Figure 1
fig 1a
axial reformated ce-CT scan during \'e\' fonation demonstrates a tumoral lesion in the right piriform sinus.
Piriform sinus carcinoma
SectionHead & neck imaging
Case TypeClinical Cases
AuthorsDe Temmerman G. From the Department of Radiology and Nuclear Medicine, Sint Andriesziekenhuis, Tielt, Belgium
Connected authors
57 years, male
Clinical History
A 57 year old male was referred to our ENT-departement with a palpable swelling in the neck on the right side. Contrast-enhanced dynamic CT-scan revealed a tumoral lesion in the piriform sinus with
lymph node metastases and ingrowth in the laryngeal skeleton. Patient underwent surgical resection followed by radiation therapy.
Imaging Findings
A 57 year old male was referred to our ENT-departement with a palpable swelling in the neck on the right side. He had no significant clinical history except for alcohol abusus and tobacco smoking.
Clinical examination confirmed a swelling in the submandibular region (region II-III) on the right side. A contrast enhanced CT-scan of the head and neck was performed. Intitially the whole region
was scanned (from the skull base to the aortic arc) with quiet respiration followed by a short scan of the larynx (from the hyoid bone down to the upper part of the trachea) during 'e'-phonation. The
examination showed an enhancing mass lesion located in the piriform sinus with characteristic lymph node metastases on the same side. The lymph nodes showed a typical enhancing rim and a
non-enhancing (necrotic) center highly suggestive for malignancy. Puncture of the enlarged lymph nodes was done. Microscopic examination revealed squamous cell carcinoma. CT images in bone window
demostrated ingrowth of the tumour in the lamina of the thyroid cartilage. The patient underwent surgery followed by radiation therapy.
Discussion
In the head and neck region most tumours are squamous cell carcinomas (95%). Other tumours like lymphomas and adenocarcinomas are quite rare. Most tumours occur in the elderly with a definite male
preponderance. Causal factors are usually tobacco smoking and ethanol abusus. Patients with hypopharyngeal carcinoma are at risk for second primary tumours along the aerodigestive tract (field
cancerization) as well as for primary tumours in the lung. In the hypopharynx 3 distinct tumour sites are discerned : 1. piriform sinus (60%), 2. post-cricoid region (25%) and 3. posterior
hypopharyngeal wall (15%). Most tumours are seen originating from the piriform sinus probably because of stasis of carcinogens within this blind-ending pouch. The piriform sinus is a space between
the thyroid lamina on the lateral side and the aryepiglottic fold on the medial side. Embryologically the piriform sinus and the supraglottic area are similar as both have a rich vascular supply and
extensive lymphatic drainage which explains the frequently seen lymph node metastases at the time of diagnosis. Prognosis is hereby reserved. The infrahyoid neck can be studied by contrast-enhanced
dynamic CT-scan or by static MRI-scan. We prefer CT because due to the short acquisition time we can make an (additional) dynamic scan during 'e'-phonation. While 'e'-phonating the vocal cords adduct
and achieve a symmetric median position, the true and false cords can be better differentiated since the laryngeal ventricle is inflated. Also the piriform sinuses are inflated during 'e'-phonation.
During quiet respiration or apnea the mucosae of the larynx and hypopharynx are usually apposed and are undistinguishable from one another, small lesions are easily missed. The long acquisition time
of MRI sequences impedes dynamic sanning since no patient can hold 'e'-phonation for a couple of minutes. That is the reason we perform a CT-scan instead of an MRI. In this case we present a state of
the art CT-exam during 'e'-phonation which clearly demonstates the tumour and his extensions in the surrounding structures. We scan with 1mm collimation in order to ensure a high spatial resolution
in axial and coronal planes. A very short scan range namely from the hyoid bone down to the upper part of the trachea is programmed. An acquisition time of only 15 seconds is no problem for most
patients to hold the 'e'-phonation. For this second scan there is no need to give a second iv bolus because there is enough fat as intrinsic contrast and the tumour is still enhanced. We routinely
make this short second scan for all problems situated in the region of the larynx and hypopharynx. Please note : all pictures are taken from the additional dynamic scan. As we don't give a second iv
bolus for the second scan these images show less enhancement than in the first static pass.
