Original Research—Laryngology and Neurolaryngology
Otolaryngology–
Triticeous Cartilage CT Imaging
Characteristics, Prevalence, Extent, and
Distribution of Ossification
Eman Alqahtani, MD, MPH1, Daniel E. Marrero, MD1,
Walter L. Champion, MD1, Ahmed Alawaji, MS2,
Philip D. Kousoubris, MD1, and Juan E. Small, MD1
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. The triticeous cartilage is a small ovoid cartilagi-
nous structure variably present as a component of the lar-
yngeal skeleton. This structure has received scant attention
in the literature and has yet to be described adequately on
cross-sectional imaging.
Study Design and Setting. Retrospective study in a tertiary
medical center.
Subjects and Methods. We investigated triticeous cartilage
prevalence in a large population utilizing computed tomogra-
phy images. The cases of all patients with computed tomo-
graphy angiography images of the neck from October 1,
2013, to September 31, 2014, were examined. A total of
663 patients were included in this study (age: range, 18-97
years; mean 6 SD, 65 6 15 years), 58.4% men and 41.6%
women. The presence of a triticeal cartilage and its site,
number, and degree of ossification were recorded.
Results. A total of 53.1% of patients had at least 1 triticeous car-
tilage (352 of 663). Prevalence was 57.4% (222 of 387) among
men and 47.1% (130 of 276) among women. The presence of
bilateral triticeous cartilages was more common than unilateral
(63.1%, 222 of 352). A minority of patients (4.5%, 16 of 352)
had a cartilaginous triticeous with no appreciable ossification,
and more than half (54.0%, 190 of 352) had mild triticeal ossifi-
cation. Moderate ossification was found in 34.9% of patients
(123 of 352) and marked ossification in 6.5% (23 of 352).
Conclusion. The presence of a triticeous cartilage is common
and of variable appearance. As the clinical and surgical signif-
icance of this anatomic structure may be misinterpreted, it
is important for imaging interpreters to be familiar with this
seldom-recognized anatomic structure and recognize its
variable appearance on cross-sectional imaging to avoid a
misdiagnosis.
Keywords
triticeous cartilage, cartilago triticea, triticeal ossification,
thyrohyoid complex
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Head and Neck Surgery
2016, Vol. 154(1) 131–137
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599815615350
http://otojournal.org
Received August 10, 2015; revised September 14, 2015; accepted
October 13, 2015.
T
he triticeous cartilage (TC), or ‘‘cartilago triticea,’’ is
named for its small, wheat grain–like ovoid appear-
ance. It is typically located centrally within the lat-
eral aspect of the thyrohyoid ligament, between the superior
cornu of the thyroid (SCT) cartilage and the greater cornu
of the hyoid (GCH) cartilage (Figure 1).1-3 At about 12
weeks of gestation, chondrification and ossification of the
laryngeal structures begin. This process results in the
separation of the GCH from the SCT. Normal variants of
this process include the formation of the TC as a separate
cartilage between the 2 cornua.2 Although there is no defini-
tively known function of the TC, it has been postulated that
it may function to support the lateral thyrohyoid ligaments.4
The presence of triticeal ossifications is considered a
normal variant related to embryologic development rather
than an aging process. As such, there is of yet no reported
relationship between age and degree of ossification.1
The TC is a rarely recognized structure on cross-sectional
imaging, perhaps owing to its scant attention in the literature,
its small size, and its location embedded next to similar-
appearing structures. The radiologic characteristics of the TC
and its variable ossification patterns were described in the
early half of the 20th century by a number of roentgenolo-
gists.1 More recently, triticeous ossifications have been
described in the dental literature in relation to their appearance
on panoramic radiographs, with great emphasis on differentiat-
ing triticeous ossification from carotid artery calcific athero-
sclerosis.5,6 Of note, none of these studies utilized cross-
sectional imaging. Although cadaveric studies have been con-
ducted to describe the TC, they are primarily small scale.4
1
Tufts University School of Medicine, Lahey Clinic, Burlington,
Massachusetts, USA
2
Saudi Arabian Cultural Mission, Fairfax, Virginia, USA
Corresponding Author:
Eman Alqahtani, MD, MPH, Tufts University School of Medicine, Lahey
Clinic, 41 Mall Road, Burlington, MA 01805, USA.
Email: eman_alqahtani@hotmail.com
132 Otolaryngology–Head and Neck Surgery 154(1)

reviewed 707 computed tomography angiography (CTA)

studies from October 1, 2013, to September 31, 2014. Only
the first CTA was included for patients with .1 examina-
tion (n = 23). Other exclusion criteria included motion
artifact limiting evaluation (n = 18) and total laryngect-
omy (n = 3).

