Anatomy and Pathology of the Larynx, Dr. Suresh Mukherji (1-23-25)
HIDEInteractive Transcript
0:02
Hello and welcome to Noon Conference, hosted by Modality
0:06
Noon Conference connects the global radiology community
0:08
through free live educational webinars that are accessible
0:12
for all and is an opportunity
0:13
to learn alongside top radiologists from around the world.
0:17
You can access the recording of today's conference
0:19
and previous noon conferences by creating a free account.
0:23
Today we are honored to welcome Dr.
0:25
Cresh McCury for a lecture entitled Anatomy
0:29
and Pathology of the Larynx.
0:31
Dr. McCury received his undergraduate degree from Duke
0:34
University and MD degree from Georgetown University.
0:38
He currently holds appointments at multiple institutions
0:41
and is a devoted educator who's been an invited speaker on
0:44
over 500 occasions and written and edited 15 textbooks.
0:47
We're especially grateful for his supportive modality
0:50
and for serving as our head and neck neuroradiology advisor.
0:54
At the end of the lecture, please join Dr.
0:56
McCury in a q and a session
0:57
where he will address questions you may
0:59
have on today's topic.
1:01
Please remember to use the q
1:02
and a feature to submit your questions so we can get to
1:04
as many as we can before our time is up.
1:07
With that, we are ready to begin today's lecture. Dr.
1:10
McCorey, please take it from here.
1:13
I just wanna thank everyone, thank medal for again, um,
1:15
having me, uh, give a talk on Head and Neck
1:19
and, um, it's a real, uh, privilege
1:21
and honor to always, uh, participate in these.
1:24
Um, and as I mentioned, uh, in the trailer, one
1:27
of the things I really like about Modality is
1:29
that it gives really enough time
1:30
to go over a topic in detail.
1:32
So, um, I know when you go to a lot of meetings, you know,
1:36
you're, a lot of the talks right now, we
1:38
as faculty members have to kind
1:39
of crunch down into 20 minutes
1:41
and, you know, oftentimes you try to pound 40 minutes
1:44
of information into 20 minutes
1:46
and it just gets kind of cumbersome.
1:47
So, um, what I wanna do is take our time
1:50
and we're gonna go through the larynx
1:52
and we're gonna talk about normal anatomy
1:55
and common pathology.
1:57
So this is our outline.
1:59
We're gonna start talking about the anatomy
2:02
and then we'll talk about neoplasms
2:04
and we'll predominantly focus on squamous cell carcinoma,
2:06
but we do have the time to go over some
2:08
of the other less common lesions that occur in the larynx.
2:12
We'll talk about infectious
2:13
and inflammatory processes, a little bit about congenital
2:17
and developmental anomalies.
2:19
And then finally we'll end our, um, we'll end our discussion
2:23
with the discussion of vocal cord palsy.
2:25
So that's gonna be our, our, uh, outline as we start today.
2:30
So the first thing that we're gonna spend a little bit
2:33
of time on is the anatomy of the, the larynx.
2:36
And, you know, I gotta tell you, when I was a, a fellow, um,
2:40
you know, the, I did a two year neuro fellowship
2:43
with focusing on head and neck.
2:44
And I hate to say it was back in the last century.
2:46
So I've been around for a while,
2:48
but I still remember those times
2:49
and, you know, the first year of my fellowship,
2:52
I really had no idea about the larynx.
2:55
It was just really, really difficult for me.
2:57
And I think as we go through the larynx,
2:59
it's really important that you understand the anatomy
3:01
because we did sort of go over in medical school,
3:04
and my son's a third year medical student right now,
3:06
and I was, uh, I think he was home or,
3:09
or during that time of covid.
3:10
Um, he was around a lot.
3:12
And I remember seeing how they learned the larynx
3:16
and these other really
3:17
complex structure, and it's really hard.
3:19
You don't get a lot of it. And then as radiologists,
3:21
you know, we're have this daunting task about trying
3:24
to remember the anatomy of the larynx
3:28
and then try to figure out it
3:29
what it looks like on cross-section imaging.
3:31
Then we're talking about tumors,
3:33
and then everything else is really based on
3:36
what we see on imaging makes such an important
3:38
difference in these patients.
3:40
Because, you know, if you've seen patients
3:42
that have had laryngeal cancers,
3:44
if their larynx have been resected, they,
3:46
it's clearly obvious from a psychosocial standpoint.
3:49
Um, we see the tracheotomy, the cosmetic deformities.
3:53
And really now in 2025, so much on
3:56
what we see on imaging makes such a big difference in
3:59
how these patients are treated.
4:00
So we're gonna spend a little bit of time about the anatomy
4:03
of the larynx, and we have to remember
4:05
that the larynx is divided into three basic subdivisions,
4:10
and it's based after the glottis,
4:12
which is a true vocal cord.
4:14
So you have the supraglottic larynx,
4:16
which is divided into this structure right here,
4:19
which is the epiglottis.
4:21
And the epiglottis is an anterior and midline structure.
4:24
And when we start going through the cross-sectional anatomy,
4:27
one of the things we always have to remember,
4:29
the epiglottis is anterior and its midline.
4:32
Then you have a fold of tissue
4:34
that runs from these cartilages,
4:37
which are the adenoid cartilages
4:39
and the attached to the lateral aspect of the epiglottis.
4:42
And that's the area epiglottic fold.
4:45
The next structure that's part
4:46
of the supraglottic larynx is the false vocal coordinate.
4:49
And we'll go through this in great detail.
4:51
And then we have the laryngeal ventricle.
4:53
So from a a purely, uh, a high level standpoint,
4:57
we have the supraglottic larynx, which is the epiglottis,
5:00
the area epiglottic fold the false focal cord
5:02
in the laryngeal ventricle.
5:04
Then the second part of the larynx is the glottis.
5:06
And the glottic larynx is basically the true vocal cords.
5:11
And as we'll see, the true vocals cords are
5:13
located at the joint.
5:14
And this joint is located between the crico cartilage
5:18
and the retinoid cartilage.
5:19
So this is the crico retinoid joint.
5:23
And then we have the subglottic larynx.
5:25
And the subglottic larynx is really formed
5:28
by the foundation of the larynx.
5:30
So it's just like your house.
5:31
If you are living in a house, the foundation
5:34
of your house is basically your basement.
5:37
And this area right here, the foundation
5:39
of the larynx is a signet ring cartilage structure,
5:44
which is the cricoid cartilage.
5:46
So the sub glottis is really defined
5:49
by the cricoid cartilage.
5:52
So when we look at the larynx, we, we always have
5:55
to look at cross-sectional images,
5:56
but remember we always have
5:58
to look at the reformats as well too.
6:00
So this is a sagittal reformat,
6:02
and this is a coronal reformat.
6:04
And the sagittal reformats really help you look at the
6:08
epiglottis, which is located here.
6:10
And as you come down inferiorly, there's a space right here
6:13
where just some fat,
6:14
and this is what we call the pre epiglottic fat.
6:18
Then the epiglottis comes down all the way to the tip,
6:21
and it forms this little structure right here,
6:23
which is called the PDL of the epiglottis.
6:26
And that's about the level of the false focal cords.
6:29
Now, when we look at the sagal images,
6:30
this is the true vocal cords.
6:32
And on the corrodal image, this is the area epiglottic fold.
6:36
This is the laryngeal ventricle,
6:38
and this is the true vocal cord.
6:40
So this is the normal anatomy on the sagittal
6:42
and the coronal images.
6:44
So what I've done is I've, I've given you kind
6:47
of a high level approach to the larynx, but as I mentioned
6:51
before, back when I was a fellow,
6:54
I really did not understand the larynx.
6:56
And in a, even in an hour lecture, it's really hard
6:59
to go over all the anatomy,
7:00
but I'll tell you how I learned the larynx.
7:02
So during my second year of my fellowship,
7:05
I was completely confused
7:07
because when we talk about the larynx, we talk about
7:10
these multi syllabic terms
7:11
that oftentimes have Latin or Greek roots.
7:14
So for instance, we talk about structures like
7:16
thyrohyoid membrane, thyrohyoid muscle
7:20
cricothyroid ligaments.
7:22
And I was just completely confused by everything.
7:24
And then one day my light bulb went on
7:27
and the light bulb went on
7:29
because all of a sudden I realized that instead of trying
7:33
to memorize every single ligament in every single membrane,
7:37
in every single muscle, what I wanted
7:39
to do was memorize the five primary
7:42
structures of the larynx.
7:43
And if you remember the big five,
7:45
and I've called these the big five, I was fortunate
7:48
to be in a safari again a few years ago,
7:50
and I just remember the big five.
7:52
And the big five of the larynx is this bone right here,
7:55
which is the hyoid bone.
7:57
Then we have another structure right here
7:59
that we talked about before, that was the epiglottis.
8:02
Then we have this cartilage right here,
8:04
which is the hyoid cartilage.
8:06
Then we have the thyroid cartilage,
8:08
and then we have the crico cartilage.
8:10
So to me, these are the big five.
8:12
And so what I ended up doing, literally
8:15
before I went to bed for the next two weeks, I,
8:18
and for five to 10 minutes I would just look at an anatomy
8:21
book and I would go over and just memorize and
8:24
and reemphasize these five cartilage
8:27
and this these four cartilage and one bony structure.
8:31
And once I remember that these big five were the components
8:35
of the larynx, and all of a sudden
8:38
it was like someone opened a window
8:40
and this fresh air came through, I could remember all
8:43
of these different structures.
8:44
So for instance, if I know that there's a hyoid bone
8:47
and an epiglottis, then I know that this ligament that goes
8:51
between the hyoid bone
8:52
and the epiglottis is the hy epiglottic ligament.
