Key points
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The clinical symptom of hoarseness carries with it an extensive differential diagnosis, which is not confined to neoplastic etiologies.
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The anatomic course of the recurrent laryngeal nerves differs bilaterally, which impacts the geographic extent of imaging coverage required to diagnose causative lesions.
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Laryngeal dysfunction can be caused by lesions located anywhere from the brainstem to the mediastinum.
Introduction
Anatomy of the larynx
Innervation of the larynx and vocal cord paralysis
Brainstem | Skull base | Carotid sheath | Thyroid | Superior mediastinum | Larynx |
---|---|---|---|---|---|
Tumor | Meningioma | Glomus vagale | Carcinoma | Tumor/lymphadenopathy | Laryngocele |
Infarction | Metastasis | Schwannoma | Iatrogenic | Vascular etiologies | Polyps, cysts |
Glomus jugulare | Trauma | Goiter | Squamous cell carcinoma | ||
Papillomatosis | |||||
Amyloidosis |
Infection/inflammation | Intrinsic vocal fold lesions | Vocal cord paralysis | Miscellaneous |
---|---|---|---|
Acute/chronic laryngitis | Laryngeal polyps/nodules/cysts | Post-tracheal intubation | Laryngocele |
Laryngeal amyloidosis | Laryngeal papilloma | Compression of CN X or RLN—mediastinal causes | Laryngeal web |
Thyroid disease | Laryngeal cancer | Compression of CN X or RLN—thyroid mass | |
Rheumatoid arthritis | Compression of CN X or RLN—skull base | ||
Traumatic Injury to CN X or RLN | |||
Neurodegenerative disorders (i.e., ALS, Parkinsons) |
Lesions and disorders of the larynx
Laryngocele
Benign inflammatory laryngeal lesions
Squamous cell carcinoma
Recurrent respiratory papillomatosis
Laryngeal amyloidosis
Brainstem lesions
Hypertrophic olivary degeneration
Lateral medullary syndrome
Lesions at the jugular foramen
Paragangliomas
Lesions of the carotid space
Benign nerve sheath tumors
Thyroid disease
Lesions of the mediastinum
Traumatic/iatrogenic nerve injury
Summary
- Laryngeal carcinoma often has a better prognosis than a similarly staged head and neck squamous cell carcinoma of another primary site. Presenting symptoms depend on the laryngeal subsite involved.
- Infiltrative laryngeal lesions such as papillomatosis and amyloidosis are benign but progressive, resulting in dysphonia and/or airway obstruction and frequently requiring multiple treatments due to extent and recurrence.
- A well-positioned brainstem lesion may affect either the inferior olivary nucleus (hypertrophic olivary degeneration) or nucleus ambiguous (lateral medullary syndrome), leading to classic constellations of higher-order neuronal symptoms including dysphonia.
- Multiple lower cranial neuropathies should trigger search for a lesion at the skull base, particularly at the jugular foramen.
- The vagus nerve is confined within the carotid sheath as it courses down the neck, rendering it susceptible to injury from neck trauma or neck mass.
- The whole spectrum of thyroid disease can result in dysphonia due to the gland’s position below the larynx.
- The recurrent laryngeal nerve can be either stretched or compressed by lesions in the superior mediastinum, resulting in vocal cord paralysis.