European Journal of Radiology 44 (2002) 108– 119

www.elsevier.com/locate/ejrad

Imaging of the post-treatment larynx

Suresh K. Mukherji a,b,*, William J. Weadock a
a
Department of Radiology, Uni6ersity of Michigan Health System, UH B2B311, 1500 E. Medical Center Dri6e, Ann Arbor,
MI 48109 -0030, USA
b
Department of Otolaryngology Head Neck Surgery, Uni6ersity of Michigan Health System, Ann Arbor, MI 48109 -0030, USA

Received 20 February 2002; received in revised form 22 February 2002; accepted 25 February 2002

Abstract

The treatment for squamous cell carcinoma of the upper aerodigestive tract includes surgery, radiation therapy (RT),
chemotherapy or a combination of various modalities. Familiarization with the expected imaging changes following therapy allow
accurate evaluation of imaging studies and may prevent misinterpretation of post-treatment changes as recurrent disease. The
intent of this manuscript will be to review the post-treatment appearance of the larynx following RT and various types of
laryngectomy. © 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Computed tomography; larynx; Larynx; carcinoma; post-treatment changes

1. Introduction procedures. Because of this advantage and creation of

centers capable of modern treatment planning and de-
The current treatment for squamous cell carcinoma livery, a growing number of patients are treated with
of the upper aerodigestive tract includes surgery, radia- RT alone for certain groups of laryngeal carcinomas.
tion therapy (RT), chemotherapy or a combination of The effects of RT occur within all areas of the larynx,
various modalities. The exact treatment depends, in hypopharynx and superficial soft tissues of the neck
part, on the location and extent of the tumor and that are included within the radiation port. The histo-
institutional preference. Both radiotherapy and surgery logical changes that occur as a result of radiation result
alter the underlying normal anatomic structures thereby mainly from edema and fibrosis. These changes result in
making interpretation of post-treatment imaging chal- a characteristic radiographic appearance that is dis-
lenging. The effects of chemotherapy alone are cur- tinctly different from pre-treatment appearance [1,2].
rently being investigated. Familiarization with the Histologically, RT results in an acute inflammatory
expected imaging changes following therapy allow ac-
reaction within the deep connective tissues character-
curate evaluation of imaging studies and may prevent
ized by leukocytic infiltration, histiocyte formation, ne-
misinterpretation of post-treatment changes as recur-
crosis, and hemorrhage. Microscopic examination of
rent disease. The intent of this manuscript will be to
the small arteries, veins and lymphatics demonstrate
review the post-treatment appearance of the larynx
detachment of the lining endothelial cells causing in-
following RT and various types of laryngectomy.
creased permeability resulting in interstitial edema [3–
5]. Within 1–4 months there is deposition of rich
2. Radiation therapy collagenous fibers with sclerosis and hyalinosis of con-
nective tissues. This inflammatory process eventually
Treatment with RT provides the patient to retain a results in obstruction in the small arteries, veins and
functional larynx without the need for reconstructive lymphatics. By 8 months, there is advanced sclerosis,
hyalinosis, and fragmentation of the collagen fibers
* Corresponding author. Tel.: +1-734-936-8865; fax: + 1-734-764-
within connective tissues. Eventually, there may be a
2412. reduction in interstitial fluid resulting from the forma-
E-mail address: [email protected] (S.K. Mukherji). tion of collateral neocapillary and lymphatic channels.

0720-048X/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. Allrights reserved.
PII: S 0 7 2 0 - 0 4 8 X ( 0 2 ) 0 0 0 6 8 - 2
 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119 109

The extent of the observed changes is dependent on the RT results in radiologic changes that involve both
area covered in the radiation port and the total dose. the exolaryngeal and endolaryngeal regions. Within 4
More advanced and persistent changes may be seen months after the completion of RT, reactive changes
with patients who continue to smoke after RT or can be visualized within the skin and subcutaneous
receive neoadjuvant or concurrent chemotherapy. tissues. These changes include thickening of the skin

Fig. 1. Post-RT: expected appearance. Pre- (a) and post-RT (b) CT of the larynx demonstrates the expected changes that can be expected
following RT. The is diffuse thickening of the epiglottis (white arrow), obliteration of the paraglottic fat (small black arrows), and thickening and
enhancement of the pharyngeal mucosa (large black arrows).

