AJR 2003; 180:207-211
© American Roentgen Ray Society
Epiglottic Carcinoma as a Cause of Laryngeal Penetration and Aspiration
Andrew Mong1,
Marc S. Levine,
Stephen E. Rubesin and
Igor Laufer
1 All authors: Department of Radiology, Hospital of the University of
Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
Received May 22, 2002;
accepted after revision July 9, 2002.
Address correspondence to M. S. Levine.
Abstract
OBJECTIVE. The purpose of our investigation was to review a series
of patients with epiglottic carcinoma to elucidate the clinical and
videofluoroscopic findings in these individuals.
CONCLUSION. Patients with epiglottic carcinoma often present with
symptoms of aspiration or pharyngeal dysphagia of relatively brief duration in
the absence of a preexisting neurologic disease. In this clinical setting,
barium studies are useful not only for detecting the epiglottic carcinoma but
also for delineating the presence and mechanism of laryngeal penetration or
tracheobronchial aspiration.
Introduction
Aspiration may be recognized on clinical grounds by a variety of signs or
symptoms, including choking or coughing during swallowing, chronic cough, and
recurrent pneumonia [1]. The
correct diagnosis often is apparent in patients with a history of stroke,
dementia, or other neurologic conditions in whom there is a temporal
relationship between the development of neurologic dysfunction and the onset
of symptoms of aspiration. However, we have encountered patients with no
preexisting neurologic disease who developed clinical signs of aspiration
because of underlying epiglottic carcinoma. To our knowledge, neither the
clinical presentation of these patients nor the findings on barium studies of
the pharynx have been adequately addressed in the radiology literature. The
purpose of this investigation therefore was to review a series of patients
with epiglottic carcinoma to elucidate the clinical and videofluoroscopic
findings in these patients.
Materials and Methods
A computerized search of radiology files at our university hospital from
1995 to 2001 and a manual search of files at our affiliated Veterans
Administration Hospital from 1993 to 2001 revealed 21 patients with definite
or probable epiglottic carcinomas that had been detected on videofluoroscopic
examinations of the pharynx. Eleven of these 21 patients were excluded from
our analysis for one or more of the following reasons: lack of availability of
the original spot images or radiography reports from the videofluoroscopic
examinations, lack of availability of clinical records to document the
clinical findings, lack of proof of epiglottic carcinoma in surgical or biopsy
specimens, and a prior history of pharyngeal surgery or radiation treatment of
the pharynx. The remaining 10 patients with pathologically proven epiglottic
carcinoma constituted our study group.
All 10 patients underwent videofluoroscopic imaging of the pharynx on
conventional fluoroscopy equipment (400-speed RFXII; General Electric Medical
Systems, Waukesha, WI) or digital fluoroscopy equipment (Diagnost 76 Plus;
Philips, Eindhoven, The Netherlands). The examinations included spot images
and video recordings of the pharynx and cervical esophagus in frontal and
lateral and, when necessary, oblique projections as the patient swallowed a
250% weight per volume barium suspension (E-Z-HD; E-Z-EM, Westbury, NY),
followed by a 50% weight per volume barium suspension (Entrobar; Lafayette
Pharmaceuticals, Lafayette, IN). The spot images of the pharynx were obtained
routinely during both suspended respiration and maneuvers to distend the
pharynx, including phonation with the vowel sound "eee" and a
modified Valsalva maneuver (blowing through closed or pursed lips) with the
patient in the frontal and lateral positions.
The spot images from these examinations were reviewed jointly by two
experienced gastrointestinal radiologists to determine the morphologic
features of the epiglottic tumors, including the size, predominant pattern of
growth (polypoid or infiltrative), presence or absence of ulceration, and
extent of laryngeal and pharyngeal involvement. Because the videocassettes
from these studies were not stored on a long-term basis, we had to rely on the
descriptions of the swallowing function from the original radiography reports
to determine the presence or absence of laryngeal penetration or
tracheobronchial aspiration (which could also be assessed indirectly by the
presence or absence of barium in the larynx or trachea on the spot images), as
well as the mechanism of penetration or aspiration in these patients. In nine
patients, additional double-contrast images of the thoracic esophagus were
obtained to evaluate the presence or absence of synchronous esophageal tumors.
In the remaining patient, the examination was terminated without evaluation of
the thoracic esophagus because of the degree of aspiration.
Clinical data (including the presenting findings and duration of symptoms)
were obtained from the medical records in all cases. The histopathologic
findings were obtained from pathology reports of the surgical or biopsy
specimens. When follow-up data were available, treatment regimens and patient
outcomes were also noted.
Our institutional review board approved all aspects of this retrospective
study and did not require informed consent from any patients whose records
were included in our study.
