Post Laryngectomy



Post Laryngectomy


Christine M. Glastonbury, MBBS





Key Facts


Terminology



  • Imaging findings following resection of whole larynx or part of larynx


  • Most often performed for neoplasm


  • Total laryngectomy (TL): Larynx completely resected, and neopharynx created



    • Neopharynx connects oropharynx to esophagus


    • Trachea no longer communicates with pharynx


    • Need tracheostomy to breathe, prosthesis to speak


  • Partial laryngectomy (PL): Conservative surgery



    • Aim is to preserve voice and breathing


    • Also to allow swallowing without aspiration


    • Cordectomy → vertical or horizontal partial laryngectomy → near total laryngectomy


    • Imaging varies from near-normal to complex reconstruction and deformity


    • Permanent tracheostomy required only with near total laryngectomy


Top Differential Diagnoses



  • Larynx trauma


  • Radiated larynx


Clinical Issues



  • • Declining use of partial and total laryngectomy with ↑ use of organ preservation chemoradiation


  • Declining use of open surgery in favor of endoscopic transoral laser surgery (TLS)


  • Laryngectomy also used for cartilaginous laryngeal tumors, invasive thyroid tumors, salvage after failed chemoradiation, chondronecrosis, nonfunctioning larynx post-treatment


Diagnostic Checklist



  • Imaging confusion occurs most often with complex appearance of partial laryngectomy


  • First determine type of procedure


  • Look for recurrent mass and lymphadenopathy






(Left) Axial CECT in patient with T4N0M0 carcinoma of the larynx with subglottic extension image and anterior extension to prelaryngeal tissues image. (Right) Sagittal graphic depicts expected appearance after total laryngectomy with all laryngeal cartilages and hyoid resected. Neopharynx image connects oral cavity to esophagus image, while trachea image is brought to skin surface as tracheostomy. Tracheoesophageal (TE) voice prosthesis image is a one-way valve that allows speech when patient manually occludes stoma.






(Left) Axial CECT in same patient following total laryngectomy, right modified neck dissection, & gastric pull-up demonstrates neopharynx as a multilayered midline tubular structure image. Both sternocleidomastoid muscles image and jugular veins image are preserved. (Right) Axial CECT shows new contour of thyroid lobes image after midline splitting of capsule. If 1 lobe is resected, remaining lobe may be mistaken for node, recurrent mass, or even pseudoaneurysm. Distal anastomosis image often has slightly irregular contour.



TERMINOLOGY


Definitions



  • Imaging findings following resection of whole or part of larynx, typically for neoplasm



    • Total laryngectomy (TL): Larynx resected, neopharynx created, permanent tracheal stoma


    • Partial laryngectomy (PL): Preserves voice & breathing without permanent tracheostomy



      • Cordectomy, vertical partial laryngectomy (VPL), horizontal supraglottic laryngectomy (SGL), supracricoid laryngectomy (SCL) with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP)



        • “Pexy” indicates surgical fixation of a structure


      • Now more often performed as endoscopic transoral laser surgery (TLS) rather than open surgery


IMAGING


General Features



  • Best diagnostic clue



    • Abnormal contour of pharyngeal airway (vestibule), absence of soft tissue ± part or whole of one or more cartilages


CT Findings



  • CECT



    • Deformed vestibule may be subtle


    • Soft tissue structures &/or cartilages absent


    • Arytenoid soft tissue thickening common with PL


    • Pseudocord scar tissue usually seen with VPL, often with SCL & SGL


    • Not uncommon to see patchy sclerosis or partial resection of cartilages



      • Not often helpful or indicative of recurrence


    • Open resection frequently accompanied by nodal dissection


Imaging Recommendations



  • Best imaging tool



    • CECT allows more consistently good quality larynx imaging



      • MR fraught with motion artifacts


    • PET: Additive value when recurrence found



      • Determine systemic disease prior to salvage TL


DIFFERENTIAL DIAGNOSIS


Larynx Trauma



  • Deformity of cartilages following open or closed injury


  • Cartilage should not be absent


Radiated Larynx



  • Mucosal and deep fat space edema


  • Cartilages present unless chondronecrosis


PATHOLOGY


Staging, Grading, & Classification



  • Surgeries defined as radical (total laryngectomy) or conservative (cordectomy or partial laryngectomy)


  • Use of chemoradiation and TLS resulted in marked decline of TL and open PL


  • Multiple different forms of partial laryngectomy



    • Defined by plane of resection and form of reconstruction


  • Cordectomy



    • Use: Tumor isolated to 1 true vocal cord (TVC) without fixation


    • Resected: TVC, vocalis muscle, and tendon



      • Typically performed endoscopically (TLS)


      • Six different types of TLS cordectomy described


    • Imaging: Very subtle; may appear normal


  • Vertical partial laryngectomy



    • Use: Early stage glottic to anterior commissure (AC) ± arytenoid, without cord fixation


    • Frontolateral laryngectomy



      • Use: Tumors to AC without TVC fixation


      • Resected: Vertical midline segment of thyroid cartilage, TVC (± arytenoid) with ventricle and false cord, AC & small part of contralateral anterior cord


      • Reconstruction: Contralateral cord mucosa sutured to perichondrium; ipsilateral side may be left to granulate


      • Imaging: Defect in midline thyroid cartilage, missing AE fold ± ipsilateral arytenoid, dense scar at site of resected cords = pseudocord


    • Hemilaryngectomy



      • Use: When more posterior extension of tumor to arytenoid cartilage


      • Resected: As with frontolateral plus ipsilateral arytenoid, mucosa of AE fold, and thyroid lamina


      • Reconstruction: Grafts, flap, muscle may be used


  • Horizontal laryngectomy

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Sep 20, 2016 | Posted by in HEAD & NECK IMAGING | Comments Off on Post Laryngectomy

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