S. Ashktorab MD; N. Grant, MD; Z. E. Deeb, MD

Department of Otolaryngology - Head and Neck Surgery, Washington Hospital Center and

Georgetown University Hospital, Washington, DC

INTRODUCTION

CONCLUSION

CASE SERIES ABSTRACT

REFERENCES

CONTACT

The larynx develops in the

embryonic period (1-8 weeks)

from the respiratory primordium in

the ventral wall of the pharynx.

Before the beginning of the fetal

period (12- 40 weeks) the

arytenoid, thyroid and cricoid

cartilages are chondrified. The

only segment of the laryngeal

framework that is calcified at birth

is the hyoid. After birth, laryngeal

calcification is consistent and is

both gender and age related;

however, the degree and pattern

of this process is unpredictable.

Most of the laryngeal skeleton is

hyaline cartilage and is subject to

calcium mineralization. Calcium

deposition in the larynx begins at

age 18 years in females and 21

years in males. The calcification

process may continue up to the

fifth decade of life. It begins in the

posterior-superior aspect of the

cricoid or the posterior inferior

aspect of the thyroid cartilage. In

forensic medicine this fact is the

basis for using the larynx to

estimate the age of individuals.1

Illustrative endoscopic, imaging

and gross anatomic findings are

presented.

In conclusion, calcifications of the larynx

and its ligaments can cause chronic

symptoms such as throat pain and

dysphagia, depending on the location and

extent of calcification. Fortunately, they can

be easily identified on plain radiographs of

the neck during the first encounter with the

patient. In order to expand our knowledge

about the process of calcification of the

larynx and its clinical implications future

studies should be dedicated to detailed

analysis of gross laryngeal anatomy.

Case One. A sixty-three year old non-smoker female

presented with cough and persistent feeling of a lump

in her throat. Barium phayngoesophagogram showed

a lobulated filling defect in the hypopharynx. Flexible

laryngoscopy revealed an irregular hard submucosal

mass that moved with external manipulation of the

larynx. In light of the flexible laryngoscopy and

consistent x-ray findings, no further investigation was

necessary. The patient was reassured that no further

investigation was necessary.

The Larynx develops during the 5th – 8th week of

intrauterine life (embryonal period). 2 It is mainly

of branchial origin, except for the vocal cords

which originate in the endoderm of the foregut. 2

Although the arytenoids, thyroid and cricoid are

chondrified by the end of this period, the only

part of the laryngeal framework that is calcified

at birth is the hyoid bone. The epiglottis is an

elastic cartilage that does not calcify. If

calcification of the epiglottis occurs, it may be

reportable. The rest of the larynx is composed of

hyaline cartilage which is subject to calcification

of various degrees and patterns. Sometimes

these calcified sites can ossify. According to

most studies, calcium deposition in the larynx

begins at about age 18 years in females and 21

years in males and may continue up to the sixth

decade.3 The process of calcification begins in

the posterior superior aspect of the cricoid and

the posterior inferior aspect of the thyroid

cartilages.3 The reason for this preferential

deposition of calcium in the posterior larynx is

unknown. This phenomenon has often been a

source of erroneous readings by radiologists of a

“foreign body” at the cricopharyngeal level,

particularly in cases of ingested chicken and

radio-opaque fish bones. (Panel 1) Historically,

in Forensic Medicine, when personal records

were not available, calcification of the larynx was

used to estimate the age of individuals, such as

in homicide victims.4,5 The laryngeal ligaments

may undergo calcification, especially the

stylohyoid and thyrohyoid ligaments, causing

symptoms of foreign body sensation, pain and

dysphagia. (Panel 2) In some patients, a

calcified stylohyoid ligament can give rise to the

stylohyoid syndrome (Eagle’s), consisting of

unilateral odynophagia, ipsilateral otalgia and

tenderness to palpation posterior to the tonsil.

(Panel 3) In addition, a calcified thyrohyoid

ligament in combination with severe cervical

osteophytes may lead to severe dysphagia and

possibly a traumatic intubation. (Panel 4) In

other patients, office laryngoscopy and images

of the neck may suggest tumors in the

laryngopharynx.