Patient Demographics
A total of 663 patients were included in this study (age:
range, 18-97 years; mean 6 SD, 65 6 15 years). Men repre-
sented 58.4% of the patient sample (n = 387; age: range,
18-92 years; mean 6 SD, 66 6 14 years), and women rep-
resented 41.6% (n = 276; age: range, 22-97 years; mean 6
SD, 65 6 16 years). Only 0.4% of our patients were \25
years old (n = 9), and 8.7% were .85 years old (n = 58).

Figure 1. Triticeous cartilage (TC): typical location within the thyr-
ohyoid complex on sagittal (A) and coronal (B) computed tomo-
graphy angiography images, with diagrammatic representations (C,
D). GCH, greater cornu of the hyoid; SCT, superior cornu of the
thyroid.
Importantly, some of these studies utilized ex vivo x-ray
imaging of the thyrohyoid complex to specifically address
the question of triticeous ossification.4 Small population sizes
and variable methodologies have resulted in a wide spectrum
of the TC prevalence reported in the literature, ranging from
12% and up to 65%.2,6 As expected, variable degrees and
morphologic differences of triticeal ossification have been
sporadically reported in the literature. For instance, triticeal
ossifications may be round, ovoid, spindle shaped, elongated,
paired, bilateral, or unilateral.7 Unfortunately, the relative
obscurity of this anatomic structure and its variable appear-
ance have led to its confusion with various pathologic pro-
cesses, such as carotid atherosclerosis, hyoid fractures,
laryngeal fractures, sialadenitis, phleboliths, calcified lymph
nodes,8 and foreign bodies.
The purpose of this study is to systematically study the
prevalence and cross-sectional imaging appearance of the
TC and triticeal ossifications in a large cohort of patients on
high-resolution, thin-section computed tomography (CT)
images. We hypothesized that the high spatial resolution
and unsurpassed contrast resolution of CT 9 would allow for
a more accurate determination of the TC prevalence and its
variable ossification.
Materials and Methods
The institutional review board of Lahey Hospital and
Medical Center approved this study. We retrospectively
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Image Acquisition
All patients were examined on a GE 64 Slice Lightspeed
VCT CT Scanner, Siemens 128 Slice Dual Source
Definition CT Scanner, or Phillips 256 Slice ICT Brilliance
CT Scanner. The standard protocol was intravenous injec-
tion of 80-mL nonionic contrast with imaging from the
aortic arch to the apex of the calvarium with CTA source
image width of 0.63 mm.
Image Analysis
Image analysis was conducted on bone window and soft
tissue window images. In addition, attention was placed on
individually tailored intermediate windowing to depict calci-
fied and cartilaginous structures within the same image
(Figure 2). The area of the thyrohyoid ligament was identi-
fied bilaterally, between the SCT cartilage and the GCH
cartilage on CTA axial, coronal, and sagittal images. The
entire length of the thyrohyoid ligaments was closely
inspected for the presence of a separate and well-defined
cartilaginous or calcified structure consistent with the TC
(Figure 1). As depicted in the Results section, 4 ossifica-
tion degree categories were created per consensus with the
senior author, an experienced neuroradiologist. These cate-
gories were cartilaginous triticeous, mild triticeous ossifica-
tion, moderate triticeous ossification, and marked triticeous
ossification. The lack of any significant ossification was
considered a cartilaginous triticeous. Tiny punctate ossifica-
tion or thin shell-like ossification was considered to be mild
triticeous ossification. More conspicuous punctate ossifica-
tion or thicker shell-like ossification was considered to be
moderate triticeous ossification. Finally, chunky ossifica-
tions .5 mm were considered to be marked triticeous ossi-
fication. If a TC was identified, the site, number, and degree
of ossification were recorded. The prevalence of the TC was
calculated per the number of patients and not the number of
cartilages that were found.
Results
The prevalence of the TC, site, number, relationship to thyr-
oid cartilage, and degree of ossification are summarized in
