Noninvasive Detection of Arytenoid Cartilage Calcification Using Computed Tomography and Prediction of Prognosis in Laryngeal Contact Granuloma

OBJECTIVE

Laryngeal contact granuloma (LCG) is a relatively uncommon disease with chronic inflammatory stimulation, and long-term reflux irritation is a vital factor for arytenoid cartilage calcification. Our investigation compared the severity of ipsilateral arytenoid cartilage calcification with the frequency of recurrence of LCG after surgical treatment.

METHODS

A retrospective chart review of prospectively gathered data over five years from 327 patients, including 153 subjects without laryngeal lesions, were age- and sex-matched normal controls, 103 patients with various other vocal cord lesions were in the laryngeal lesion group and 71 LCG patients met the diagnostic criteria pathologically. All subjects underwent laryngeal high-resolution computed tomography (HRCT) prior to therapeutic interventions. The computed tomography (CT) value and arytenoid cartilage calcification were obtained using image data before surgery, and their clinical significance was further analyzed.

RESULTS

Seventy-one patients with LCG, including sixty-two males, were enrolled in the study. Among these cases, there were 67 patients with unilateral vocal cord lesions. Of the 103 eligible patients in the laryngeal lesion group, 87 had unilateral lesions, which including eighty-seven men. Of the 153 average subjects, 105 were male. The rate of arytenoid cartilage calcification in the LCG group was dramatically higher in the lesion side than in the laryngeal lesions and normal group (P < 0.01). Furthermore, the CT value (P < 0.01) and range of calcification (P < 0.01) were significantly higher in patients with LCG than in those with laryngeal lesions. Importantly, patients with high CT values and the calcification range of lesions in the arytenoid cartilage displayed a greater lesion size and recurrence rate than patients with low CT values and lesion areas (P < 0.01).

CONCLUSION

Our results suggest that most patients with LCG present with calcification of the arytenoid cartilage. The more severe the calcification in the arytenoid cartilage, the greater the risk of granuloma size and recurrence in LCG after surgical treatment. CT and bone density testing of the arytenoid cartilage may be an essential method to evaluate the prognosis of LCG.

Automated measurement of inter-arytenoid distance on 4D laryngeal CT: A validation study

Changes to the voice are prevalent and occur early in Parkinson's disease. Correlates of these voice changes on four-dimensional laryngeal computed-tomography imaging, such as the inter-arytenoid distance, are promising biomarkers of the disease's presence and severity. However, manual measurement of the inter-arytenoid distance is a laborious process, limiting its feasibility in large-scale research and clinical settings. Automated methods of measurement provide a solution. Here, we present a machine-learning module which determines the inter-arytenoid distance in an automated manner. We obtained automated inter-arytenoid distance readings on imaging from participants with Parkinson's disease as well as healthy controls, and then validated these against manually derived estimates. On a modified Bland-Altman analysis, we found a mean bias of 1.52 mm (95% limits of agreement -1.7 to 4.7 mm) between the automated and manual techniques, which improves to a mean bias of 0.52 mm (95% limits of agreement -1.9 to 2.9 mm) when variability due to differences in slice selection between the automated and manual methods are removed. Our results demonstrate that estimates of the inter-arytenoid distance with our automated machine-learning module are accurate, and represents a promising tool to be utilized in future work studying the laryngeal changes in Parkinson's disease.

Radiological correlates of vocal fold bowing as markers of Parkinson's disease progression: A cross-sectional study utilizing dynamic laryngeal CT

OBJECTIVE

To determine whether arytenoid cartilage position and dynamics change with advancing duration and severity (as graded by MDS-UPDRS part III scores) in Parkinson's disease, in a cross-sectional study design, we performed laryngeal four-dimensional computed tomography (4D-CT) in people with Parkinson's disease and controls.

METHODS

31 people with Parkinson's disease covering a range of disease duration and severity and 19 controls underwent laryngeal 4D-CT whilst repeatedly vocalizing. We measured on each CT volume the glottic area (GA), inter-arytenoid distance (IAD), IAD-Area index (IAI) and arytenoid cartilage velocity ([Formula: see text]).

RESULTS

People with Parkinson's disease had reductions in the mean/effective minimum IAD when compared to controls, while mean/effective minimum GA and mean/effective maximum IAI were increased. Arytenoid cartilage velocities showed no difference. On Spearman correlation analyses, advancing disease duration and severity of PD showed moderately strong and significant correlations with increasing mean/effective minimum GA, increasing mean/effective maximum IAI and decreasing effective minimum IAD. Linear mixed models which considered the effects of intra and inter-individual variation showed that both disease duration (b = -0.011, SEb = 0.053, 95% CI [-0.022, 0], t(27) = -2.10, p = 0.045) and severity (b = -0.069, SEb = 0.032, 95% CI [-0.14,-0.0039], t(27) = -2.17, p = 0.039) were significant predictors for IAD, and also for transformed values of the GA and IAI.

CONCLUSIONS

There are progressive alterations in phonatory posturing as Parkinson's disease advances. The increases in GA despite reductions in IAD are concordant with prior observations of vocal fold bowing. Our study provides a basis for using laryngeal 4D-CT to assess disease progression in Parkinson's disease.

[Cervical Abscess after Surgery for Subglottic Granuloma due to Suture Thread Used at Thyroplasty with Arytenoid Adduction]

A 83-year-old man underwent thyroplasty with arytenoid adduction for right recurrent laryngeal nerve palsy 1 year ago. He had been suffering from hemosputum and cough for last 2 months, and was referred to our hospital for medical examination. Laryngoscopy and neck computed tomography showed subglottic nodule. No evidence of malignancy was noted by a transbronchial biopsy of subglottic nodule. Since subglottic nodule grew rapidly during 2 months observation period, subglottic nodule resection was performed by bronchoscope. Histopathologic examination revealed that the tumor was suture granuloma with no evidence of malignancy. Cervical abscess as a complication of subglottic suture granuloma resection was occurred, because of suture material for arytenoid adduction and the injury of mucous membrane for removing the granuloma with the fenestration of thyroid cartilage for thyroplasty.