We present a sample from amongst several

hundred cases of adult patients seen by the

senior author (Z.E.D.) with head and neck

symptoms and heavy calcium deposition in

different sites of the laryngeal skeleton.

1. Turkmen S, Cansu A, Turedi S et al. Age-dependent structural and

radiological changes in the larynx. Clinical radiology. 2012; 67: e22-e26.

2. O’Rahilly, R. and Muller, F. Respiratory and alimentary relations in staged

human embryos: New embryological data and congenital anomalies. 1984.

Ann Otol Rhinol Laryngol. 93: 421-428.

3. Hately, W. Evison, G. and Samuel, E. The pattern of ossification in the

laryngeal cartilages: a radiological study. 1965. Brit J Radiol. 38: 585-591.

4. Tucker, J.A. The endoscopic aspects of the infant larynx. American

Academy of Ophthalmology and Otolaryngology. 1976. Course 580

5. Gordon, I. Aspects of the hyoid-larynx complex in forensic pathology. 1976.

Forensic Science. 1.7 (2): 161-170.

6. Morden, NE, Colla CH, Sequist TD and Rosenthal, MB. Choosing wisely-

The politics and economics of labeling low-value services. New England

Journal of Medicine. 2014. 370:589-592.

Samaneh Ashktorab

Georgetown University

Email: samaneh.ashktorab@gunet.georgetown.edu

MedStar Georgetown

University Hospital

DISCUSSION

Panel 1

Panel 2

A. Soft tissue view of lateral neck. B. Xerogram of the neck used

in Head and Neck Radiology in the 1970s (Yellow arrow-

posterior superior calcification of cricoid).

A B

Calcified superior cornia

of thyroid and greater

cornia of hyoid.

Case One

A

A. Flexible laryngoscopy with fullness of the right pyriform sinus. B&C. AP and

Lateral neck view. Note calcification of both the stylohyoid ligament (yellow) and

thyrohyoid junction (blue).

B C

Case Two. A seventy year old female complained of a

mass in her throat with dysphagia. On flexible

laryngoscopy an irregular mass was noted in the right

pyriform sinus. Plain neck radiograms showed a

heavily calcified thyrohyoid ligament. Direct

laryngoscopy showed a 1.5 cm irregular rock hard

mass in the lateral wall of the pyriform sinus. The

mass moved with external manipulation of the larynx.

Planned biopsy was aborted. A computed

tomography (CT scan) later confirmed extensive

calcification of the thyrohyoid junction.

Case Two

A. Direct laryngoscopy demonstrating a firm mass that was mobile with external

manipulation of the larynx . B. CT scan with evidence of calcification of the

thyrohyoid junction protruding into the hypopharynx.

Case Three. A young woman presented with

unilateral neck pains radiating to the ipsilateral ear

and aggravated with swallowing. A CT scan of her

neck at another facility was reportedly normal. A plain

lateral soft tissue view of the neck clearly showed a

calcified stylohyoid ligament on the side of her

symptoms. She declined surgery.

A B

Case Three

A. Lateral x-ray demonstrating stylohyoid ligament calcification.

A

As shown in these cases, symptoms from

calcification of the laryngeal framework

typically begin after the fourth decade of

life. Patterns of calcification vary in extent

and location causing variable symptoms on

initial patient intake. The presenting

symptoms include otalgia, globus

sensation, dysphagia, and odynophagia.

Initial evaluation must include a thorough

physical examination in the office with

palpation of the oral cavity and oropharynx.

During flexible laryngoscopy the laryngeal

mass will move with external palpation of

the larynx.

Plain radiography of the neck allows good

visualization of the laryngeal skeleton. In

our clinical experience, it was not unusual

for the pathology to be overlooked on CT

scan readings while it was clearly obvious

on the plain films. If the patient is at high

risk for cancer, then a CT scan may

provide additional information in the initial

work-up. In view of the current ongoing

national campaign to change practice

habits and “choose wisely”, the order in

which diagnostic studies are requested

plays an important role in reduction of risks

and costs to patients and the health care

system as a whole. 6

Panel 3

Calcified thyrohyoid ligament

impacting on cervical

osteophyte causing severe

dysphagia.

Panel 4

Calcified

Stylohyoid

ligament.