8:56
If I know that this is the epiglottis
8:58
and this is the hyoid cartilage, then I know that this fold
9:01
of tissue that's running from the hyoid cartilage
9:04
to the lateral margin of the epiglottis is the
9:06
airy epiglottic fold.
9:08
This fat right here, this space right here,
9:11
which is anterior to the epiglottis, so what do you call
9:14
that space that's anterior to the epiglottis?
9:16
Well, that's just the pre epiglottic space
9:19
because pre is essentially anterior.
9:21
Similarly, what do we call the joint now?
9:23
Well, we know it's a crico and the retinoid.
9:25
So that's the crico OID joint.
9:27
What do we call the muscle
9:29
that goes from the thyroid cartilage
9:31
or the retinoid cartilage?
9:32
That's the hyoid muscle.
9:35
And now we can get really fancy,
9:36
what do you call this ligament right here?
9:38
Well, that ligament runs from the thyroid cartilage
9:41
to the crico cartilage.
9:42
So pure and simply, that's the thro cricoid ligament.
9:45
Or if you want to, you can call it the
9:47
cricothyroid ligament.
9:49
And again, this big one right here,
9:51
what do you call this membrane
9:52
that goes from the thyroid cartilage to the hyoid bone?
9:55
Well, that's the thyrohyoid membrane.
9:58
So again, if um, from my standpoint, the way I learned it,
10:01
and you sort of have to determine how you we,
10:03
because we all learn a little bit differently,
10:05
but for me, I really ended up spending a lot
10:07
of time on the big five.
10:08
And once I had these,
10:10
it really made the anatomy just jump out at me.
10:14
So what we did initially was talked about the
10:17
anatomy of the larynx.
10:19
And now what we're gonna do is
10:21
that we're gonna talk about neoplasms
10:23
and we're gonna focus our time on squamous cell
10:28
is when we talk about the neoplasms.
10:30
But what I'm gonna do is I'm gonna take
10:32
a little bit different approach.
10:33
I'm not gonna show you 30 cases
10:35
of a squamous cell carcinoma larynx,
10:37
but what I'm gonna do is take what we just learned
10:40
before regarding the normal anatomy, the larynx,
10:43
and integrate that into squamous cell carcinomas.
10:48
And I think you'll see as we get done, all
10:51
of this information is gonna help provide you better
10:54
information that can help treat your patients.
10:57
So we'll first talk about the epiglottis.
10:59
And as I mentioned before,
11:01
this sagittal images is a squamous cell carcinoma
11:04
involving the, excuse me, the normal epiglottis.
11:07
And here's the squamous cell carcinoma.
11:10
So when you perform an endoscopy, this structure right here,
11:13
that's anterior midline,
11:15
remember the epiglottis is anterior midline.
11:17
This is the epiglottis.
11:19
So this is what you end up seeing at endoscopy.
11:22
And this is what we end up seeing on
11:24
cross-sectional imaging.
11:25
So when cross-sectional imaging,
11:27
this structure right here is the epiglottis,
11:29
then we have these two air fill saddlebags.
11:32
That's how I learned them. These were the vallecula.
11:35
And then this structure right here that extends from
11:38
the epiglottis to the base
11:41
of the tongue is going be the median glosso epiglottic fold.
11:45
Now if you're not familiar with head and neck
11:47
and you're just tuning in this
11:48
because you wanna learn some head
11:50
and neck, one of the things that oftentimes gets confused is
11:53
where is the relationship between the molecular
11:56
and the piriform sinus?
11:57
Well, the piriform sinuses are located laterally here.
12:01
So this is the piriform sinus and this is the vallecula.
12:04
So when we look in this image, here's the epiglottis.
12:06
Here's one piriform sinus,
12:09
and here's the other piriform sinus.
12:11
So this is the normal appearance of the epiglottis.
12:14
And here's a a mass right here.
12:15
This is a patient with squamous cell
12:17
carcinoma involved in the epiglottis.
12:19
How do we know it's involved in the epiglottis?
12:21
Because it's anterior and midline.
12:24
So when we do a CT scan
12:25
and we see this mass right here, that's anterior
12:29
and midline, that we know this tumor has
12:31
to be arising from the epiglottis.
12:34
So the principle number one is
12:35
that the epiglottis is anterior midline.
12:38
Now the next part
12:40
of the supraglottic larynx is gonna be this structure,
12:43
which is the area epiglottic fold.
12:45
And as I mentioned before,
12:46
the area epiglottic fold runs from the retinoid cartilage.
12:50
Now remember the retinoid cartilages are
12:52
paraline structures.
12:54
They're not midline like the epiglottis,
12:55
but the retinoids are paraline.
12:58
So when we talk about the area epiglottic folds realize
13:01
that when we look at cross-sectional imaging,
13:03
these structures are gonna be paraline.
13:06
So when we look at endoscopy,
13:08
here's the epiglottis anterior,
13:10
here's one area epiglottic fold,
13:12
and there's the other area epiglottic fold.
13:15
And just lateral to this is the piriform sinus
13:17
and there's the piriform sinus.
13:19
So on cross-sectional imaging, here's the epiglottis,
13:22
which is anterior midline.
13:23
Here is one area epiglottic fold.
13:26
Here's the other area, epiglottic fold.
13:28
And just lateral to this are the piriform sinuses.
13:31
So this is an endoscopy of a patient
13:33
that has a tumor involving the right area.
13:36
Epiglottic fold. Again, notice this, it's exophytic,
13:39
it's involving the area epiglottic fold.
13:41
So this is what we see clinically
13:43
and this is what we see radiologically.
13:46
So this is a patient with a right area epiglottic fo cancer,
13:49
the yellow arrow points of the thickening
13:51
of the area epiglottic fold.
13:53
Now the last thing that we're gonna talk about today is a
13:55
paralyzed true vocal cord.
13:57
Now at the end, sometimes these area epiglottic
14:00
fos can be thickened.
14:02
And sometimes if you're not really comfortable with the head
14:05
and neck, it can be confusing as to
14:08
what is a paralyzed epi area epiglottic fold.
14:10
And what's a tumor notice in this case,
14:13
which is a tumor involving the area epiglottic fold.
14:16
This area epiglottic fold is thickened.
14:18
And look what it's doing to the air in the piriform sinus.
14:21
It's actually narrowing this and contrast this with the air
14:25
and the piriform sinus and the contralateral side.
14:28
So if you see a thick
14:29
and right area epiglottic fold, the next thing you have
14:31
to do is look at the piriform sinus.
14:33
And the combination of these two findings will tell you
14:36
that you're dealing with the squamous cell carcinoma
14:38
involving the area epiglottic fold.
14:42
So what we've done so far is
14:44
that we talked about the epiglottis,
14:45
which is anterior midline.
14:47
Then we talked about the fold of tissue
14:49
that runs from the OID cartilage to the epiglottis,
14:52
which is the area epiglottic fold.
14:54
So what we've done so far is
14:56
that on this par coronal images,
14:58
this airfield images we're sort of up to here.
15:01
Now what we're gonna do is talk about the false focal cord.
15:05
And conceptually the false focal cord
15:07
is the hardest structure.
15:09
So we know the area epiglottic fold is this
15:11
lateral fold of tissue.
15:13
Now the way I think of the false vocal cord is
15:16
that the inferior reflection of the area epiglottic fold.
15:20
This free margin here forms the false focal cord.
15:24
And right below the false vocal cord,
15:26
we're gonna run into this laryngeal ventricle.
15:29
So principle number one is
15:31
that the false focal cord is a continuation
15:33
of the area epiglottic fold.
15:35
Principle number two is that the false focal cord is
15:39
above the laryngeal ventricle.
15:41
So, so you can see the air in the laryngeal ventricle here.
15:44
And then the third uh, principle is
15:47
that this false vocal cord attaches to the top
15:50
of the hyoid cartilage.
15:52
So what is our radiological landmark?
15:54
That tells us when we look at a cross-sectional imaging,
15:58
we're looking at the false vocal cord.
16:00
And that landmark is, is if we can see the top
16:04
of the hyoid cartilage.
16:05
So this is the normal appearance of the false focal cord.
16:08
We can see the top of the retinoid cartilage on the CT scan.
16:12
We know that this tumor right here,
16:14
this is the false focal cord carcinoma, we can see
16:17
that's involving the top of the retinoid cartilage.
16:19
Now I want to contrast this with what I just showed.
16:22
Again, paraline area epiglottic fold.
16:25
Notice there's no cartilage.
16:27
But on the other hand, when we do look at the false focal
16:30
cord, we know we're at this level
16:31
because we just see the top of the hyoid cartilage.
16:35
This is conceptually the hardest landmark to remember.
16:39
I sometimes I even get confused,
16:40
but conceptually this is harder.
16:43
So top of the retinoid cartilage tells us
16:45
we're at the false focal cord.
16:47
Remember, we're above the laryngeal ventricle.
16:49
And we'll see how that's gonna be important in about five
16:52
slides when we talk about tumor mapping.
16:55
So that's the false focal cord.
16:57
This is part of the supraglottic larynx.
16:59
Now things get easier
17:01
because now what we're gonna do is we're gonna jump from the
17:04
false focal cord, cross the laryngeal ventricle.
17:07
And now we're at the level of the true vocal cord.
17:10
So the true vocal cord, as we talked about
17:13
before, is at the cricoarytenoid joint.
17:15
So if you see this crico OID joint,
17:19
we know we're at the level of the true VCAL cord.
17:22
So here's an axial T one weighted image demonstrating the
17:25
cricoid cartilage.
17:26
Here's the retinoid cartilage.
17:28
This is the thyroid cartilage anterior.
17:30
So this is the crico retinoid joint.