Fig. 2. Post-RT: expected appearance. Pre- (a) and post-RT (b) CT of the larynx demonstrates the expected changes that can be expected
following RT. There is diffuse thickening of the epiglottis (arrowhead) and aryepiglottic folds (small black arrows). There is thickening of the
platysma and reticulation of the subcutaneous and deep fat (white arrows). The submandibular glans demonstrate a radiation induced sialadenitis
(s).
110 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119

Fig. 3. Post-RT: resolution of the primary site indicative of local control. Pre- (a) and post-RT (b) CT of the larynx demonstrates the expected
appearance of the primary site that can be expected with supraglottic tumor that are locally controlled. The epiglottic tumor present on the
pre-treatment study (a, —arrowhead) is completely resolved followed completion of RT (b, arrowhead).

Fig. 4. Post-RT: persistent tumor at the primary site indicative of recurrence. Pre- (a) and post-RT (b) CT of the larynx demonstrates the expected
appearance of the primary site that can be expected with supraglottic tumor that recur. The large epiglottic tumor present on the post-treatment
study (b) is unchanged in size compared to the pre-treatment study (a).

and platysma muscle, as well as reticulation of the These changes occur in over half of the treated patients
subcutaneous and deep investing fat [1,2]. Resolution of (Figs. 1 and 2).
these changes occurs in about 50% of treated patients. Irradiation initially results in acute sialadenitis of the
Pharyngeal changes include increased enhancement of submandibular glands within 12 h after delivery of
the pharyngeal mucosa, thickening of the posterior treatment [1–5]. The acute effects are transient and
pharyngeal wall retropharyngeal space edema [1,2]. usually resolve within 1– 2 days. Increased size and
 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119 111

enhancement of the gland may be seen if imaging is an ominous sign in patients treated with definitive
performed within 1 week following the completion of radiotherapy for SCCA of the upper aerodigestive
RT. Because imaging is usually performed at least 2 tract.
months after completion of therapy, the radiographic In the larynx, radiotherapy results in thickening of
changes most commonly observed are those of chronic the suprahyoid and infrahyoid epiglottis and is typically
sialadenitis, these changes include increased enhance- seen on computer tomography (CT) within 3 months
ment and atrophy of the submandibular glands. after completion of RT. Almost all patients will have
Lymph node atrophy occurs in the vast majority of thickening and infiltration of the fat within the
pre-treatment CT-negative nodes [1,2]. Treated nodes aryepiglottic folds as well as thickening of the false
involute to about 25% of their original pre-treatment vocal cords and increased attenuation of the paralaryn-
size. Consequently, enlarging lymph nodes after RT is geal fat. These changes are initially seen within 2.5

Fig. 5. Axial contrast-enhanced CT performed following laryngectomy shows the typical normal appearance following total laryngectomy. (a)
Note the smooth round appearance of the esophagus (arrow). The esophagus is ‘released’ following removal of the larynx, which normally
compresses the larynx at this level. (b) Axial contrast-enhanced CT performed following laryngectomy shows the appearance or recurrent disease
within the esophagus following total laryngectomy (arrows).

Fig. 6. Supraglottic laryngectomy: schematic illustration of the surgical resection.

112 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119

Fig. 7. Axial contrast CT obtained through the thyroid cartilage demonstrates a supraglottic carcinoma (a) without involvement of the true vocal
cords (b). Based on imaging, this patient is a candidate for supraglottic laryngectomy.

