Diagnostic Imaging of Pharynx & Larynx

Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

Pharynx & Larynx
a) Nasopharynx
b) Hypopharynx, Larynx
c) Parapharyngeal Space

Normal anatomy of the pharynx, AP air-contrast image shows that the true anatomic
dividing line between the oropharynx and hypopharynx is the obliquely coursing
pharyngoepiglottic fold (curved arrows), the vallecular pouches (V) are symmetric,
divided by the median glossoepiglottic fold (open arrows), the free margin (straight
solid arrows) of the epiglottis projects superior to the valleculae, the hypopharynx
consists of the piriform sinuses (P), the posterior pharyngeal wall, and the postcricoid
region, the lateral wall of the piriform sinus demarcates the lateral margin (solid
arrowheads) of the hypopharynx, the entire bulk of the larynx pressing on the anterior
pharynx creates a coated mucosal surface known as the “postcricoid line” (open
arrowheads)

Normal anatomy of the pharynx, on a lateral air-contrast image, the slightly
nodular surface of the base of the tongue (bot) is superior to the
valleculae (V), although the hyoid bone (H) moves and changes its position
relative to the pharynx during swallowing, it can be used as a proxy
landmark to delineate the dividing line between the oropharynx and
hypopharynx, the free margin (black arrows) of the epiglottis (E) projects
posterior and superior to the vallecula, the aryepiglottic fold (white arrow)
covers the posterior surface of the arytenoid cartilage (a), the prevertebral
soft tissues (PV) lie between the posterior wall of the oropharynx and
hypopharynx and the vertebral column, P = piriform sinuses

a) Nasopharynx :
1-Thornwaldt Cyst
2-Retropharyngeal Abscess
3-Juvenile Angiofibroma
4-Squamous Cell Carcinoma

1-Thornwaldt Cyst :
a) Incidence
b) Radiographic Features

a) Incidence :
-Cystic midline nasopharyngeal notochordal
remnant (3% of population)
-May occasionally become infected
-Age : 15 to 30 years

b) Radiographic Features :
-Hemispherical soft tissue density seen on
lateral plain films
-Typical cystic appearance by CT and MRI
-Location : midline, same level as adenoids

2-Retropharyngeal Abscess :
a) Etiology
b) Radiographic Features
c) Differential Diagnosis

a) Etiology :
-Dental disease, pharyngitis, penetrating
trauma, vertebral osteomyelitis
-Organism : Staphylococcus, Streptococcus,
anaerobes, Mycobacterium tuberculosis
(TB)

b) Radiographic Features :
1-Plain Radiography :
-Soft tissue swelling posterior to the pharynx
-Widened retropharyngeal space
2-CT :
-Gas
-Necrotic tissue and edema appear
hypodense
-Stranding of fat
-Rim enhancement with contrast

Retropharyngeal abscess in a 3-year-old girl with fever and throat pain,
(a) Lateral neck radiograph shows diffuse prevertebral soft tissue
swelling (arrows), (b) CT+C demonstrates a mildly enhancing, thick-
walled retropharyngeal fluid collection (arrow), these findings are
indicative of an abscess

Retropharyngeal abscess in a 30-year-old man who presented with
worsening odynophagia and dysphagia, lateral image from a barium
pharyngographic study demonstrates marked widening of the
prevertebral soft-tissue stripe (PV) caused by a soft-tissue mass
containing small foci of gas (arrowheads)

Retropharyngeal abscess, CT+C shows a large retropharyngeal fluid
collection (arrows) with peripheral rimlike enhancement

Retropharyngeal abscess, CT+C shows a peripherally enhancing left
RPS fluid collection (large arrow) under tension, heterogeneous
enhancement is present in the right RPS (small arrow) consistent
with inflammatory change

3-MRI :
*T1 : central low to intermediate signal
*T2 : central high signal
*T1+C : peripheral enhancement
*DWI : restricted

c) Differential Diagnosis :
-Prevertebral soft tissue mass in a child on lateral
cervical X-ray :
1-Trauma / hematoma
2-Abscess
3-Lympahtic malformation
4-Lymphoma
5-Nasopharyngeal rhabdomyosarcoma
6-Neuroblastoma

-Prevertebral soft tissue mass in an adult on
lateral cervical X-ray :
1-Trauma / hematoma
2-Abscess
3-Postcricoid carcinoma
4-Chordoma
5-Pharyngeal pouch (air fluid level)
6-Retropharyngeal goiter

3-Juvenile Angiofibroma :
a) Incidence
b) Clinical Picture
c) Radiographic Features
d) Differential Diagnosis

a) Incidence :
-Vascular tumor of mesenchymal origin
-Most frequent benign nasopharyngeal
tumor in adolescents (age : 10 to 20)
-Males only, however some cases were
reported in females

b) Clinical Picture :
-Presentation is typically with obstructive
symptoms, epistaxis and chronic
otomastoiditis due to obstruction to
the eustachian tube
-Patients may present with life threatening
epistaxis
-On examination it may be seen as a pale
reddish blue mass

c) Radiographic Features :
-Usually large soft tissue mass causing local bony
remodeling
-Centered on the sphenopalatine foramen (which
is often widened) and typically bowing the
posterior wall of the maxillary antrum anteriorly
(Holman-Miller sign, also called antral sign)
-Highly vascular :
Intense enhancement by CT and MRI
MRI : very hyperintense on T2, flow voids
Tumor blush by angiography
-Embolization before resection :
Main supply from ECA particularly maxillary artery
May have supply from ICA

Homogenously enhancing mass lesion centered at sphenopalatine foramen
(widened by the mass, shown by black arrows), extending into nasopharynx
(yellow arrow) and pterygopalatine fossa (red arrow), the mass also fills
ipsilateral nasal cavity, pushing the septum to left

Bowing of the posterior wall of the maxillary antrum
(Holman Miller or antral sign; red arrows)

Juvenile angiofibroma in a 15-year-old boy with recurrent epistaxis,
axial unenhanced CT image depicts a homogeneous mass centered
in the sphenopalatine foramen, the mass extends into the nasal
cavity and widens the pterygopalatine fossa)