17:33
And this tells us we're at the false foco.
17:35
Here's an another patient, a a different patient
17:38
that has a tumor involving the right true vocal cord.
17:41
Now, how do we know we're at the true vocal cord?
17:43
Again, cricoid cartilage or retinoid cartilage.
17:46
And for me, just the way I like to think the this,
17:49
this crico cartilage of the true vocal cord,
17:51
it's smiling at me
17:52
because it loves head and neck radiology too.
17:54
It's gonna be a big smile. So there's a smile right here.
17:57
This is like the lips that are kind of the
17:59
inside that are turning in.
18:01
It looks like a big smile to me.
18:02
So when I see this, I know I'm at the
18:04
level of the true vocal.
18:06
So right now we're at the level of the Crico OID joint.
18:11
The third component of the larynx is the subglottic larynx.
18:15
So how do we know we're the subglottic larynx?
18:18
So remember the crico cartilage is the
18:21
foundation of the larynx.
18:22
And right now this screw vocal cord is smiling at us.
18:25
It's smiling, but how do we know where the sub glottis?
18:28
Well, all of a sudden that smile turns into a surprise.
18:31
It's like that mouth gets really,
18:33
really big open right here.
18:35
And that tells us where the subglottic larynx.
18:37
So here is the airway that's below the true vocal cord.
18:40
This is the subglottic larynx.
18:43
This is a sagittal image demonstrating this tumor
18:46
that's at the level of the subglottic larynx.
18:48
This is the normal appearance.
18:50
Notice the big O shaped right here.
18:52
Instead of a smile, it looks like a surprise.
18:54
And here we can see the signal,
18:56
the high T one signal in the car cord cartilage.
18:59
And that's the normal airway.
19:01
And this is a patient that has a tumor involving the
19:04
subglottic larynx.
19:05
Notice it's eroding the cartilage.
19:07
And the reason these patients present with stridor is
19:10
because that airway has been narrowed.
19:13
So what we've done so far is that we've gone
19:16
through the anatomy of the larynx.
19:18
Now I'm not gonna spend all the time talking on tumors,
19:21
but what I do wanna do is
19:23
that if you are gonna be looking at squamous cell
19:25
carcinomas, is
19:26
that I don't necessarily believe in standardized reports in
19:30
the sense of one size fits all.
19:32
'cause I've noticed if I ask 50 people, if they,
19:35
if they have a standardized report
19:36
or what is a standardized report,
19:38
I'm gonna get 50 responses.
19:40
But what I like to do is talk about key elements.
19:43
So what I'm dealing with patients
19:45
that have squamous cell carcinomas, these are the things
19:48
that I include in my report.
19:50
So this patient has a tumor involving
19:52
where we're at the CRICO retinoid joint.
19:54
This is involving the true vocal cord.
19:56
So one of the key elements I always like
19:59
to discuss is whether or not this tumor extends inferiorly
20:02
and whether or not it's involving the subglottic larynx.
20:05
So how do we do that? We do it from our anatomy.
20:08
So here's the cricoid cartilage,
20:10
here's the retinoid cartilage.
20:11
You can see a little bit of the smile right here.
20:13
But on the other hand, notice
20:15
how we lose the crico retinoid joint.
20:17
This is the crico cartilage and we see tumor.
20:20
So this is an example of a patient
20:22
that has a subglottic spread of a true vocal cord carcinoma.
20:26
So I always include this
20:28
because at least in our practice,
20:30
if there's more than six millimeters of subglottic spread,
20:33
at least in our institution,
20:35
these patients are typically treated with chemotherapy
20:38
and radiation therapy
20:39
because the main surgical options at most institutions is
20:43
gonna be total laryngectomy.
20:46
The next thing that I wanna do is we'll comment on the
20:50
presence of trans glottic spread.
20:52
So what is trans glottic spread?
20:54
Trans glo spread means
20:55
that the tumor extends from either the false vocal cord
20:59
to the true vocal cord
21:00
or the true vocal cord to the false vocal cord.
21:03
Now we use the term trans glo spread, but actually,
21:07
and my friends and my,
21:08
my fellows in Tanzania taught me this years ago,
21:11
we should call it trans ventricular spread
21:13
because the tumor actually crosses over the ventricle.
21:16
But we use the term trans glottic spread.
21:19
So how do we make that diagnosis?
21:21
Well, this is a, a patient has a tumor
21:24
involved in the left area epiglottic fold.
21:26
We can see this diffuse thickening on the left.
21:28
And in fact we can see the narrowing of the piriform sinus.
21:31
Now look where we're at right now.
21:33
We see the crico cartilage and the oid cartilage.
21:36
It's smiling at us, right?
21:37
Everyone can appreciate that big smile.
21:39
But notice how there's no thickening on either side
21:42
and we can see the nice normal para laryngeal fat place.
21:46
So this tumor is limited to the area epiglottic fold.
21:49
It does not cross over the laryngeal ventricle
21:51
to the true vocal cords.
21:53
So there's no trans glottic spread here.
21:56
But in this case we have a large epiglottic carcinoma.
21:59
I remember this case very well.
22:00
The EMT surgeon thought that it was just localized
22:03
to the supraglottic larynx.
22:05
But I remember I looked at the CT and I said, Dr.
22:07
Soandso, I think it's there.
22:08
And he says, no, no it's not there.
22:10
They went in an endoscopy and lo
22:12
and behold, there's the cricoid cartilage,
22:13
there's the retinoid cartilage,
22:15
and we can see this tumor extending inferiorly to the level
22:19
of the true vocal cord.
22:20
So this was actually submucosal spread
22:23
of trans glottic spread.
22:25
So as a result, this patient could not undergo this type
22:28
of supraglottic laryngectomy
22:30
and the only option
22:31
for him would've been total laryngectomy.
22:33
And as a result, they were treated
22:35
with chemotherapy and radiation.
22:37
Another example here, this is the opposite transo spread.
22:41
Here's a nice smiley face right here.
22:43
There is the true vocal cord.
22:45
We can see this tumor on the right. Where are we at now?
22:48
We do a CT scan.
22:49
We see one retinoid cartilage,
22:51
we see the other OID cartilage.
22:52
There's no cry cord cartilage,
22:54
no one's really smiling at us.
22:56
This is the false vocal cord,
22:57
but there's no fat, there's no tumor here.
23:00
So this is no evidence of trans lytic spread.
23:03
But what about here? Here's a tumor
23:05
that's involving in the right true vocal cord.
23:07
What level are we at now?
23:09
We see the top of the hyoid cartilage.
23:11
Draw a line down the middle,
23:12
compare the right side to the left side.
23:14
Notice my nice little tiger stripes on the left.
23:17
We see black, we see gray, we see black, we see white.
23:20
Notice how all that's obliterated. And this is superior.
23:24
Uh, submucosal.
23:26
Transo spread of a true vocal cord carcinoma.
23:29
And if they see this,
23:31
and these patients cannot really undergo a partial layer in
23:34
most institutions and at least at our institutions,
23:37
they'll be treated with chemotherapy and radiation therapy.
23:42
The next one is gonna be cartilage spread.
23:44
So when we look at these key elements,
23:46
what we wanna do is determine whether the
23:48
cartilage is eroded.
23:50
And you can perform CT or you can perform mr.
23:52
Either one of these are fine.
23:54
In the United States, we tend to do a little bit more ct.
23:58
If it just erodes the inner cortex, it's a T three.
24:01
If it's the inner, the outer cortex and it's a T four.
24:05
You can also look at this on mr.
24:07
And there's been a lot of work done predominantly in Europe
24:10
on looking at MR to detect cartilage invasion.
24:13
What I like to do, my favorite sequence honestly,
24:16
is a non-contrast T one weighted sequences.
24:18
And notice on the left hand side here,
24:20
notice a nice horseshoe though thyroid
24:23
cartilage is like a horseshoe.
24:25
But notice we can see this high T one signal
24:27
in the left lamina.
24:28
Notice on the right side we can see a little bit
24:30
of high signal, but it's absent.
24:33
So this is an example of cartilage invasion.
24:35
I want to thank Sapr, the aria from India
24:36
for giving this beautiful example,
24:38
this pathologic example that tells us.
24:40
So we can see the diagnostic accuracy is somewhat similar,
24:45
but in general, um, I tend
24:47
to use a little bit more CT than I do.
24:49
Mr. The next one is pretty easy.
24:53
You know, we just wanna see whether
24:54
or not there's tumor extending outside of the larynx.
24:57
And this is X laryngeal spread.
24:59
So these are two obvious cases of tumor that extends
25:02
outside of the larynx.
25:03
Both of these have completely eroded the thyroid cartilage.
25:07
And here's is an example
25:08
of actually a piriform sinus carcinoma
25:11
that extended laterally through the thyroid hyoid membrane.
25:15
This type of invasion cannot be palpated clinically.
25:18
In fact, I just saw a case this, um,
25:20
two days ago with our tumor clinic.
25:22
And what happens here is that these tumors can extend
25:25
through the thyrohyoid membrane
25:27
and notice how the fat plane surrounding the superior
25:30
laryngeal artery neurovascular bundle is gone.
25:32
Compare the right side to the left side.
25:35
So this is actually early laryngeal spread
25:38
that really we make because we have to look for it.
25:41
So again, this is really hard to detect clinically,
25:44
but I always look at that in my reports.
25:47
And then the next thing that I do, especially
25:50
for true vocal cord, is I always play c attention
25:53
to the anterior commissure.
25:55
So this is a true vocal cord carcinoma.
25:57
They can cross over the anterior commissure,
26:00
anterior commissure, they can erode the cartilage.
26:02
So this is a tumor that's limited
26:04
to the anterior commissure.