Fig. 8. Supraglottic laryngectomy: expected appearance: (Courtesy of Roberto Maroldi, MD). There is ‘collapse’ of the thyroid cartilage (small
arrow) that overlaps the cricoid cartilage (large arrow) (a). At the level of the true vocal cords, note the preservation of the cricoarytenoid joints
bilaterally (arrows) (b).

months after conclusion of treatment and are usually occur following RT. These changes may be used to
irreversible (Figs. 1 and 2) [1,2]. predict outcome in patients treated with RT. Progres-
Early changes at the glottic level include increased sive sclerosis of laryngeal cartilages is associated with
attenuation of the paraglottic fat planes, this typically an increased likelihood of local tumor recurrence
identified within 2 months following RT. Symmetric whereas resolution of pre-treatment cartilage sclerosis is
subglottic thickening occurs in about 80% of patients. indicative of successful control [1,2].
Late changes at the glottic level include thickening of
the anterior and posterior commissure. These changes 2.1. Primary site
occur within 7 and 14 months, respectively, and are
persistent [1,2]. Imaging plays an important role in helping to iden-
Radiation in the degree of cartilage sclerosis may tify patients who are successfully treated with RT from
 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119 113

Fig. 9. Supraglottic laryngectomy: recurrence. Axial CT following supraglottic laryngectomy demonstrates a marginal recurrence along the along
both the superior (a) and inferior surgical margins (arrows) (b).

Fig. 10. Vertical hemi-laryngectomy: schematic illustration of the surgical resection.

those who fail. Previous studies have suggested that

imaging is most accurate when performed both prior to
treatment and approximately 3– 4 months following the
completion of definitive RT (Fig. 3) [1,2]. Complete
resolution of the lesion on the post-treatment study
strongly suggests a successfully controlled primary site.
Patients with a persistent mass at the primary site that
is unchanged in imaging appearance is indicative of
treatment failure (Fig. 4). Partial resolution of a mass
on the post-treatment CT study is an indeterminate
finding [1,2]. These patients require further imaging and
close clinical observation. Interval enlargement of a
focal mass is suggestive of recurrent disease or laryn-
geal necrosis. However, stability of the mass over a Fig. 11. Vertical hemilaryngectomy: expected appearance. Axial CT
2-year period is suggestive of fibrosis and scarring. demonstrates the surgical defect of the thyroid cartilage (arrow)
Regardless of these potential benefits, differentiation without evidence of a focal aggressive soft tissue mass.
114 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119

Fig. 12. Vertical hemilaryngectomy: recurrence. Axial CT demonstrates a marginal recurrence extending into the surgical defect of the thyroid
cartilage (arrow) (a) and extending inferior into the subglottic larynx (arrow) (b).

Fig. 13. Supracricoid with cricohyoidopexy: expected appearance. Schematic illustration of the surgical resection.

between recurrent tumor and laryngeal necrosis is of- of metabolic imaging agents such as F-18 fluoro-2-de-
ten not possible by CT or MR alone. Imaging modal- oxy-D-glucose and Thallium-201 for differentiating re-
ities aimed at measuring metabolic activity may prove current disease from radiation changes is currently
beneficial for aiding in this differentiation. The value under investigation [6–8].
 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119 115

3. Surgery procedure entails complete resection of all endolaryn-

geal structures including the epiglottis, aryepiglottic
3.1. Introduction folds, true and false vocal cords, and subglottis. There
is removal of the entire thyroid and cricoid cartilages
Historically, the treatment of choice for laryngeal and the hyoid bone. There is a typical appearance
cancers has been surgical resection. The exact type of following total laryngectomy that should be familiar to
procedure depends on the location and extent of the radiologists interpreting post-treatment studies. Follow-
primary lesion, presence and extent of nodal metas- ing total laryngectomy, the esophagus has a characteris-
tases, and the preference of the otolaryngologist. This tic look [12]. The larynx consists of a rigid cartilaginous
section will review the most common surgical proce- framework. Following removal of the entire larynx,
dures for treatment of laryngeal carcinoma and their there is no firm structure anterior to the esophagus
expected post-treatment on cross-sectional imaging. compressing it posteriorly against the vertebral bodies.
As a result, the esophagus is essentially ‘released’ and
3.2. Total laryngectomy has a more anterior location (Fig. 5a). It also coverts
from a flattened oval appearance to a more rounded
Total laryngectomy is the surgical procedure of shape. The anterior portion of the esophagus is located
choice for treating advanced laryngeal cancers. This just deep to the subcutaneous fat of the neck. The walls