CT+C shows a large heterodense destructive soft tissue lesion seen in the
superior postero-lateral wall of the right nasal cavity, extending into the
nasopharynx and adjacent pterygopalatine fossa, right pre-maxillary space
causing bowing of the posterior antral wall: The characteristic Holman Miller
sign (yellow arrow) with erosion/ destruction of adjacent bones

(a) Axial CT shows a tumor that arises from the right pterygoid plate and grows
into and widens the pterygopalatine fossa (asterisk), the tumor then grows
anteromedially through the sphenopalatine foramen (white arrow), laterally
through the pterygomaxillary fissure (black arrow), and posteriorly into the
Vidian canal (arrowheads), (b) Coronal CT demonstrates destruction of the
pterygoid plate just posterior to the pterygopalatine fossa

A comparison of axial unenhanced (a) and contrast-enhanced (b) T1
shows avid enhancement of the mass (arrows in b), note the flow
voids in the pterygopalatine fossa (arrowheads in b),

(a) T1 shows a large, well-defined mass (arrow) in the region of the pterygo-
maxillary fissure and sphenopalatine foramen on the right side with a
heterogenous intensity, (b) T2 shows a large, well-defined mass in the
region of the pterygo-maxillary fissure and spheno-palatine foramen on the
right side with heterogenous intensity, tiny flow voids are noted within the
lesion (yellow arrows) consistent with hypervascularity

(a) Axial gradient echo and (b) axial T2 of a left-sided tumor growing anteriorly
into the nasal cavity (black arrow), dislocating the ipsilateral maxillary sinus
anteriorly (white arrow) and growing into the masticator space (black
arrowhead), notice also growth into the broadened Vidian canal (white
arrowheads), the rich vascularity of the tumor gives rise to the typical small
dotted flow void

Right ECA angiogram shows the feeding internal maxillary
artery (arrow) and the hypervascular lesion (arrowheads)

d) Differential Diagnosis : Nasopharyngeal mass
1-Adenoid Hypertrophy
2-Trauma , hematoma
3-Infection , abscess
4-Benign Neoplasm :
Angiofibroma , antrochoanal polyp
5-Malignant Neoplasm :
-Nasopharyngeal carcinoma
-Lymphoma
-Rhabdomyosarcoma
-Plasmacytoma
-Direct extension of paranasal sinus tumor
6-Encephalocele :
-Midline defect on skull base with herniation of
meninges and brain

4-Squamous Cell Carcinoma :
a) Incidence
b) Location
c) Staging
d) Radiographic Features
e) Differential Diagnosis

a) Incidence :
-SCC accounts for 80%-90% of malignant
tumors in the nasooropharynx
(lymphoma : 5%, rare tumors :
adenocarcinoma, melanoma & sarcoma)
-Strongly associated with Epstein Barr virus
(EBV)

b) Location :
1-Nasopharynx :
-Tumors most commonly arise from lateral
pharyngeal recess (fossa of Rosenmeller)
2-Oropharynx :
-Palate
-Tonsil
-Tongue, pharyngeal wall
-Lips, gingiva, floor of mouth

c) Staging :
*T :
Tis : carcinoma in situ
T1 : tumor confined to 1 site of nasopharynx or no
tumor visible
T2 : tumor involving 2 sites (both posterosuperior
and lateral walls)
T3 : extension of tumor into nasal cavity or
oropharynx
T4 : tumor invasion of skull, cranial nerve
involvement or both

*N :
N0 : clinically positive node
N1 : single clinically positive homolateral node ≤3
cm in diameter
N2 : single clinically positive homolateral node >3
cm but not >6 cm in diameter
N3 : node >6 cm
*M :
M0 : no distant metastases
M1 : distant metastases

d) Radiographic Features :
1-CT :
-Asymmetry of soft tissues, primarily infiltrating
carcinomas produce only slight asymmetry
-Mass, ulceration & infiltrating lesion
2-MRI :
*T1 : typically isointense to muscle
*T2 : isointense to somewhat hyperintense to
muscle, fat saturation is helpful, fluid in the
middle ear is a helpful marker
*T1+C : prominent heterogeneous enhancement is
typical

Squamous cell carcinoma of the nasopharynx, CT+C shows an
abnormal soft-tissue mass with relatively uniform contrast
enhancement filling the left lateral fossa of Rosenmueller

The configuration of NPC is almost always asymmetric as seen in this
contrast enhanced, axial T1 weighted fat saturation MRI image

T1+C shows small NPC (short arrows) centered in left Rosenmeller
fossa (long arrow), which is the most common site for this cancer,
and involving posterior wall, tumor is confined to nasopharynx (T1),
and there is small metastatic left retropharyngeal node (curved
arrow)

Nasopharyngeal carcinoma (NPC) with parapharyngeal extension (T2), T1+C
shows NPC (white arrows) with left parapharyngeal extension and
involvement of parapharyngeal fat space, note normal levator palatini
muscle (red arrow), tensor palatini muscle (blue arrow), pharyngobasilar
fascia (black arrow), and fat space (yellow arrow) on normal right side

Nasopharyngeal carcinoma with prevertebral extension (T2), T1+C
shows nasopharyngeal carcinoma (straight arrows) with extensive
spread predominantly posteriorly into longus muscles (arrowheads)
and clivus (curved arrows)

NPC with skull base foraminal invasion, (a) Coronal T1+C shows NPC (straight arrows)
with skull base invasion at foramen ovale (arrowhead) with invasion into cavernous
sinus (curved arrow), (b) Coronal T1+C shows invasion of NPC (straight arrows) into
foramen lacerum (arrowheads), where it encases carotid artery and extends into
cavernous sinus (curved arrow), (c) Axial T1+C shows NPC invading pterygopalatine
fossa (circle), pterygomaxillary fissure (arrow), and vidian canal (arrowhead)

e) Differential Diagnosis :
-The differential for a small mass confined
to the mucosal space includes :
1-Prominent but normal adenoidal tissue
2-Nasopharyngeal lymphoma
3-Low grade / early other primary
nasopharyngeal malignancies

-The differential for a larger mass with
involvement of base of skull includes all of
the above with the addition of the
following:
1-metastases
2-Chordoma
3-Chondrosarcoma
4-Meningioma
5-Even pituitary macroadenoma

b) Hypopharynx, Larynx :
1-Vocal Cord Paralysis
2-Laryngocele
3-Laryngeal Trauma
4-Benign Laryngeal Tumors
5-Laryngeal Carcinoma
6-Postsurgical Larynx

