A Possible Mechanism of Laryngohyoid Fractures in Hanging: A Preliminary Observation.

ABSTRACT: Fractures of the hyoid bone, particularly the greater horns, and thyroid cartilage (superior horns) are known to be associated with hanging deaths. Depending on the literature, the frequency of these fractures varies from 0% to 83%. The mechanism underlying these fractures is believed to be direct compression or indirect traction from the ligature. The relationship of these structures with the cervical spine cannot be visualized with traditional internal examination, due to obstruction by surrounding soft tissue. Postmortem computed tomography scan offers an unobscured view of the relationship of the laryngohyoid structures with the cervical spine.We aim to illustrate the phenomenon of displacement of the laryngohyoid structures associated with fractures of the horns. In our case reports, the laryngohyoid structures were displaced, not only superiorly and posteriorly, but also in 2 of the cases, by tilting, when the suspension point was at the posterior or posterolateral aspect of the neck. This displacement had caused the greater horns of the hyoid bone and superior horns of the thyroid cartilage to be approximated against the cervical spine, particularly the transverse processes. We believe that, in these circumstances, the fractures were caused by pressure of the horns of the laryngohyoid structures against the cervical spine.

Thyroid cartilage infiltration in advanced laryngeal cancer: prognostic implications and predictive modelling.

Objective: Detection of laryngeal cartilage invasion is of great importance in staging of laryngeal squamous cell carcinoma (LSCC). The role of prognosticators in locally advanced laryngeal cancer are still widely debated. This study aimed to assess the impact of volume of thyroid cartilage infiltration, as well as other histopathologic variables, on patient survival. Materials and methods: We retrospectively analysed 74 patients affected by pT4 LSCC and treated with total laryngectomy between 2005 and 2021 at the Department of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia, Italy. We considered as potential prognosticators histological grade, perineural (PNI) and lympho-vascular invasion (LVI), thyroid cartilage infiltration, and pTN staging. Pre-operative CT or MRI were analysed to quantify the volume of cartilage infiltration using 3D Slicer software. Results: The 1-, 3-, and 5-year disease free survivals (DFS) were 76%, 66%, and 64%, respectively. Using machine learning models, we found that the volume of thyroid cartilage infiltration had high correlation with DFS. Patients with a higher volume (>670 mm3) of infiltration had a worse prognosis compared to those with a lower volume. Conclusions: Our study confirms the essential role of LVI as prognosticator in advanced LSCC and, more innovatively, highlights the volume of thyroid cartilage infiltration as another promising prognostic factor.

Assessment of thyroid cartilage ossification pattern in cancer patients: A suggestion of active ossification by tumor progression.

BACKGROUND: Ossified cartilage is much more susceptible to cancer infiltration, but the reason remains unknown, and the relationship between the ossification pattern and cancer infiltration has not been studied. METHODS: The presence of thyroid cartilage ossification, cancer infiltration, ossification pattern (usual: direction from inferior to superior; unusual: other than the usual pattern), and distance between cancer and ossified cartilage were evaluated in laryngectomy specimens. RESULTS: There were 28 and 27 cases of usual and unusual patterns, respectively. There was no association between ossification pattern and cancer infiltration. However, the distance between the ossified area and cancer cells was greater in the usual pattern than in the unusual pattern (p = 0.006). And the usual pattern was more frequently observed in cases with a distance >1 mm than in cases with cancer infiltration or a distance ≤1 mm (p = 0.004). CONCLUSION: These results suggest the possibility of an active ossification due to tumor progression.

Chondrosarcoma of the thyroid cartilage: surgical management of a rare case.

Laryngeal malignancy encompasses about 1% of all cancers. Chondrosarcoma in the head and neck region represents about 0.1% of head and neck malignancies. Typical presenting symptoms relate to the anatomical location of these tumours and include dysphonia, inspiratory stridor, dysphagia, odynophagia or a neck mass. Benign and malignant cartilaginous cancers of the larynx have been described, and preoperative diagnosis can be difficult. Our report highlights the surgical management of a male patient in his 50s with chondrosarcoma of the thyroid cartilage.