Tables 1 and 2. We identified 53.1% of patients with at
Alqahtani et al
Figure 2. Broad-windowed images (A, C) obscure nonossified
portions of the thyrohyoid complex. Partially ossified structures
(arrow and arrowhead) may appear as a fracture or triticeous car-
tilage. Narrow windows (B, D) reduce this concern.
least 1 TC (n = 352), 63.1% men and 36.9% women. Of
note, prevalence was similar across all age groups as shown
in Table 3. Among all male patients, the prevalence of TC
was 57.4% (n = 222). The prevalence was slightly less
among females, with 47.1% having at least 1 TC (n = 130).
Mild triticeal ossification was the most common type
of ossification seen in 54.0% of patients (n = 190). It
was identified as either thin peripheral shell-like or tiny
scattered punctate calcific foci. Mild ossifications were
more common in men (62.2%, n = 138) than women
(40.0%, n = 52).
The second-most common type of triticeous ossification
was moderate ossification, with a thick peripheral shell or
larger scattered calcific foci. This type of ossification was
seen in 34.9% of patients (n = 123). Moderate triticeous
ossification was seen more commonly in women (47.7%, n
= 62) than women (27.5%, n = 61). Last, marked ossifica-
tion was identified as chunky prominent round or ovoid
Table 1. Patients with Triticeous Cartilage.
Total (n = 663)
Triticeous Cartilage n %
Total 352 53.1
Bilateral 222 63.0
Right 66 18.8
Left 64 18.2
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133
ossification, seen in 6.5% of patients (n = 23). Similar to
moderate ossification, marked triticeous ossification was
found to be more common in women (11.5%, n = 15) than
men (3.6%, n = 8). In summary, male patients had milder
triticeous ossification, whereas females had more moderate
to marked ossification (Table 2). The spectrum of triticeal
ossification is shown in Figure 3. Of note, careful attention
was placed in distinguishing triticeal ossification from other
confounding foci of ossification, including carotid athero-
sclerotic plaques (see Figure 4). In addition to the variable
spectrum of ossification, a variety of triticeal shapes were
noted, as depicted in Figure 5. Furthermore, a spectrum of
variable locations within the thyrohyoid ligament were
observed, as shown in Figure 6.
Most patients had bilateral TCs (63.0%, n = 222), with
no sex differences in prevalence of bilateral TCs; both were
at 63.1% (n = 130 and 82 in men and women, respectively).
Fewer patients had unilateral TCs (18.8%, n = 66, on the
right; 18.2%, n = 64, on the left). Slightly more men had
TCs on the right (20.7%, n = 46) versus the left (16.2%, n =
36). In contrast, more women had TCs on the left (21.5%, n =
28) versus the right (15.4%, n = 20). When the TC was unilat-
eral, the contralateral side demonstrated variable appearances
of the SCT cartilage (Figure 7).
Few patients had 2 ipsilateral ovoid triticeous ossifications
(1.4%, n = 5). Four of 5 patients with these paired triticeous
ossifications had them on the right side. A completely nonos-
sified cartilaginous triticeous was identified in 4.5% of the
patients (n = 16) and was much more common in men (n =
15), with only 1 woman demonstrating a completely cartilagi-
nous triticeous.
Discussion
Annually in the United States, .1 million patients require cer-
vical spine CT assessment for neck trauma.10 Additionally,
neck CT angiograms are performed routinely to evaluate new-
onset or recurrent strokes in .610,000 Americans each year.11
Therefore, the accurate recognition of the TC on CT, along
with its wide spectrum of ossification, is important to prevent
confusion with hyoid and laryngeal fractures in emergent
scans and with carotid atherosclerosis and other calcified soft
tissue abnormalities on routine studies.8 Our report is the first
study to describe the CT imaging characteristics, prevalence,
extent, and distribution of triticeal ossification in a large adult
population.
Women (n = 276) Male (n = 387)
n % n %
130 47.1 222 57.4
82 63.1 140 63.1
20 15.4 46 20.7
28 21.5 36 16.2
134 Otolaryngology–Head and Neck Surgery 154(1)

Table 2. Description of Triticeous Cartilage Ossification.

