title: The fetal larynx and pharynx: structure and development on two- and three-dimensional ultrasound.
abstract: OBJECTIVE
  To present a systematic approach for evaluating the fetal pharynx and larynx based on two- and three-dimensional ultrasound (2D-US and 3D-US) modalities, describing the sonographic appearance and function of the fetal upper respiratory tract and measuring the anatomical components of the pharynx and larynx.
  
  
  METHODS
  Gravidae presenting from the late first trimester to mid-gestation for routine booked examinations with structurally normal singleton fetuses of confirmed gestational age were enrolled. Transabdominal 2D-US was performed for anatomical and functional evaluation of the pharynx and larynx. Color Doppler was used to show fluid motion in the target area. 3D-US (Voluson® E6 with RAB-4-8-D transducer) scans of the fetal neck were acquired during fetal quiescence and in the absence of movements of the pharynx and larynx. Multiplanar reconstruction (MPR) in post-processing allowed adjustment of the volume to obtain the coronal plane. After a learning period to understand the sonographic anatomy of the target area, we measured the pharynx width and height, the upper, middle and lower larynx width and the larynx height. Render mode was applied for spatial evaluation of the target area. We developed a new methodological approach for structured evaluation of the fetal pharynx and larynx based on five spatial planes: posterior and anterior coronal planes and high, mid and low axial planes.
  
  
  RESULTS
  We examined 582 fetuses during the second trimester of pregnancy; target anatomy was imaged successfully in 218 patients at 11-24 gestational weeks. Acquisition added approximately 1 min to examination time. Rates of successful visualization and measurements increased significantly as pregnancy progressed, being 23% (46/194) at 11-13 weeks, 29% (69/240) at 14-16 weeks, 35% (18/51) at 17-19 weeks and 88% (85/97) at 20-24 weeks (P < 0.01). Pharynx components identified were: the sphenoid bone, pterygoid processes, constrictor muscles, piriform recesses and uvula. Larynx components identified were: the epiglottis, aryepiglottic folds, corniculate cartilages, arytenoid cartilages, cricoid cartilage, thyroid cartilage and vocal cords. MPR showed the biconcave shape of the uvula, which may explain the 'equals sign' observed on 2D-US. We observed the bilateral mode of movements of the constrictor muscles, aryepiglottic folds and vocal cords, and the bidirectional fluid jet flows through the larynx. Scatterplots of measured structures vs gestational age were created. Pharynx width ranged from 0.11 to 0.93 (mean ± SD, 0.48 ± 0.17) cm; pharynx height ranged from 0.23 to 2.01 (mean ± SD, 0.94 ± 0.34) cm; upper larynx width ranged from 0.04 to 0.37 (mean ± SD, 0.15 ± 0.07) cm; middle larynx width ranged from 0.08 to 0.77 (mean ± SD, 0.34 ± 0.16) cm; lower larynx width ranged from 0.05 to 0.64 (mean ± SD, 0.24 ± 0.11) cm; and larynx height ranged from 0.20 to 1.83 (mean ± SD, 0.71 ± 0.31) cm. All measurements were positively correlated with gestational age.
  
  
  CONCLUSIONS
  The fetal larynx and pharynx can be evaluated thoroughly using 2D- and 3D-US modalities. Knowledge of normal anatomy, function and biometry may prove useful in the evaluation of anatomical or functional pathology involving the fetal upper respiratory tract. Recognition of anatomical anomalies may enhance fetal intervention such as balloon placement in cases of diaphragmatic hernia.
authors.affiliation: Department of Obstetrics and Gynecology, Barzilai Medical Center, Ashkelon, Israel. liberg2@gmail.com
authors.forename: G
authors.initials: G
authors.lastname: Liberty
authors.forename: R
authors.initials: R
authors.lastname: Boldes
authors.forename: O
authors.initials: O
authors.lastname: Shen
authors.forename: C
authors.initials: C
authors.lastname: Shaul
authors.forename: S M
authors.initials: SM
authors.lastname: Cohen
authors.forename: S
authors.initials: S
authors.lastname: Yagel
mesh_terms: D047109:Fetal Development / Q000502:physiology; D005865:Gestational Age; D006801:Humans; D021621:Imaging, Three-Dimensional; D007818:Laryngeal Diseases / Q000000981:diagnostic imaging; D007830:Larynx / Q000000981:diagnostic imaging / Q000196:embryology*; D010610:Pharyngeal Neoplasms / Q000000981:diagnostic imaging; D010614:Pharynx / Q000000981:diagnostic imaging / Q000196:embryology*; D011446:Prospective Studies; D013724:Teratoma / Q000648:ultrastructure; D014138:Tracheoesophageal Fistula / Q000000981:diagnostic imaging; D016216:Ultrasonography, Prenatal / Q000379:methods