The Multidisciplinary Approach for the Diagnosis of Laryngohyoid Lesions: a Systematic Literature Review and Meta-Analysis.

Background: The diagnosis of neck lesions remains a medico-legal diagnostic challenge because of the complexity of the anatomical relationship of the neck's organs and their anthropometric morphological variability. We compared the multidisciplinary approach using autopsy and postmortem computed tomography (PMCT), postmortem fine preparation (PMFP), postmortem micro-computed tomography (micro-CT), and postmortem magnetic resonance (PMMR) with the performance of a single diagnostic method among them evaluating the significance of different results. The multidisciplinary approach significantly reduced the number of unidentified neck lesions. The analysis demonstrates the need to better define the scan protocols and compose forensic guidelines for radiological application. The results of this study point out the need to compare the different diagnostic approaches in deceased subjects to better define the radiological scan protocol based on a multidisciplinary approach, including autopsy and radiological methods and the radiological scan protocols. Methods: We performed a systematic electronic search of retrospective scientific articles in PubMed, the Scopus database, and the Cochrane Library. The following combinations of words were used: "hyoid fracture"; "comparison between PMCT AND autopsy"; "hyoid fracture PMCT AND autopsy"; "hyoid bone fracture AND forensic imaging"; "hyoid fracture AND PMCT"; "neck fracture PMCT AND autopsy"; "laryngohyoid lesions"; "postmortem CT AND autopsy in strangulation"; "postmortem AND strangulation Signs "; "strangulation virtopsy"; and "strangulation AND MRI". We selected 16 articles that were published between March 2003 and June 2020. We conducted a meta-analysis with R software to evaluate the rates. We obtained related confidence intervals and a forest plot. Results: Thyroid cartilage damages were significantly more common than hyoid bone fractures (61.7% vs 42.2%) in a sample of 128 subjects. The synergic uses of autopsy/PMCT, autopsy/PMFP, autopsy/microCT, and autopsy/PMMR revealed significantly higher rates than a single investigation. We analyzed the PMCT scan data. The scan parameters evaluated were as follows: row, scan sample, reconstruction, kernel, slice thickness, kVp, and mAs. A lack of uniformity in the application of the protocol was observed. Conclusion: Further studies are needed to better define the radiological scan protocols and to draw guidelines to identify the appropriate radiological methods in relation to the specific case.

Laryngeal function-preserving of frontolateral vertical partial laryngectomy (FLVPL) for selected T4a glottic cancer with thyroid cartilage invasion adherence to the anterior commissure: an innovative attempt.

OBJECTIVE: To evaluate the feasibility and efficacy in selected T4a glottic cancer (thyroid cartilage invasion adherence to the anterior commissure) treated with frontolateral vertical partial laryngectomy (FLVPL) and laryngeal framework reconstruction using titanium mesh. METHODS: Six patients with the limited T4a glottic cancer with thyroid cartilage destruction adherence to the anterior commissure, underwent FLVPL from 2009 to 2016 in Sun Yat-Sen University Cancer Center. All patients were followed up postoperatively. RESULTS: All patients comprised radical tumor resection and favorable functional outcomes, and no aspiration and laryngeal stenosis were observed. According to postoperative pathology, four patients should go through postsurgical radiotherapy with a mean dose of 66 Gy. But one of them refused to undergo postoperative radiotherapy, who observed local recurrence in postcricoid area underwent total laryngectomy (TL) and ipsilateral selected neck dissection in post-surgery two year. During follow-up period, all patients were still alive, and five patients without local recurrence and distant metastases. CONCLUSION: FLVPL and laryngeal framework reconstruction using titanium mesh is one viable surgical procedure to obtain adequate oncologic and functional outcomes.

Application of digital modeling and three-dimensional printing of titanium mesh for reconstruction of thyroid cartilage in partial laryngectomy.