Total (n = 352) Women (n = 130) Male (n = 222)

Degree of Ossification n % n % n %

Cartilage 16 4.5 1 0.8 15 6.7

Mild 190 54.0 52 40.0 138 62.2
Moderate 123 34.9 62 47.7 61 27.5
Marked 23 6.5 15 11.5 8 3.6

Table 3. Age Distribution of Patients with Triticeous Cartilage.

All Patients (n = 654) Patients with TC (n = 350)

Age, y n % n %

25-35a 31 4.7 16 51.6

36-45 41 6.2 20 48.8
46-55 90 13.6 48 53.3
56-65 146 22.0 82 56.2
66-75 163 24.6 89 54.6
76-85 125 18.9 65 52.0
.85 58 8.7 30 51.7
a
Because \10 patients were \25 years old, an \25-year age group was not included.

Figure 3. The spectrum of triticeal ossification (arrows) on sagittal (upper row; A, C, E, G) and axial (lower row; B, D, F, H) computed
tomography angiography images.

We find that the presence of the TC as a part of the lar- part to its small size and location embedded in close apposi-
yngeal skeleton is quite common, as it was easily identified tion to similar-appearing structures. Our results indicate a
on CT imaging in 53.1% of our patients. Nevertheless, it prevalence in the upper range noted in the literature
can easily overlooked by CT imaging interpreters, due in (12%-65%).2,6 This is likely due in part to the high spatial
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Alqahtani et al
Figure 4. Calcified carotid plaque (white arrows) lateral to ossi-
fied triticeous cartilages (black arrows) on axial computed tomo-
graphy angiography (A), oblique 3-dimensional (B), and coronal
maximum intensity projection (C) images, a finding not well evident
on anteroposterior radiograph (D).
resolution and unsurpassed contrast resolution of CT. In par-
ticular, the contrast resolution of CT as compared to those of
radiographs makes identification of cartilaginous structures
easier—namely because these structures may be obscured on
radiographs secondary to subtle differences in the contrast of
adjacent structures or overlap of structures of similar density.
For the same reasons, the detection and characterization of
Figure 5. Spectrum of some of the variable shapes of the triticeal cartilage on multiple sagittal computed tomography angiography images.
Downloaded from oto.sagepub.com at RMIT University Library on January 14, 2016
135
small noncalcified or minimally calcified structures can be
challenging. Of note, more than half of the TCs that we
detected on CT were either noncalcified or minimally calci-
fied. These facts make the characterization of this structure
on CT essential, as all previous studies have been conducted
on the basis of radiographs. Last, the accuracy of our preva-
lence estimate is supported by our large sample size as com-
pared with the small sample sizes of previous anatomic and
radiographic studies highlighted in the introduction.7
Familiarity with the wide spectrum of triticeous ossifica-
tion, regardless of age, is important for the CT imaging
interpreter. As prior reports suggested, there is no relation
between age and degree of triticeal ossification.1 For
instance, one of the most prominent ossified TCs that we
found was in a 23-year-old woman (seen in Figure 3).
Therefore, our findings further support the theory that tritic-
eous ossification represents a variable developmental pro-
cess rather than a progressive, degenerative, or senescent
change. Similar to the TC embryologic origin, complete
ossification of the thyrohyoid ligament is another reported
normal variant of the thyrohyoid complex. Instead of form-
ing a ligamentous structure between the SCT and the GCH,
the entire length of the thyrohyoid ligament ossifies.2 Of
note, we did not identify this known rare variant in our
sample, as all our findings were distinctly separated by a
gap from the hyoid bone as well as the SCT cartilage.
As is well documented in the plain radiograph literature, tritic-
eous ossification may be confused with carotid calcific athero-
sclerosis in older patients. The wide range of anatomic variation
associated with the course of carotid arteries and the spectrum of
carotid and laryngeal ossification can pose major challenges.
Triticeous and carotid ossification can be multiple, elongated,
drop-shaped, spindle, irregular, or linear. In a few of our cases,
the carotid artery had a markedly medialized course, approximat-
ing the course of the thyrohyoid ligament. These factors should
be considered when describing the accuracy of plain or panora-
mic radiograph as a tool for detection and characterization of
136
Figure 6. Spectrum of triticeous cartilage (arrows) location. Midway (A), superior (B), and inferior (C) locations within the thyrohyoid liga-
ment as well as atypical locations (eg, above the greater cornu of the hyoid; D) may be seen.
Figure 7. Elongated superior cornu of the thyroid (SCT; A, B;
double arrows) similar in size to combined triticeous and SCT
(single arrow). Rodlike (C) and teardrop (D) triticeous (single
