Ann 0101 Rhinol LaryngollOl: 1992
IMAGING CASE STUDY OF THE MONTH
CARTILAGINOUS TUMOR OF THE LARYNX JAMES A. WIESE, MD
THOMAS
F.
VINER, MD
KENNETH D. DOLAN, MD
RICHARD J. RINEHART IOWA CITY, IOWA
Later the patient underwent a laryngofissure subglottic mass excision. The mass was noted to be mucosa-covered, indurated, and apparently arising from the posterior wall of the cricoid cartilage and first two tracheal rings. The mass was removed in macroscopic entirety without difficulty or complication. Histopathologic examination of the surgical specimen confirmed the clinical diagnosis of chondroma.
CASE REPORT
The patient was an 80-year-old woman who presented with complaints of exertional dyspnea and progressive hoarseness. She reported having had an inability to climb stairs for 6 months and difficulty walking across the room for 2 months because of shortness of breath. She had also noticed a progressive hoarseness of several months' duration. She had received a diagnosis of bronchial asthma and congestive heart failure, and had been treated medically for approximately 5 years. She had had no known previous surgical procedures.
DISCUSSION
Tumors of the larynx are frequently encountered by the head and neck surgeon. The vast majority of these neoplasms are squamous cell carcinomas. Cartilaginous tumors of the larynx comprise only a small number of the nonsquamous neoplasms that affect the larynx. There are about 200 cases of these tumors now recorded in the literature." The location of these tumors in 75 % of cases is the endolaryngeal surface of the posterior lamina of the cricoid cartilage. The thyroid, arytenoid, and epiglottic cartilages are next affected, in declining order. The tumors commonly affect men between the ages of 30 and 70. The reported incidence in men is roughly three times that in women."
Physical examination revealed a large subglottic mass originating from the posterior wall of the larynx. The subglottic air space was significantly narrowed, such that a patent airway passage was not apparent on indirect mirror examination. There were no palpable neck masses. The remainder of the findings on head and neck examination were unremarkable. RADIOGRAPHIC FINDINGS
Computed tomography of the head and neck with contrast was performed. Multiple enhanced slices of the neck revealed an irregular, heavily calcified 3-cm mass at and below the level of the true vocal cords. The mass contained scattered punctate and ringlike calcific densities. The lesion narrowed the subglottic airway to a 5-mm opening located in the left anterior portion of the trachea. The lesion appeared to be contained by the thyroid cartilage without evidence of direct invasion to the surrounding deep fat planes (see Figure; C,D). SURGERY
The clinical presentation of these tumors is primarily dependent on their location and size. The majority originate in the subglottis and present with stridor, hoarseness, or dyspnea. Tumors in this location eventually lead to some degree of airway obstruction. It is not uncommon for these patients to receive a misdiagnosis of asthma." Supraglottic tumors may produce hoarseness, dyspnea, dysphagia, odynophagia, or otalgia. Occasionally, extralaryngeal extension will present as a neck mass. J
Tracheostomy with subsequent direct laryngoscopy and biopsy were performed with a working diagnosis of laryngeal chondroma. Direct laryngoscopy revealed a large posterior subglottic mass that narrowed the airway and encroached upon the arytenoids. Multiple biopsies were read as nondiagnostic. There was no evidence of inflammation or malignancy.
Cartilaginous tumors are diagnosed on the basis of histopathologic characteristics. Batsakis and Raymond" classify them into four groups: 1) chondrometaplasia, 2) chondroma, 3) chondrosarcoma, and 4) cartilage within otherwise classified lesions. Chrondromatous metaplasia of the larynx has been found in up to 2 % of human larynx specimens at necropsy." Hill et al" note that these metaplastic
From the Departments of Radiology (Wiese) and Otolaryngology (Viner). Mercy Hospital, and the Department of Radiology, The University of Iowa College of Medicine (Rinehart, Dolan), Iowa City, Iowa. REPRINTS - Kenneth D. Dolan, MD, Dept of Radiology, The University of Iowa Hospitals, Iowa City, IA 52242.