26:05
And no, normally that little mucosa is just a couple
26:08
of millimeters, but in this case it's actually about four
26:11
or five millimeters.
26:13
So this is all tumor.
26:14
And this was a case my colleagues, uh, son Kim gave me.
26:17
This was a patient that had an anterior
26:19
commissure carcinoma.
26:21
The surgeons had sort of whittled it away
26:23
and they presented with recurrent tumor.
26:25
And in this case, what we see here,
26:27
the reason this patient recurred
26:29
after re a local resection is
26:32
that this had actually eroded the thyroid cartilage.
26:34
So notice the white on the left, notice
26:37
how the white is gone.
26:38
This is all marrow replacement
26:40
and you can actually see tumor right here extending
26:43
into the soft tissue.
26:44
So, and this patient underwent actually Sabin, uh,
26:47
sorry about not, it's not, uh, sung the sub sabin.
26:50
And this patient actually underwent total resection
26:53
and at surgery they found
26:54
that this was actually true exo laryngeal spread.
26:56
And again, cannot be seen clinically
26:59
but can be seen radiologically.
27:01
So these are the five things that I include in my report.
27:05
So what we've done so far is that we talked about anatomy
27:09
of the larynx and we talked about squamous cell carcinoma.
27:12
And what we've gone over is probably gonna be 70% of
27:16
what you're gonna encounter in your routine practice.
27:21
But now what I'll do is I'll spend a little bit
27:23
of time going over the non-squamous cell carcinomas.
27:26
Now, typically when you go to a talk on, on the larynx
27:29
and basically oftentimes in head
27:31
and neck, the most common tumor is gonna be
27:33
squamous cell carcinomas.
27:35
And after a while you look at these tumors
27:37
and you just can't tell the difference what they look like.
27:40
So what I'm gonna do is I'm gonna go over the next most
27:43
common tumor involving a non-squamous cell
27:46
and then we will talk about specific imaging findings
27:49
that can allow us to make a specific diagnosis.
27:53
So the second most common tumor
27:55
to involve the larynx are gonna be minor salivary gland
27:58
tumors and they can be adenoid cystic or muco epidermoids.
28:02
And these are all examples of adenoid cystic
28:05
and muco epidermoid.
28:06
The challenge here is that radiologically, it's really hard
28:10
for us to make the diagnosis prospectively.
28:13
What we can do is this though, is that you guys know
28:16
that I see patients once a week
28:18
and when we actually see patients
28:20
that have minor salivary gland tumors,
28:23
remember squamous cell carcinomas arise from the mucosa.
28:26
They're typically keratinized or basiloid.
28:28
When they do occur in the larynx,
28:30
oftentimes they're keratinized.
28:32
But for these minor salivary gland tumors,
28:35
oftentimes the patients will present as a submucosal mass.
28:39
So oftentimes what happens if the patients,
28:41
if the ENT surgeons see a mass and it's submucosal, um,
28:46
and it's hard, it's firm, uh,
28:48
but not as hard as bone, then we can suggest a diagnosis
28:51
of a minor salivary gland tumor.
28:53
Can we separate between adenoid cystic and muco epidermoid?
28:57
You know, definitely not. That's really hard to do.
28:59
But that's how I can suggest
29:01
that if I see an aggressive mass
29:03
and they tell me there's nothing mucosally,
29:05
then I can suggest a diagnosis
29:07
of a minor salivary gland tumor.
29:10
Now another benign tumor that can arise.
29:13
And I oftentimes see this incidentally,
29:15
especially on cervical spine cts and cervical spine Mrs.
29:19
And these are these little encon romas.
29:22
And when I usually see the encon romas,
29:24
they typically arise from one of the thyroid lamina.
29:27
So there are these small benign expansile lesions
29:30
that typically arise in the medullary cavity
29:32
and they oftentimes contain highline cartilage.
29:35
So this is a cute little enchroma here,
29:38
I think we can make the diagnosis.
29:39
And this was an unusual case of an encon
29:42
that's actually arising from the retinoid cartilage.
29:45
And again, from a principal standpoint, you can see
29:48
how it has a similar appearance to
29:49
what we see in the right lamina of the thyroid cartilage.
29:53
So again, classic examples of NDRs.
29:57
Now if we have encon romas, which are benign,
30:00
then we can also have chondro sarcomas
30:03
and chondro sarcomas again, typically arise in the larynx
30:07
where I've seen them the most have been at
30:09
the CRICO cartilage.
30:10
So these are two examples of chondro sarcomas
30:13
that arose from the CRICO cartilage.
30:15
This is the typical expanse lesion
30:17
with this internal matrix.
30:20
And this is what it looks like on Mr Again, for me it's hard
30:25
to make a specific diagnosis on this.
30:27
Um, I tend to like CT over MR
30:29
because I get a better appreciation
30:31
of the potential cartilaginous matrix.
30:33
But when you do seem on on mr, they're typically low signal
30:38
and oftentimes have this high T two signal.
30:40
So this is just the MR appearance of a chondra sarcoma,
30:44
but I do want you to focus on this,
30:46
which is a characteristic CT appearance
30:48
of a chondra sarcoma involving the cricoid cartilage.
30:52
Now these are some other non-squamous cell carcinomas.
30:56
We can see things such as neurogenic,
30:58
hematopoietic or mesenchymal.
31:00
These are just a couple of examples that you may be able
31:03
to make the diagnosis if you're a member of cupra features.
31:06
So this is a mass right here
31:08
that's extending into the retro pharyngeal space
31:10
and pushing anteriorly the posterior portion
31:13
of the posterior pharyngeal wall at the level of the larynx.
31:16
This is a lipoma, this was a diffusely enhancing mass
31:19
involving the right area epiglottic fold.
31:22
This was an unusual case
31:23
of a paraganglioma involving the larynx.
31:26
Here we can suggest the diagnosis.
31:28
In fact, we made this prospectively
31:30
because we looked at the right side of the neck.
31:32
We saw this osteoid lesion right here,
31:35
this new bone formation.
31:37
So we correctly made the diagnosis of an osteosarcoma.
31:41
The reason we thought it was osteosarcoma versus chondra
31:44
sarcoma is that the chondra sarcomas typically allies from
31:47
the privileges, but this was arising from the soft tissue
31:50
and had a bony matrix.
31:52
And this was an unusual case given
31:54
to my wonderful colleagues in Tanzania of Kosi sarcoma.
31:58
So in the US we don't nearly see as much of this.
32:01
You can see this endemic areas.
32:03
I think we've seen a few of these over the last few years in
32:06
the US when I grew up, I grew up in the AIDS era, so we used
32:09
to see this relatively frequently
32:11
and forging in patients that were HIV,
32:13
but now we don't see it as much.
32:15
So if you are in an endemic area
32:17
and you do see an aggressive mass involving the larynx, um,
32:21
you know, uh, you can always in the back of your mind
32:24
when you think of non-squamous cell tumors
32:26
to consider cap c sarcoma.
32:30
So the next thing that we'll talk about is
32:32
that we talked about the anatomy,
32:33
we talked about squamous cell,
32:35
we talked about non-squamous cell neoplasms.
32:37
And now we'll turn our attention to various infectious
32:40
and inflammatory processes.
32:42
And I wanted to give a shout out to my colleague Myra Sarpy,
32:45
who's now at University of Florida,
32:47
and also my wonderful friends from Brazil.
32:50
As we're about to, uh, this paper just, uh, is about
32:53
to be published in Radiographics.
32:54
So if you wanna learn more about an imaging of infectious
32:57
and inflammatory process of the larynx,
32:59
I would refer you to this, this paper.
33:01
And some of these images are from that paper.
33:05
So I gotta tell you, it's been a long time since I looked at
33:08
plain films, but I do remember plain films play a,
33:12
a big part in some of these lesions,
33:15
in these infectious processes that involve the larynx.
33:19
So this is an example of a child that presents with strider,
33:22
sort of coughs like a barks, like a seal when they coughed.
33:25
And this is an example of croup.
33:27
And in croup, instead
33:28
of having the curved shoulders like we've seen
33:30
before, we can have this almost steeple shaped
33:32
appearance of the croup.
33:34
So this is in a way the other term can be used, lary,
33:38
tracheitis, uh,
33:39
and this is an example of croup, which is typically due
33:42
to the virus of parainfluenza.
33:45
Here's an example of a patient on a plain film, a child
33:48
that presents with a sore throat
33:51
and oftentimes have the drooling.
33:53
And when you look at the sagal images,
33:55
this is diffuse thickening
33:56
of the free margin, the epiglottis.
33:58
And this is epiglottis.
33:59
I did my internship in the emergency room
34:01
and I remember when these cases came in, you always tried
34:05
to make the ca patients really, really calm.
34:07
You didn't want that child to cry
34:09
because that they did, they could close off the airway.
34:12
So it was at that time a medical emergency.
34:16
The nice thing is, is that the incidence of
34:19
of epiglottitis has decreased
34:21
because of the vaccinations of H flu.
34:24
So it's caused by the H one B virus.
34:27
And now this is uh, uh, or I should say the bacteria.
34:29
And now this is substantially reduced
34:32
because of the vaccinations.
34:34
Now epiglottitis is what we typically talk about in kids,
34:37
but sitis is something that we sometimes refer to
34:41
as adult epiglottitis.
34:43
So this is an example of SGLT looking at diffuse thickening
34:47
of the epiglottitis here.
34:48
And again, we don't see this very often again
34:51
because of the vaccinations.
34:52
So vaccinations are terrific.
34:54
Make sure you, I'm a big vaccine fan,
34:56
so make sure you get all your vaccinations
34:58
because I have had firsthand evidence
35:01
that these potentially life-threatening diseases
35:04
are indeed less common because of that.
