David J. DiSantis, M.D. Dennis M. Balfe, M.D. Richard E. Hayden, M.D. Stuart S. Sagel, M.D. Donald Sessions, M.D.

Joseph K. T. Lee, M.D.

The Neck CT Study1

after Total

Laryngectomy:

.5

4.

Computed tomographic scans in 23 patients who had undergone total laryngectomy were analyzed retrospectively to determine normal postoperative appearance and to evaluate the role of CT in assessing recurrent neoplasm. Nine patients without clinical evidence of recurrence illustrated the normal postoperative changes: a round or ovoid neopharynx connecting the base of the tongue with the cervical esophagus and intact fat planes surrounding the neopharynx, neurovascular bundles, and sternocleidomastoid muscles. In the 12 patients with recurrent neoplasm, the CT manifestations included masses involving the internal jugular lymph node chain (adjacent to the neopharynx, neurovascular bundles, or sternocleidomastoid muscles), tracheostomy site, or paratracheal region. Recurrence was mimicked on CT in two patients, one with an abscess and one with metastases from an adenocarcinoma of unknown primary site. In eight patients, a distended neopharyngeal lumen correlated with benign or malignant stricture.
CT supplemented physical examination

LINICAL evaluation of patients following total laryngectomy (TL) frequently is difficult. Palpation is limited by postsurgical scarring and radiation fibrosis, while indirect mirror examination fails to evaluate the more caudal portions of the pharynx. Even esophagoscopy and biopsy may fail to detect tumor recurrence (1). Radiographic studies may provide help in evaluating these patients. Barium examination aids in defining fistulas, strictures, and tumor recurrence involving the pharynx and esophagus (2); it cannot, however, adequately assess lymph node enlargement on extranodal tumor spread. While not focusing on postlaryngectomy patients, recent reports have demonstrated the utility of postoperative neck computed tomography (CT) for assessment of tumor recurrence (3-5), similar to its established role in primary laryngeal malignancy (6, 7). Consequently, we have correlated postlaryngectomy CT findings with clinical, surgical, and pathologic data in 23 patients, in order to differentiate the normal from the pathologic postoperative CT appearance.

SURGICAL

CONSIDERATIONS
that, surgery. extend

Total laryngectomy is performed for laryngeal neoplasms because of size on location, are not amenable to conservation In general, those tumors that invade the laryngeal cantilages,

-4-V

and indirect mirror examination, providing data regarding presence and extent of recurrent tumor and aiding in planning the mode and scope of therapy.
Index
271.1211

subglottically about the cricoid cartilage, or cause vocal cord fixation are best managed by this type of surgery. Tumors that recur after conservation surgery or radiation therapy also are treated by total laryngectomy. After a low collar-type incision and tnacheostomy, the hyoid bone is severed from the supnahyoid musculature (Fig. la). The thyroid and cnico.id cartilages are severed from their pharyngeal muscular attachments (Fig. ib). The incision is extended to encompass the hyoid bone, epiglottis, anyepiglottic folds, pyniform fossae, thyroid and cricoid cartilages, and true and false vocal cords. The resultant anterior pharyngeal defect is closed in layers: an inner one of pharyngeal mucosa; a second one comprising a variable amount of cnicopharyngeus and pharyngeal constrictor musculature; and an outermost layer of penipharyngeal from the base is termed the connective of the tongue neopharynx tissue. A conical passageway extending to the proximal esophagus is formed, and (Fig. ic) (2).

terms:
#{149}

Larynx,

computed

tomography, 271.37
#{149}

Larynx,

neoplasms,

Larynx,

surgery
Radiology

#{149}

Neck,

computed

tomography

1984; 153: 713-717

PATIENTS
Review of the records from our studies of the neck in 23 patients
either with as primary a mean age therapy surgery. of 64 years. for The or conservation

AND
institution who had

METHODS
from 1980-1983 undergone total
or had had after 19 men and

yielded 24 CT laryngectomy,
failed four radiation women as therapy

laryngeal population Twenty

carcinoma included patients

radiation

From

the

Mallinckrodt (R.E.H.,

Institute D.S.),

of Radiology

(D.J.D.,

D.M.B.,

S.S.S., J.K.T.L.)

and the Department

Washington University

of 22,
ht

well, and four had Of the 23 patients, tumor recurrence,

evaluations extent of disease tomatic

Otolaryngology

undergone unilateral radical neck dissection. I 6 were referred for CT evaluation because of suspected usually because of suggestive but inconclusive clinical on because of dysphagia. The examination was requested to assess
in two were patients included with documented group recurrence. to define Five the asympnormal as a control

School of Medicine, St. Louis, 1984; accepted May 17, 1984.

