1. Pamies Guilabert J, Braun P 1, Ballesta M, Collado D 2, Moreno V. 1 Department of Radiology. Hospital de la Plana, Vila-real, Spain 2 Department of Otolaryngology. Hospital La Fe, Valencia, Spain Department of Radiology UNIVERSITARY HOSPITAL “LA FE” VALENCIA SPAIN Larynx and Hypopharynx Anatomy TNM staging

2. ANATOMY OF THE LARYNX 1.Hyoid bone 2.Epiglottis 3.Hyoepiglottic ligament 4.Thyrohyoid membrane 5.Thyroid cartilage 6.Arytenoid cartilage 7.Cricoid cartilage 8.Cricothyroid membrane or conus elasticus 9.Trachea 10.Pre-epiglottic fat 1 1 2 2 3 4 4 5 5 6 7 7 8 8 9 9 3 Sobotta SKELETON 10

3. Subglottis Glottis Supraglottis REGIONS OF THE LARYNX Sobotta ANATOMY OF THE LARYNX

4. FAT SPACES OF THE LARYNX Invasion of these fat spaces has significant surgical implications, therefore, its evaluation must be part of any radiologic analysis ANATOMY OF THE LARYNX Paraglottic fat Pre-epiglottic fat

5. A. Laryngoscopic image. B. MDCT allows us to evaluate in detail the complex laryngeal anatomy. GLOTTIC AREA 1.Anterior commissure 2.Vocal cord 3.Posterior commissures 1 A B 1 2 2 3 3 3 1 2 3 Parts of the glottic area

6. 65-70 % of all laryngeal cancers 65-70 % of all laryngeal cancers Provokes symptoms early: Provokes symptoms early: Hoarseness: the most frequent Hoarseness: the most frequent There is no lymphatic tissue in the glottic region  Adenopathies uncommon There is no lymphatic tissue in the glottic region  Adenopathies uncommon Staging: TNM T1 - Tumor limited to the vocal cord(s), which may involve anterior or posterior commissure with normal mobility T1a: Tumor limited to one vocal cord T1b: Tumor involves both vocal cords Glottic cancer

7. Staging: TNM T2 : Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility T3 : Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex)  8 % adenopathies  30% adenopathies T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Glottic cancer

8. 30% of all laryngeal cancers 30% of all laryngeal cancers Provokes symptoms later: Provokes symptoms later: Dysphagia Dysphagia Dyspnea Dyspnea Sore throat Sore throat Referred otalgia Referred otalgia Hoarseness Hoarseness Lump in neck * Lump in neck * Lymphatic tissue present  Adenopathies common* Lymphatic tissue present  Adenopathies common* SUBSITES OF THE SUPRAGLOTTIS 1.Ventricular bands (false cords) 2.Arytenoids 3.Suprahyoid epiglottis 4.Infrahyoid epiglottis 5.Aryepiglottic folds (laryngeal aspect) 1 2 3 4 5 Supraglottic cancer 3 4 5 1 2

9. T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, or medial wall of pyriform sinus) without fixation of the larynx T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex) T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging: TNM Supraglottic cancer

10. T1: Tumor limited to the subglottis T2: Tumor extends to vocal cord(s) with normal or impaired mobility T3: Tumor limited to larynx with vocal cord fixation < 5% of all laryngeal cancers < 5% of all laryngeal cancers Usually, diagnosis in advanced stage with vocal cord involvement Usually, diagnosis in advanced stage with vocal cord involvement T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Subglottic cancer Staging: TNM

11. About four-times less common than laryngeal cancer. About four-times less common than laryngeal cancer. Provokes symptoms later: Provokes symptoms later: Dysphagia Dysphagia Chronic sore throat Chronic sore throat Foreign body sensation Foreign body sensation Referred otalgia Referred otalgia Lump in neck * Lump in neck * Lymphatic tissue present  Adenopathies common* Lymphatic tissue present  Adenopathies common* SUBSITES OF THE HYPOPHARYNX 1.Pyriform sinus 2.Posterior pharyngeal wall 3.Postcricoid area 3 1 2 Hypopharynx cancer

12. T1: Tumor limited to one subsite of the hypopharynx and 2 cm or less in greatest dimension T2: Tumor invades more than one subsite of the hypopharynx or an adjacent site, or measures more than 2 cm but 4 cm or less in greatest diameter without fixation of hemilarynx T3: Tumor measures more than 4 cm in greatest dimension or with fixation of hemilarynx Staging: TNM T4a: Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissue, which includes prelaryngeal strap muscles and subcutaneous fat T4b: Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures Hypopharynx cancer

13.  N0 No regional lymph node metastasis  N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm  N2 Metastasis lymph node > 3 cm and ≤ 6 cm  N2a Single ipsilateral adenopathy > 3 cm but ≤ 6 cm  N2b Multiple ipsilateral adenopathies ≤6 cm  N2c Bilateral or contralateral adenopathies ≤ 6 cm  N3 Metastasis lymph node >6 cm Regional lymph nodes, N stage Neck cancer Staging: TNM

14. Level I: Ia: Submental nodes Ib: Submandibular nodes Level II: Upper internal jugular nodes IIa: Anterior to the spinal accessory nerve (SAN) IIb: P osterior to the SAN Level III: Middle jugular nodes Level IV: Low jugular nodes Level V: P osterior triangle Va: A ccessory spinal - superior half Vb: A ccessory spinal - inferior half Level VI: Upper visceral nodes Level VII: Superior mediastinal nodes Level system of lymph node classification