other
hand if you on the back of your mind
especially if they were hypothyroid then
you have to consider the diagnosis of a
lingual thyroid tissue but the key thing
is that tip-off based on that location
another example here sagittal
t1-weighted image is a nice example here
of the lingual thyroid tissue if you're
not sure you can do it also in addition
to a CT do a nuclear medicine study and
in this take case we can see the
protective tape uptake that corresponds
with the abnormality that we see on the
non-contrast t1-weighted mr well as I
mentioned before the thyroid gland has
this relative assent and you can now
have a thyroid glosso ducts in
following the frame and cecum this is
involving the hyoid bone and this is
involving the infrahyoid larynx if you
will know thyroglossal duct cyst this is
a thyroglossal duct cyst is a thyroid
tissue yes technically it's ectopic
thyroid but it contains fluid so then
the real challenge is is how do we know
that these guys right here are
thyroglossal duct cyst is it the fact
that it's pyramid line or the fact that
it's midline unil or ocular multilocular
the bottom line is is that none of those
are really definitive what's definitive
to me is that this is located and
embedded within the strap muscles
because it's a strap muscle you don't
need to perform CT scans to say that you
have a thyroid Glassell duct cyst powder
doctor lucassi luck cysts Mon swallowing
so if someone swallows that the lesion
moves right so think about how the
larynx works again this is my simplistic
way of looking at this when you swallow
what happens your soft palate closes
your epiglottis flips down so the food
doesn't go down your larynx but the
other way your body helps you not
aspirate is that the larynx comes up and
so when the larynx comes up then the
epiglottis closes the opening the larynx
so you have two things happening so how
does the larynx comes up it is pulled up
by the strat muscles so it's almost like
an elevator how does an elevator rise it
gets pulled up by the pullys so the
strap muscles are like pulleys that
elevate the larynx so as a result when a
thyroglossal duct Cyst occurs the way
the referring physician makes a
diagnosis that they ask the patient to
swallow and to see if the mass moves is
on swallowing ie undeglutination so
this essentially is the Radiological
correlate to the clinical phenomenon
that's occurring this lesion is embedded
in the strap muscles so therefore when
the strap muscle moves in swallowing the
lesion follows the strap muscles so it's
not the unilocularity the
multilocularity the midline the pyramid
line it's the fact that this lesion
these
thyroglossal duct cyst are embedded in the
strap muscle that to me is the most most
convincing finding that we're dealing
with the thyroglossal duct cyst the type
of surgery that's performed as a system
procedure in this case they take a cup
of cup of tissue and follow it back all
the way to the anterior neck and this
happens to be the little duct associated
with the thyroglossal duct cyst this is
a benign thyroglossal duct cystic an be
very large but on the other hand this is
a thyroid lhasa ducts sis that has a
diffusely enhancing mass within it and
what do you guys think this is it's
papillary thyroid carcinoma
so papillary thyroid carcinoma has been
associated with thyroglossal duct system
een I think it's six to seven percent at
least in my experience is probably less
than that but a coincidental or
concommittant papillary thyroid
carcinomas can occur and thyroglossal
duct cyst so we have to be aware of that
if you have dilatation here of the
laryngeal ventricle you then have a
legacy and the laryngocele can be deep
to the thyrohyoid membrane in which case
it's called a simple laryngocele but if
it extends through the thyrohyoid
membrane into the soft tissues of neck
then you can have a complex or a mixed
laryngocele in this case the most common
cause that we see especially when in my
old institution and now now is squamous
cell carcinoma something that's
including the laryngeal ventricle I know
back when I was a resident it was due to
trumpet players and glass blowers I
never met a glass blower until four
years ago when until I went to Holland I
know if you've been to Holland Michigan
and you've been to the glassblowers I
finally met a glass blower and he did
have a laryngocele so I'll get up grant
on that much but by the same token
globally the cause of laryngoceles
tend not to be trumpet players or people
like Dizzy Gillespie because most of us
don't do that but it tends to be
squamous cell carcinoma which ends up
including the laryngeal ventricle and
then leads to dilatation of the of the
laryngeal ventricle another example of a
laryngocele this was due again due to us
missile carcinoma on the left-hand side
in this particular case on the
right-hand side so this is airfield and
they can be fluid-filled and when they
become infected you can develop what we
refer to as a laryngopyocele or you
can call it a pyolaryngocele
whichever suits suits your preference in
this case that's a mixed or a complexed
laryngopyocele we can have our tear
of venous malformations a involving the
larynx as well - in this particular case
this was all evolving the floor of the
mouth and here's our tear venous
malformation involving the larynx this
is it on em are kind of tough to see but
certainly when you do a CT scan and this
this particular case is CT unequivocal
we can see a substantial amount of flow
and all these multiple dilated vessels
submucosa lee at the level of the true
vocal cord at the level of the
supraglottic larynx and at the level of
the subglottic larynx again we know what