BACKGROUND: Digital modeling and three-dimensional (3D) printing techniques have been used to assist the resection of the laryngeal lesions and repair the remnant larynx in glottic cancer patients with anterior commissure involvement. AIMS/OBJECTIVES: To evaluate the feasibility of digital modeling and 3D printing of titanium mesh for thyroid cartilage reconstruction in partial laryngectomy, and compare the advantages and disadvantages with crico-hyoido-epiglottopexy (CHEP). MATERIAL AND METHODS: Forty-four glottic cancer patients with anterior commissure involvement were randomly assigned into group A and group B. The digital modeling and 3 D printing were used for patients in group A, and patients in group B underwent the modified CHEP. RESULTS: In group A, 10 patients underwent tracheotomy and tracheal tube was removed after 2 weeks. All the patients were discharged within 10 d after surgery, and the majority of them had a satisfactory level of pronunciation. In group B, the majority of the patients were discharged 2 - 3 weeks after surgery with a moderate level of pronunciation. CONCLUSIONS AND SIGNIFICANCE: The proposed surgical method, employing digital modeling and 3D printing to facilitate resection of laryngeal lesions and reconstruction of residual larynx, exhibited to be beneficial for accurate reconstruction of thyroid cartilage and soft tissues.

Giant cell tumor of thyroid cartilage: A diagnostic dilemma on aspiration cytology.

Giant cell tumor of the larynx is an uncommon entity with only 44 cases reported in the literature. These tumors occur most commonly in the epiphysis of the long bones of female patients in third decade. Here in we report a case of 23 years old male patient who presented with an anterior neck swelling since past 4 months. Ultrasound and computed tomography of neck revealed a heterogenously enhancing lesion involving posteroinferior half of right thyroid cartilage with extension into the extra laryngeal strap muscle and intralaryngeal right true vocal cord and false vocal cord. The findings were suggestive of a neoplastic cartilagenous lesion. A fine needle aspiration of the right anterior neck mass was performed which showed many mononuclear cells along with multinucleated osteoclast type giant cells. No thyroid follicular cells or inflammatory cells were seen. A diagnosis of giant cell tumor of the thyroid cartilage was rendered on cytology. A biopsy was subsequently performed for the patient which confirmed the same. Hence, although giant cell tumor of the larynx is a rare entity, with very few cases reported in the literature, these tumors should be included in the differential diagnosis of giant cell lesions of the neck and aspiration cytology can offer an accurate and quick diagnosis in such cases.

Laryngeal Chondrosarcoma of the Thyroid Cartilage.

Laryngeal chondrosarcoma is rare and accounts for 0.2% of all larynx malignancies. Although chondrosarcoma is the most common sarcoma seen in the larynx, laryngeal involvement by cartilage tumors is rare. In this article, we aimed to present the differential diagnosis of chondrosarcoma located in the thyroid cartilage, which is a rare site, in a 75-year-old male patient. The patient underwent total laryngectomy by the otolaryngology department. The macroscopy of the laryngectomy material sent to the pathology laboratory revealed a 3x2 cm tumor with a polypoid extension to the lumen from the bottom of the right vocal cord. Although clinical and radiological findings are important in the diagnosis, the definite diagnosis is based on the pathological examination. It is especially important to differentiate the lesion from chondromas.

Two Different Tracts and Origin of Pyriform Sinus Fistula.

OBJECTIVE: Suppurative acute thyroiditis is caused by pyriform sinus fistula (PSF), and PSF frequently elicits deep neck abscess. However, complete fistulectomy is the ideal management of PSF, and studies on surgical findings of PSF are exceedingly rare. This study aimed to reveal the origins of PSF, each route, and clinical presentation. METHODS: This is a multicenter study. We have conducted 19 complete fistulectomies of PSF in Japan, analyzed routes of the fistulas, estimated the origins, and investigated their histological and clinical findings. RESULTS: No recurrence was observed in all cases. Five of 12 cases showed thymic and/or parathyroid tissues around the fistulas, passing inside the inferior horn of thyroid cartilage, were regarded as having 3rd pouch origin, and tended to have low frequency of severe deep neck abscess. The remaining 7 cases originated from the 4th pouch running outside of the horn and showed frequent severe infection. CONCLUSION: PSF have 2 different routes depending on their generation and may present different clinical manifestations.

