Case Studies in the LarynxNon-SCC Pathology

Nicholas S. Pierson, MD

University of Utah Neuroradiology

12th Intensive Interactive

Head and Neck Imaging Conference

• 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

Objectives

• 49 year old male• Progressive difficulty breathing• Globus sensation• 30 pack year smoking history

Case 1

• Polyp• Nodule• Polypoid degeneration• Squamous papilloma• SCC

DDX

• 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

Vocal Cord Polyp

Companion Case 1a

Vocal Cord Nodule

• 75 year old male with hoarseness• Obvious mass on laryngoscopy• Abnormality found incidentally on

imaging 10 years prior• Refused treatment at the time

Case 2

T1

T2 FS

T1 FS Post

• Chondroid lesion: Chondroma\sarcoma• Other sarcomas• Inflammatory cartilaginous processes

such as relapsing polychondritis• SSC• Rare lesions: Carcinoid, paraganglioma,

giant cell tumors• Mets/Myeloma

DDX

• 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

Low Grade Chondrosarcoma

• 67 year old male • Incidental lesion seen on MRI C-spine• Asymptomatic

Companion Case 2a:

• 39 year old male• Difficulty breathing

Companion Case 2b:

Giant Cell Tumor

• 64 year old male• History of multiple myeloma and right

inguinal melanoma• Metastatic workup

Case 3:

Multiple Myeloma

T2 FS T1 T1 FS Post

• 76 year old male• History of multiple myeloma

Companion Case 3a:

Multiple Myeloma

• 71 year old male• History of prostate cancer

Companion Case 3b:

• 74 year old male with skull base lesion• Surgical debulking of the left skull base

and orbit many years prior• Dysphonia, dysphagia

Companion Case 3c: Pitfall

Teflon Granuloma

• 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

Vocal Cord Medialization Pitfall

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

Case 4

T2FS

• Laryngocele• Other cystic neck masses

• Thyroglossal duct cyst• Branchial cleft cyst 2 and 4

• Lateral hypopharyngeal pouch• Abscess• Vallecular cyst• Cystic nodal mass

DDX

• Paraglottic/Supraglottic• Extend through the

thyrohyoid membrane• Circumscribed, thin

walled, may contain fluid or air

• Present as neck mass in low submandibular space

External (mixed) Laryngocel

• Internal/Simple: confined to paraglottic space

• External/Mixed: internal and external components

• Pyolaryngocele: superinfection• Secondary: Glottic or inferior supraglottic

mass obstructs laryngeal ventricle

Laryngocele Types

• 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

Companion Case 4b

SCC with Secondary Laryngocele

• 34 year old mixed martial artist• 2 days following tournament• Throat injury with progressive pain and

difficulty breathing

Case 5

8/2013 8/2012

• 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

Thyroid Cartilage Fracture

• Equestrian injury

Companion Case 5a

• 38 year old female• 8 weeks of hoarseness

Case 6

T1

T1Post

T1Post

T2

• Sail sign- ballooned ventricle• Medial rotation of arytenoid• Medialized aryepiglottic fold • Enlarged pyriform sinus

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

Vocal Cord Paralysis

• 73 year old male • Extensive smoking history• Hoarseness

Companion Case 6a

• 43 year old male • Acute Horner’s syndrome and

nystagmus

Companion Case 6b

Lateral Medullary Syndrome

DTIFlairFS

• 33 year old woman• Progressive, worsening shortness of

breath

Case 7

• Iatrogenic• Post traumatic• Thyroid mass/mass effect

• Idiopathic/congenital• RP, Wegener’s• Amyloid, Sarcoid• Schwannoma• Vascular rings/slings• SCC

DDX: Subglottic Stenosis

Craniotomy for traumatic brain injury 10 years ago

• Most common intrinsic cause, ~90%

• Hx of prolonged intubation• Pressure necrosis• Describe level and length• Is the cricoid involved?

Iatrogenic Subglottic Stenosis

• 44 year old female• Dysphagia

Case 8

T1

T1FS+C

T1FS+C

T2

• Paraganglioma• Schwannoma• Vasoformative lesion• Metastasis• Hemangiopericytoma

DDX

• 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

Paraganglioma

• 63 year old female• Dysphagia, dysphonia• Difficulty breathihng

Companion Case 8a

Vasoformative Lesion

• 35 year old female• Dysphagia, dysphonia

Companion Case 8b

Schwannoma

Pre Post

• 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

Conclusion

Case Studies in the LarynxNon-SCC Pathology

Nicholas S. Pierson, MD

University of Utah Neuroradiology

12th Intensive Interactive

Head and Neck Imaging Conference

• Incidental findings in 2 different patients• Low density foci in the thyroid cartilage• Recently described as “benign tumor like

lesions” and “pseudo-lesions”

Companion Case 3d: Mimic