Fig. 14. Supracricoid with cricohyoidopexy: expected appearance (Courtesy of Roberto Maroldi, MD). Axial CT demonstrates the preservation
of one cricoarytenoid joint (arrow) (a). The false cord and aryepiglottic fold above this level are preserved (arrow) (b). There may be some
expected post-operative mucosal thickening in the subglottic region (arrow) (c); however, the presence of a focal soft tissue mass is abnormal.
116 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119

3.3. Supraglottic laryngectomy

Supraglottic laryngectomy is a form of partial laryn-

gectomy that may be performed for low volume tumors
arising from the supraglottic larynx [9,10]. Primary sites
that may be suitable for treatment with this form of
partial laryngectomy include the epiglottis, aryepiglottic
fold and false vocal cord. This procedure involves
complete resection of endolaryngeal structures above
the laryngeal ventricle but preservation of the glottic
and subglottic larynx. The structures that are resected
during a standard supraglottic laryngectomy are the
suprahyoid and infrahyoid epiglottis, both aryepiglottic
folds, both false vocal cords. A portion of the thyroid
resected (Fig. 6). The hyoid bone may need to be
resected for those tumors that invade the pre-epiglottic
space. Extended supraglottic laryngectomy may be per-
formed for more advanced tumors and may consist of
resection of one arytenoids cartilage, base of tongue
without [10] exceeding the circumvallate papillae, or a
portion of the involved pyriform sinus.
Fig. 15. Supracricoid with cricohyoidopexy: recurrence (Courtesy of
Roberto Maroldi, MD). Axial image demonstrates the presence of a
Imaging plays and important role in patients that are
focal mass arising from the surgical margin (large arrow). The potential candidates for supraglottic laryngectomy.
presence of the large focal mass is suggestive of recurrent tumor. Various forms of spread that would preclude patients
(Small arrow, arytenoid cartilage). from being considered for a supraglottic laryngectomy
may only be seen on imaging. Indications for a supra-
glottic laryngectomy include a supraglottic carcinoma
that crosses the laryngeal , normal vocal cord, no
of the esophagus are typically not thickened and are involvement of the arytenoid cartilage, and no cartilage
usually 2– 3 mm in thickness. The mucosal may nor- invasion (Fig. 7).ventricle
mally enhance following surgery. The amount of thy- Radiographically, the post-operative appearance of
roid gland that is resected is variable. Residual thyroid the supraglottic region of the larynx is often air-filled
gland may be misinterpreted for residual or recurrent and dilated due to resection of the resection of the
disease. The presence of a focal soft tissue mass or an normal supraglottic structures. The glottic and subglot-
enlarging mass is suspicious for recurrent tumor (Fig. tic structures appear normal as they are not involved in
5b). the primary resection. However, the larynx is shortened

Fig. 16. Supracricoid with cricohyoidoepiglottoplexy: schematic illustration of the surgical resection.
 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119 117

Fig. 17. Supracricoid with cricohyoidoepiglottopexy: expected appearance (Courtesy of Roberto Maroldi, MD). Axial CT demonstrates the
preservation of one cricoarytenoid joint (arrow) (a) there may be some expected post-operative mucosal thickening in the subglottic region (arrow)
(b). The appearance is similar to the cricohyoidopexy; however, imaging of the superior part of the larynx demonstrates preservation of a portion
of the epiglottis as shown by a transverse soft tissue mass (arrowhead) (c). This is a normal finding.