CT-based radiomics features in the prediction of thyroid cartilage invasion from laryngeal and hypopharyngeal squamous cell carcinoma.

BACKGROUND: Laryngeal and hypopharyngeal squamous cell carcinoma (LHSCC) with thyroid cartilage invasion are considered T4 and need total laryngectomy. However, the accuracy of preoperative diagnosis of thyroid cartilage invasion remains lower. Therefore, the purpose of this study was to assess the potential of computed tomography (CT)-based radiomics features in the prediction of thyroid cartilage invasion from LHSCC. METHODS: A total of 265 patients with pathologically proven LHSCC were enrolled in this retrospective study (86 with thyroid cartilage invasion and 179 without invasion). Two head and neck radiologists evaluated the thyroid cartilage invasion on CT images. Radiomics features were extracted from venous phase contrast-enhanced CT images. The least absolute shrinkage and selection operator (LASSO) and logistic regression (LR) method were used for dimension reduction and model construction. In addition, the support vector machine-based synthetic minority oversampling (SVMSMOTE) algorithm was adopted to balance the dataset and a new LR-SVMSMOTE model was constructed. The performance of the radiologist and the two models were evaluated with receiver operating characteristic (ROC) curves and compared using the DeLong test. RESULTS: The areas under the ROC curves (AUCs) in the prediction of thyroid cartilage invasion from LHSCC for the LR-SVMSMOTE model, LR model, and radiologist were 0.905 [95% confidence interval (CI): 0.863 to 0.937)], 0.876 (95%CI: 0.830 to 0.913), and 0.721 (95%CI: 0.663-0.774), respectively. The AUCs of both models were higher than that of the radiologist assessment (all P < 0.001). There was no significant difference in predictive performance between the LR-SVMSMOTE and LR models (P = 0.05). CONCLUSIONS: Models based on CT radiomic features can improve the accuracy of predicting thyroid cartilage invasion from LHSCC and provide a new potentially noninvasive method for preoperative prediction of thyroid cartilage invasion from LHSCC.

Is thyroid excision mandatory with laryngectomy in carcinoma larynx?

BACKGROUND: Advanced stage operable cancers of larynx are treated with total laryngectomy including thyroid resection in most of the cases, which may expose patient to hypothyroidism and hypoparathyroidism. The requirement of thyroidectomy during Total Laryngectomy is controversial. METHODS: A cross sectional observational study was set out to review preoperative clinical and radiological assessment; intraoperative and histopathological findings; and follow-up data to predict thyroid gland invasion in the setting of squamous cell carcinoma of the Larynx. RESULTS: 11 (16%) out of 69 patients had thyroid gland involvement on histopathological examination with mean age 63 years. Out of these 11 cases, 8 (72%) underwent primary total laryngectomy. 90% patients with thyroid gland involvement were male. 9 cases with thyroid gland involvement were staged as T4a preoperatively. CONCLUSION: Invasion of thyroid gland by laryngeal cancer is uncommon. Unnecessary hemithyroidectomies lead to hypothyroidism and hypoparathyroidism. The study points out the clear indications of thyroid excision in patients undergoing total laryngectomy. We can suggest that total thyroidectomy should be done with total laryngectomy in cases which have gross clinical, radiological or intraoperative thyroid gland involvement, subglottic extension and thyroid cartilage invasion. This can save the patients from the brunt of unnecessary morbid hypothyroidism and hypoparathyroidism.

Current role of computed tomography imaging in the evaluation of cartilage invasion by laryngeal carcinoma.