An Exploratory Study into the Implantation of Arytenoid Cartilage Scaffold in the Horse

Respiratory function in the horse can be severely compromised by arytenoid chondritis, or arytenoid chondropathy, a pathologic condition leading to deformity and dysfunction of the affected cartilage. Current treatment in cases unresponsive to medical management is removal of the cartilage, which can improve the airway obstruction, but predisposes the patient to other complications like tracheal penetration of oropharyngeal content and dynamic collapse of the now unsupported soft tissue lateral to the cartilage. A tissue engineering approach to reconstructing the arytenoid cartilage would represent a significant advantage in the management of arytenoid chondritis. In this study, we explored if decellularized matrix could potentially be incorporated into the high motion environment of the arytenoid cartilages of horses. Equine arytenoid cartilages were decellularized and a portion of the resultant acellular scaffolds was implanted in a full-thickness defect created in the arytenoids of eight horses. The implantation was performed bilaterally in each horse, with one side randomly selected to receive an implant seeded with autologous bone marrow-derived nucleated cells (BMNCs). Arytenoids structure and function were monitored up to 4 months. In vivo assessments included laryngeal ultrasound, and laryngeal endoscopy at rest and during exercise on a high-speed treadmill. Histologic evaluation of the arytenoids was performed postmortem. Implantation of the cartilaginous graft had no adverse effect on laryngeal respiratory function or swallowing, despite induction of a transient granuloma on the medial aspect of the arytenoids. Ultrasonographic monitoring detected a postoperative increase in the thickness and cross-sectional area of the arytenoid body that receded faster in the arytenoids not seeded with BMNCs. The explanted tissue showed epithelialization of the mucosal surface, integration of the implant into the native arytenoid, with minimal adverse cellular reaction. Remodeling of the scaffold material was evident by 2 months after implantation. Preseeding the scaffold with BMNCs increased the rate of scaffold degradation and incorporation. Replacement of arytenoid portion with a tissue-engineered cartilaginous graft preseeded with BMNCs is surgically feasible in the horse, is well tolerated, and results in appropriate integration within the native tissue, also preventing laryngeal tissue collapse during exercise.

Current management of arytenoid sub-luxation and dislocation

PURPOSE

To review the current management of arytenoid subluxation/dislocation (AS/AD) focusing on diagnostic, therapeutic, and prognostic controversies.

METHODS

The international literature of the last 20 years has been considered. After the application of inclusion criteria, 20 studies were selected (471 AS/AD cases in total).

RESULTS

All the included investigations were retrospective case series. AS/AD was often iatrogenic occurring at least in 0.01% of patients undergone endo-tracheal intubation. The most common symptom was persistent hoarseness. The diagnosis was made by video-laryngoscopy and neck computed tomography in most reports, while some used also laryngeal electromyography. Laryngeal electromyography was fundamental to rule out unilateral vocal fold paralysis, the main differential diagnosis. The surgical relocation of AS/AD under general or local anesthesia was achieved in about 80% of patients.

CONCLUSION

AS/AD is a mechanical disorder of the larynx that can be successfully treated if promptly diagnosed. Clinical trials and multi-centric studies are necessary to set management guidelines.

Three-dimensional imaging of vocalizing larynx by ultra-high-resolution computed tomography

PURPOSE

Ultra-high-resolution computed tomography (UHRCT) is an emerging imaging technology that is able to achieve simultaneous 160 slices with super-thin 0.25 mm thickness. The purpose of this study was to assess the feasibility of UHRCT to visualize laryngeal structure and kinetics.

METHODS

Three normal volunteers and three patients with unilateral vocal fold paralysis (UVFP) were incorporated in this case series. First, images were taken under five conditions in normal volunteers. Five tasks consisted of (1) air inspiration through the nose (IN), (2) breath holding (BH), (3) sustained vowel /i:/ phonation (IP), (4) humming phonation (HP), and (5) forced glottic closure during exhalation (FC). Three-dimensional CT images of arytenoid and cricoid cartilages, as well as virtual laryngoscopic images, were reconstructed using UHRCT data. Reconstructed images were compared among five conditions to assess the best tasks to picture laryngeal kinetics. Second, pre- and post-phonosurgical images were examined in UVFP patients to evaluate potential role of UHRCT to assess laryngeal pathology in hoarse patients.

RESULTS

Among the five conditions, IN and IP conditions were considered suitable to visualize laryngeal structure at rest and during phonation, respectively. Kinetic abnormalities including asymmetric motion of arytenoid cartilages were elucidated in UVFP patients, and virtual endoscopy visualized the clinically invisible posterior three-dimensional glottic chinks. Furthermore, UHRCT was useful to understand changes in laryngeal structure achieved by phonosurgery.

CONCLUSIONS

UHRCT is an emerging imaging technology that can be used for minimally invasive visualization and assessment of laryngeal structure and kinetics. Future studies to assess more number of patients with laryngeal dysfunction are warranted.

RETRACTED: The role of laryngeal ultrasound in diagnosis of infant laryngomalacia

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Authors and the Editor-in-Chief. After a thorough investigation, the Editor-in-Chief has concluded that details in the origin of data and permissions integral to the article’s acceptance in the journal necessitate a retraction. A single hospital was mentioned in the article but this was not where the data was collected. Reviewers would have assumed that informed consent was received and properly reviewed by this institution, as it was not otherwise specified. Several oversights within the article that were brought forward by the Authors make it clear that the article that was accepted had misrepresentation of key data. While the Authors presented some differences of opinion about how these concerns about the key data originated, it is clear that when the manuscript was accepted that Reviewers and Editors would not have had knowledge of these difficulties, and this may have created a different review process and outcome for this manuscript. One of the Authors has requested an ability to provide additional information to address the concerns. However, the Editor-in-Chief has decided that this would not follow the process for accepted manuscripts or address some of the concerns presented and, therefore, has settled on the retraction of the manuscript as the final decision regarding this paper.