Results
Clinical Findings
The mean patient age was 57.6 years (range, 44-75 years). All the patients
were men. Four patients (40%) presented with pharyngeal dysphagia, two (20%)
with choking or coughing during swallowing, two (20%) with pharyngeal
dysphagia and choking or coughing during swallowing, one (10%) with a sore
throat, and one (10%) with dyspnea on exertion. The mean duration of symptoms
was 9 weeks (range, 2-24 weeks). Seven patients (70%) had associated weight
loss (range, 14-30 lb [6-13 kg]; mean weight loss, 23 lb [10 kg]), including
three (75%) of four with symptoms of aspiration. All 10 patients (100%) had a
history of cigarette smoking (mean, 57 pack years; range, 11-120 pack years),
and all had a history of alcohol consumption. One patient (10%) had a remote
history of stroke more than 10 years earlier. The other nine patients (90%)
had no history of stroke, dementia, or other neurologic conditions known to be
associated with the development of aspiration. In seven patients (70%), the
diagnosis of epiglottic carcinoma was not yet known at the time of the barium
study.
Radiographic Findings
The epiglottic cancers were characterized on videofluoroscopic imaging of
the pharynx as polypoid in seven patients (70%) (Figs.
1A,1B
and
2A,2B)
and as infiltrative in three (30%) (Fig.
3). Two of the polypoid lesions contained areas of ulceration. The
tumors had a mean length of 4 cm (range, 1-8 cm). The tumors predominantly
involved the tip of the epiglottis in seven patients, the base of the
epiglottis in one, and the entire epiglottis in two. These supraglottic tumors
also involved the aryepiglottic folds in five patients, the base of the tongue
in five, the valleculae in five, and the arytenoids in two.
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Fig. 1B. —75-year-old man with epiglottic carcinoma. Lateral spot image
of pharynx from pharyngoesophagogram during swallowing shows epiglottic mass
(solid straight arrows) extending inferiorly to level of anterior
commissure (open arrow). Also note penetration of barium into larynx
and associated aspiration into proximal trachea (curved arrow). This
patient had such a bulky mass involving epiglottis that the mass lodged
against posterior wall of pharynx during swallowing, preventing epiglottic
tilt.
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Fig. 2B. —50-year-old man with epiglottic carcinoma. Frontal spot image
of pharynx from pharyngoesophagogram also shows polypoid mass
(arrows) extending superiorly from region of epiglottis. Although
this lesion involved epiglottis, patient had no laryngeal penetration or
aspiration.
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Fig. 3. —50-year-old man with epiglottic carcinoma. Lateral spot image
of pharynx from pharyngoesophagogram during phonation shows infiltrative tumor
(straight arrows) expanding both vallecular and vestibular surfaces
of epiglottis and extending inferiorly toward anterior commissure (open
arrow). Also note small amount of aspirated barium (curved
arrow) in proximal trachea.
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Nine (90%) of the 10 patients with epiglottic cancer had laryngeal
penetration during swallowing, and seven (70%) had subsequent tracheobronchial
aspiration (Figs. 1B and
3). Seven (77%) of the nine
patients with penetration or aspiration had decreased epiglottic tilt as a
result of tumor involving the epiglottis. In two of these patients, the mass
involving the epiglottis was so bulky that the mass lodged against the
posterior pharyngeal wall during swallowing, preventing further epiglottic
tilt (Fig. 1B). In the
remaining two patients with penetration or aspiration, no information about
epiglottic tilt was given in the radiography reports. Finally, one patient
(10%) had no evidence of laryngeal penetration or tracheobronchial aspiration
on videofluoroscopy (Fig.
2A,2B).
No synchronous esophageal tumors were identified in any of the nine
patients in whom additional images of the thoracic esophagus were
obtained.
Treatment and Clinical Follow-Up
All 10 patients had squamous cell carcinomas of the epiglottis at biopsy
(eight patients) or surgical (two patients) specimens. Treatment included
total laryngectomy in one patient, radiation therapy in two, total
laryngectomy and radiation therapy in one, and radiation therapy and
chemotherapy in three. Two other patients were newly diagnosed and had not yet
received treatment, and the remaining patient refused treatment. Of the six
patients with follow-up, two had died and four were alive an average of 9.2
months (range, 2-16 months) after the time of diagnosis.
Discussion
Aspiration is a frequent problem in elderly patients because of swallowing
dysfunction related to neurologic conditions affecting the cerebral cortex,
including stroke, dementia, and demyelinating diseases
[2], but aspiration may also be
caused by neuropathies, myopathies, and diseases affecting the neuromuscular
junction [1]. Although some
patients have classic symptoms of aspiration, such as choking or coughing
during swallowing, others may bevelop less specific signs of aspiration, such
as chronic cough or recurrent pneumonias
[1]. Most of these patients
have chronic symptoms of aspiration, which are temporally related to the onset
of an identifiable neurologic disease
[2]. This temporal relationship
usually alerts the clinician to the cause of swallowing dysfunction in these
individuals.