OBJECTIVES: To evaluate thyroid, arytenoid, and cricoid cartilage invasion on computed tomography (CT) imaging in patients undergoing total laryngectomy for both primary and recurrent laryngeal carcinoma. Secondary endpoint was to compare laryngeal cartilage invasion between primary and recurrent tumours. METHODS: Pre-treatment CT of 40 patients who had undergone total laryngectomy was retrospectively evaluated and compared with histology. Focal erosions of thyroid cartilage were accounted for neoplastic invasion of the inner cortex. Full-thickness thyroid cartilage invasion was defined as a tumour-like tissue replacing thyroid cartilage or extended in extra-laryngeal soft tissues. Sclerosis and erosion of arytenoid and cricoid cartilages were assessed as signs of neoplastic invasion. RESULTS: CT erosion showed perfect agreement for thyroid inner cortex and cricoid cartilage invasion and almost perfect agreement (87%) for arytenoid cartilage invasion. For tumours in contact with thyroid cartilages, the absence of CT erosion underestimated inner cortex infiltration. CT showed perfect agreement in predicting full-thickness thyroid cartilage invasion only in the case of extra-laryngeal neoplastic extension. Arytenoid sclerosis showed poor correlation with neoplastic invasion. For primary tumours, CT demonstrated good (inner cortex 75%; full-thickness 85%), substantial (67.5%), and perfect (100%) accuracy in thyroid, arytenoid, and cricoid cartilage invasion, respectively. No CT differences were observed between primary and recurrent laryngeal tumours. CONCLUSION: Tumour-like tissue extension in the extra-laryngeal soft tissues was accurate in predicting thyroid cartilage full-thickness invasion. Erosions of arytenoid, cricoid, and thyroid cartilages' inner cortex on CT were highly indicative of neoplastic infiltration. No CT difference in cartilage infiltration between primary and recurrent tumours was observed.

Postmortem Magnetic Resonance Imaging and Postmortem Computed Tomography in Ligature and Manual Strangulation.

PURPOSE: The aim of this study was to evaluate magnetic resonance imaging (MRI) findings in cases of fatal manual or ligature strangulation. Verification of strangulation by computed tomography (CT), MRI, and at autopsy as well as its detectability in each modality was assessed. METHODS: We retrospectively analyzed 6 manual and ligature strangulation cases between 2013 and 2019 who all underwent a whole-body CT, head and neck MRI, and an autopsy. Two radiologists examined head and neck imaging data and compared the data to autopsy findings. RESULTS: Magnetic resonance imaging showed a high efficiency in verifying intramuscular hemorrhages, which were confirmed in autopsy. Moreover, in one case without a visible strangulation mark, soft tissue injuries associated with strangulation were detected. Fractures, especially thyroid cartilage fractures, were successfully diagnosed by CT. CONCLUSIONS: As MRI showed a successful detection of soft tissue lesions in relation to strangulation, it can serve as an alternative method or provide additional value to an autopsy. Intramuscular hemorrhages are a common finding in manual and ligature strangulation, providing a useful sign of applied pressure on the neck. However, to evaluate fractures, an additional CT or autopsy is recommended.

The added value of postmortem magnetic resonance imaging in cases of hanging compared to postmortem computed tomography and autopsy.

The purpose of this study was to evaluate the added value of postmortem magnetic resonance imaging (MRI) compared to postmortem computed tomography (CT) and autopsy in cases of fatal hanging. In addition, the study analyzed the strengths of each examination method regarding typical injuries in these cases. We investigated a cohort of 25 decedents who underwent CT, MRI and autopsy. Two radiologists assessed all MR images of the head and neck as well as the corresponding CT images. The results were compared to autopsy findings by retrospectively analyzing the autopsy reports. Postmortem MRI revealed intramuscular hemorrhages in a large number of cases, however, autopsy did not confirm all of the detected hemorrhages. CT and autopsy detected fractures in several cases, whereas MRI showed a fracture in just one single case. Other previously described vital signs and relevant findings, such as fracture-related gas bubbles, soft tissue emphysema or pneumomediastinum, were observed in only a few individual cases. MRI provided added diagnostic value in the detection of soft tissue injuries and lymph node swelling in fatal hangings. As an adjunct to autopsy, postmortem MRI may reveal additional hemorrhages, which might be missed at autopsy. Since standard MRI demonstrated low sensitivity for the detection of fractures, an additional imaging modality or autopsy is required to overcome this limitation.

