Case Studies in the Larynx - University of Utah

Report
Case Studies in the Larynx
Non-SCC Pathology
Nicholas S. Pierson, MD
University of Utah Neuroradiology
12th Intensive Interactive
Head and Neck Imaging Conference
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
Case 1
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•
•
•
49 year old male
Progressive difficulty breathing
Globus sensation
30 pack year smoking history
DDX
•
•
•
•
•
Polyp
Nodule
Polypoid degeneration
Squamous papilloma
SCC
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
Companion Case 1a
Vocal Cord Nodule
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
T1
T1 FS Post
T2 FS
DDX
• Chondroid lesion: Chondroma\sarcoma
• Other sarcomas
• Inflammatory cartilaginous processes
such as relapsing polychondritis
• SSC
• Rare lesions: Carcinoid, paraganglioma,
giant cell tumors
• Mets/Myeloma
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
Companion Case 2a:
• 67 year old male
• Incidental lesion seen on MRI C-spine
• Asymptomatic
Companion Case 2b:
• 39 year old male
• Difficulty breathing
Giant Cell Tumor
Case 3:
• 64 year old male
• History of multiple myeloma and right
inguinal melanoma
• Metastatic workup
T2 FS
T1
T1 FS Post
Multiple Myeloma
Companion Case 3a:
• 76 year old male
• History of multiple myeloma
Multiple Myeloma
Companion Case 3b:
• 71 year old male
• History of prostate cancer
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
Teflon Granuloma
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
Case 4
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•
•
•
55 year old male with dysphagia
Fluctuant neck mass
Changes in size and tenderness
Occasional copious secretions
T2
FS
DDX
• Laryngocele
• Other cystic neck masses
• Thyroglossal duct cyst
• Branchial cleft cyst 2 and 4
•
•
•
•
Lateral hypopharyngeal pouch
Abscess
Vallecular cyst
Cystic nodal mass
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
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
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
SCC with Secondary
Laryngocele
Case 5
• 34 year old mixed martial artist
• 2 days following tournament
• Throat injury with progressive pain and
difficulty breathing
8/2013
8/2012
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
Companion Case 5a
• Equestrian injury
Case 6
• 38 year old female
• 8 weeks of hoarseness
T1
T2
T1
Post
T1
Post
Vocal Cord Paralysis
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•
•
•
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
Companion Case 6a
• 73 year old male
• Extensive smoking history
• Hoarseness
Companion Case 6b
• 43 year old male
• Acute Horner’s syndrome and nystagmus
DTI
Lateral Medullary Syndrome
Flair
FS
Case 7
• 33 year old woman
• Progressive, worsening shortness of
breath
DDX: Subglottic Stenosis
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•
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•
Iatrogenic
Post traumatic
Thyroid mass/mass effect
Idiopathic/congenital
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RP, Wegener’s
Amyloid, Sarcoid
Schwannoma
Vascular rings/slings
SCC
Craniotomy for
traumatic brain injury
10 years ago
Iatrogenic Subglottic Stenosis
• Most common intrinsic
cause, ~90%
• Hx of prolonged intubation
• Pressure necrosis
• Describe level and length
• Is the cricoid involved?
Case 8
• 44 year old female
• Dysphagia
T1
T2
T1
FS
+C
T1
FS
+C
DDX
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•
•
•
•
Paraganglioma
Schwannoma
Vasoformative lesion
Metastasis
Hemangiopericytoma
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
Companion Case 8a
• 63 year old female
• Dysphagia, dysphonia
• Difficulty breathihng
Vasoformative Lesion
Companion Case 8b
• 35 year old female
• Dysphagia, dysphonia
Pre
Post
Schwannoma
Conclusion
• Discussed part of the spectrum of nonSCC 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
Case Studies in the Larynx
Non-SCC Pathology
Nicholas S. Pierson, MD
University of Utah Neuroradiology
12th Intensive Interactive
Head and Neck Imaging Conference
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”

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