Less commonly, aspiration can occur as a result of structural lesions of
the pharynx, such as carcinoma of the larynx, in the absence of preexisting
neurologic disease [3].
However, little attention has been focused in the radiology literature on the
association between aspiration and epiglottic carcinoma. In our study, four
(40%) of 10 patients with epiglottic carcinoma presented with symptoms of
aspiration because a tumor involving the epiglottis prevented normal
epiglottic tilt during swallowing. Although one patient had a remote history
of stroke, the other nine had no preexisting neurologic conditions known to be
associated with the development of aspiration. Also, the mean age of our
patients was 57.6 years, a younger age than would typically be expected for
patients to be aspirating as a result of stroke, dementia, or other neurologic
conditions. Unlike elderly patients in whom symptoms of aspiration tend to be
chronic, our patients with epiglottic carcinoma were symptomatic for a mean
duration of only about 2 months. Seven patients also had weight loss, and all
10 had a history of cigarette smoking and alcohol consumption, known risk
factors for the development of head and neck tumors, including epiglottic
carcinoma [4]. The possibility
of epiglottic cancer therefore should be considered in patients with symptoms
of aspiration of relatively brief duration who have associated weight loss or
a history of tobacco or alcohol consumption in the absence of a preexisting
neurologic disease.
When patients have clinical signs of aspiration, videofluoroscopy of the
pharynx is frequently performed to document the presence or absence of
laryngeal penetration or tracheobronchial aspiration and the mechanism of
swallowing dysfunction in these individuals
[5]. In our study, nine (90%)
of 10 patients with epiglottic carcinoma had laryngeal penetration, and seven
(77%) of these nine patients had decreased epiglottic tilt as a result of
tumor involving the epiglottis (Figs.
1B and
3).
A high index of clinical suspicion is paramount in patients with epiglottic
or other supraglottic carcinomas because delayed detection of these lesions
has been shown to have an adverse effect on patient survival
[6]. In our study, seven (70%)
of 10 patients were not yet known to have epiglottic carcinoma at the time of
the radiographic examination. In a previous study, the mean interval from the
time of presentation to the time of diagnosis of all laryngeal carcinomas was
3-4 months; this lag was primarily attributed to a low index of suspicion by
the clinician [7]. It is
therefore important for radiologists to be aware of the presenting findings in
patients with epiglottic carcinoma when videofluoroscopy of the pharynx is
performed.
Although dynamic videofluoroscopic recordings of the pharynx were needed to
determine the mechanism of swallowing dysfunction, double-contrast spot images
of the pharynx with the patient in the frontal and lateral and, when
necessary, oblique positions permitted assessment of the morphologic features
and extent of these tumors. The epiglottic carcinomas in our patients appeared
on spot images as polypoid masses (with or without ulceration) (Figs.
1A,1B
and
2A,2B)
or as infiltrating lesions (Fig.
3) involving the epiglottis. These tumors often extended into
adjacent structures, including the aryepiglottic folds, arytenoids,
valleculae, and base of the tongue. When epiglottic cancer is suspected on the
basis of the radiographic findings, direct visualization and biopsy of the
lesion are required for a definitive diagnosis. Cross-sectional imaging
studies such as CT and MR imaging can then be performed for proper staging of
these tumors [8,
9].
The epiglottis is the most common site of involvement by supraglottic
cancer [10]. Because of the
rich supply of lymphatics in this region, patients with supraglottic tumors
tend to present at a more advanced stage and with earlier nodal metastases
than those with glottic or subglottic tumors
[10]. The treatment for
patients with epiglottic carcinoma includes surgery (either a supraglottic or
total laryngectomy), radiation therapy, or both
[11], but the prognosis is
even worse than that for other patients with supraglottic cancer
[11], most likely because of
rapid lymphatic dissemination of tumor.
In conclusion, patients with epiglottic carcinoma often present with
symptoms of aspiration or pharyngeal dysphagia of relatively brief duration in
the absence of preexisting stroke, dementia, or other neurologic diseases. In
this clinical setting, barium studies are useful not only for detecting the
epiglottic carcinoma but also for delineating the presence and mechanism of
laryngeal penetration or tracheobronchial aspiration. It is important for
radiologists to be aware of the characteristic clinical and radiographic
findings of epiglottic carcinoma to detect these tumors at the earliest
possible stage.
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Abstract
Introduction