and there is reduced distance between the hyoid bone patients from being candidates for hemilaryngectomy
and the true vocal cords (Figs. 8 and 9) [12]. [11–14]. This procedure involves resection of the in-
volved true vocal cord along with the ipsilateral ary-
3.4. Hemilaryngectomy tenoid cartilage. The involved side is reconstructed with
a ‘pseudocord’. The overlying thyroid ala and its exter-
Hemilaryngectomy is performed for early glottic can- nal perichondrium is included in the resection (Fig. 10).
cers. Indications for treatment of a glottic carcinoma The imaging findings show the thickened pseudocord
with hemilaryngectomy include tumors that involves less with absence of the normal paraglottic fat associated
than 1/3 of the contralateral true vocal cord, no cartilage with an ipsilateral surgical defect of the adjacent thyroid
invasion, no transglottic spread, B 10 mm of anterior cartilage (Fig. 11). The presence of an enlarging enhanc-
subglottic extension, and B 5 mm of posterior subglottic ing mass is suggestive of recurrent tumor (Fig. 12)
extension. Imaging findings of such extension preclude [12– 15].
118 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119

3.5. Supracricoid laryngectomy with cricohyoidopexy 3.6. Supracricoid laryngectomy with

cricohyoidoepiglottopexy
Supracricoid laryngectomy with cricohyoidopexy is
partial laryngectomy performed as a voice conservation A supracricoid laryngectomy with cricohy-
procedure for advanced supraglottic carcinomas that oidoepiglottopexy is used to remove advanced glottic
may extend to the laryngeal ventricle, invade the glottis carcinomas. The main difference between supracricoid
or, in selected cases, tumors that have small focal areas laryngectomy with cricohyoidopexy and supracricoid
of thyroid cartilage invasion [16,17]. A supracricoid laryngectomy with cricohyoidoepiglottopexy concerns
laryngectomy involves resection of the false and true the epiglottis [16,17]. The epiglottis is entirely resected
cords, paraglottic spaces, thyroid cartilage, epiglottis in the first procedure, while it is spared in its suprahy-
and preepiglottic space while sparing the cricoid carti- oid part in the latter. The indications for supracricoid
lage, the hyoid bone and at least one arytenoid carti- laryngectomy with cricohyoidoepiglottopexy are ad-
lage. The inferior cornu of the thyroid cartilage is also vanced true vocal cord carcinoma with transglottic
preserved to avoid injury of the adjacent recurrent extension, absence of pre-epiglottic extension, preserva-
laryngeal nerve (Fig. 13). A cricohyoidopexy is accom- tion of the superior part of the epiglottis, B 7 mm of
plished by moving the cricoid cartilage upwards and by anterior subglottic extension, and no cricoid cartilage
approaching the cricoid cartilage and the hyoid bone invasion [12]. The presence of thyroid cartilage invasion
[16,17]. Contraindications to performing a supracricoid is not a contraindication to supracricoid laryngectomy
laryngectomy with cricohyoidopexy are subglottic with cricohyoidopexy. This procedure includes resec-
spread with invasion of the cricoid cartilage. tion of the supraglottis, pre-epiglottic space, one
Post-surgical imaging demonstrates absence of the cricoarytenoid joint, and thyroid cartilage. The
hyoid and supraglottic structures and ‘collapse’ of the suprahyoid epiglottis, cricoid cartilage, hyoid bone, and
larynx. At the glottic level, only one cricoarytenoid at least one arytenoids cartilage is preserved (Fig. 16).
joint is present. There is an oblique soft tissue mass Tumors that cannot be successfully resected with con-
located at the level of the false cord that represents servation surgery require a total laryngectomy.
redundant mucosal thickening just above the preserved Post-surgical imaging demonstrates absence of the
true vocal cord (Fig. 14). This normal appearance hyoid and supraglottic structures and ‘collapse’ of the
should not be confused with recurrent tumor (Fig. 15) larynx. At the glottic level, only one cricoarytenoid
[12]. joint is present. There is an oblique soft tissue mass