Differential Diagnosis List
piriform sinus carcinoma with lymph node metastases
Final Diagnosis
piriform sinus carcinoma with lymph node metastases
References
[1] Philippe Henrot, MD, Alain Blum, MD, Bruno Toussaint, MD, Philippe Troufleau, MD, Joseph Stines, MD and Jacques Roland, MD. Dynamic Maneuvers in Local Staging of Head and Neck Malignancies with Current Imaging Techniques: Principles and Clinical Applications.Radiographics. 2003;23:1201-1213. (PMID: 12975510)
[2] Gourin CG, Terris DJ. Carcinoma of the hypopharynx. Surg Oncol Clin N Am. 2004 Jan;13(1):81-98. (PMID: 15062363)
[3] Pameijer FA, Mukherji SK, Balm AJ, van der Laan BF. Imaging of squamous cell carcinoma of the hypopharynx. Semin Ultrasound CT MR. 1998 Dec;19(6):476-91. (PMID: 9861665)
Case information
| URL: | https://www.eurorad.org/case/4930 |
| DOI: | 10.1594/EURORAD/CASE.4930 |
| ISSN: | 1563-4086 |
Figure 2
fig 1b
axial reformated ce-CT scan during \'e\'-fonation demonstrates a mass lesion in the right piriform sinus which cannot inflate. On the left side a normal inflated piriform sinus is nicely depicted.
Figure 3
fig 2a
coronal reformated ce-CT scan during \'e\' fonation at the level of the arytenoids demonstrates a tumoral lesion within the right priform sinus. A normal sinus is seen on the left side.
Figure 4
fig 2b
coronal reformated ce-CT scan during \'e\' fonation depicts an ulcerated tumoral lesion in the right piriform sinus. Note the lymph node metastasis in region III on the right side on the lateral side of the thyrohyoid membrane which is known as the primary lymph drainage site.
Figure 5
fig 3a
coronal reformated ce-CT scan during \'e\' fonation in bone window demonstrates ingrowth of the tumour in the thyroid lamina. Lymph node metastases are also nicely depicted on the lateral side of the thyrohyoid membrane.
Figure 6
fig 4a
drawing of the larynx while \'e\'-phonating. The true cords adduct (large grey arrow) and achieve a symmetric median position. The piriform sinus inflates (small black arrow).
Figure 7
fig 7a
normal coronal reformatted dynamic scan during \'e\'-phonation (other patient) showing symmetric inflation of the laryngeal ventricle with clear separation of the false and true vocal cords. Note also symmetric inflated piriform sinuses.
fig 1a
axial reformated ce-CT scan during \'e\' fonation demonstrates a tumoral lesion in the right piriform sinus.
fig 1b
axial reformated ce-CT scan during \'e\'-fonation demonstrates a mass lesion in the right piriform sinus which cannot inflate. On the left side a normal inflated piriform sinus is nicely depicted.
fig 2a
coronal reformated ce-CT scan during \'e\' fonation at the level of the arytenoids demonstrates a tumoral lesion within the right priform sinus. A normal sinus is seen on the left side.
fig 2b
coronal reformated ce-CT scan during \'e\' fonation depicts an ulcerated tumoral lesion in the right piriform sinus. Note the lymph node metastasis in region III on the right side on the lateral side of the thyrohyoid membrane which is known as the primary lymph drainage site.
fig 3a
coronal reformated ce-CT scan during \'e\' fonation in bone window demonstrates ingrowth of the tumour in the thyroid lamina. Lymph node metastases are also nicely depicted on the lateral side of the thyrohyoid membrane.
fig 4a
drawing of the larynx while \'e\'-phonating. The true cords adduct (large grey arrow) and achieve a symmetric median position. The piriform sinus inflates (small black arrow).
fig 7a
normal coronal reformatted dynamic scan during \'e\'-phonation (other patient) showing symmetric inflation of the laryngeal ventricle with clear separation of the false and true vocal cords. Note also symmetric inflated piriform sinuses.