Age-related changes affecting the cricoarytenoid joint seen on computed tomography

We conducted a retrospective chart review to compare four characteristics-cricoarytenoid joint ankylosis, narrowing, erosion, and density increases-in patients younger and older than 65 years. Our study population was made up of 100 patients, who were divided into two groups on the basis of age. The younger group (<65 yr) comprised 49 patients (27 men and 22 women), and the older group (≥65 yr) was made up of 51 patients (25 men and 26 women). Findings on computed tomography (CT) of the neck were used to determine whether each of the four characteristics was present or absent. Overall, we found only one statistically significant difference between the two groups: ankylosis was significantly more common in the older group (p = 0.036). When we looked further at the side of these anatomic changes, we found that the older group had significantly more right-sided and left-sided ankylosis than did the younger group (p = 0.026 for both), as well as significantly more left-sided narrowing (p = 0.028) (some patients had bilateral involvement). When we analyzed age as a continuous variable, older age was again associated with significantly more ankylosis (p = 0.047) and narrowing (p = 0.011). We conclude that CT can be useful for assessing radiologic changes in the cricoarytenoid joint in elderly patients during the workup of dysphonia and abnormal movement of the vocal folds.

A Novel Lateral Approach to the Assessment of Vocal Cord Movement by Ultrasonography

BACKGROUND

Ultrasonography is a non-invasive technique that is commonly used by endocrinologists and endocrine surgeons to examine the thyroid region and could be useful for the assessment of vocal cord movement by these specialists. However, previous studies reported a low rate of successful visualization of vocal cord movement by ultrasonography. To address this issue, we devised a novel ultrasonographic procedure for assessing vocal cord movement indirectly by observing the arytenoid movement from a lateral view.

METHODS

Subjects were 188 individuals, including 23 patients with vocal cord paralysis and 13 with vocal cord paresis. We performed ultrasonographic assessment of vocal cord movement using two different procedures: the conventional middle transverse procedure and the novel lateral vertical procedure.

RESULTS

The rate of visualization of vocal cords with the middle transverse procedure was 70.2% and that of the arytenoid cartilage with the lateral vertical procedure was 98.4%. The lateral vertical procedure enabled visualization of all patients with vocal cord paresis/paralysis and detected all 23 patients with vocal paralysis; only one of 13 patients with vocal cord paresis was positively identified. The conventional procedure enabled visualization of 21 of 36 patients with vocal cord paresis/paralysis with high accuracy. There was no false-positive case in either procedure.

CONCLUSION

The proposed lateral vertical procedure improved the rate of visualization of vocal cord movement by ultrasonography, suggesting that it is a useful technique to screen for vocal cord paralysis by ultrasonography.

Arytenoid cartilage movements are hypokinetic in Parkinson's disease: A quantitative dynamic computerised tomographic study

BACKGROUND

Voice change is one of the earliest features of Parkinson's disease. However, quantitative studies of vocal fold dynamics which are needed to provide insight into disease biology, aid diagnosis, or track progression, are few.

METHODS

We therefore quantified arytenoid cartilage movements and glottic area during repeated phonation in 15 patients with Parkinson's disease (symptom duration < 6 years) and 19 controls, with 320-slice computerised tomography (CT). We related these measures to perceptual voice evaluations and spirometry. We hypothesised that Parkinson's disease patients have a smaller inter-arytenoid distance, a preserved or larger glottic area because vocal cord bowing has previously been reported, less variability in loudness, more voice dysdiadochokinesis and breathiness and a shortened phonation time because of arytenoid hypokinesis relative to glottic area.

RESULTS

Inter-arytenoid distance in Parkinson's disease patients was moderately smaller (Mdn = 0.106, IQR = 0.091-0.116) than in controls (Mdn = 0.132, IQR = 0.116-0.166) (W = 212, P = 0.015, r = -0.42), normalised for anatomical and other inter-subject variance, analysed with two-tailed Wilcoxon's rank sum test. This finding was confirmed in a linear mixed model analysis-Parkinson's disease significantly predicted a reduction in the dependent variable, inter-arytenoid distance (b = -0.87, SEb = 0.39, 95% CI [-1.66, -0.08], t(31) = -2.24, P = 0.032). There was no difference in glottic area. On perceptual voice evaluation, patients had more breathiness and dysdiadochokinesis, a shorter maximum phonation time, and less variability in loudness than controls. There was no difference in spirometry after adjustment for smoking history.

CONCLUSIONS

As predicted, vocal fold adduction movements are reduced in Parkinson's disease on repeated phonation but glottic area is maintained. Some perceptual characteristics of Parkinsonian speech reflect these changes. We are the first to use 320-slice CT to study laryngeal motion. Our findings indicate how Parkinson's disease affects intrinsic laryngeal muscle position and excursion.

Cadaveric position of unilateral vocal cord: a case of cricoid fracture with ipsilateral arytenoid dislocation

We report a case of cricoid cartilage fracture with unilateral arytenoid dislocation following a motorcycle accident. This 25 year old male sustained blunt injury to the head, face and neck. He presented late to the hospital with one week history of dysphonia. Laryngoscopy revealed cadaveric position of the non-functioning left vocal cord. CT and MRI showed laterally displaced left vocal cord. Displaced fractures were noted in the cricoid at the junction of lamina with the anterior arch on the left side and at the right side of the anterior arch, along with dislocated left arytenoid resulting in ipsilateral vocal cord palsy. Medialization thyroplasty was performed to improve his phonation. Laryngeal trauma warrants close monitoring because of the risk of airway compromise. Radiologists play a crucial role in early diagnosis and should always have high index of suspicion. Recognition of laryngeal injury is important for initial resuscitation as well as for long term airway and vocal function.