Recommended Practices for Macerating Human Thyroid Cartilage.

Visible abnormalities on the thyroid cartilage may be indicative of perimortem trauma including fractures or sharp force trauma. During autopsy, the thyroid cartilage must be freed of surrounding soft tissue before these abnormalities can be clearly observed. Several processing methods were first experimentally tested on pig ears to narrow down which might work best to process human thyroid cartilage. Several methods in the categories of hot water maceration, chemical/enzyme maceration, and dermestid beetles were then tested on a sample of 37 human thyroid cartilages. An adapted 22-point scoring system was used to score the efficacy of each processing method. Chemical maceration using bleach was found to be the best method for removing surrounding tissue from thyroid cartilage, with Arm & HammerTM powdered laundry detergent as a close second. These methods are inexpensive, quick, and easy to implement, making them a simple addition to busy medical examiner's offices or forensic anthropology laboratories.

Thyroid Cartilage Cysts, A Rare Entity Causing Dysphonia.

Five cases are presented with a strained voice quality due to a unique underlying cause: thyroid cartilage cysts. Laryngoscopy and radiological images show antero-medial displacement of both vestibular and vocal fold(s). Swelling in the ala of the thyroid cartilage results in a pear-shaped lumen. These cysts were marsupialized with CO2 laser, fluid emerged, and histological biopsies confirmed cartilaginous cysts. Postoperatively, all cases report largely reduced or completely resolved vocal complaints, with a consistent follow-up of 2 years. Together with previous publications, an overview of 17 cases is presented, to enhance awareness that thyroid cartilage cysts can cause a strained voice quality. Laryngoscope, 130:E628-E631, 2020.

Laryngeal Squamous Cell Carcinoma with Osteosarcomatous Differentiation and Involvement of Thyroid Cartilage Mimicking Sarcoma Arising from Thyroid Cartilage.

Basaloid squamous cell carcinoma (BSCC) with a spindle cell component of the head and neck is an uncommon entity. In this case, we present a radiology-pathology correlation of a rare laryngeal BSCC with sarcomatous transformation and osteosarcomatous differentiation involving the laryngeal cartilage, which thus mimicked clinically and radiographically osteosarcoma or chondrosarcoma with calcification. Microscopic examination revealed predominantly BSCC with extensive osseous metaplasia among sheets and nests of basaloid tumor cells. There were also small foci of osteosarcoma, undifferentiated pleomorphic sarcoma, and spindle cell carcinoma. The presence of squamous cell carcinoma (SCC) in-situ, small areas of conventional SCC and diffuse positivity of p40 in conventional and basaloid squamous components confirmed that this tumor was indeed derived from surface squamous epithelium. Awareness of the broad differentiation potentials of SCC can avoid misdiagnosis of SCCs as sarcoma. This case emphasizes the importance of radiologic-pathologic correlation in definitive diagnosis and clinical management of laryngeal malignancies.

Unusual extra-podal fungal mycetoma with black grains in a Senegalese child.

Mycetoma remains endemic in the tropical and subtropical regions of the "mycetoma belt" including Senegal. It affects more commonly young men in the age group of 20 to 40 years. The foot represents the most commonly affected site. The most common extra-podal localizations are leg, knee, buttocks, hand and arm. We report an exceptional case of cervical fungal mycetoma that occurred in a 13-year-old Senegalese child. He consulted for a cervico-submandibular tumefaction with multiple sinuses and black grains discharge evolving since 6 years, associated to laryngeal dyspnoea. Mycological examination with culture isolated Madurella mycetomatis. Cervical CT Scan showed bone and soft tissue invasion. Terbinafine alone was administered. During the evolution, tracheotomy was performed following the aggravation of the laryngeal disorders. Death from severe sepsis occurred after 8 months of evolution. The particularities of our case are the occurrence of fungal mycetoma in a child, the cervical localization and the difficulties of therapeutic management largely due to the diagnostic delay.