Fig. 18. Supracricoid with cricohyoidoepiglottopexy: recurrence (Courtesy of Robert Sigal, MD). Axial image demonstrates the presence of a focal
mass arising from the superior aspect of the surgical site in the rea of the epiglottis (large arrow) (a). Note the substantial asymmetric, which is
suspicious for recurrent tumor (b).
 S.K. Mukherji, W.J. Weadock / European Journal of Radiology 44 (2002) 108–119 119

located at the level of the false cord that represents [5] Calcaterra TC, Stern F, Ward PH. Dilemma of delayed radia-
redundant mucosal thickening just above the preserved tion injury of the larynx. Ann Otol Rhinol Laryngol
1972;81:501 – 7.
true vocal cord [12]. The ‘epiglottopexy’ is identified by [6] Amdur RJ, Parsons JT, Mendenhall WM, Million RR, Stringer
a transverse soft tissue mass at the level of the hyoid SP, Cassisi NJ. Postoperative irradiation for squamous cell
bone (Fig. 17). These normal post-operative structures carcinoma of the head and neck: an analysis of treatment results
should not be confused with recurrent tumor (Fig. 18). and complications. Int J Rad Onc Biol Phy 1989;16:25 – 36.
[7] Mukherji SK, Drane WE, Tart RP, Mancuso AA. Comparison
of SPECT FDG and SPECT Thallium-201 for imaging of
squamous cell carcinoma of the head and neck. AJNR
4. Summary 1994;15:1837 – 42.
[8] Mukherji SK, Gapany M, Phillips D, et al. Squamous cell
There are various treatment options for treating carcinoma of the upper aerodigestive tract: the ability of thal-
SCCA of the larynx, which include both surgical and lium-201 SPECT to detect recurrent tumor. AJNR
1999;20:1215 – 20.
non-surgical alternatives. These treatment options have [9] Fried MP, Girdhar-Gopal HV. Advanced cancer of the larynx.
a characteristic imaging appearance. Knowledge of this In: Bailey BJ, editor. Head and neck surgery. Philadelphia: JB
appearance will help improve the ability to identify Lippincott, 1993:1347 – 59.
recurrent disease and prevent misinterpretation of nor- [10] Desanto LW. Supraglottic laryngectomy. In: Bailey BJ, editor.
mal post-treatment changes as recurrent tumor. Head and neck surgery. Philadelphia: JB Lippincott, 1993:1334 –
45.
[11] Bailey BJ. Early glottic cancers. In: Bailey BJ, editor. Head and
neck surgery. Philadelphia: JB Lippincott, 1993:1313 – 33.
References [12] Maroldi R, Battaglia G, Nicolai P, et al. CT appearance of the
larynx after conservative and radical surgery for carcinomas. Eur
[1] Mukherji SK, Mancuso AA, Kotzur I, et al. Radiographic Radiol 1997;7:418 – 31.
appearance of the irradiated larynx: part I: expected changes. [13] Mukherji SK, Castillo M. The larynx. In: Orrison W, editor.
Radiology 1994;193:141 –8. Neuroradiology. Philadelphia, PA: WB Saunders, 2000:1441 –60.
[2] Mukherji SK, Mancuso AA, Kotzur I, et al. Radiographic [14] Curtin HD. Larynx. In: Som PM, Curtin H, editors. Head and
appearance of the irradiated larynx: part II: primary site re- neck imaging, 3rd ed. New York: Mosby, 1996:612 – 707.
sponse. Radiology 1994;193:149 –54. [15] DiSantis DJ, Balfe DM, Hayden RE, Sessions D, Sagel SS. The
[3] Manara M. Histological changes of the human larynx irradiated neck after vertical hemilaryngectomy: computed tomographic
with various technical therapeutic methods. Arch Ital Otol study. Radiology 1984;151:683 – 7.
1966;79:596 – 635. [16] Charlin B, Guerrier B, Balmigere G. Subtotal laryngectomy with
[4] Parsons JT. The effect of radiation on normal tissues of the head cricohyoidopexy. Head Neck Surg 1988:17 – 24.
and neck. In: Million RR, Cassisi NJ, editors. Management of [17] Chevalier D, Piquet JJ. Subtotal laryngectomy with cricohy-
head and neck cancer: a multidisciplinary approach, 2nd ed. oidopexy for supraglottic carcinoma: review of 61 cases. Am J
Philadelphia: JB Lippincott, 1984:173 – 205. Surg 1994;168:472 – 3.