Asymmetric mineralization of the arytenoid cartilages in patients without laryngeal cancer

BACKGROUND AND PURPOSE

Sclerosis of the arytenoid cartilage may be seen as an incidental finding in patients who do not have laryngeal cancer but may also be an early sign of neoplastic infiltration. Our purpose was to determine the frequency of asymmetric mineralization, in particular sclerosis, of the arytenoid cartilages on CT scans in adults who have no history of laryngeal cancer.

MATERIALS AND METHODS

Cervical CT scans of 972 consecutive patients seen in our emergency department were retrospectively evaluated. Three hundred twenty-two patients were excluded who were younger than 18 years of age or whose arytenoids could not be reliably seen due to artifacts. Six hundred fifty patients (424 men, 226 women) were assessed, and their arytenoid cartilages were graded as nonmineralized, calcified, sclerotic, or ossified on each side separately. The mean age of patients was 44.3 ± 17.8 years (range, 18-97 years).

RESULTS

The frequencies of asymmetric arytenoid cartilage sclerosis, calcification, and ossification were 4.9% (32/650), 4.4% (29/650), and 3.4% (23/650), respectively, with an overall asymmetric mineralization frequency of 12.9% (84/650). Asymmetric sclerosis was more common in women (16/226, 7.1%) than in men (16/424, 3.8%), but the difference was just at statistical significance (P = .05). The rate of unilateral arytenoid sclerosis was 4.6% in all subjects, 6.6% in women, and 3.5% in men. Unilateral sclerosis is much more frequently associated with the left arytenoid than the right.

CONCLUSIONS

Asymmetric mineralization of the arytenoid cartilages was seen in 12.9% of our study population. This should be taken into account when evaluating CT scans of patients with laryngeal cancer for arytenoid cartilage invasion to avoid false-positive reads.

Partial laser arytenoidectomy in the management of bilateral vocal fold immobility. A modification based on functional anatomical study of the cricoarytenoid joint

OBJECTIVES

To establish the anatomical relationships of the arytenoid and cricoid cartilages and apply these findings to design an arytenoidectomy based on a sound anatomical basis.

METHODS

We prospectively conducted this study between 1996 and 2002 at the Main University Hospital of Alexandria, Egypt. In 50 patients, we endoscopically measured the length of the vocal process and the distance between the vocal process tip and upper border of the cricoid cartilage. We sagittally and axially sectioned 25 total laryngectomy specimens to verify the position of the arytenoids and their relation to the cricoid. The anatomical findings led to the design of a laser partial arytenoidectomy and cordotomy (L-PAC), which we used in 45 patients with bilateral cord paralysis in adduction.

RESULTS

The anatomical findings showed that the cricoarytenoid joint did not contribute to the airway in any of the measured specimens. Using L-PAC, we decannulated 100% of the patients and no patient needed postoperative tracheostomy at any time. Only 3 patients experienced minimal postoperative aspiration to liquids (6.7%). We achieved reasonable phonation as assessed by a speech analysis battery. However, 3 patients (6.7%) needed contralateral L-PAC.

CONCLUSION

The present extra-articular technique, L-PAC, showed its superiority to previous endoscopic or transcervical complete arytenoidectomy techniques in providing an effective balance between the protective, respiratory, and to a lesser extent the phonatory functions.

[CT findings in isolated laryngeal trauma]

The purpose of this article is a retrospective analysis of cases with suspected laryngeal trauma. The clinical importance, possibilities and limits of computertomographic diagnostics in laryngeal trauma are discussed.

PATIENTS AND METHODS

Between 1992 and 2003 we performed high resolution computed tomography (CT) in 7 patients after an isolated laryngeal trauma with a standardized examination protocol.

RESULTS

Following CT findings we made: one fracture of the thyroid cartilage, two fractures of the cricoids cartilage, one luxation of the arytenoids cartilage and four extensive soft tissue swelling of the larynx. One of the patients showed no lesions on CT. In another patient we found an intensive increase of density of arytenoids cartilage as sign of an arytenoids necrosis.

CONCLUSION

High resolution spiral computed tomography is the method of choice to detect or exclude laryngeal fractures after an isolated neck trauma. Special parameters are necessary for detection of subtle pathological findings. In the estimation of mucosal or vocal cord changes the CT is inferior to endoscopy.

Neoplastic invasion of laryngeal cartilage: the significance of cartilage sclerosis on computed tomography images

Cartilage sclerosis has been cited as a sensitive and a specific sign of neoplastic cartilage invasion, on cross-sectional computed tomography (CT) images of the larynx. We retrospectively reviewed 36 consecutive patients, who underwent a total laryngectomy for squamous cell carcinoma of the larynx. Preoperative CT images were compared with formal histological sections of the larynx in order to assess cartilage invasion by tumour. Isolated asymmetrical cartilage sclerosis was found to have a sensitivity of 62% and a specificity of 42% for predicting neoplastic cartilage invasion when compared with histopathological sections of the tumour. In this study we found that cartilage sclerosis was not a useful early radiological sign of neoplastic cartilage invasion when taken in isolation.

Cricoarytenoiditis in Rheumatoid Arthritis: Radiologic and Clinical Study

The cricoarytenoid (CA) joint involvement in rheumatoid arthritis (RA) is not uncommon. In this study, clinical assessment, laryngeal endoscopy, and high-resolution computed tomography (HRCT) were used in 15 patients with RA to evaluate the diagnostic criteria of CA joint involvement. Symptoms owing to CA joint involvement were present in 66.6% of the patients. The frequency of involvement was 13.3% on laryngeal endoscopy but 80.0% with HRCT assessment. The most common HRCT findings were CA prominence (46.6%), density and volume changes (46.6%), and CA subluxation (39.9%). In some of the patients, soft tissue swelling (20%) near the CA joint and narrowing in the piriform sinus (33.3%) were also observed. Radiologic abnormalities related to CA joint involvement generally precede clinical symptomatology. Therefore, HRCT evaluation may be a useful method in the assessment of CA joint involvement in RA patients to exclude possible causes of laryngeal signs and symptoms.