**Anatomy of the larynx :
a) Laryngeal Cartilages
b) Laryngeal Ventricular Complex (LVC)
c) Anterior and Posterior Commissure
d) The Paraglottic Space (PLS) and the Pre-
Epiglottic Space (PES)

a) Laryngeal Cartilages :
-The larynx extends from the tip of epiglottis to the inferior
margin of the cricoid cartilage
-The epiglottis, thyroid, cricoid and the paired arytenoid
cartilages are the four principal laryngeal cartilages
1-The Epiglottis :
-Is the superiormost, midline leaf-shaped cartilage, it has a
free margin and a fixed portion (stem)
-The hyoepiglottic ligament attaches the free epiglottic
margin to the hyoid bone and the thyroepiglottic ligament
attaches the epiglottic stem to the inner surface of the
thyroid cartilage at a caudal level
-The free epiglottic margin appears before the hyoid is
visualized

2-The Thyroid Cartilage :
-Has two laminae fused anteriorly, and
enlarged posteriorly, to form the superior
and inferior cornua
-The superior cornua provide attachment to
the thyrohyoid ligament and the inferior
cornua articulate medially with the sides of
the cricoid at the cricothyroid joint

3-The Cricoid Cartilage :
-Is the inferiormost ring-shaped laryngeal cartilage
and the foundation of the larynx
4-The Paired Arytenoid Cartilages :
-Sit along the upper margin of the cricoid lamina,
forming the cricoarytenoid joints
- The vertical height of the arytenoid spans the
laryngeal ventricle
-The apex of the arytenoid attaches the vestibular
ligament and corresponds to the level of the
false cords
-The base of the arytenoids projects the vocal
processes anteriorly, that attach the vocal
ligament running along the inner margin of true
vocal cords

Normal anatomy of the larynx (frontal view)

Normal anatomy of the larynx (lateral view)

Normal anatomy of the larynx, (a) supraglottic, tip of the
epiglottis in the midline (arrow), (b) supraglottic, paired
vallecullae (curved arrows) on either sides of
hypoepiglottic ligaments (elbow arrow), epiglottis is seen
in the midline (thin arrow)

Normal anatomy of the larynx, (a) supraglottic, the pre-epiglottic space (white
asterisk) seen anterior to the epiglottis (thin arrow), note the aryepiglottic
folds (bent arrows) and the piriform sinuses (notched arrows), (b)
supraglottic, the stem of the epiglottis is seen attaching to the inner surface
of the thyroid cartilage in the midline (thin arrow), the aryepiglottic folds
(bent thick arrows), piriform sinuses (notched arrows) and paraglottic
spaces (curved elbow arrows) are seen

Normal anatomy of the larynx, supraglottic, the tip of the arytenoid
cartilages (double headed arrows) and the false cords (small
arrows) are seen, the paraglottic spaces (curved elbow arrows) are
seen deep to the false cords, this section represents the superior
margin of the laryngeal ventricular complex

Normal anatomy of the larynx, glottic, the cricoarytenoid joints (straight
arrows) are seen, the thyroarytenoid muscle forms the bulk of the
true focal cords (block arrows) at this level, note the anterior
commissure (elbow arrow) and the posterior commissure (curved
arrow)

Normal anatomy of the larynx, subglottic, shows the cricoid
ring

b) Laryngeal Ventricular Complex (LVC) :
-This is the key component in organizing the larynx into the
supraglottis, glottis and subglottis
-It comprises the false cords, true cords and intervening
laryngeal ventricle
-The LVC is best identified on coronal images, the ventricle
itself is seen as a small air-filled outpouching between
the false and true cords
-On axial images, the superior margin of the LVC is defined
by a section through the apex of the arytenoids, the false
cords and the fat-filled paraglottic spaces deep to the
false cords
-The inferior margin is defined by a section through the true
cords with the thyroarytenoid muscle and the
cricoarytenoid joint

Coronal CT image through the larynx shows the epiglottis (thin arrow) ,
false cords (elbow arrow), laryngeal ventricle (thick arrow) , true
cord (curved elbow arrow) and paraglottic space (black arrows)

Normal anatomy of the larynx, (a) supraglottic, the tip of the arytenoid cartilages (double
headed arrows) and the false cords (small arrows) are seen, the paraglottic spaces
(curved elbow arrows) are seen deep to the false cords, this section represents the
superior margin of the laryngeal ventricular complex, (b) glottic, the cricoarytenoid
joints (straight arrows) are seen, the thyroarytenoid muscle forms the bulk of the true
focal cords (block arrows) at this level, note the anterior commissure (elbow arrow)
and the posterior commissure (curved arrow)

c) Anterior and Posterior Commissure :
-The anterior commissure is the midline
anterior meeting point of the true vocal
cords
-The posterior commissure is the mucosal
surface on the anterior surface of the
cricoid cartilage between the arytenoid
cartilages

d) The Paraglottic Space (PLS) and the Pre-
Epiglottic Space (PES) :
-The PGS is located deep to the mucosal surfaces
of the true and false cords and bound laterally by
the thyroid and cricoid cartilages and is best
seen on axial CT and MR sections through the
supraglottis
-The pre-epiglottic space (PES) is a fat-filled
space, rich in lymphatics. It is bound superiorly
by the hyoepiglottic ligament, anteriorly by the
thyrohyoid membrane, inferiorly by the
thyroepiglottic ligament and posteriorly by the
epiglottis

Normal anatomy of the larynx, supraglottic, (a) the pre-epiglottic space (white
asterisk) seen anterior to the epiglottis (thin arrow), note the aryepiglottic
folds (bent arrows) and the piriform sinuses (notched arrows), (b) the stem
of the epiglottis is seen attaching to the inner surface of the thyroid cartilage
in the midline (thin arrow), the aryepiglottic folds (bent thick arrows), piriform
sinuses (notched arrows) and paraglottic spaces (curved elbow arrows) are
seen, (c) the tip of the arytenoid cartilages (double headed arrows) and the
false cords (small arrows) are seen, the paraglottic spaces (curved elbow
arrows) are seen deep to the false cords, this section represents the
superior margin of the laryngeal ventricular complex