35:06
And if this is not treated, it can go on
35:08
to develop an abscess.
35:10
And this is an example of an epiglottic abscess.
35:14
Now a lot of these infectious
35:16
or inflammatory processes, again, are nonspecific.
35:19
Now, as I mentioned before, I, I see patients in the clinic.
35:23
And so when these patients come in, how can I
35:25
as a radiologist who've seen the patients suggest this?
35:29
Well, I do have a bit of a, uh, an advantage
35:32
because these lesions again,
35:33
are typically submucosal like I mentioned
35:36
before, squamous cell carcinomas or mucosal lesions.
35:39
So this was a case of a relapsing polyon
35:42
that we saw clinically.
35:43
This was a, a patient that came in, had a hoarseness,
35:47
decreased vocal cord mobility.
35:49
And we can see this mass is located in this area.
35:52
It's not the anterior commissure,
35:54
it's a posterior commissure.
35:55
So we saw this enhancing mass.
35:57
The surgeons went and looked at it, nothing mucosally,
36:00
even biopsied and, and nothing came back.
36:03
So because of this we went ahead
36:05
and suggested the possibility of relapsing polyon.
36:08
The patient was treated with antibiotics and steroids
36:10
and made a complete recovery.
36:12
So this was an example of relapsing polyon.
36:16
This is something that can look similar.
36:18
This was an unusual case of a patient
36:20
that had rheumatoid arthritis.
36:22
The soft tissue thickening usually arises from the CRICO
36:25
joint from that synovial joint.
36:27
That's when you end up getting this
36:28
thickening of the larynx.
36:30
Here's a, a case given to me by my friend, um,
36:33
and mentee Martine Ferraro down in uh,
36:36
Argentina and Buenos Aires.
36:37
This was a nice example of an amyloid
36:40
involving the right false vocal cord.
36:42
And this was cases of poly angiitis,
36:45
granulomatosis and sarcoidosis.
36:47
Again, we really can't make a specific diagnosis.
36:51
The only thing that we can do is
36:53
that if we do see something like this, we can include this
36:56
and say Hey, could this be an infectious
36:57
or inflammatory processes?
36:59
And then we can include it in our differential.
37:02
So in this particular case we can suggest getting ANCA
37:05
titers, which would be confirmatory.
37:07
And in sarcoid we can do
37:09
and look, you know, look at chest x-rays
37:11
and look for um, mediastinal nodes, et cetera.
37:13
But again, nothing really specific.
37:16
But on the other hand there are things we can make
37:18
a specific diagnosis.
37:20
So if you see something like this, a big mass right here,
37:23
biopsy negative, and then you do a chest CT
37:26
and you see this lesion in the apex where you can put this
37:30
and this together and suggest a diagnosis of tuberculosis
37:33
and realize that laryngeal tuberculosis is
37:36
typically due to the coughing.
37:38
Here's an example of a patient
37:39
that comes in diffuse air involving the soft tissues.
37:42
This patient was immunocompromised
37:45
and mal uh, nourished if we see air in the soft tissues
37:49
and they've never had surgery, well look at this,
37:51
we look at the skin right here
37:52
and this is all necrotizing fasciitis
37:55
so we can make a specific diagnosis.
37:57
These are two examples of patients
37:59
that again have air involving the larynx
38:01
and also involving the cartilage.
38:03
If I tell you these patients have been treated
38:05
with chemotherapy and radiation therapy,
38:08
well these are nice examples of chondro necrosis
38:10
so we can make that diagnosis.
38:12
And this is an example of a patient
38:14
that has these bilateral prop pillow.
38:16
This was given to me by Apci Agarwal.
38:18
When we look at the Sagal images, we look at all
38:20
of this diffuse thickening involving the airway.
38:23
And this was due to laryngeal papillomatosis.
38:26
So on rare occasions we can make these diagnosis
38:30
but again they tend to be more the exception than the rule.
38:35
Well now let's go on to congenital
38:37
and developmental malformations.
38:40
So we'll first talk about the lary seal.
38:42
So what is a lary seal?
38:44
Well, we already went over the anatomy,
38:45
so I'll just go over the anatomy again
38:47
'cause repetition's important.
38:49
Remember the epiglottis is anterior and midline.
38:52
Then we have this fold of tissue,
38:53
which is the area epiglottic fold.
38:56
Right at the base of it we have the reflection,
38:58
which is the false vocal cord.
39:00
And now we have the opening to the laryngeal ventricle.
39:03
Well, what a laryngeal is is dilatation
39:06
of the laryngeal ventricle.
39:08
And this laryngeal can be located with um, medial
39:12
to the thro hyaloid membrane,
39:13
which case it's an internal lary seal
39:16
or it can extend through the thyroid hyoid membrane,
39:19
in which case it becomes external.
39:21
And if it's both internal external,
39:23
sometimes we'll call this a complex laryn seal in kids.
39:27
Sometimes what we end up seeing is this little dilatation
39:30
of the tip of the laryngeal ventricle
39:32
and we t tend to call that a sac cyst.
39:35
So for me, a sac cyst and lary seal are the same thing.
39:38
It's just sac cyst we tend to attribute to kids
39:41
and they tend to be smaller as well too.
39:44
So schematically, this is what we see in a laryn seal
39:47
and this is what we see radiologically.
39:49
So this is an example
39:50
of an air fill laryngeal notice here's a normal airway
39:54
and we see this airway right here in the
39:56
per laryngeal space.
39:58
And it's extending laterally right to the level
40:00
of the thyrohyoid membrane.
40:02
In fact, it may be extending through it.
40:04
Here's the same patient on the coronal images.
40:06
In this case we see large dilatation
40:09
of the laryngeal ventricle.
40:10
I'll show you in the next slide.
40:12
You always don't necessarily have
40:14
to have a narrowing right here.
40:15
Sometimes they can be blown open
40:17
and you'll see this on the next slide.
40:19
But this is an example here of a large laryngeal,
40:22
same one just in the cornal view.
40:25
Laryngeals can also be air filled.
40:27
If you do have an occlusion right here,
40:29
then you can have air
40:31
or should should say fluid completely
40:33
replacing that laryngeal.
40:35
So here we have an internal component
40:37
and an external component and it's fluid fill.
40:40
So I would call this a complex
40:42
laryngeal involving the endo laryngeal
40:44
and the exo laryngeal structures.
40:47
Now like I mentioned
40:48
before, there are different causes of laryn seals.
40:51
So this was a famous trumpet player,
40:54
this is a ugal horn, dizzy Gillespie.
40:56
This patient had huge cheeks and probably had laryn seals
41:00
and this was a glass blower.
41:01
So if you've ever been to the Netherlands
41:03
or if you've been to the western part of Michigan
41:05
where I used to live, when you blow real hard you can
41:08
develop these laryn seals
41:09
and that laryn seals is probably why this expansion occurs.
41:14
But on the other hand, as I mentioned,
41:16
you can also have occlusion that's causing that laryngeal.
41:19
And one of the things that can occlude the opening
41:21
of the laryngeal ventricle is a squamous cell carcinoma.
41:25
So every time I see a lary seal,
41:27
the next place my eye goes is I go to the level
41:30
of the false vocal cord
41:31
and the true vocal cord to see if there's a mass.
41:34
And this was an example
41:35
of a squamous cell carcinoma involving the false vocal cord
41:39
in a patient that developed a lary seal.
41:41
And typically unfortunately
41:42
that's due to smoking and drinking.
41:45
Now if the lary seal looks like this,
41:47
this is a fluid feel lary seal, if it contains protein
41:51
or blood, it can have this sort of atypical appearance.
41:55
But on the other hand, if you look at the ring laryn seal,
41:57
it has an irregular margin and the patient is febrile.
42:01
Well now you have a laryn go peoe.
42:03
You actually have a laryn seal
42:04
that's actually become infected.
42:06
So you can call this apy lary seal
42:08
or a laryn go peoe either one.
42:11
But when we as a radiologist should,
42:13
should su suspect this is
42:15
that when we lose our normal margin right here,
42:18
normally there should be a crisp margin
42:19
between the lary Ringo seal and the fat.
42:21
And you can see all of that's gone.
42:22
So that's the lary, Ringo Peoe
42:24
and again a very, very rare complication.
42:27
But it does occur.
42:30
Now the other things that could involve the larynx from a
42:32
developmental standpoint or thyroid gloss of duct cyst.
42:35
Now congenital lesions involving the larynx are atopic
42:39
and upon its own,
42:40
but I wanna leave you with just to reminder
42:43
that remember the thyroid gland arises from the
42:45
frame and cecum.
42:47
It has this descent where it's above the hyoid bone,
42:50
then it's behind the hyoid bone,
42:52
then it extends in the anterior neck
42:54
and eventually ends up as a thyroid gland.
42:57
So these things I often again times see most commonly is
43:02
in the adult population in in cervical spine MRIs.
43:05
So this was an incidental thyroglossal duct cyst
43:08
that was seen at the frame and cecum.
43:10
So this is a nice little thyroglossal duct cyst right
43:13
here at frame and secum.
43:15
Now both of these lesions are actually
43:17
thyroglossal duct cyst.
43:20
Now thyroglossal duct cyst can be midline
43:22
or they can be paraline, they can be ocular
43:25
as we see here, they can be multi.
43:28
What's the common thread?
43:30
What tells us that I know
43:31
that this is a thyroglossal duct cyst,
43:33
for me it's the embedding of the strap muscle
43:36
because when patients swallow the this lesion moves
43:40
and the reason they move is
43:41
that the strap muscles act like an elevator shaft
43:44
to elevate the larynx.