arrows) with absent (arrowheads) and small and elongated SCTs
(double arrows).
triticeous ossifications and, more important, when differentiating
triticeal from carotid calcifications.5,6
There are important practical implications from an under-
standing of the spectrum of imaging appearance of the TC.
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Otolaryngology–Head and Neck Surgery 154(1)
Lack of familiarity with the wide spectrum of asymmetry,
size, shape, and degree of ossification may unfortunately
lead to misinterpretation. In particular, the lack of symmetry
may be particularly vexing. We found 37.0% of TCs to be
unilateral. Furthermore, although 63.0% of the identified
TCs were bilateral, most were not on the same axial plane
and had variable locations within the thyrohyoid ligaments.
Without the aid of a symmetric contralateral comparison,
the imaging interpreter must be comfortable in assessing the
asymmetric appearance of the thyrohyoid complex. As pre-
vious studies have documented,1 we found that when the
TC was unilateral, the contralateral side demonstrated sev-
eral variations of the contralateral thyroid cartilage, includ-
ing a hypoplastic, small, even elongated SCT cartilage.
Awareness of this phenomenon is crucial for everyday prac-
tice, as the unilateral triticeous can be confused in the set-
ting of trauma with a fracture of the superior cornu. Aside
from these important practical implications, interesting theo-
retical implications arise. Whether the variations of the con-
tralateral cornu represent a compensatory change or an
embryologically fused triticeous or whether the unilateral
triticeous is an unfused superior cornu are matters yet unre-
solved. As of our current understanding, these differences
may represent arbitrary semantic distinctions.
Our study is limited by the geographic makeup of our
population, as there may be ethnic variations in prevalence.
In addition, our study is limited by the age range of our
population, as a pediatric population was not significantly
included.
Conclusion
The presence of a TC is common and of variable appear-
ance. The high spatial resolution and unsurpassed contrast
resolution of CT allowed us to more accurately determine
the prevalence and variable ossification patterns of the tritic-
eous. We report a prevalence of 53.1%, with a wide range
of variability in the TC morphology, shape, ossification, and
Alqahtani et al
position within the thyrohyoid ligament. Due to this varia-
bility and asymmetry, it is essential for CT imaging inter-
preters to be familiar with the spectrum of appearance of
the TC to avoid confusion with pathologic entities.
Author Contributions
Eman Alqahtani, study design, data acquisition, data analysis, and
data interpretation; manuscript drafting, manuscript revision, and
manuscript approval; agrees to be accountable for all aspects of
this study and ensures that questions related to the accuracy or
integrity of any part of this study are appropriately investigated
and resolved; Daniel E. Marrero, study design, data acquisition;
manuscript drafting, manuscript revision, and manuscript approval;
agrees to be accountable for all aspects of this study and ensures
that questions related to the accuracy or integrity of any part of
this study are appropriately investigated and resolved; Walter L.
Champion, data interpretation; manuscript drafting, manuscript
revision, and manuscript approval; agrees to be accountable for all
aspects of this study and ensures that questions related to the accu-
racy or integrity of any part of this study are appropriately investi-
gated and resolved; Ahmed Alawaji, data analysis, and data
interpretation; manuscript drafting, manuscript revision, and manu-
script approval; agrees to be accountable for all aspects of this
study and ensures that questions related to the accuracy or integrity
of any part of this study are appropriately investigated and
resolved; Philip D. Kousoubris, study design, and data interpreta-
tion; manuscript drafting, manuscript revision, and manuscript
approval; agrees to be accountable for all aspects of this study and
ensures that questions related to the accuracy or integrity of any
part of this study are appropriately investigated and resolved;
Juan E. Small, study design, data acquisition, data analysis, and
data interpretation; manuscript drafting, manuscript revision, and
manuscript approval; agrees to be accountable for all aspects of
10. Griffith B, Kelly M, Vallee P, et al. Screening cervical spine
this study and ensures that questions related to the accuracy or
integrity of any part of this study are appropriately investigated
and resolved.
11. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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137
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