(a) CT, (b) T1 show epiglottis (thin arrow), and the pre-epiglottic fat
space (thick arrow), note the clear relationship of the base of the
tongue (elbow arrow) with the epiglottis

1-Vocal Cord Paralysis :
a) Incidence
b) Etiology

a) Incidence :
-Can cause laryngeal dysfunction ranging from
slight hoarseness to life-threatening airway
obstruction
-The RLN is a branch of vagus nerve, the vagus
nerve descends with the carotid artery sheath
into the upper mediastinum
-The RLNs enter the larynx posterior to the
cricoarytenoid joints and innervate the intrinsic
laryngeal muscles, the cricothyroid muscle is
the only intrinsic laryngeal muscle not supplied
by the RLN instead receiving its motor supply
from the superior laryngeal nerve

Left anterior oblique dissected view shows the left vagus nerve exiting the skull base through the
jugular foramen and descending through the neck posterolateral to the internal carotid arteries
(ICA) and common carotid arteries (CCA), as the left vagus nerve passes anterolateral to the
aortic arch, the left RLN branches off and passes below the arch posterior to the ligamentum
arteriosum, it then ascends within the left tracheoesophageal groove to enter the larynx
posteriorly at the level of the cricoarytenoid joint, the right vagus nerve descends posterolateral to
the internal and common carotid arteries from the right jugular foramen, giving rise to the right
RLN as it passes anterior to the right subclavian artery (SCA), the right RLN then passes
posterior to the right brachiocephalic artery (BCA) before ascending to the larynx within the right
tracheoesophageal groove, JV = jugular vein

At the level of the skull base, each vagus nerve is found within the
posterolateral aspect of its respective jugular foramen (the pars
vascularis) and posterolateral to the internal carotid artery.CCA =
common carotid artery, JV = jugular vein

At the level of the origin of the right subclavian artery (SCA), the right
vagus nerve passes anterior to the subclavian artery, with the RLN
crossing the mediastinum immediately below this point to reach the
right tracheoesophageal groove. BCA Bifurc. = brachiocephalic
artery bifurcation, CCA = common carotid artery, Tr = trachea

At the level of the aortic arch (AoA), the left vagus nerve gives rise to
the RLN, which passes below the arch to reach the left
tracheoesophageal groove. SVC = superior vena cava, Tr = trachea

The vagal nerves in the posterior fossa, axial heavily T2-weighted thin-slice MR
image through the brainstem with the position of the nucleus ambiguus
(white circles), the exit of the vagal nerves from the olivary sulcus (curved
arrow), the cisternal segment of the vagal nerves (long arrow), and the pars
nervosa of the jugular foramen (short arrow)

The course of the vagal nerves and recurrent laryngeal nerves, a Coronal MIP reformat showing the
expected course of the vagal nerves bilaterally within the carotid sheath and proximal parts of the
recurrent laryngeal nerves (dotted lines), the right recurrent laryngeal nerve branches just
caudally to the right subclavian artery (short arrow) and crosses the right subclavian artery
towards the tracheo-oesophageal groove, the left recurrent laryngeal nerve (long arrow) runs
below the aortic arch, b CT+C of the skull base showing the jugular foramen with the jugular vein
(long arrow), the pars nervosa (short arrow) and the internal carotid artery (*), c The carotid
sheath with the ICA (A), the jugular vein (V) and the expected position of vagal nerve (*), d At the
level of the subclavian arteries (S) the vagal nerves (long arrows) lie anteriorly in the upper
mediastinum, at this level, the recurrent laryngeal nerves run more posteriorly in the tracheo-
oesophageal groove (short arrows), e The left recurrent laryngeal nerve crosses the aortic arch
from anterior to posterior (curved arrow) at the level of the aorto-pulmonary window (AP)

b) Etiology :
-Innervation of vocal cord muscles is through the
recurrent laryngeal nerve of the vagus (CN X)
-The left recurrent laryngeal nerve is more
commonly injured
-Causes of paralysis include :
1-Idiopathic
2-Traumatic, surgical (thyroidectomy, carotid
endarterectomy and anterior approaches to the
cervical spine)
3-Tumor : mediastinum, left hilum or lung apex
(primary or mets)
4-Arthritis (degenerative changes of cricoarytenoid
cartilage)

1-Abnormal movement of the involved cord
2-Enlarged laryngeal ventricle & piriform
sinus
3-Flattening of false vocal cords & subglottic
angle
4-Atrophy of the thyroarytenoid muscle (the
most characteristic finding is the result of
atrophy of the thyroarytenoid muscle
which makes up the bulk of the true cord)
& posterior cricoarytenoid muscle

(a) Axial CT scan shows the normal appearance of the abducted vocal cords
during quiet respiration, the level of the true cords is confirmed with
visualization of the cricoarytenoid joints (arrow), (b) Axial CT scan shows
the normal appearance of the adducted vocal cords during held respiration,
as might be seen at thoracic CT

Normal appearance of the vocal cords, a Axial CT images during quiet
breathing showing the anterior commissure (short arrow), the posterior
commissure (long arrow) and the true vocal cords (T), b Image at the same
level during breath-hold, c Normal appearance of the laryngeal ventricles on
coronal reformat: right laryngeal ventricle (arrow); left true vocal cord (T); left
false vocal cord (F)

Specific imaging characteristics of vocal cord paralysis (right side),
a Widening of the right laryngeal ventricle (arrow), b Medial
deviation and thickening of the right aryepiglottic fold (arrow),
c Dilatation of the right piriform sinus (arrow)

Left RLN palsy, axial CT scan obtained at the level of the hypopharynx
during quiet respiration shows left RLN palsy, note the distention of
the ipsilateral piriform fossa with air (*) and the medially rotated,
thickened ipsilateral aryepiglottic fold (arrow)

-PET / CT : asymmetric increased uptake in the
normal cord due to compensation by and
hypertrophy of the nonparalyzed muscles
-The following criteria should be taken into account
when assessing abnormal FDG avidity in the
larynx :
1-The side and location of increased metabolic
activity relative to any CT findings that indicate
VCP
2-History of recent chemotherapy treatment with
vinka alkaloids (known to cause transient VCP)
3-The site of previous radiation treatment (a cause
of acute and chronic neuropathy)

