Ultrasound-Guided Endolaryngeal Biopsy—A Novel Use of the Endobronchial Ultrasound

Significance Statement

Laryngeal cancer is one of the most common malignancies of the head and neck. Posttreatment surveillance with positron emission tomography–computed tomography (PET/CT) can detect small lesions which may be difficult to sample with traditional biopsy techniques. Here, we report a novel use of the linear endobronchial ultrasound (EBUS) bronchoscope for supraglottic biopsy of a locally recurrent laryngeal squamous cell carcinoma.

Clinical Report

A 79-year-old male was initially diagnosed with a T2N2bM0 squamous cell carcinoma (SCC), primarily involving the right arytenoid extending to the aryepiglottic fold. He completed chemoradiation with no evidence of recurrent disease at initial surveillance visits or on surveillance imaging. Positron emission tomography/CT performed 1 year after completion of therapy demonstrated focal intense fluorodeoxyglucose uptake in the right larynx suspicious for recurrent disease. Subsequent CT scan confirmed a 12-mm enhancing submucosal supraglottic nodule (Figure 1). No concerning findings were noted on flexible laryngoscopic exam performed in clinic.

Figure 1.

The area of concern is indicated with red arrow on axial (A) and coronal (B) CT scans as well as axial (C) and coronal (D) PET/CT scans. CT indicates computed tomography; PET, positron emission tomography.

Direct laryngoscopy was performed and was notable for submucosal fullness and 1-cm nodularity near the apex of the right pyriform sinus, extending from the medial wall of the pyriform sinus to the lateral pharyngeal wall. Ultrasound-guided fine-needle aspiration (FNA) was then performed using an Olympus BF-UC180F EBUS bronchoscope. The lesion was identified approximately 1 cm lateral to the right aryepiglottic fold with aid of the calcified right thyroid cartilage as an ultrasound landmark (Figure 2). The lesion was sampled using a 22-gauge EBUS needle and rapid on-site examination was performed, suggesting the tissue was adequate for immediate diagnosis. An additional pass was performed for cell block. Final pathology confirmed a diagnosis of recurrent SCC. The area of concern in the pyriform sinus was additionally biopsied using a cup forceps, revealing only chronic inflammation, negative for dysplasia or malignancy.

Figure 2.

A, The lesion is identified using endobronchial ultrasound. The calcified thyroid cartilage is marked with an asterisk (*). B, Sampling of the lesion using ultrasound-guided FNA. The needle can be seen entering the tumor and is marked with an asterisk (*). Ultrasound depth (cm) is indicated on the right of each figure. C, The point of entry of the FNA needle in the supraglottis is indicated with the red arrow. D, The nodularity noted in the right pyriform sinus during direct laryngoscopy is identified with a red arrow.

Due to the recurrent nature of the disease, a multidisciplinary tumor board recommended total laryngectomy with neck dissection versus palliative chemotherapy. The patient elected to undergo palliative chemotherapy.

There were 12 410 new diagnoses of laryngeal cancer and 3760 deaths in the United States in 2019. ¹ With the rise of CT and PET/CT, we are now able to detect small lesions concerning for head and neck cancer recurrence before they may become clinically evident. Confirmation of such a diagnosis typically requires direct laryngoscopy with biopsy of a suspicious lesion under direct visualization in the operating room. Submucosal lesions can be challenging and require the surgeon to blindly sample the area of suspicion, possibly utilizing intraoperative fresh-frozen pathologic confirmation to determine adequacy of sampling. This can be a costly and inefficient process in terms of both resources and time under anesthesia.

Endobronchial ultrasound is a well-established method of imaging thoracic soft tissue structures adjacent to the large airways. The use of EBUS has become the preferred modality of minimally invasive tissue sampling of mediastinal and hilar lymph nodes as well as accessible malignancies.^2,3 The advantages over traditional techniques include obtaining the sample under direct visualization of the suspect lesion, improving sampling yield, as well as sonographic information regarding the lesion. ³ Ultrasound has gained significant interest within the Otolaryngology community for point of care diagnosis and evaluation of cancers in the head and neck, including the larynx. ⁴

The use of radial endoscopic ultrasound during microlaryngoscopy has been described. ⁵ However, to our knowledge, the use of linear EBUS bronchoscope technology to guide biopsy of an endolaryngeal lesion has not previously been reported. This technique provides a unique minimally invasive method to reliably identify a lesion of concern for directed tissue diagnosis. In this case, the use of linear EBUS bronchoscope technology allowed for timely and accurate tissue diagnosis while preventing the morbidity associated with multiple blind biopsies in the endolarynx.