Accommodation to changes in bolus viscosity in normal deglutition: a videofluoroscopic study

Videofluoroscopic swallow studies were performed on 60 normal adult volunteers. Swallowing variables were measured during swallows of a 3-cm3 paste bolus and a 3-mL liquid bolus and were compared to identify changes in swallow gesture displacement and timing, as well as changes in bolus movement timing. The study revealed that some differences measured by videofluoroscopy appear to be the result of the inherent bolus characteristics, while others likely represent changes in swallow gestures needed to accommodate variations in bolus viscosity. The overall timing of pharyngeal transit did not vary between bolus types. Oropharyngeal transit trended toward being faster for a liquid bolus with a concurrent early elevation of the aryepiglottic folds. The hyoid bone elevated at the same time, at the same rate, and to the same extent irrespective of bolus viscosity. During a liquid bolus swallow, the hyoid bone trended toward a more prolonged elevation, corresponding to prolonged pharyngoesophageal sphincter opening. The pharyngoesophageal sphincter, however, opened to a greater extent with a paste bolus.

[Three-dimensional reconstructions with volume-rendering method of the arytenoid and cricoid cartilages by means of multidetector row CT]

We created volume-rendering (VR) three-dimensional (3-D) images of the larynx using a multidetector row CT. The study included 17 examinations of 15 patients. After obtaining volume data of the larynx, VR 3-D images of airways and arytenoid and cricoid cartilages were reconstructed. The threshold of airways and calcification were set as -1025/-625 HU and 80/1560 HU, respectively. The base of the vocal processes of arytenoid cartilages and cricoarytenoid joints were demonstrated at rates of 70.6% and 53.4%, respectively. VR 3-D laryngeal images were more useful in assessing anatomy than the surface-rendering images previously reported.

The external frame function in the control of pitch, register, and singing mode: radiographic observations of a female singer

This study investigates pitch control, register, and singing mode related movements of the laryngo-pharyngeal structures by radiographic methods. One trained female singer served as the subject. The results show that singing voice production involves complex movements in the laryngeal structures. Pitch related increase in the thyro-arytenoid distance (vocal fold length) is nonlinear, slowing down as pitch rises. Similar observations have been made earlier. At the highest pitches, a shortening of the distance can be seen, suggesting the use of alternative pitch control mechanisms. The various observations made support the existence of three registers in this trained female singing voice. Open and covered modes of singing seemed to be distinguishable on the basis of different amounts of inner and outer forces acting on the larynx. Therefore, caution must be exercised when generalizing from the results.

Anatomic study for posterior medialization thyroplasty

To attain posterior medialization by thyroplasty type I, we simulated the surgery using 3 cadaveric larynges. Two approaches were applied to adduct the arytenoid cartilage: one involved compression of the vocal process, and the other, compression of the muscular process inward. The inner perichondrium was incised to reach the arytenoid cartilage from the framework. To compress the vocal process, a large silicone plug was required. In this method, there was some difficulty in compressing the vocal process precisely, and there was the risk of postoperative extrusion of the large plug. In contrast, the muscular process was more superficial relative to the framework, and it could be precisely compressed, resulting in sufficient posterior glottal closure. The silicone plug required for this procedure has a shallow depth that may provide the advantage of preventing postoperative extrusion. In conclusion, the compression of the muscular process is preferable for safely achieving posterior glottal closure.

Arytenoid cartilage sclerosis: normal variations and clinical significance

PURPOSE

Our purpose was to determine the variation in location, distribution, and sex predilection of arytenoid cartilage sclerosis in a population of patients without laryngeal cancer as an aid to understanding the significance of this entity when seen in patients with laryngeal cancer.

METHODS

One hundred CT examinations of patients of different ages and with no history of laryngeal cancer or radiation therapy were evaluated for the presence of arytenoid cartilage sclerosis. The arytenoid cartilage was subdivided into three regions: superior process, body, and vocal process. Each region was assessed on each side separately on bone window scans.

RESULTS

Arytenoid cartilage sclerosis was seen in 16% (n = 16) of the patients. Sclerosis was most common in the body (n = 12) and least common in the true vocal process (n = 2); the left side was the preferred location for all three regions. In 50% of the patients, at least two regions were affected. Eighty-one percent of sclerotic arytenoid cartilage was seen in women.

CONCLUSION

Knowledge of the frequency and distribution of arytenoid cartilage sclerosis as a normal variant can aid in determining the risk of arytenoid cartilage involvement in patients with laryngeal cancer.

[Spiral CT in arytenoid cartilage dislocation: the optimization of the study parameters with a cadaver phantom and its clinical evaluation]

PURPOSE

To evaluate an optimal scan protocol in a cadaver phantom and its clinical assessment in 40 patients.

MATERIALS AND METHODS

In a cadaver larynx phantom helical CT (HiSpeed Advantage; GE, Milwaukee, Wis) was performed with increasing collimation (1-10 mm) and pitch (1.0-3.0). 40 patients with an immobile vocal cord were randomly assigned to undergo CT with a certain protocol.

RESULTS

Best resolution was obtained with a collimation of 1 mm and pitch 1. The pitch could be increased up to 2 without losing information. With a collimation of 3 mm and higher, anatomical details were missed. In the patient studies a combination of 1 mm collimation with a pitch of 2.0 showed less motion artifacts than a pitch of 1.0.

CONCLUSION

The quality of CT imaging of the arytenoid cartilage depends greatly on the scanning parameters, the compliance of the patients and the mineralisation of the cartilage. For clinical assessment a collimation of 1 mm with a pitch of 2 is recommended. The increase pitch has the advantage of shorter acquisition times and decreased radiation exposure.

