What does minimal epiglottic thickening with indeterminate soft‑tissue thickening of the glottis and arytenoids and incidental dental caries on a neck computed tomography (CT) indicate, and what are the recommended next steps?

Minimal Epiglottic and Glottic/Arytenoid Thickening on CT Neck

This imaging pattern most likely represents post-inflammatory changes, laryngopharyngeal reflux (LPR), or early infectious supraglottitis, and requires direct laryngoscopy for definitive assessment rather than relying on CT findings alone.

Primary Diagnostic Considerations

Most Likely Etiologies

• Laryngopharyngeal reflux (LPR) is the most common cause of epiglottic and arytenoid edema/thickening, though laryngoscopy alone lacks specificity to confirm GERD as the etiology, and these findings can be observed in asymptomatic volunteers 1
• Post-radiation changes commonly cause epiglottic thickening and are seen more frequently after radiation therapy than before treatment, though this is only occasionally associated with tumor involvement 2
• Early supraglottitis presents with thickening of the epiglottis, aryepiglottic folds, and true/false vocal cords on CT, though diagnosis is generally made by history and direct endoscopy 3
• Chronic inflammatory changes from various causes can produce similar soft-tissue thickening patterns in the supraglottic region 3, 2

Critical Distinction Required

The "indeterminate" nature of the glottic/arytenoid thickening means CT cannot reliably differentiate benign inflammatory changes from early neoplastic processes in this region 4. CT imaging remains the gold standard for laryngeal assessment but has limited sensitivity (74%) and specificity (90%) for detecting neoplastic invasion in the glottis and arytenoid regions 4.

Immediate Next Steps

Direct Laryngoscopy is Mandatory

• Perform direct laryngoscopic examination to visually assess the epiglottis, arytenoids, and glottic structures for mucosal abnormalities, ulceration, or mass lesions 5
• This follows the NI-RADS 2a approach: superficial mucosal abnormalities on imaging should prompt direct clinical inspection with biopsy at the surgeon's discretion 5
• Focal mucosal enhancement or enhancement deep to an ulceration is more concerning than diffuse mucosal enhancement 5

Clinical History Assessment

Obtain specific history for:

• LPR symptoms: chronic throat clearing, globus sensation, chronic cough, hoarseness (particularly morning hoarseness) 1
• Infectious symptoms: fever, odynophagia, dysphagia, stridor, rapid symptom onset suggesting supraglottitis 3
• Prior radiation therapy: epiglottic thickening is common after head/neck radiation 2
• Exercise-related symptoms: consider exercise-induced laryngeal dysfunction (EILD) or vocal cord dysfunction if symptoms worsen with exertion 1

Management Algorithm Based on Laryngoscopy Findings

If Laryngoscopy Shows Only Edema/Erythema Without Mass

1. Initiate empiric LPR treatment trial (most common scenario):

   • Twice-daily PPI therapy combined with lifestyle modifications for 3 months 1
   • Weight reduction if BMI >25, elevate head of bed 6-8 inches, avoid eating within 2-3 hours of bedtime 1
   • PPIs alone without lifestyle modifications are ineffective and should not be used as isolated therapy 1

2. Reassess at 8-12 weeks with repeat laryngoscopy to evaluate for improvement 1

3. If no improvement after 3 months, perform objective testing with esophageal manometry and 24-hour pH monitoring before additional medications 1

If Laryngoscopy Shows Concerning Features

• Ulceration, nodularity, or asymmetric mass: Biopsy immediately to exclude malignancy 5
• Severe edema with airway compromise: Consider acute supraglottitis requiring urgent airway management 3

Role of Additional Imaging

When to Consider MRI

• MRI with contrast is superior to CT for characterizing soft-tissue abnormalities and should be obtained if:
  • Laryngoscopy reveals a discrete mass requiring staging 5
  • Deep tissue invasion is suspected beyond what CT can characterize 5
  • Intracranial or skull base extension is a concern 5

When to Consider PET/CT

• Not indicated for initial evaluation of indeterminate laryngeal thickening 5
• May be appropriate if malignancy is confirmed and staging is required 5

Addressing the Incidental Dental Caries

• Document and communicate the dental caries finding to the patient and referring provider 5
• Dental caries can serve as a source of chronic inflammation and infection that may contribute to laryngeal irritation
• Recommend dental evaluation and treatment, particularly if the patient proceeds with any head/neck intervention

Common Pitfalls to Avoid

• Do not prescribe antireflux medications based solely on CT findings without laryngoscopic correlation and appropriate clinical context 1
• Do not assume minimal thickening is benign without direct visualization—the glottis and arytenoid regions are particularly difficult to assess on CT alone 4
• Do not continue empiric therapy beyond 3 months without objective response—proceed to diagnostic testing instead 1
• Do not biopsy ill-defined, non-mass-like abnormalities without additional data from short-term follow-up or PET imaging, as these are poor biopsy targets 5
• Be aware that neoarytenoid soft tissue after arytenoidectomy can appear as eccentric prominence up to 11mm thick and should not be mistaken for recurrent disease in post-surgical patients 6