43:46
So because these tumors
43:48
or should say these benign lesions are located in the strap
43:51
muscle, when you swallow the strap muscle contracts,
43:55
that's why the thyroglossal duct cys moved.
43:57
So basically this is that radiological correlate.
44:00
So for me what I look for is this mass
44:03
that's embedded in the strap muscle.
44:05
And if I see this then I have a high,
44:08
a very high confidence level that I'm dealing
44:10
with a thyroglossal duct cyst.
44:13
Now on rare occasions you have a thyroid gloss duct cyst
44:16
and you see an enhancing mass.
44:18
Occasionally you can have concomitant coincidental papillary
44:22
thyroid carcinomas.
44:23
So the most common is gonna be papillary thyroid carcinomas
44:27
followed by mixed papillary follicular
44:29
and occasionally squamous cell.
44:31
These again are relatively rare,
44:33
but I will suggest the diagnosis if I see
44:36
what I think is a thyroglossal duct cyst
44:38
'cause it's located in the right location
44:40
and then I see an enhancing or solid mass within that cyst.
44:45
If I see that, I'll go ahead
44:47
and raise the possibility
44:48
that it's a thyroid gloss duct cyst.
44:51
Tell the surgeons so they can determine how much
44:54
of the thyroid to move, how much of this to remove.
44:57
They're gonna do a cyst trunk procedure anyway,
45:00
but how much of that thyroid gland do they need to remove?
45:02
Also you need to tip off the pathologist
45:04
because then they can look really closely
45:06
to make sure there really is that tumor.
45:09
So we do play a really important role if we can suggest the
45:13
diagnosis of that, of that uh, coincidental tumor.
45:18
And this was a little bit of an unusual lesion.
45:20
This was a lesion right here with subglottic.
45:22
He anoma typically we don't get CT scans on this,
45:25
but they are sort of these developmental lesions.
45:28
These patients typically present with stridor.
45:30
We can see the true vocal cords are gonna be right here.
45:33
And this was just an example
45:35
of a nice sub glottic key angio.
45:37
These lesions are typically treated
45:39
with propanolol and steroids.
45:40
If they get really big they can perform the laser excisions.
45:44
But in general, I think in most kids the uh,
45:47
pediatric otolaryngologist will treat
45:49
with propranolol and with steroids.
45:53
So the last thing that I'm gonna leave you
45:55
with is vocal cord palsy.
45:59
And I specifically put this here
46:01
because this is one of the most common reasons
46:04
that we end up evaluating um,
46:06
the larynx in the general population.
46:09
So you'll have a certain percentage of patients
46:11
that are gonna be squamous cell carcinomas,
46:13
but if you're in the general population, this is one
46:15
of the most common indications that you'll look at this.
46:18
Also, sometimes we will end up picking up vocal cord palsies
46:23
incidentally, so I do want you to be familiar
46:25
with what they look like.
46:28
So when we talk about the larynx, we need
46:31
to talk a little bit about the innervation.
46:33
So the motor innervation
46:35
of the true voc cords arises from this nerve
46:38
and this nerve is a branch of the vagus nerve.
46:41
So this is the recurrent laryngeal nerves.
46:43
So the vagus nerve comes down
46:45
and it actually gives some innervation to the larynx
46:49
as it's coming down and that's the superior laryngeal nerve
46:53
that provides innervation.
46:55
But the main motor is gonna come from
46:56
the recurrent laryngeal nerve.
46:58
And on the left hand side this crosses under the aortic arch
47:01
on the left and then the subclavian artery on the right.
47:05
So when we are looking at patients with vocal cord palsies,
47:08
as you'll see in the next slide, you need
47:12
to have a very structured and an organized approach
47:14
because we always have to remember
47:16
as the vagus nerve is coming down,
47:18
it's in the carotid space,
47:20
but as the recurrent laryngeal nerve comes up,
47:23
it's actually in the trache esophageal groove bilateral.
47:26
And you'll see what I mean in just a jiffy.
47:29
Now this is the classical appearance of a vocal cord palsy.
47:32
So what we see here is dilatation of the left lateral, uh,
47:36
the laryngeal ventricle on the left
47:38
and we can see ipsilateral enlargement
47:41
of the left piriform sinus.
47:44
Now you say this and you say, wow,
47:45
this looks like it's thick right here.
47:47
Is it possible this could be a tumor?
47:49
The tip off is to look for this dilatation
47:52
of the laryngeal ventricle
47:53
and then also the ipsilateral enlargement
47:56
of the piriform sinus.
47:57
This is why we talked spent so much time on this before.
48:00
And this is an example of squamous cell carcinoma.
48:03
This is right at the tip of the hyoid cartilage.
48:05
So this is at the junction of the, uh,
48:08
area epiglottic fold in the false vocal cord.
48:11
And we here, here, here we have this mass right here.
48:13
Notice there's no enlarge from the laryngeal ventricle
48:16
and there's no enlarged from the piriform sinus.
48:19
So these two things are juxtaposed
48:20
to emphasize the difference
48:22
that we see on imaging at the level the true vocal cord.
48:27
Now here's an example at the level
48:28
of the area epiglottic fold.
48:30
So here we have this thickening
48:32
of the left area epiglottic fold looks thick, right?
48:34
But look at the piriform sitis, it's enlarged.
48:38
Now contrast this with the appearance of this,
48:40
which is an area epiglottic fold carcinoma.
48:43
Notice the thick and left area epiglottic fold,
48:46
but look at the piriform sinus.
48:47
See how narrow that is.
48:49
You can actually with a leap of faith say
48:51
that this is actually narrowing that piriform sinus.
48:55
So ipsilateral enlargement of the piriform sinus.
48:57
This tells you you're likely dealing
48:59
with the vocal cord palsy
49:01
and you can also notice the para median thickening
49:03
of the area epiglottic fold.
49:05
But in this case what we have is diffuse thickening
49:08
and narrowing of the piriform sinus.
49:09
So this suggests that we're dealing with a cancer.
49:12
Now if you're not sure, just remember
49:15
to always recommend a laryngoscopy as clinically indicated
49:18
because you know, I have seen very unusual cases
49:21
of a patient that had both a vocal cord palsy
49:23
and a separate cancer.
49:25
So they can be confusing.
49:27
So uh, you know, if you're not sure,
49:29
just recommend a laryngoscopy in your report.
49:32
Now this is the segmental approach
49:34
that I was talking about before.
49:36
So when I'm looking at patients with vocal cord palsy,
49:39
this is just the coronal images demonstrating ipsilateral
49:42
dilatation here of the left lge ventricle.
49:46
Again, notice that paramedian cord
49:49
and you can see there's almost enlargement of the ear
49:51
with the way I think this looks like a head in two ears.
49:54
This ear here is enlarged.
49:55
So this is that ipsilateral dilatation.
49:58
So all of the things that I'm showing on the right here
50:02
paused the patient's vocal cord palsy.
50:05
And these are, you know, like I said, actual cases
50:06
that I've come across over the last few years.
50:09
So anytime that I have a vocal cord palsy,
50:11
I will always wanna look at the brainstem.
50:13
And specifically I wanna look for Chiari malformations
50:16
because in children's that have Chiari malformations, one
50:20
of the unusual presentations can be bilateral
50:23
vocal cord palsy.
50:24
So especially in kids if they had vocal cord palsy,
50:27
my eye immediately goes to the dorsal midbrain
50:30
and it goes to the frame in Magnum
50:31
to make sure there's no chiri.
50:33
This was a patient that presented
50:35
with a left-sided vocal cord palsy.
50:38
So if I draw a line down the middle, compare the right side
50:40
to the left side, no look at the carotid space right here.
50:44
See the carotid artery, see the jugular vein,
50:47
see the nice fat planes on the right.
50:49
And in this case, unfortunately this was a very unusual case
50:53
of squamous cell carcinoma
50:54
that was actually growing along the carotid space.
50:57
So why would it EC clip and cause a vocal cord palsy?
51:00
Because cranial nerve tend runs in the carotid space.
51:05
So you can see how this tumor would encase cranial nerve 10
51:09
as it's descending in the neck.
51:11
So this was caused by tumor involving the carotid space.
51:15
Now when we look at patients here,
51:17
once we get into the mediastinum, we always have
51:20
to look under the aortic arch on the left
51:24
and the subclavian artery on the right.
51:26
But remember the recurrent laryngeal nerve courses
51:30
anteriorly or superiorly I should say in the,
51:32
in the trache esophageal groove.
51:34
So we always wanna look at the trache esophageal groove.
51:37
And this was a patient that had an esophageal carcinoma
51:40
that presented with a left focal cord palsy.
51:44
The other tumors that I see most commonly do this are gonna
51:47
be metastases to tracheal esophageal lymph nodes.
51:50
But most commonly it's gonna be to a thyroid carcinoma.
51:54
And typically anaplastic thyroid carcinomas are really
51:58
advanced papillary thyroid carcinomas can do it.
52:01
So from my standpoint, I always have to look very,
52:03
very closely because first I talked about the brain,
52:07
then I talked about the carotid space.
52:09
Now I'm looking right here at the thro, uh, uh,
52:12
trache esophageal groove.
52:14
And then finally you always have to look at the vessels.
52:18
So this is an example of a patient
52:20
that ended up having a ductus diverticulum years ago in
52:24
1897, NAR described any cardiovascular abnormalities
52:29
that would actually result in a vocal cord palsy.
52:32
So I remember this. So I always look
52:34
for things like ductus diverticulum, I looked
52:36
for subclavian artery aneurysm, so on and so forth.
52:40
So realize vascular structures then can cause this.
52:43
But remember bronchogenic carcinomas can cause it too.