FDG-PET findings in VCP, a Non-contrast CT image showing medial deviation
and thickening of the left aryepiglottic fold (*) indicative of left VCP, b Fused
PET-CT showing FDG uptake in the right vocal cord (arrow) due to
compensatory hypertrophy, this should not be confused with disease. Note
the paramedian position of the left true vocal cord (T)

Right RLN palsy, (a) Fused PET/CT image at the level of the vocal cords shows
abnormally increased muscle activity within the left vocal cord (*) and medialization of
the right posterior cord margin (arrow), findings that are typical of right VCP,
(b) Fused PET/CT image at the level of the hypopharynx demonstrates abnormal
compensatory muscle activity on the left side (*) and a thickened, medially rotated
right aryepiglottic fold (arrow), findings that are typical of right RLN palsy. At FDG
PET/CT, unilateral VCP appears as asymmetric increased uptake in the normal cord
due to compensatory activity and hypertrophy of the nonparalyzed muscles, with a
lack of uptake in the paralyzed cord

2-Laryngocele :
-Laryngocele is a saccular cyst that contains air and that
maintains communication with the laryngeal lumen
-Dilatation of the laryngeal ventricle
-Most commonly seen in glassblowers or patients with
chronic obstructive pulmonary disease (COPD)
-Laryngoceles are classified as internal, external, or a
combination thereof based on their relationship with the
thyrohyoid membrane :
a) Internal laryngocele remains confined within the larynx
between the false vocal cord and the medial surface of
the thyrohyoid membrane
b) External laryngocele extends upward and protrudes
laterally through the thyrohyoid membrane
c) Combined laryngocele contains dilated internal and
external components
-Saccular cysts and Laryngoceles are associated with
laryngeal cancer, and these patients should be evaluated
accordingly
-May be fluid or air filled

CT+C shows air filled internal laryngocele (arrow) on the
right and mixed laryngocele (arrowhead) on the left side

CT showing a) external laryngocele as a cystic fluid filled mass (large
arrows) on the left side with the trachea indicated by small arrow
and b) laryngocele causing compression of the airway

External laryngocele, (a) AP from a barium pharyngogram demonstrates an air-
filled structure in the left side of the neck (arrows) that is lateral to the
pharyngeal structures, (b) Lateral image shows an air-filled external
laryngocele (arrows) located anterior to the pharynx and just inferior to the
mandible

3-Laryngeal Trauma :
a) Etiology
b) Types

a) Etiology :
1-Intubation : erosions, laryngomalacia &
stenosis
2-Direct force : fractures
-Displaced fractures of thyroid or cricoid
cartilage
-Arytenoid dislocation
-A false passage
-Displacement of epiglottis

b) Types :
1-Thyroid : longitudinal, paramedian, transverse or
comminuted fractures
2-Cricoid : always breaks in 2 places, the posterior
component is often not clinically recognized
3-Epiglottis : may be avulsed posteriorly and
superiorly
4-Arytenoids : anterior and posterior dislocation

Fracture of the mid anterior thyroid cartilage

Acute comminuted fracture of both aspects of the cricoid cartilage

4-Benign Laryngeal Tumors :
-Papilloma and hemangioma are the most
common tumors
-Less common tumors : chondroma,
neurofibroma, fibroma, paraganglioma ,
rhabdomyoma, pleomorphic adenoma &
lipoma
-Vocal cord polyps (not true tumors) are the
most common benign lesions of the larynx

Axial CT image showing a right cord nodule (white arrow)

Axial CT image showing an anterior laryngeal polyp (black
arrow)

5-Laryngeal Carcinoma :
a) Pathology
b) Types
c) Staging

a) Pathology :
-Squamous Cell Carcinoma (SCC), 90%
-Other,10% :
1-Adenocarcinoma
2-Metastases
3-Tumors arising from supporting tissues of
larynx (chondrosarcoma, lymphoma, rare)
4-Carcinosarcoma
5-Adenocystic carcinoma

b) Types :
1-Supraglottic, 30 %
2-Glottic, 65 %
3-Subglottic, 5 %

Axial CT scans through (a) false cords, (b) true cords, (c) subglottis to illustrate normal
anatomy, (a) The tip of the arytenoids cartilages (white arrowhead) indicates the level
of the false cords (open arrowhead) and also the superior aspect of the ventricular
complex, (b) The anteriorly pointing vocal processes of the arytenoids (arrow) and the
thyroarytenoid muscle (white arrowhead) are effacing the paraglottic fat within the wall
of the larynx, this defines the level of the true cords and also the inferior aspect of the
ventricular complex, the anterior and posterior (open arrowhead) commissures should
only be represented by a thin mucosal layer, (c) There should be no soft tissue seen
internal to the ring of the cricoid cartilage at subglottic level

Coronally reformatted CT demonstrates the supraglottis, glottis and
subglottis as defined by the level of the ventricular complex (false
cords (F), true cords (T) and intervening ventricle)

1-Supraglottic , 30 % :
-May arise in the anterior compartment (epiglottis)
or the postero-lateral compartment (aryepiglottic
fold and false cords)
-They often present in advanced stages, because
symptoms (hoarseness, due to vocal cord
involvement) do not occur until late
-Treated by supraglottic Laryngectomy or radiation
therapy

a) Epiglottic SCC :
-These are anterior midline cancers that primarily
invade into the PES
-While the SCC arising from the mobile portion of
the epiglottis may spread from the PES further
into the base of tongue and laterally into the
PGS, those arising from the stem often invade
the low PES and via the anterior commissure,
reach the glottis or subglottis
-The primary sign of PES invasion at imaging is
replacement of the normal fat by abnormal
enhancing soft tissue

Pathway of spread of the of epiglottic mass

Supraglottic SCC, epiglottis, axial contrast CT image shows a lobulated
enhancing epiglottic mass filling the pre-epiglottic space (black
asterisk)