Changes in length and spatial orientation of the vocal fold with arytenoid adduction in cadaver larynges

Videoendoscopy suggests that arytenoid adduction (AA) surgery not only medializes the paralyzed vocal fold, but increases the length of its membranous portion so that it more closely resembles the normal side. This could represent either real length change or out-of-plane rotation. Computed tomography scanning was performed on adult male cadaver larynges before and after the AA procedure to measure changes in length and spatial orientation of the vocal fold. Three-dimensional coordinates of radiopaque markers on the anterior commissure, posterior glottic midline, and vocal processes were determined. The distance between the vocal processes was 3.9 mm before, and 0.8 mm after AA. The mean vocal fold length was 12.4 mm before, and 13.4 mm after AA (p = .14). The vocal process moved consistently caudally, an average of 3.5 mm (p = .02). The data suggest that clinically apparent vocal fold length changes with AA could be an illusion due to vertical displacement of the vocal process, and not actual lengthening.

Neoplastic invasion of the laryngeal cartilage: reassessment of criteria for diagnosis at CT

PURPOSE

To evaluate eight different diagnostic criteria to help detect neoplastic invasion of laryngeal cartilage at computed tomography (CT).

MATERIALS AND METHODS

In a prospective series, 111 patients with carcinoma of the larynx or hypopharynx underwent thin-section, contrast material-enhanced CT before total or partial laryngectomy. The following CT criteria were evaluated: extralaryngeal tumor, sclerosis, tumor adjacent to nonossified cartilage, serpiginous contour, erosion or lysis, obliteration of marrow space, cartilaginous blowout, and bowing. Histologic findings were correlated with findings on CT scans obtained at each level.

RESULTS

Histologically, 122 of 412 cartilages were invaded. Depending on the diagnostic criteria and each specific cartilage, there was great variation in sensitivity (7%-83%) and specificity (40%-100%). Sclerosis was the most sensitive criteria in all cartilages but often corresponded to reactive inflammation in the thyroid cartilage. Extralaryngeal tumor and erosion or lysis yielded the highest specificity. Tumor adjacent to nonossified cartilage, serpiginous contour, and obliteration of marrow space were specific although not sensitive signs of invasion in the arytenoid and cricoid cartilage and were nonspecific in the thyroid cartilage. Blowout and bowing were not useful. Selection of the appropriate combination of criteria enabled an overall sensitivity of 91% (associated specificity, 68%) or an overall specificity of 79% (associated sensitivity, 82%).

CONCLUSION

Detection of neoplastic cartilage invasion with CT greatly depended on the appropriate use of individual and combined CT criteria.

Cricoarytenoid arthritis as an early sign of juvenile chronic arthritis

A 14-month-old girl developed chronic stridor and dyspnoea. Four months later she presented arthritis, anterior uveitis and positive ANA. Juvenile chronic arthritis (JCA) was diagnosed. Laryngoscopy demonstrated the presence of cricoarytenoid arthritis (CA). The left vocal cord was adducted and immobile, while the right vocal cord had decreased mobility. Erythema and swelling of the arytenoid cartilage on both sides was seen. Steroid treatment resulted in the resolution of these symptoms and made airway control unnecessary. This case demonstrates that CA may be the first sign of JCA, preceding peripheral arthritis. CA should be considered in every child with chronic stridor and laryngeal obstruction.

Three-dimensional motion of the arytenoid adduction procedure in cadaver larynges

To determine whether variation in suture placement could improve the results of the arytenoid adduction procedure, a model was developed using fresh human cadaver larynges. Three-dimensional (3-D) motion of the arytenoid was determined by utilizing computed tomographic imaging with radiopaque markers on the apex and muscular and vocal processes. By utilizing principles previously applied to the study of rigid body mechanics for the carpal, knee, and tarsal joints, rotation and translation of the arytenoid about the axial, coronal, and sagittal axes were calculated. Subglottic airflow resistance was measured before and after the procedure. Posterior glottic closure was reproducibly achieved, as determined by computed tomographic imaging and airway resistance. Conflicting reports on cricoarytenoid joint mechanics can be attributed to reliance on trigonometric analysis of two-dimensional images, which results in errors in out-of-plane motion. This paper presents a useful model for obtaining detailed anatomic information describing arytenoid 3-D motion.

Vocal process granulomata

The case records and histology of 34 patients with vocal process granulomata were reviewed. The five patients presenting most recently with idiopathic vocal process granulomata were investigated by axial computerized tomography (CT). Increased density of the arytenoid cartilage on the side of the lesion was found in all five cases. It is suggested that this indicates cartilage ossification, secondary to perichondritis. This perichondritis, playing either a primary or a secondary role in granuloma development, may explain the annoying tendency of vocal fold granulomata to recur after excision.

Laryngeal carcinoma: sclerotic appearance of the cricoid and arytenoid cartilage--CT-pathologic correlation

PURPOSE

To assess the significance of sclerotic-appearing cricoid and arytenoid cartilage with computed tomography (CT) in patients with laryngeal carcinoma.

MATERIALS AND METHODS

CT scans obtained in 75 patients with laryngeal carcinoma were prospectively studied; laryngeal CT studies obtained in 50 patients without laryngeal carcinoma were retrospectively reviewed.

RESULTS

Twenty-four of the 75 patients (32%) with laryngeal carcinoma had sclerotic cartilage. Evaluation of pathologic specimens obtained in 12 of these 24 patients showed 11 cases of sclerotic arytenoid cartilage and two cases of sclerotic cricoid cartilage. Tumor infiltration was demonstrated in six of these cases but not in the seven others. In 11 of the 12 cases with pathologic proof, however, tumor was adjacent to the perichondrium. In the 12 cases without pathologic proof, the proportion was similar. The positive predictive value of this sign for cartilaginous invasion was 46%.

CONCLUSION

Although it is not a reliable sign of cartilaginous invasion, sclerotic-appearing cricoid and arytenoid cartilage in patients with laryngeal carcinoma is predictive of the tumor to this cartilage.

Vocal granuloma, including sclerosis of the arytenoid cartilage: radiographic findings

Vocal granulomas are uncommon benign tumors that may not respond readily to medical treatment or surgical removal. Gastroesophageal reflux is said to be a causative factor. Osteosclerosis of the arytenoid cartilage was found on computed tomographic scan in a series of 21 consecutive patients. The relationship of vocal granuloma to so-called contact ulcer (better called contact pachydermia) is discussed. Imaging of the granuloma and the arytenoid has little, if any, place in management, but should be recognized in the differential diagnosis of a vocal cord mass if the mass lies immediately adjacent to a sclerotic arytenoid.