#{176}RSNA,1984

MO. Received

March

volunteers

postoperative

CT appearance. 713

Figure

///

II I
b.
C.

a and

b.
C.

Frontal cartilage; Formation

(a) and lateral (b) depictions of the c = cricoid cartilage; e epiglottis. of the neopharynx using mucosal

total and

laryngectomy muscular layers.

procedure.
,i
=

Ii

hyoid

bone;

thyrohyoid

membrane;

thyroid
4

neopharynx.

Generally,

high-resolution

CT

studies

were performed with and the neck extended;

from the In rami two was cephalad were time, at of the cases, the the area

the patient scans were

mandible

supine obtained
the tracheso

Normal Postoperative Examinations

In nine patients there was no sign of tumor recurrence; this group included the five asymptomatic volunteens. In the volunteers, since no laryngeal landmarks remained to act as a guide, three levels have been chosen to illustrate the normal postoperative appearance. The most cephalad level is at the base of the tongue, followed by a midneck level 2-3 cm more caudally and a lowermost level at the tracheostome, usually 3-4 cm more caudal. The neopharynx is sutured anteniorly to the base of the tongue (Fig. 2a). It appeared as a round or ovoid softtissue mass just ventral to the vertebral body, often containing a small amount of air within its lumen. In each of the volunteers, smaller air collections were present ventrolateral to the main neopharyngeal lumen, representing small anastomotic diverticula frequently seen on barium studies (2). While the fat planes about the ventral on lateral aspects of the neopharynx were often indistinct, no masses abutted the neopharynx. The fat planes about the neunovascular bundles remained distinct in four of the five volunteers. In one case, a small area of contact between the carotid artery and neopharynx interrupted the otherwise intact fat plane. Similarly, the fat planes sun-

through

upper
site. ostomy more

thorax

to include

the
region

tracheostomy
of the concern, not imaged. a 3-5-second with 5-mm material of the postopermonths Clinical to

of clinical were using intervals the contrast discretion

Images
scan

levels obtained 5-mm

collimation. Intravenous was administered at monitoring radiologist. In the five normal ative follow-up 3 years with ranged a mean of

volunteers, from 3.5 18 months.

follow-up after the CT scan in this group averaged 4 months. Since greater than 90% of laryngeal tumor recurrences occur within 2 years of surgery or radiation therapy (8),

and

since

the clinical

examinations

in these

asym ptomatic patients remained unremarkable, they were thought to define the normal postoperative appearance. The remaining 18 patients underwent open biopsy (12 cases), pharyngoesophagoscopy doscopic biopsy neck (1 case). dissection (3 cases), (2 cases), or en-

RESULTS
Retrospective laryngectomy CT analysis scans of the defined postthree

patient groups: (I) those with postoperative examinations; tients with recurrent tumor strated by CT; (III) patients findings mimicking tumor rence.

normal (II) pademonwith CT recur-

rounding the stennocleidomastoid muscles remained intact in four of the five volunteers. In one patient the fat plane deep to the right sternocleidomastoid was obliterated due to a partial neck dissection on that side (Fig. 2b). Two to 4 centimeters more caudally in the midneck, the neopharynx assumed a more rounded configuration (Fig. 2c). Although the fat planes about the neopharynx were preserved, the fat was often somewhat higher than nonmal in attenuation value, probably secondary to postsurgical fibrosis. The fat planes about the neunovasculan bundles and the stennocleidomastoid muscles were again preserved. At the level of the tracheostome, the relationship of the trachea, esophagus, neunovascular bundles, and sternocleidomastoid muscles remained unaltered (Fig. 2d). Although no frank mass was present, the fat plane between the dorsal aspect of the sternocleidomastoid muscle and the neunovascular bundle was indistinct in the normal volunteers. Of the remaining four patients in this group, three were evaluated because of dysphagia and one because of a questionable neck mass. The patients with dysphagia demonstrated the expected postoperative CT changes; however, the cephalad portion of the
neopharyngeal lumen was distended

I
-

with

air.

In each

case,

a benign

stricture 1984

714

#{149}

Radiology

December

TABLE

I:

Site of Recurrent Patients

Tumor

in

12

Figure

Site Internal jugular lymph nodes (adjacent to neurovascular bundle, neopharynx, or sternocleidomastoid muscle) Peristomal soft tissue Trachea Mediastinum Neck subcutaneous tissue

No. of Patients 8

3 2 2 2

of the neopharynx was diagnosed by barium examination and/on endoscopy (Fig. 2e). The patient evaluated for questionable neck mass showed nonmal postoperative changes on CT, with

b.