Supraglottic SC, epiglottis, axial contrast CT shows the epiglottic mass
(arrowheads) filling the right vallecula (white asterisk), enlarged
necrotic deep cervical node level II on the right side (elbow arrow)

b) Aryepiglottic Fold (AE fold) SCC :
-These cancers present as exophytic or
infiltrative masses
-They expand the AE fold and spread into
the PGS
-They may spread further anteriorly into the
PES or posteriorly to invade the piriform
sinus

Supraglottic mass arising from the aryepiglottic fold, line diagram
shows a section through the aryepiglottic fold in the axial plane, the
mass in the false cord is seen in red with pathways of spread in
black curved arrows

Supraglottic SCC, aryepiglottic fold, a right aryepiglottic fold mass (thin white
arrows) is seen invading into pre-epiglottic (white asterisk) and right
paraglottic space (black asterisk) and narrowing the right piriform sinus
(curved white arrow), note sclerosis of thyroid lamina (thin black arrow) with
extralaryngeal tumor (white curved elbow arrows)

c) False Cord SCC :
-These are lateral masses with a strong
predilection for submucosal spread into the
PGS
-More extensive tumor may destroy the thyroid
cartilage and spread transglottically into the
glottis and subglottis
-Tumor spread to the PGS on CT or MRI is seen
as replacement of the normal paraglottic fat by
the enhancing tumor tissue

Supraglottic mass arising from the false cord, line diagram shows a
section through the false cord in the axial plane, the mass in the
false cord is seen in red with pathways of spread in black curved
arrows

Supraglottic SCC, false cord, axial contrast CT section through the
false cords shows a mass within the right false cord and invading
into the right PGS (black asterisk)

2-Glottic, 65 % :
-Usually small when discovered (hoarseness is an early
finding)
-Early symptoms, good prognosis
-Glottic SCC commonly arise from the anterior half of the
vocal cord and spread into the anterior commissure,
anterior commissural disease is seen on CT or MRI as
soft tissue thickening of more than 1-2 mm
-From the anterior commissure, the tumor may spread
further anteriorly into the contralateral cord and the
thyroid cartilage or posteriorly into the posterior
commissure, the arytenoids, cricoarytenoid joint and the
cricoid cartilage
-The tumor may spread superiorly to access the PES and
the PGS, or inferiorly to reach the subglottis, subglottic
spread below the anterior commissure is seen as an
irregular thickening of the cricothyroid membrane, tumor
may gain access into the extra-laryngeal tissues through
the cricothyroid membrane

Pathway of spread of glottic mass

Glottic SCC, axial contrast CT image shows a glottis mass in the left true cord
reaching the anterior commissure (black asterisk), mild thickening of
posterior commissure is noted (thick black arrow) with sclerosis of left
arytenoid and left lamina of thyroid cartilage

Advanced SCC, axial CT+C shows a left cord mass (thin white arrows)
reaching anterior commissure (asterisk), note the sclerosis of the
left thyroid lamina and left cricoarytenoid joint (thin black arrows)

Advanced glottic SCC, axial CT+C at a caudal level shows the mass
(thin white arrows) with disease in the in the posterior commissure
(curved black arrow) and cricoid erosion (thick black arrow)

Advanced glottic SCC, axial CT+C through the subglottis shows the
mass extending into the subglottis (thin white arrow) with irregularity
of the cricothyroid membrane and extra-laryngeal spread (white
elbow arrow)

3-Subglottic, 5 % :
-Uncommon as an isolated lesion and usually seen
as an extension of glottic tumors
-Poor prognosis because of early nodal
metastases
-Subglottic cancer is diagnosed if any tissue
thickening is noted between the airway and the
cricoids ring
-Due to their late presentation, invasion of the
cricoids cartilage, trachea and the cervical
esophagus with extra-laryngeal spread are
common findings in these patients at imaging

Subglottic SCC, axial contrast CT image through the subglottis shows a
smooth well-defined enhancing mass is seen on the right side (thin
white arrows) reaching anteriorly just below the anterior commissure
(black asterisk)

Advanced subglottic SCC, axial CT image through the subglottis in
another patient shows a circumferential subglottic mass with
destruction of the cricoid and the thyroid cartilages (curved black
elbow arrows) and extra-laryngeal spread of tumor (thin white
arrows)

**N.B. : Transglottic SCC
-Laryngeal SCC encroaching on both, the glottis
and supraglottis, with or without subglottic
component and when the site of origin is
unclear, is termed as transglottic tumor
-This tumor spread is frequently through the PGS
and is readily identified on CT or MR imaging
-Transglottic carcinoma is frequently accompanied
by metastatic lymphadenopathy
-Coronal images are particularly helpful in
assessing transglottic extension of tumor

Transglottic mass, sagittal line diagram shows a large supraglottic
mass (red color) spanning the glottis and the subglottis

Transglottic mass, sagittal line diagram shows a transglottic mass (red
color) in the glottis extending into the supraglottis and subglottis

Transglottic mass, coronal line diagram shows the spread
of the transglottic cancer in the paraglottic space (PGS)

Large transglottic SCC, axial CT+C shows mass in the supraglottis
invading the PES (black asterisk) and right PGS (white asterisk),
extra-laryngeal tumor (white arrows) is seen along outer aspect of
RT thyroid lamina abutting RT carotid artery (black arrow)

Large transglottic SCC, axial CT shows tumor in RT true cord, anterior
commissure (curved black elbow arrow) and anterior LT true cord
(thick black arrow), widened thyroarytenoid gap (curved black
arrow), extra-laryngeal tumor (thin white arrows) abutting RT carotid
artery (black arrow)

Large transglottic SCC, axial CT+C shows subglottic
extension with extra-laryngeal tumor (thin white arrows)

Large transglottic SCC, Coronal CT shows the entire extent of
transglottic mass spreading along the RT PGS (thin arrows), note
the normal LT paraglottic fat space (thick arrow)

Large transglottic SCC, sagittal CT very nicely shows tumor
in the lower PES (curved arrow)

c) Staging :
-T1 : confined to true vocal cords, normal
mobility
-T2 : confined to true vocal cords, limited
mobility but no fixation of cords
-T3 : fixation of cords

1-CT
2-MRI
3-PET-CT

1-CT :
-Common locations of mass lesions :
1-Pyriform sinus (most common)
2-Postcricoid
3-Posterolateral wall
-Determine mobility of cords (fluoroscopy) ,
locate the cause of cord fixation