Early marked arytenoid calcification in a case of suspected foreign body

A case of early marked calcification of the arytenoid cartilages is presented in a patient with a suspected pharyngeal foreign body. The calcification on X-ray had the appearance of the expected foreign body. Calcification of the arytenoid cartilages is discussed.

Xeroradiographic evaluation of the equine larynx

The normal radiographic anatomy of the equine larynx was determine by use of xeroradiography and dissection. The body and laminae of the thyroid cartilage, the muscular process of the arytenoid cartilages, and the dorsal lamina and arch of the cricoid cartilage had radiographic evidence of mineralization (calcification) and/or ossification in clinically normal horses. There was a significant (P less than 0.01) increase in the degree of mineralization of the thyroid and arytenoid cartilages with advancing age. Horses with diagnosis of arytenoid chondrosis (arytenoid chondral dysplasia, arytenoid chondropathy) by use of endoscopy had radiographic changes that included: enlargement with increased density of the arytenoid cartilage region, abnormal patterns of mineralization (dystrophic mineralization or osseous metaplasia), abnormal contour of the corniculate process(es) and laryngeal masses, sometimes obliterating part or all of the lateral laryngeal ventricles.

Acute upper airway obstruction in rheumatoid arthritis of the cricoarytenoid joints

We have reported two cases of acute, life-threatening upper airway obstruction due to previously unrecognized rheumatoid arthritis of the cricoarytenoid joints with severe acute and chronic deformities of the larynx. Attempted endotracheal intubation with the rigid laryngoscope failed in each case, resulting in the need for emergency tracheostomy. We recommend the use of the fiberoptic bronchoscope for elective or emergency endotracheal intubations in patients with severe rheumatoid arthritis involving the cervical spine and the larynx.

Cricoarytenoid subluxation, computed tomography, and electromyography findings

A case of cricoarytenoid subluxation secondary to endotracheal intubation and documented by computed tomography (CT) and electromyography (EMG) is reported. Successful endoscopic reduction of the displaced arytenoid is confirmed by CT. The normal anatomy and physiology of the cricoarytenoid joint is presented and the literature regarding this rarely reported injury is reviewed. Based on this review and the case reported, a treatment plan is proposed.

[Imaging diagnosis of head and neck cancer--diagnosis of laryngeal cancer, hypopharyngeal cancer and cancer of the cervical esophagus by CT x-ray]

Fifty-six patients with laryngeal cancer were examined. The rate of correct diagnosis of clinical staging was 64.3%. Whereas the rate of correct diagnosis of staging by CT was markedly improved, 89.3%. In particular, CT facilitated correct diagnosis of T4. Supraglottic T3 cancer is diagnosed on the basis of deep infiltration or fixation of the hemi-larynx. Disappearance of the pre-epiglottic space or ulcer formation was recognized as a CT finding of deep infiltration. Disappearance of the paraglottic space and dislocation of the arytenoid cartilage were used as the standard for CT findings of laryngeal T3 cancer. CT allowed diagnosis to be made in 84.4% of cases which were pathologically determined to be T4. It can be said that CT is a very effective method for staging diagnosis in patients with laryngeal cancer. Fifty-seven patients with hypopharyngeal cancer and cancer of the cervical esophagus were also examined. When 40 post-surgical patients were compared according to pathological classification of T, the rate of correct diagnosis of clinical staging was 77.5% while that of staging diagnosis by CT was 82.5%. The rate of correct diagnosis by postoperative CT was 80.0% compared with the pathological determination of depth of invasion. The diagnosis of depth of invasion by CT on initial examination is thus an effective means for the determination of prognosis.

Cricoarytenoiditis: CT assessment in rheumatoid arthritis

The cricoarytenoid (CA) joint is a true diarthrodial joint that can be affected by rheumatoid disease. Its strategic location in the airway anatomy makes its evaluation of clinical importance. Direct fiberoptic laryngoscopy (DFL) and high-resolution computerized tomography (HRCT) were used to assess the larynx in 32 rheumatoid patients. Abnormalities were seen in 75% of patients at endoscopic examination. HRCT studies showed abnormalities in 72%. Erosion-luxation of the CA joint and surrounding soft-tissue swelling can be demonstrated on HRCT scans. A radiologic grading of the rheumatoid larynx is proposed, stressing that accurate evaluation of the larynx should be part of the diagnostic evaluation of every rheumatoid arthritic patient, given the high frequency of occurrence of rheumatoid laryngitis.

Cricoarytenoiditis in rheumatoid arthritis: comparison of fibrolaryngoscopic and high resolution computerized tomographic findings

Cricoarytenoid involvement in rheumatoid arthritis has been assessed in 32 patients by combining clinical evaluation, direct fiberoptic laryngoscopy (DFL), and high resolution computerized tomography (CT). Symptoms were inconstant, variable, and rarely prominent. Absence of symptoms does not exclude an involvement. One case presented as an acute respiratory distress. The study showed an unexpected frequency of involvement with 75% of abnormal DFL and 72% of abnormal CT. Semiology of laryngoscopy and CT are described.

Rheumatoid arthritis of the cricoarytenoid joints: a case of laryngeal obstruction due to acute and chronic joint changes

A 63-year-old female with severe rheumatoid arthritis and respiratory obstruction with stridor due to cricoarytenoid (c.a.) arthritis is described. Low voltage radiography of the neck revealed erosive changes in the c.a. joints. At laryngoscopy the arytenoids were fixed in adduction, and there were signs of active arthritis. Corticosteroid therapy was instituted with remarkable effect on the obstruction. After the active arthritis had subsided, there remained limited arytenoid mobility with a glottic chink of about 5 mm, but no laryngeal symptoms.