the level of true vocal cord because of
what the cricoarytenoid joined the last
thing that we'll talk about in the
remaining time is vocal cord palsy and
just to give you a couple tips because
it's probably if you're in a general
practice it's probably one of the most
confusing things that you see because in
this particular case we see this mass
right here and we just talked about
supraglottic carcinomas and
aryepiglottic fold carcinomas and you see
my gosh something's not right here
involved in the aryepiglottic fold
is this a squamous cell carcinoma well
it can be confusing but some of the
tricks of the trades that I've learned
over time is that if you do see this
Mira median appearance to the area
epiglottis old look at that EPSA lateral
piriform sinus if this was a large mass
as I showed before that piriform sinus
on would be compressed but instead it's
dilated so that tells you you're having
an ex vacuo phenomena on the left hand
side the recurrent laryngeal nerve wraps
around the aortic arch down the right
hand side it wraps around the subclavian
artery so in this particular case this
vocal cord palsy was due to this
bronchogenic carcinoma that was
involving the mediastinum particularly
at the AP window because you
seed this is located just below the
aortic arch well where do we
specifically should we look for vocal
cord palsies certainly we need to look
at the brain to make sure there's not an
infarct but particularly we need to pay
attention here to the trachea esophageal
groove so there's our trachea there's
the esophagus so we need to look and
analyze these fat planes very very
carefully another example of a vocal
cord palsy in this case the pair
immediate area epiglottis fold here's
our area of robotic foe
look at the ipsilateral piriform sinus
its dilated in this particular case
there's also dilatation of the laryngeal
ventricle so you see something like this
you're not sure where should your eye go
to next
look at the ipsilateral piriform sinus
look at the laryngeal ventricle these
two things are dilated there's no way
a mass that big could be amassed that
big right it should have some type of
compression but instead we see ex vacuo
Mahna in this particular case this was
due to this this in fact was a little
aneurysm probably a ductus aneurysm
arising from the aortic arch again
pinching off on the left hand side the
left recurrent laryngeal nerve another
example here of a vocal cord palsy again
paramedian cord written I'd has
tipped immediately this on MR there is
dilatation of the piriform sinus and in
fact when we look at the mediastinum
this was due to a huge aortic aneurysm
again clipping off the recurrent
laryngeal nerve this is a nice paper
written by I think Hugh Curtin a few
years ago demonstrating that not only
can we determine whether or not there's
a vocal cord palsy we can look at
chronicity and if indeed we look at the
thyroid excuse me the thyroid the the
groove sorry about that we can see in
this case denervation atrophy we can see
fatty replacement of the muscles so if
we look I got it now the tracheal
esophageal groove and we look at the
trachea esophageal groove we also need
to look at the various cricoid and
cricoarytenoid muscles
notice a normal appearance on the left
hand side on the right hand side we can
see there's fatty replacement so that
tells us we're dealing with chronic
denervation atrophy so it's not a cute
vocal cord palsy but it's certainly
long-standing another example here
chronic vocal cord palsy look at the
denervation atrophy involving some of
the para glottic musculature on the left
and compared to the right again due to
bronchogenic carcinoma because sometimes
these vocal cord palsies are due to
their acute and if we can't see anything
else that's causing it we just sort of
as dr. Salim said we just described it
to a viral process but on the other hand
if we look at this and we begin to see
the denervation atrophy and we really
have to look for some anatomic basis for
the vocal cord palsy so that's why I
think it's important that we look at the
post cricoid musculature and we also
look at the paragliding musculature well
too because it typically tells us
there's something more ominous how do
they treat this they can treat this with
Teflon injection or some type of cynical
silicone replacement so essentially
there is a mechanical displacement of
the vocal cord medially so this vocal
cord essentially becomes fixed pair of
midline so the normal vocal cord can
begin to oppose itself and you can
recreate your function so in this
particular case this was a Teflon
injection at the level of the cricoid
written or joint you can also put a
piece of silicon there this is still
referred to I believe as a Shiki
procedure where they can place a silicon
submucosa lee at the level of the true
vocal cord the thing about these Teflon
injections is that if if you do have bad
luck if you will you can inject the
silicon but it can also result in a
gross inflammatory response in fact this
was a Teflon granuloma formation so this
appearance in and of itself is is fine
this appearance in and of itself is fine
but if you start developing this
additional soft tissue that essentially
creates a rind along where we see this
radio density this is not normal and
that's typically due to granuloma formation
the implant so in summary what I've
tried to do over the last 40 minutes is
talk a little bit about the technique we
talked about the anatomy tumors
infections and inflammatory processes
developmental and we ended up with vocal
cord palsy so thank you very much for
your attention and what we'll go for
break and we'll see you back here at 11
o'clock Thanks