-Invasion :
1-Fat spaces become obliterated, >2 mm soft
tissue indicates tumor spread to contralateral
side of cord
2-Thickening of anterior commissure
3-Cartilage invasion : erosion, distortion
(bowing , bulging & buckling) & sclerosis
(microinvasion)
4-Adenopathy

Axial CT scan shows thickening of the anterior commissure
by glottic tumor (arrowhead)

Erosion of the thyroid cartilage (a) and cricoid cartilage (b) indicates
cartilage involvement by tumor, sclerosis (arrowhead) is less
specific, however may be used as an indicator of cartilage
involvement for the arytenoid (c) or cricoid cartilages

Cartilage invasion, (a) CT+C shows LT true cord mass with LT thyroid
lamina sclerosis (white arrow) and cricoid destruction (black arrow),
(b) axial bone window in another patient shows destroyed LT thyroid
lamina and LT cricoarytenoid joint

2-MRI :
*T1 : low
*T2 : high
*T1+C : enhancement
*Good for intracartilaginous invasion
3-PET-CT :
-Has an increasing role play in diagnosis ,
staging and follow-up

Axial T1 demonstrates bulky invasion of the pre-epiglottic space by a
supraglottic carcinoma which resulted in invasion of the hyoid bone

Cartilage invasion on MRI, T1+C fat-suppressed shows a large
laryngohypopharyngeal mass invading preepiglottic (white asterisk),
right paraglottic space (black asterisk) and right piriform sinus (thick
arrow), intracartilaginous enhancement is seen of similar intensity
as tumor with thin rim of extra-laryngeal tumor (thin arrow)

Cartilage invasion on MRI, (a) T1 shows a large mass destroying the
LT thyroid lamina with extra-laryngeal spread encasing LT carotid
artery (curved arrow), see the normal ossified RT thyroid lamina
(thick arrow), (b) T2 shows the large mass with cartilage
destruction , the intracartilaginous signal is similar to the adjacent
mass (thin arrow)

6-Postsurgical Larynx :
a) Vertical Hemilaryngectomy
b) Horizontal Hemilaryngectomy
(Supraglottic)
c) Total Laryngectomy
d) Radical Neck Dissection

c) Parapharyngeal Space :
1-Branchial Cleft Cyst
2-Thyroglossal Duct Cyst

1-Branchial Cleft Cyst :
a) Incidence
b) Classification
c) Location
e) Differential Diagnosis

a) Incidence :
-Embryologic cysts derived from 1st or 2nd
(most common) cervical pouch
-Mass in anterior triangle
-May be infected

b) Classification : Bailey and colleagues originally
classified four types of BCC
*Type I : is just deep to platysma muscle and the anterior
lateral surface of sternocleidomastoid muscle
*Type II : more medial than type I, is seen along the
anterior surface of the sternocleidomastoid muscle, just
lateral to carotid space and posterior to the
submandibular glands, arising on a line between the skin
of the lateral neck and the ipsilateral faucial tonsil
*Type III : extend further medially between the internal
carotid artery and external carotid artery at the carotid
bifurcation, visualization of the cyst’s extension or “tail”
between the internal carotid artery and external carotid
artery has been considered pathognomonic for type III
*Type IV : is the least common and arises in the
pharyngeal mucosal space just deep to the palatine
tonsil, often extending upward from tonsil toward the
skull base

c) Location :
-First branchial cleft anomalies are relatively less
common and typically closely related to the
parotid gland (Type I) or appear at the angle of
the mandible and may involve the
submandibular gland (Type II)
-Typically second branchial cleft cysts present as a
rounded swelling just below angle of mandible,
anterior to sternocleidomastoid
-Third branchial cleft cyst is characteristically
located deep to the sternocleidomastoid muscle

First branchial cleft cyst: (A) Axial and (B) coronal contrast enhanced
CT images show a well defined hypodense mass (arrows) within the
right parotid gland

Second branchial cleft cyst, CT+C reveals a cystic lesion (arrows) in
the right neck lateral to the carotid sheath, behind the
submandibular gland and along the anterior border of the
sternocleidomastoid muscle

Third branchial cleft cyst, CT+C at the level of the thyroid cartilage
reveals a large, well-defined, nonenhancing, water attenuation mass
(m) deep to the right sternocleidomastoid muscle (s), medially
displacing the common carotid artery and internal jugular vein

1-U/S
2-CT
3-MRI

1-U/S :
-Sharply demarcated
-Posterior acoustic enhancement
-Imperceptible walls
-Echogenicity is variable :
Anechoic
Homogeneously hypoechoic with internal
debris
Heterogenous

(a) Longitudinal sonogram of an anechoic second BCC (calipers) with posterior enhancement, (b)
Longitudinal sonogram of a second BCC (open arrows), predominantly hypoechoic with faint
internal debris. Note the presence of posterior enhancement, (c) Transverse sonogram of a
second BCC (straight arrows) with homogeneous, hyperechoic, internal echoes (pseudosolid),
note the lack of posterior enhancement, curved arrows identify the bifurcation of the carotid
artery, note that no portion of the cyst extends into carotid bifurcation, (d) Transverse sonogram
of a second BCC (large arrows) with heterogeneous internal echoes, debris, and septa (small
arrows), note the lack of posterior enhancement, curved arrows identify the bifurcation of the
carotid artery, note that no portion of the cyst extends into carotid bifurcation, (e) Transverse
sonogram of a second BCC (straight arrows) with thick walls (arrowheads) and internal echoes.
Note the lack of posterior enhancement, curved arrow identifies the common carotid artery

2-CT :
-Rounded, sharply circumscribed
-Water density (<20 HU) unless infected
(debris)
-Intense rim enhancement in infected cysts
-Extension of the cyst wall between the ICA
and ECA just above the carotid bifurcation
(sometimes referred to as the notch sign)
is said to be pathognomonic

Beak sign (notch sign) in second branchial cleft cyst, CT+C
demonstrates a curved rim of hypodense mass (arrows) pointing
between left internal and external carotid arteries

3-MRI :
*T1 : variable signal dependant on protein
content :
High protein content : high signal
Low protein content : low signal
*T2 : usually high signal
*T1+C : no enhancement in uncomplicated
lesions , rim enhancement in infected