52:46
So anytime that you have a tumors involved in the aor aortic
52:49
pulmonary window or oftentimes recurrent carcinomas down in
52:53
the mediastinum, that can cause the vocal cord palsy too.
52:57
So when I'm looking at vcps, this is my checklist, brain
53:02
carotid space, paricular esophageal groove,
53:05
and superior mediastinum.
53:08
So in summary, what we've done over the last 50 minutes
53:11
or 55 minutes is
53:12
that we have taken a deep dive into the larynx.
53:15
So what we talked about first was the anatomy.
53:18
And the anatomy is so important.
53:20
As I said at the the beginning of the lecture.
53:22
Remember the big five, if you remember those big five
53:25
structures, the hyoid bone, the epiglottitis,
53:28
the thyroid cartilage, the adenoid cartilage,
53:30
and the cricoid cartilage.
53:32
If you can just remember those five things,
53:34
you can remember all of these crazy terms
53:36
for the muscles and the ligaments.
53:38
We talked about neoplasms
53:40
and we talked about squamous cell carcinoma
53:42
and we went over a checklist of key elements
53:45
to include in your squamous cell carcinomas.
53:48
We talked about various infectious
53:50
and inflammatory processes, um,
53:53
and we also talked about the specific findings
53:55
where you can be a hero
53:56
and come up with the exact diagnosis.
53:59
We spent a little bit of time on congenital
54:01
and developmental lesions focusing on lary seals
54:04
and also, uh, with um, thyroglossal duct cyst.
54:08
And then we ended with vocal cord palsy.
54:11
So if you want to, you can follow me on YouTube.
54:13
We have this free YouTube channel that has several
54:16
of my other head and neck talks on it as well too.
54:18
Medals a place to go. But we have a couple here on YouTube.
54:22
I'm also on X and I'm also on LinkedIn.
54:24
And then we are gonna be offering our head
54:28
and neck fellowship beginning in May.
54:31
And you have been doing this now for four or five years.
54:33
And as I travel around the world, I'm just so pleased
54:35
and honored, uh, to meet people that have taken it.
54:38
I can tell you five
54:40
or six people right now that have taken are now either
54:43
are doing a hundred percent head and neck radiology
54:45
or actually the head and neck go-to person
54:47
or the head of, of head and neck radiology in their group.
54:50
So for me doing it five years, it's great to see, um, some
54:54
of the successes that we've had in people
54:56
that have been taking it.
54:57
So if you wanna do this, this is the, the code, if you will.
55:00
Um, and you can get a 25% discount if you would like.
55:03
So I'll go ahead and stop there. Ashley.
55:05
Um, I've saved a lot of time for questions, so I'll,
55:09
I can be here for, uh, as long as you guys want.
55:11
So again, thank you very much for the honor, the invitation,
55:14
and, um, happy to answer any questions.
55:16
Thank you so much for sharing your lecture
55:18
with us, uh, today, Dr.
55:20
McCury. Um, yes, at this time we will open the floor
55:22
for any questions from our audience,
55:24
and you may submit your questions
55:26
through the q and A feature.
55:28
And we have a couple in here already. Uh, Dr.
55:31
McCury, can you discuss which
55:33
of the five elements are identified relative
55:36
to the hyoid bone as a landmark?
55:39
Uh, yeah, uh, let's see if I can go back to this one.
55:42
So, yeah, so here are the five landmarks.
55:45
So this is the hyoid bone that's, that's here,
55:47
and then the hyoid bone is gonna be the top.
55:49
So this is the hyoid bone here.
55:52
Here's the thyroid cartilage here.
55:55
This is gonna be the retinoid, this is gonna be the cricoid,
55:59
and then this is gonna be epiglottis.
56:00
So there's our landmark right here for the hyoid bone.
56:04
And then when we look at the axial images, um,
56:07
here is the hyoid bone here on mr.
56:10
So this was a younger patient, so there wasn't a lot of fat,
56:12
but we can see the hyoid bone here.
56:15
And then on the CT scan we can see, uh, the base
56:17
of the hyoid bone here.
56:23
All right, great. Do you routinely use CT MR
56:26
or PET imaging for T one, T two supraglottic larynx cancers?
56:32
So, uh, for, um, for me, um, you know, it,
56:37
it, it really depends.
56:39
So I gotta tell you, in the United States, um, we tend
56:43
to do more CT than mr.
56:45
And I know in Europe you, Europeans tend
56:47
to do more MR than ct.
56:50
You know, there are many factors to this
56:52
'cause I spend usually three or four weeks in Europe
56:54
and the rest of the time, I mean in,
56:56
in the US giving talks and things.
56:58
Um, and part
56:59
of it in the United States is it's essentially standard
57:02
of cure, I would say in most institutions that if you,
57:04
even if you have a T one
57:06
or T two larynx cancers, um,
57:09
some laryngologists will not get ima any imaging
57:12
at all for T one cancer.
57:13
So if it's an early T one lesion
57:15
and you have an experienced laryngologist,
57:17
they will won't get imaging, any imaging at all.
57:20
The next question is, is
57:21
that if you did get imaging, which one would you do?
57:24
In the US we tend to do more CT than mr, and part of it is
57:28
because we do a lot of PET cts.
57:31
So some clinicians that I work with will say, well,
57:33
I gotta get a pet CT anyway, so I'll just go ahead
57:36
and get a ct because at some places they'll do 'em both.
57:40
But on the other hand, you know, when, when I'm in Europe
57:42
and you have, uh, experienced technologists
57:46
and also you have patients that can hold still
57:48
and not breathe, the MR studies are beautiful.
57:51
So I would say there's no firm
57:55
consensus one way or the other.
57:56
What I would do is talk with your, um, referring physicians
58:01
and make sure that you're on the same page, um,
58:03
and do whatever you really feel, uh, most comfortable doing.
58:09
All right. Can a patient with laryngitis have the problem
58:13
to produce sound?
58:16
Um, yeah, they sure can.
58:18
Um, and I get laryngitis sometimes.
58:21
So yes, a patient with laryngitis can have sound,
58:23
uh, problems with sound.
58:25
Um, part of it is probably due to the inflammation.
58:29
Um, and, um, I know, you know,
58:32
I've had laryngitis numerous times.
58:34
I'm sure I have some inflammation involving my vocal
58:37
cords from overuse.
58:38
And that type of swelling
58:41
of somehow affects the laryngeal motion.
58:43
Whether it actually reduces it or not, I don't know,
58:45
but it probably has to do with the normal vibratory motion
58:49
of the true vocal cords,
58:50
and that's what gives us the hoarseness of the voice.
58:56
All right. How do you approach the cases
58:58
where it is too difficult to tell whether
59:00
or not the internal emia
59:02
or of thyroid cartilage was invaded?
59:06
Ah, great case. Uh, great questions.
59:08
Was that on the, um, q was that on the q and a there? Yeah,
59:12
You had it pulled up momentarily.
59:13
I don't know. I did. Yeah, you did.
59:16
Oh, no, I'm sorry. So
59:18
that is a super, super good question.
59:20
It's something that I struggle with every day.
59:22
So, um, I'm gonna give you my approach for this.
59:27
So when you actually look at the thyroid cartilage, like,
59:30
like this, I'm gonna give you, um,
59:34
I'm gonna give you my approach for looking
59:37
for cartilage invasion.
59:38
So when I look at a cartilage,
59:41
the first thing I do is I look at the ossification pattern.
59:45
Now, if I looked at Ashley's
59:46
and Jackie's cartilages compared to my cartilages, um,
59:50
we're going to probably have different ossifications,
59:53
but in general, it's symmetric.
59:55
So one side is, is is going to be equal
59:58
to the opposite side.
59:59
So we have different ossification patterns
60:02
between different people,
60:03
but within us it tends to be symmetric.
60:05
So what I look at is that I look
60:07
for abnormalities from one side to the other.
60:09
So this is an example here where the inner cortex is eroded,
60:12
but the outer cortex is intact,
60:14
and this is a T three lesion.
60:17
Now, here's an example
60:19
where this right lamina is, is eroded.
60:23
Now you can say, how do you, how are you
60:25
so confident for that?
60:26
And the reason is the following.
60:28
If I draw a line down the middle
60:29
and I compare the right side to the left side,
60:32
what I wanna do is see
60:33
what the normal ossification pattern is in this patient.
60:37
So on the left hand side,
60:39
what I see here is I see ossification right here involving
60:43
the posterior aspect of the thyroid cartilage,
60:46
and I see a little bit of ossification anteriorly,
60:49
but I don't see any ossification here.
60:52
So if I know that the patient has a right-sided tumor,
60:56
I cannot confidently say
60:58
that this area right here is invaded by tumor.
61:02
Why? Because if I look at the opposite side,
61:04
this area is not ossified.
61:07
But on the other hand, if I look at the posterior aspect
61:09
of the lamina thyroid cartilage, notice how all
61:13
of this cartilage is gone
61:15
and in this patient that should be there.
61:17
So that's my approach to looking at invasion of the,
61:22
uh, the thyroid cartilage or any cartilage on ct.
61:31
All right. Uh, we do have someone asking if you'd be
61:34
willing to put up the slide again for the five things
61:36
to mention in your report for SCC.
61:40
Be happy to do that, and here they are.
61:43
So I can leave this up for a, for a minute or so.
61:46
Um, if people wanna write that down, I really think
61:48
that this is really important to include.
61:51
You know, for me, I see so many different reports that come
61:55
through, um, just
61:56
because, uh, uh, uh, you know, as being a referral center,
62:00
but, um, they're, they're in all ways and,
62:02
and they're all beautiful reports, uh,
62:04
and people are really, really good out there.
62:06
Um, but just remember if you just say
62:08
that there's a cancer involving the larynx.