Arytenoid dislocation and computed tomography

The insertion of endotracheal tubes is surprisingly free of laryngeal complications. Although the exact incidence of endotracheal tube-induced laryngeal trauma is unknown, recent reports of arytenoid dislocations have led to an increased awareness of the possibility for this type of laryngeal injury. Since indirect examination of the larynx in a postoperative patient is not always an easy procedure, the use of a computed tomographic (CT) scan may provide help in making the diagnosis of arytenoid dislocation and in confirming the return of the arytenoid to its usual position following endoscopic manipulation. A 27-year-old man had a weak voice following an atraumatic intubation. A scan done on a body scanner without contrast revealed a right arytenoid dislocation. Following laryngoscopic manipulation, an improved position of the arytenoid was confirmed by a subsequent CT scan done in the same manner. The use of this noninvasive technique may be an additional aid in the diagnosis of laryngeal disorders following intubation.

Rheumatoid arthritis of the crico-arytenoid and crico-thyroid joints: a radiological and clinical study

Low-voltage neck radiography and indirect laryngoscopy was performed in 22 randomly selected rheumatoid patients with the purpose of detecting intralaryngeal arthritis. Radiographic evidence of erosive arthritis of the crico-arytenoid (CA) joints was found in 45% of the patients. Clinical acute CA arthritis without erosive changes was present in two patients, the overall incidence of CA arthritis being 55%. The incidence was higher in females (65%) than in males (20%). The CA arthritis was asymptomatic in 58% of the patients. Radiography revealed osseous destruction at the crico-thyroid joint in four females.

CT of the normal larynx

The ability of CT to depict cross-sectional anatomy allows the radiologist and the laryngologist to build a clear three-dimensional image of the site and extent of laryngeal diseases. This paper reviews normal CT anatomy of the larynx.

Ossification and calcification of the laryngeal skeleton

Low voltage radiography of the neck was performed in 64 patients (48 males, 16 females) aged over 34 years. The degree and frequency of ossification of the thyroid and cricoid cartilage were lower in the females than in the males, especially in the anterior parts of the cartilages. The arytenoids were ossified or calcified in all females and in 94 per cent of the males. Dense homogeneous appearance of the arytenoids was present in 74 per cent of the females and 19 per cent of the males, probably due to a marked calcification of the cartilages.

Computed tomography vs. histology of laryngeal cancer: their value in predicting laryngeal cartilage invasion

Twenty-seven cancerous larynges were examined preoperatively by computed tomography and postoperatively by transaxial anatomic sections. Data from this correlative study provides a new radiographic classification based upon the relationship of the plane of maximal tumor size to the apex, body, or vocal process of the arytenoid. Unlike those tumors whose maximal size lies at or above the apex of the arytenoid, those below have a very high association with cartilage invasion (8% in former group, 86% in latter group). This is explained by our observation of sites of predilection of tumor invasion of the thyroid, cricoid, and arytenoid cartilages. At these sites collagen fibers have been observed to pass through the perichondrium and attach directly to cartilage. These same fibers may serve as a pathway to direct growth of tumor cells. There was no correlation between six histologic parameters and the presence of cartilage invasion.

Visualisation of the intralaryngeal joints: a low voltage radiological study

Low-voltage radiography of the neck was adjusted for visualisation of the crico-arytenoid joints. Sixty-four patients (48 males, 16 females) with laryngeal tumours were examined. The degree of ossification in the laryngeal cartilage around the crico-arytenoid joints was different in the males and the females. All males had ossification in the plate of the cricoid, and 94% in the arytenoids. The articular facets on the cricoid were visible in 94%, and on the arytenoid in 85%. All females had ossification in the arytenoids, and 94% in the plate of the cricoid. The articular facets on the arytenoids were visible in all females, and on the cricoid in 88%. One or both articular facets in the crico-arytenoid joints were visible in all patients, making the method useful in detecting erosive arthritis in the joints.

Computed tomography vs laryngography: a comparison of relative diagnostic value

The computed tomography (CT) scans and laryngograms of 25 patients with laryngeal cancer were compared and evaluated in an assessment of the diagnostic accuracy of each modality in the supraglottic, glottic, and subglottic regions. Fourth generation scanners were used in these patients, all of whom subsequently underwent laryngectomy or partial laryngectomy. The clinical superiority of CT scanning was evident in several areas--confirming clinical impressions that laryngography is not as accurate as CT, is frequently misleading, and offers no significant advantages over CT. In this regard, we now believe that computed tomography is the most important radiologic adjunct in the diagnosis of laryngeal cancer, and we no longer order the laryngogram on a routine basis.

CT in carcinoma of the larynx and pyriform sinus: value of phonation scans

The structural and functional information obtained from CT performed during quiet breathing and phonation of the letter E was investigated in 25 patients with carcinoma of the larynx or pyriform sinus. Significant additional information was obtained from the phonation scans in all patients. In 16 patients, vocal cord dysfunction was found on the phonation scans. In 14 patients, phonation CT demonstrated an abnormal aryepiglottic fold better than CT during quiet breathing. A pyriform sinus was distorted or displaced in 11 patients and CT during phonation was more accurate than laryngoscopy or CT during quiet breathing in detecting abnormalities deep to this region. CT scans were the most accurate method of detecting tumor extension into the subglottic space, and into the preepiglottic space; each extension was seen in seven patients. Thyroid cartilage destruction was detected only by CT in six patients. CT scans during phonation should be an integral part of laryngeal CT and in conjunction with laryngoscopy could possibly replace laryngography for the evaluation of patients with laryngeal carcinoma.

Evaluation of laryngeal cartilages by computed tomography

Computed tomography of the larynx was performed in 21 patients and 3 anatomic specimens for evaluation of laryngeal cancer. Special attention was directed to the appearance of the laryngeal cartilages in both the normal and abnormal examinations in order to establish criteria for cancerous invasion. The problem presented by the normal nonuniformity of density of the cartilages is discussed in detail.