617
Downloaded from aor.sagepub.com at FLORIDA ATLANTIC UNIV on July 19, 2015
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Wiese et al, Imaging Case Study of the Month
Axial computed tomograms. A,B) At true vocal cord level. A) Soft tissue technique with large calcific mass originating in cricoidarytenoid area producing marked airway compression. B) Bone mode technique of same area. C,D) Ten millimeters below A and B, showing relation of mass to tracheal ring. C) Soft tissue mode. D) Bone mode at same level.
nodules are generally small asymptomatic foci most commonly located in the region of the false cords. They also hypothesize that some chondromas diagnosed in earlier reports may in fact have been chondrometaplastic nodules. The differentiation between chondromas and chondrosarcomas can be a difficult task. Histologic grading of laryngeal chondrosarcomas is equivalent to the grading scheme used for extralaryngeal chondrosarcomas. Greater than 50 % of presenting cartilaginous tumors will be chondrosarcomas, and nearly 50 % of these tumors will be low-grade (grade 1) malignancies. I These low-grade lesions are easily mistaken for more benign chondromas. In one of the largest single reports to date, Neel
and Unni" studied 33 patients seen for treatment of cartilaginous tumors of the larynx. Only 2 of these patients had chondromas. The remaining 31 patients had chondrosarcomas. Likewise, two earlier diagnosed cases of chondroma were reclassified as chondrosarcoma after further review. In addition, tumors diagnosed as chondromas have been known to present years later as recurrent low-grade chondrosarcomas." It is apparent that a diagnosis of chondroma should carry a degree of suspicion, and should be followed for possible future recurrence. Radiology can be very useful in defining these tumors for surgical procedures. However, diagnosis relies on histopathology. Plain anteroposterior films generally show a discrete mucosally covered soft tissue mass arising from the laryngeal cartilage.
Downloaded from aor.sagepub.com at FLORIDA ATLANTIC UNIV on July 19, 2015
Wiese et al, Imaging Case Study of the Month
Coarse scattered calcification occurs in 75 % of these tumors.' Tomograms and computed tomography can be useful in delineating local anatomy and tumor extension. In general, benign and low-grade lesions have a favorable prognosis. High-grade lesions are progressive, and up to 10 % of patients with these lesions have been shown to die of their tumors. 2 Metastases are unusual but have been reported. Recurrence rates re-
619
ported by Neel and Unni" ranged from 21 months to 16 years, with a mean recurrence rate of 6 years. Treatment for these tumors must be individualized. The malignant potential of the tumor should be ascertained, for this weighs directly on the aggressiveness of the approach taken in management. Whenever possible, conservative treatment is advisable. However, conservative excision has been shown to carry a 65 % recurrence rate. 2
REFERENCES
1. Tiwari RM, Snow GB, Balm AJM, Gerritsen GJ, Vos W, Bosma A. Cartilagenous tumours of the larynx. J Laryngol Otol 1987;101:266-75. 2. Batsakis JG, Raymond AK. Cartilage tumors of the larynx. South Med J 1988;81:481-4. 3. Levine HL, Tubbs R. Nonsquamous neoplasms of the larynx. Otolaryngol Clin North Am 1986;19:475-88. 4. Hill MJ, Taylor CL, Scott GBD. Chondromatous meta-
plasia in the human larynx. Histopathology 1980;4:205-14. 5. Neel HB lIl, Unni KK. Cartilaginous tumors of the larynx: a series of 33 patients. Otolaryngol Head Neck Surg 1982;90: 201-7. 6. Houston LW, Hinke ML. Neuroradiology case of the day. AJR 1986;146:1094-7. 7. Zizmor J, Noyek AM, Lewis JS. Radiologic diagnosis of chondroma and chondrosarcoma of the larynx. Arch Otolaryngol 1975;101:232-4.
THE JERUSALEM SYMPOSIUM ON SURGERY OF THE SKULL BASE AND ADJACENT MIDLINE REGION TheJerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region will be held March 21-26, 1993, in Jerusalem, Israel. For further information, contact Dr F. Umansky, The Jerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region, PO Box 50006, Tel Aviv 61500, Israel; Telephone 972 3 5174571; Telex 341171 KENS IL; Fax 972 3 655674.
AMERICAN DIOPTER AND DECIBEL SOCIETY The American Diopter and Decibel Society will hold its biennial meeting January 16-23, 1993, at the Westin Camino Real in Puerto Vallarta, Mexico. Abstracts are currently being accepted. For further information, contact Robin L. Wagner, American Diopter and Decibel Society, 3518 Fifth Avenue, Pittsburgh, PA 15213; fax (412) 647-8720, phone (412) 647-2227.