.1

endoscopy follow-up rence. Patients Twelve recurrent

TABLE I lists

and subsequent revealing no tumor

clinical recur-

with

Recurrent

Tumor documented neoplasm.

by tumor

patients had on metastatic

the sites involved

and their relative frequency. Several patients had multiple sites of involvement. Most often (8/12), the tumor was centered in the internal jugular lymph node chain, effacing the normal fat planes about adjacent structures. In each case, a mass obliterated part on all of the fat plane deep to the sternocleidomastoid, on surrounding the neurovascular bundle (Fig. 3a and b). Concomitant infiltrative enlargement of the sternocleidomastoid muscle was present in five patients (Fig. 3c). Tumor obliterated part or all of the penineopharyngeal fat plane in three instances

a.

Normal
b n
=

CT scan
of tongue;

at base-of-tongue

level.

base

tennal
=

carotid

arteries;
lumen;

neopharynx base of

internal and exv = jugular vein; arrowhead neo-

pharyngeal
with

diverticulum
tongue; s

at anastomosis
sternocleidoright fat plane neck deep muscle

b.

modified dissection. Note loss of the to the right sternocleidomastoid

mastoid muscle. Asymmetry due to

due to lymph node dissection. f preserved fat plane deep to left sternocleidomastoid
C.

muscle

(s).

--V

(Fig. 3d). Less frequent rence included

ses external

Normal
a carotid

midneck
artery;

level.
v

sites of tumor recursubcutaneous metastastennocleidomastoid

n neopharynx; jugular vein; s

sternocleidomastoid

muscle.

to the

d.

Normal
a carotid

tracheostome
muscle;
artery;

level.

muscle (2 patients) and penistomal recunrence (5 patients). In two stomal recurrences, the tumor was manifested as irregular thickening of the tracheal wall or stomal soft tissue, extending into the tracheal lumen (Fig. 3e), while the other three had penistomal masses extending deep to the sternocleidomastoid muscle (Fig. 3f). Two of the patients with stoma-level recurrences also had upper mediastinal metastases that were not clinically suspected (Fig. 3g). In three patients in this group, CT demonstrated the neophanyngeal lumen to be distended with air. Barium examination results were available in two of these; both demonstrated marked narrowing of the cervical esophagus, in one case due to benign stricture, and in the other case due to circumferential tumor recurrence. Volume 153 Number 3

cleidomastoid esophageal

v = jugular arrowhead

sternovein; air in

lumen.
pharyngogram, lateral view of n dilated proximal neolumen; arrowheads benign

e.

Barium

neopharynx.
pharyngeal

stricture esophagus

at the junction.

neopharynx-cervical

CT Findings Recurrent

Mimicking Tumor

primary
ineopharyngeal

site.

In the

second

case,
mass

a perwas

soft-tissue

Two patients had CT findings that mimicked tumor recurrence. In one, internal jugular lymphadenopathy obliterated the fat planes about the stennocleidomastoid muscle and neunovascular bundle, as in the Group II cases. Biopsy, however, revealed metastatic adenocancinoma with no known

thought to represent metastatic disease (Fig. 4). At surgery, however, it was found to be an abscess with no focus of malignancy. In both of these patients, the neopharyngeal lumen was distended with air (Fig. 4). Barium examination revealed strictures of the neopharynx or cervical esophagus in both cases. Radiology 715

#{149}

Figure

e.

a. b.

C.

d.

e. f.

g.

Necrotic internal jugular lymph node metastasis obliterating adjacent fat planes. Note the rim of contrast enhancement. in metastasis; s sternocleidomastoid muscle; z jugular vein. Large necrotic internal jugular lymph node metastasis. In prospect, this was misinterpreted as internal jugular vein thrombosis. At surgery, the mass was compressing a small patent jugular vein. m metastasis; c carotid artery; S = sternocleidomastoid muscle; g submandibular gland; z neopharynx; 1 = internal jugular vein. Infiltrative enlargement of the sternocleidomastoid muscle. m neoplastic mass; s = sternocleidomastoid muscle; r smaller recurrent tumor adjacent to the neopharynx (n). Tumor recurrence obliterating the perineopharyngeal fat planes. Arrow neopharynx lumen with nasogastric tube; arrowhead large diverticulum of the neopharynx, extending caudally; in tumor surrounding the neopharynx. Tracheal tumor recurrence at tracheostome level. Arrowhead recurrent tumor; = esophagus. Tumor recurrence adjacent to the sternocleidomastoid muscle and neopharynx at cephalad aspect of tracheostome. m malignant mass; s sternocleidomastoid muscle; z neopharynx. Mediastinal tumor recurrence. in = malignant mass adjacent to the trachea.

g.