62:10
So for, in this particular case, you know, if I just say
62:13
that there's a cancer involved in the anterior two thirds
62:15
of the true vocal cord
62:17
and it's getting close to the anterior commissure,
62:20
you haven't added much information
62:21
because the surgeons can see this.
62:24
So what we always have to remember,
62:26
especially when we're dealing with larygeal carcinoma, is
62:29
to include information that cannot be seen clinically, that
62:33
that's gonna change how these patients are treated.
62:36
And as I mentioned before, if it's subglottic cancer,
62:38
then these patients, um,
62:40
if there is more than six millimeters of spread, at least
62:43
with the group that I work with,
62:44
they'll probably treat treated
62:45
with chemotherapy and radiation therapy.
62:48
Trans glottic again, too, the, uh,
62:50
if it's trans glottic spread, instead
62:52
of doing a partial Lyme, uh, laryngectomy,
62:54
the only option would be a total.
62:56
So we want to give chemo and radiation,
62:57
likely cartilage invasion is gonna upstage these tumors.
63:02
And the surgeons really have a hard time looking at
63:04
cartilage invasion because all of that's submucosal
63:07
ex laryngeal spread, especially if it's early,
63:10
cannot be determined by clinical examination.
63:13
And as I mentioned before,
63:14
this patient right here had undergone numerous local
63:18
resections and finally presented
63:20
with an anterior soft tissue mass,
63:22
and that was that alge spread.
63:25
So yeah, I'm glad you mentioned that.
63:27
And, um, these are the five things I
63:29
try to include in the report.
63:32
Excellent. Um,
63:33
and I'm gonna apologize in advance for messing up a bunch
63:37
of these words coming up,
63:39
but can you please explain the reason for
63:42
pyriform sinus dilation of
63:45
on ipsilateral vocal cord palsy?
63:48
Yeah, sure. It's a great question.
63:50
Um, so let me go ahead and close that.
63:55
Yeah. So the, the reason that ends up happening,
63:58
and I think this will show at the best, is that,
64:03
uh, probably this won't show at the best.
64:05
So the reason is, is
64:06
that when you have a paralyzed vocal cord,
64:10
what ends up happening is that your true vocal cord tends to
64:15
become paramedian.
64:16
So, so it ends up, what happens is that normally
64:19
what happens, that your vocal cords move like this.
64:21
But what ends up happening is
64:22
that when you have a paralyzed vocal cord,
64:24
you have one vocal cord that moves like this.
64:27
So as the vocal cord goes from lateral to medial,
64:31
what it ends up doing is literally dragging over the area
64:35
epiglottic fold.
64:36
And so instead of the area epiglottic fold, kind
64:39
of being out
64:40
and being compressed by this area, epiglottic, excuse me,
64:43
instead of this piriform sinus being somewhat compressed
64:46
by the area epiglottic fold,
64:50
when the vocal cord moves medially,
64:52
the retinoid cartilage moves medially.
64:56
Remember, the false vocal cord is attached
64:58
to the area epiglottic fold that moves medially,
65:01
and that basically uncovers or un roofs
65:04
or expands the left piriform sinus.
65:07
So that's why you end up getting this ipsilateral dilatation
65:11
of the piriform sinus.
65:14
Hopefully that helped.
65:17
Great. All right. Um, could you please explain how
65:21
to accurately identify false and true vocal chords?
65:25
Yeah, that's, I'm glad someone asked that
65:27
because that's so important.
65:28
Um, so let me try to go back
65:32
and I'll just go back to this one here.
65:34
So I'll go over this real quickly again.
65:38
So area epiglottic fold is here,
65:41
area epiglottic fold is here.
65:43
And notice there's no cartilage here now.
65:47
And when we look at this image right here, this is
65:49
where we are, we're right about here.
65:51
Then what happens is that when we get
65:53
to the false focal cord,
65:55
the false focal cord is gonna be here, it attaches
66:00
to the top of the retinoid cartilage.
66:02
And when we look at a CT scan, or excuse me, an MR scan
66:06
and a CT scan, if we just see the top
66:09
of the retinoid cartilage,
66:11
then we know we're at the level of the false focal cord.
66:14
So burn this into your memory, top
66:16
of the retinoid cartilage, top of the retinoid cartilage.
66:19
Now what happens? Keep your eye right here.
66:23
And now we see cricoid cartilage
66:25
and we see a retinoid cartilage.
66:27
So this is crico retinoid joint.
66:29
So this is the true VCAL cord.
66:31
And then on the CT scan, there's the crico cartilage,
66:33
there's the retinoid cartilage.
66:35
And remember, see, hopefully I made you smile.
66:38
Did I make you smile, Ashley?
66:39
There's my little smile right here involving the CRI cord
66:43
cartilage, and they're the little lips
66:44
that are turned medially.
66:45
So that's a little smiley face right here
66:48
that tells us we know we're at the
66:49
love of the true vocal cord.
66:54
Excellent. Uh, let's see.
66:56
We're gonna take a couple more questions
66:58
before we wrap today.
67:00
Uh, any key points on determining cord fillers verse
67:04
pathology when the order doesn't say,
67:07
or the MHR is equivocal?
67:10
Yeah. Um, yeah, so I didn't have time to get into
67:13
that just because there's so much to cover,
67:14
but, um, yeah, I can give you a little bit of a, um,
67:19
a little primer on that.
67:20
So, um, what ends up happening is that, um,
67:24
if you have a patient that has a, here,
67:28
if you have a patient that has a vocal cord palsy,
67:30
so remember when you have a vocal cord palsy,
67:33
this vocal cord is not gonna be moving,
67:35
it's gonna be paralyzed.
67:37
So this vocal cord is actually moving.
67:39
So this is going to abduct
67:41
and abduct, so it's gonna be normally moving,
67:43
but this one over here is kind of,
67:44
it's just gonna be floppy.
67:46
So what you end up doing is that what you wanna be able
67:51
to do is move this true vocal cord to the midline.
67:55
You wanna shift it over to the midline.
67:57
And the way you do that is that in the old days,
68:00
we would actually take silicon
68:02
and inject it at the true vocal cord,
68:04
and you would literally push the true vocal cord over
68:07
to the midline, and it would be static,
68:10
but you can still get good function
68:12
because the right vocal cord is moving.
68:14
So you get some of your voice back,
68:15
but it wouldn't be completely normal.
68:17
But you could get some, because you
68:19
literally push this over.
68:21
And now what's done most commonly is they use some type of,
68:25
um, not, not necessarily, it can be a prosthesis,
68:27
but it's called a YI procedure, uh, named
68:30
after a, a very famous German laryngologist,
68:33
which they put either put a piece of cartilage
68:36
or a firm piece of silicon.
68:38
And instead of just injecting silicon,
68:41
it actually looks like a triangle.
68:42
Because when you look at the true vocal cord, um,
68:45
as I mentioned before, I'll just go back to that one image
68:48
for the true vocal cord, um,
68:50
because it basically, this area kind
68:53
of looks like a triangle.
68:54
So they literally put something right here
68:56
and then that pushes the paralyzed cords and midline.
68:59
So what you can do is you look for a triangular area
69:03
of increased attenuation
69:05
that's located at the paralytic space,
69:07
and that's how, you know, you've had some type of, uh,
69:10
vocal cord, um, uh, laryngoplasty that's,
69:14
that's been done in order to medial that cord.
69:16
We call it a medial, uh, cord medialization procedure.
69:22
All right. And this will be our last question for today.
69:26
Um, where do we usually look for lymph nodes?
69:30
Oh, for the lymph nodes? For squamous cell carcinomas?
69:32
Yeah, that's a great question. So in general,
69:34
for the lymph nodes, for squamous cell carcinomas,
69:38
they typically are located at levels two, three, and four.
69:43
So if you have a tumor that's involving the right,
69:48
uh, side of the, um, epiglottis
69:52
or the area epiglottic
69:53
or the true vocal cord,
69:55
the lymph node groups most at risk are gonna be levels two,
69:59
three, and four on the ipsilateral side.
70:03
Now, if you have a tumor that involves the
70:07
area epi, uh, excuse me.
70:08
If you have a tumor that involves the epiglottis
70:12
and crosses the midline, then it's going
70:15
to bring the contralateral side at risk two.
70:18
So in general, it's two, three,
70:20
and four on the ipsilateral side.
70:23
But then on the opposite side, if the tumor crosses
70:26
to the opposite side, then two, three
70:27
and four become at risk.
70:29
In general, laryngeal carcinomas, um, do not, um,
70:34
tend to involve level one,
70:36
and they tend not to involve the
70:38
retropharyngeal lymph nodes.
70:42
All right. Excellent. Thank you so much, uh,
70:44
for taking the time to answer all the questions today, Dr.
70:47
McCury, and you're sharing your lecture with us.
70:51
It's my pleasure. Thanks again for having me.
70:53
And thanks to all of you
70:54
for participating in our noon conference
70:56
and asking great questions along the way.
70:58
You can access the recording of today's conference
71:01
and all our previous noon conferences
71:02
by creating a free account.
71:04
We'll also email out a link to the replay later today.
71:09
Be sure to join us on Thursday,
71:11
January 30th at 11:00 AM Eastern, where Dr.
71:15
Mohit Aggarwal will deliver a lecture entitled
71:17
Orbital Pathologies.
71:19
You can register for it@mrionline.com
71:22
and follow us on social media
71:24
for updates on future noon conferences.
71:25
Thanks again, and have a great day.
Suresh K Mukherji, MD, FACR, MBA
Clinical Professor, University of Illinois & Rutgers University. Faculty, Michigan State University. Director Head & Neck Radiology, ProScan Imaging
© 2026 Medality. All Rights Reserved.