Downloaded from aor.sagepub.com at FLORIDA ATLANTIC UNIV on July 19, 2015
IMAGING CASE STUDY OF THE MONTH
CARTILAGINOUS TUMOR OF THE LARYNX JAMES A. WIESE, MD
THOMAS
F.
VINER, MD
KENNETH D. DOLAN, MD
RICHARD J. RINEHART IOWA CITY, IOWA
Later the patient underwent a laryngofissure subglottic mass excision. The mass was noted to be mucosa-covered, indurated, and apparently arising from the posterior wall of the cricoid cartilage and first two tracheal rings. The mass was removed in macroscopic entirety without difficulty or complication. Histopathologic examination of the surgical specimen confirmed the clinical diagnosis of chondroma.
CASE REPORT
The patient was an 80-year-old woman who presented with complaints of exertional dyspnea and progressive hoarseness. She reported having had an inability to climb stairs for 6 months and difficulty walking across the room for 2 months because of shortness of breath. She had also noticed a progressive hoarseness of several months' duration. She had received a diagnosis of bronchial asthma and congestive heart failure, and had been treated medically for approximately 5 years. She had had no known previous surgical procedures.
DISCUSSION
Tumors of the larynx are frequently encountered by the head and neck surgeon. The vast majority of these neoplasms are squamous cell carcinomas. Cartilaginous tumors of the larynx comprise only a small number of the nonsquamous neoplasms that affect the larynx. There are about 200 cases of these tumors now recorded in the literature." The location of these tumors in 75 % of cases is the endolaryngeal surface of the posterior lamina of the cricoid cartilage. The thyroid, arytenoid, and epiglottic cartilages are next affected, in declining order. The tumors commonly affect men between the ages of 30 and 70. The reported incidence in men is roughly three times that in women."
Physical examination revealed a large subglottic mass originating from the posterior wall of the larynx. The subglottic air space was significantly narrowed, such that a patent airway passage was not apparent on indirect mirror examination. There were no palpable neck masses. The remainder of the findings on head and neck examination were unremarkable. RADIOGRAPHIC FINDINGS
Computed tomography of the head and neck with contrast was performed. Multiple enhanced slices of the neck revealed an irregular, heavily calcified 3-cm mass at and below the level of the true vocal cords. The mass contained scattered punctate and ringlike calcific densities. The lesion narrowed the subglottic airway to a 5-mm opening located in the left anterior portion of the trachea. The lesion appeared to be contained by the thyroid cartilage without evidence of direct invasion to the surrounding deep fat planes (see Figure; C,D). SURGERY
The clinical presentation of these tumors is primarily dependent on their location and size. The majority originate in the subglottis and present with stridor, hoarseness, or dyspnea. Tumors in this location eventually lead to some degree of airway obstruction. It is not uncommon for these patients to receive a misdiagnosis of asthma." Supraglottic tumors may produce hoarseness, dyspnea, dysphagia, odynophagia, or otalgia. Occasionally, extralaryngeal extension will present as a neck mass. J
Tracheostomy with subsequent direct laryngoscopy and biopsy were performed with a working diagnosis of laryngeal chondroma. Direct laryngoscopy revealed a large posterior subglottic mass that narrowed the airway and encroached upon the arytenoids. Multiple biopsies were read as nondiagnostic. There was no evidence of inflammation or malignancy.
Cartilaginous tumors are diagnosed on the basis of histopathologic characteristics. Batsakis and Raymond" classify them into four groups: 1) chondrometaplasia, 2) chondroma, 3) chondrosarcoma, and 4) cartilage within otherwise classified lesions. Chrondromatous metaplasia of the larynx has been found in up to 2 % of human larynx specimens at necropsy." Hill et al" note that these metaplastic
From the Departments of Radiology (Wiese) and Otolaryngology (Viner). Mercy Hospital, and the Department of Radiology, The University of Iowa College of Medicine (Rinehart, Dolan), Iowa City, Iowa. REPRINTS - Kenneth D. Dolan, MD, Dept of Radiology, The University of Iowa Hospitals, Iowa City, IA 52242.