DISCUSSION
Symmetry of neck structures pro-

cheostome level. The penineopharyngeal fat most often had a higher

normal attenuation value, which

than
we

neopharynx bias, since

likely would

probably central
be

reflects selection tumor recurrence

obvious on barium

vides a convenient starting point in CT evaluation after total laryngectomy. Consequently, in patients who have not had a modified or radical neck
dissection, fat planes about the neo-

ascribed
viously, should

to postsurgical
a frank mass raise suspicion

change.
in these of tumor

Obregions recur-

nence. Residual
tomy is for manifest T-3

tumor
on

pharynx, sternocleidomastoid muscles, and neurovascular bundles should be essentially preserved bilaterally. Exceptions, as defined by the five normal volunteers, were blurring of the penneopharyngeal fat planes at the level of the base of the tongue and of the fat plane between the sternocleidomastoid muscle and the neck vessels at the tra716 Radiology

after total laryngecT-4 lesions reportedly

local recurrence (in-

as

cluding stomal recurrence) in 55% of cases, and local nodal disease in 65% (7). In our study, recurrent tumor generally involved the internal jugular
lymph nodes (63%), on the stomal on

penistomal region (45%). The of cases of recurrence centered

absence in the

examination or mirror examination, and thus may not be evaluated by CT. In the 1 1 patients with tumor recurnence, masses effacing the fat planes about the neopharynx, neunovasculan bundles, on stennocleidomastoid musdes (often with infiltrative enlargement of the muscle) provided a reliable sign of metastases involving the intennal jugular lymph nodes. In view of the proximity of these nodes to the neck vessels, we now routinely use a
bolus-dnip technique of intravenous

.4

#{149}

December

1984

contrast
laryngectomy

enhancement
patients,

(4)
to

in

all

assess

postvas-

tients

with

postoperative

dysphagia

Figure

culan invasion better. At the level of the tracheostome, inregular thickening of the tracheal wall and penistomal soft tissue, along with peritracheal soft-tissue masses, were reliable signs of recurrence. The necessity of obtaining scans at and below tracheostomy level was borne out by the five instances of tracheal and peristomal tumor, as well as by the two examples of superior mediastinal metastases. In the latter circumstance, CT

but no demonstrable rence. In view of its ability

normal anatomy,

tumor

recur-

to distinguish

from pathologic postoperative as well as to assess the most

frequent sites of recurrent well suited to evaluation after total laryngectomy.

tumor, CT is of patients

obviated attempts at surgical cure and aided in delineation of radiation thenapy portals. In the two cases in which abscess and metastatic adenocarcinoma mimicked tumor recurrence, masses were noted in the internal jugular lymph node or penineopharyngeal regions. Even in retrospect, no distinguishing features allowed differentiation from metastatic
squamous-cell history might carcinoma . Clinical aid in diagnosing ab-

Dennis M. Balfe, M.D. Mallinckrodt Institute Washington University 510 South Kingshighway St. Louis, MO 63110

of Radiology School of Medicine

References
1. Jung TI, Adams GL. Dysphagia in laryngectomized patients. Otolaryngol Head Neck Surg 1980; 88:25-33. Balfe DM, Koehler RE, Setzen M, Weyman PJ, Baron RL, Ogura JH. Barium examination of the esophagus after total laryngectomy. Radiology 1982; 143:501-508. Harnsberger HR. Mancuso AA, Muraki AS, Parkin JL. The upper aerodigestive tract and neck: CT evaluation of recurrent tumors. Radiology 1983; 149:503-509. Mancuso AA, Harnsberger HR. Muraki AS, Stevens MH. Computed tomography of cervical and retropharyngeal lymph nodes: Normal anatomy, variants of normal, and applications in staging head and neck cancer. Part II: Pathology. Radiology 1983; 148: 715-723.

Perineopharyngeal crotic metastasis. lumen, distended ture.

abscess abscess; as a result

mimicking
ii

a nestric-

neopharynx

of a distal

5.

2.

6.

scess, while biopsy would be necessary to exclude nonsquamous metastases. While no controlled trial with companison barium examinations was done, CT demonstration of a dilated neopharyngeal lumen without a sunrounding mass correlated with benign postoperative stricture in six patients.
This finding may be important in pa-

3.

7.

4.

8.

DiSantis DJ, Balfe DM, Hayden R, Sessions D, Sagel 55. The neck after vertical hemilaryngectomy: computed tomographic study. Radiology 1984; 151:683-687. Archer CA, Sagel 55, Yeager VL, Martin 5, Friedman WH. Staging of carcinoma of the larynx: comparative accuracy of CT and laryngography. AJR 1981; 136:571-575. Sagel 55. AufderHeide JF, Aronberg DJ, Stanley RJ, Archer CR. High resolution computed tomography in the staging of carcinoma of the larynx. Laryngoscope 1981; 91:292-300. Brandenburg JH, Rutter SW. Residual carcinoma of the larynx. Laryngoscope 1977; 87:224-236.

Volume

153

Number

Radiology

#{149}

717