Second branchial cleft cyst in a 30-year-old woman with a 14-month history of a mass in the left side
of the neck that was unresponsive to antibiotics and that enlarged somewhat the month before
surgery, (a) Axial T1 shows a well-defined mass (m) along the anterior border of the left
sternocleidomastoid muscle (arrowhead), lateral to the carotid space (white arrow), and posterior
to the submandibular gland (black arrow), the classic location for a second branchial cleft cyst,
increased signal intensity of the mass is due to either proteinaceous debris or prior hemorrhage,
(b) Axial T2 reveals moderate to marked hypointensity of the mass (m), consistent with
accumulation of proteinaceous debris or hemorrhage, (c) Coronal T1+C with fat suppression
shows mild rim enhancement of the mass (m)

Second Branchial Cleft Cyst, axial non-contrast MRI images (above) T1 and T2
and sagittal T1+C images below, there is a cystic mass filled with a simple
fluid surrounded by a homogeneously enhancing thin-wall in the right neck
anteriorly, the cyst is located anterior to the right sternocleidomastoid
muscle and inferoposterior to the right parotid gland and is most consistent
with a second branchial cleft cyst

e) Differential Diagnosis :
1-Paramedian thyroglossal cyst
2-Cystic lymph nodes :
-Necrotic nodal metastases , especially SCC and papillary
thyroid cancer
-Tuberculous adenitis
3-Vascular lesions :
-Jugular vein thrombosis
-Mycotic aneurysm of the neck
4-Neurogenic tumors :
-Schwannoma
-Neurofibroma
-Ganglioneuroma
5-Cervical dermoid cyst
6-Cavernous lymphangioma
7-Thyroid nodule/cyst

2-Thyroglossal Duct Cyst :
a) Incidence
b) Location
d) Differential Diagnosis

a) Incidence :
-The most common congenital neck cyst
-They are typically located in the midline and are
the most common midline neck mass in young
patients
-They typically present during childhood (90%
before the age of 10) or remain asymptomatic
until they become infected in which case they
can present at any time
-The second most common benign neck mass
after lymphadenopathy

b) Location : (Hyoid Bone)
-The cysts can occur anywhere along the
course of the thyroglossal duct although
infrahyoid location is most common
-Suprahyoid, 20%
-At hyoid bone, 15%
-Infrahyoid, 65%

Normal adult neck, sagittal CT+C shows the normal anatomic course of the thyroglossal
duct (magenta line), the thyroid primordium originates as the median thyroid anlage
(•) at the foramen cecum (white arrow), the path of the primordial descent wraps
anteriorly, inferiorly, and posteriorly to the hyoid bone (black arrow) and courses
anteriorly to the thyrohyoid membrane and thyroid cartilage (arrowhead)

1-U/S
2-CT
3-MRI

1-U/S :
-As branchial cleft cyst
2-CT & 3-MRI :
-As branchial cleft cyst
-Anterior midline or para-midline location

(a) Longitudinal sonogram of a predominantly anechoic TDC with internal
debris and thick walls (solid white arrows) below the level of the hyoid bone
(black arrow), open arrow indicates the head end of the patient, (b)
Longitudinal sonogram of an anechoic, multiloculated TDC (solid white
arrows) with extension posterior to the hyoid bone (black arrow), open
arrow indicates the head end of the patient

(a) Transverse sonogram of a uniformly echogenic, pseudosolid appearance of
a TDC (large arrows), note, however, the posterior enhancement (small
arrows), suggesting its cystic nature, (b) Longitudinal sonogram of a TDC
shows a mixed echo pattern with internal debris (arrowhead) and septa
(solid arrows). Note its relationship to the hyoid bone (H) and the intense
posterior enhancement, open arrowindicates the head end of the patient

Longitudinal sonogram of a TDC shows thick septa (solid arrows), note
its relationship to the hyoid bone (H) and the intense posterior
enhancement, open arrow indicates the head end of the patient

Thyroid ectopia associated with the hyoid bone in three patients, (a) Axial CT+C of a 36-
year-old man shows a thyroglossal duct cyst (arrowhead) intimately involved with the
anterior aspect of the hyoid bone (black arrow); normal fat is preserved in the
preepiglottic space (white arrow), (b, c) Sagittal (b) and axial (c) CT+C of a 49-year-
old man depict a thyroglossal duct cyst that conforms to the embryologic course of
the thyroglossal duct (magenta line in b), both anterior and posterior to the hyoid
bone, and compresses the preepiglottic fat (arrow), (d) Axial CT+C image of a 28-
year-old woman shows ectopic thyroid tissue in the same position as in c, appearing
both anterior and posterior to the hyoid bone

Paramedian thyroglossal duct cyst

d) Differential Diagnosis : Midline neck masses
1-Lymph Nodes :
-Inflammatory adenopathy
-Malignant
2-Thyroid Gland : (7)
-Thyroglossal duct cyst
-Thyroid cyst
-Thyroid neoplasm
-Multinodular goiter
-Thyroiditis
-Ectopic thyroid
-Parathyroid adenoma

3-Larynx :
-Laryngocele
4-Ranula (sublingual gland)
5-Epidermoid Cyst
6-Neurofibroma
7-Cystic Hygroma / Lymphangioma :
-Well circumscribed and are of fluid density
-90 % in children < 2 years
-Mostly located in the posterior cervical space
-High signal on T2 , variable signal on T1 (depend on
protein content)
8-Hemangioma / Vascular malformation
9-Lipoma

*N.B. : Neck masses in infants & children
a) Soft :
1-Lipoma
2-Vascular malforamtion
3-Lymphatic malforamtion
b) Firm :
1-Cyst : thyroglossal , branchial cleft , lingual and thymic
2-Abscess
3-Hematoma
4-Lymphadenopathy
5-Fibromatosis coli
6-Rhabdomyosarcoma
7-Thyroid :
-Diffuse enlargement (Grave’s disease , MNG & Thyroiditis)
-Focal mass (Cyst , benign adenoma , malignancy is rare ,
papillary carcinoma being the most common malignancy)

Diagnostic Imaging of Pharynx & Larynx

Diagnostic Imaging of Pharynx & Larynx

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