617
Downloaded from aor.sagepub.com at FLORIDA ATLANTIC UNIV on July 19, 2015
618
Wiese et al, Imaging Case Study of the Month
Axial computed tomograms. A,B) At true vocal cord level. A) Soft tissue technique with large calcific mass originating in cricoidarytenoid area producing marked airway compression. B) Bone mode technique of same area. C,D) Ten millimeters below A and B, showing relation of mass to tracheal ring. C) Soft tissue mode. D) Bone mode at same level.
nodules are generally small asymptomatic foci most commonly located in the region of the false cords. They also hypothesize that some chondromas diagnosed in earlier reports may in fact have been chondrometaplastic nodules. The differentiation between chondromas and chondrosarcomas can be a difficult task. Histologic grading of laryngeal chondrosarcomas is equivalent to the grading scheme used for extralaryngeal chondrosarcomas. Greater than 50 % of presenting cartilaginous tumors will be chondrosarcomas, and nearly 50 % of these tumors will be low-grade (grade 1) malignancies. I These low-grade lesions are easily mistaken for more benign chondromas. In one of the largest single reports to date, Neel
and Unni" studied 33 patients seen for treatment of cartilaginous tumors of the larynx. Only 2 of these patients had chondromas. The remaining 31 patients had chondrosarcomas. Likewise, two earlier diagnosed cases of chondroma were reclassified as chondrosarcoma after further review. In addition, tumors diagnosed as chondromas have been known to present years later as recurrent low-grade chondrosarcomas." It is apparent that a diagnosis of chondroma should carry a degree of suspicion, and should be followed for possible future recurrence. Radiology can be very useful in defining these tumors for surgical procedures. However, diagnosis relies on histopathology. Plain anteroposterior films generally show a discrete mucosally covered soft tissue mass arising from the laryngeal cartilage.
Downloaded from aor.sagepub.com at FLORIDA ATLANTIC UNIV on July 19, 2015
Wiese et al, Imaging Case Study of the Month
Coarse scattered calcification occurs in 75 % of these tumors.' Tomograms and computed tomography can be useful in delineating local anatomy and tumor extension. In general, benign and low-grade lesions have a favorable prognosis. High-grade lesions are progressive, and up to 10 % of patients with these lesions have been shown to die of their tumors. 2 Metastases are unusual but have been reported. Recurrence rates re-
619
ported by Neel and Unni" ranged from 21 months to 16 years, with a mean recurrence rate of 6 years. Treatment for these tumors must be individualized. The malignant potential of the tumor should be ascertained, for this weighs directly on the aggressiveness of the approach taken in management. Whenever possible, conservative treatment is advisable. However, conservative excision has been shown to carry a 65 % recurrence rate. 2
REFERENCES
1. Tiwari RM, Snow GB, Balm AJM, Gerritsen GJ, Vos W, Bosma A. Cartilagenous tumours of the larynx. J Laryngol Otol 1987;101:266-75. 2. Batsakis JG, Raymond AK. Cartilage tumors of the larynx. South Med J 1988;81:481-4. 3. Levine HL, Tubbs R. Nonsquamous neoplasms of the larynx. Otolaryngol Clin North Am 1986;19:475-88. 4. Hill MJ, Taylor CL, Scott GBD. Chondromatous meta-
plasia in the human larynx. Histopathology 1980;4:205-14. 5. Neel HB lIl, Unni KK. Cartilaginous tumors of the larynx: a series of 33 patients. Otolaryngol Head Neck Surg 1982;90: 201-7. 6. Houston LW, Hinke ML. Neuroradiology case of the day. AJR 1986;146:1094-7. 7. Zizmor J, Noyek AM, Lewis JS. Radiologic diagnosis of chondroma and chondrosarcoma of the larynx. Arch Otolaryngol 1975;101:232-4.
THE JERUSALEM SYMPOSIUM ON SURGERY OF THE SKULL BASE AND ADJACENT MIDLINE REGION TheJerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region will be held March 21-26, 1993, in Jerusalem, Israel. For further information, contact Dr F. Umansky, The Jerusalem Symposium on Surgery of the Skull Base and Adjacent Midline Region, PO Box 50006, Tel Aviv 61500, Israel; Telephone 972 3 5174571; Telex 341171 KENS IL; Fax 972 3 655674.
AMERICAN DIOPTER AND DECIBEL SOCIETY The American Diopter and Decibel Society will hold its biennial meeting January 16-23, 1993, at the Westin Camino Real in Puerto Vallarta, Mexico. Abstracts are currently being accepted. For further information, contact Robin L. Wagner, American Diopter and Decibel Society, 3518 Fifth Avenue, Pittsburgh, PA 15213; fax (412) 647-8720, phone (412) 647-2227.
Downloaded from aor.sagepub.com at FLORIDA ATLANTIC UNIV on July 19, 2015
