Head and Neck

CT and MR Imaging in the Diagnosis of Scleritis

Fellows’ Journal Club

Scleritis is a rare vision-threatening condition that can occur isolated or in association with other orbital abnormalities and whose etiology is typically inflammatory/noninfectious, either idiopathic or in the context of systemic disease. The authors analyzed 11 cases of scleritis in which CT and/or MR imaging were performed during the active phase of disease and assessed the diagnostic utility of these techniques. The most important imaging findings of scleritis were scleral enhancement, scleral thickening, and focal periscleral cellulitis. MR imaging is the recommended imaging technique.

Summary

Figure 1 from paper
Asynchronous IOID with scleritis. A, CECT depicts outward, eccentric thickening and enhancement of the right globe wall with focal periscleral cellulitis (black arrow), compatible with posterior scleritis. There is associated pre- and postseptal cellulitis (white arrow) and proptosis. B, CECT 18 months after examination (A) shows almost identical findings in the left orbit. Black and white arrows point to the scleritis and cellulitis, respectively. Notice the complete resolution of the alterations of the right orbit. Also, notice involvement of the tendon of the lateral rectus anteriorly (dashed arrow).

Scleritis is a rare, underdiagnosed vision-threatening condition that can occur isolated or in association with other orbital abnormalities. The etiology of scleritis is mainly inflammatory noninfectious, either idiopathic or in the context of systemic disease. Ultrasonography remains the criterion standard in diagnostic imaging of this condition but might prove insufficient, and studies on the diagnostic value of CT and MR imaging are lacking. We retrospectively analyzed 11 cases of scleritis in which CT and/or MR imaging were performed during the active phase of disease and assessed the diagnostic utility of these techniques. The most important imaging findings of scleritis were scleral enhancement, scleral thickening, and focal periscleral cellulitis. MR imaging is the recommended imaging technique, though posterior scleritis also can be accurately diagnosed on

Imaging Features of Malignant Lacrimal Sac and Nasolacrimal Duct Tumors

Fellows’ Journal Club

This case series presents 18 patients with primary and secondary malignant lacrimal sac and nasolacrimal duct tumors and their pattern of tumor spread. Squamous cell carcinoma was the most common histology and, in 15/18 patients tumor involved both the lacrimal sac and duct at the time of diagnosis. In 11/16 patients on CT, the nasolacrimal bony canal was smoothly expanded without erosive changes. Tumor was not observed solely within the nasolacrimal duct in any patient. Only 1 patient presented with nodal metastasis and there was no intracranial tumor extension or perineural tumor spread. The authors conclude that malignant lacrimal sac and nasolacrimal duct tumors tend to expand the nasolacrimal bony canal, rather than erode it. CT was superior to MR imaging in characterizing expansion versus erosion of the nasolacrimal bony canal.

Summary

Figure 5 from paper
A 73-year-old woman with well-differentiated SCCA of the lacrimal sac and nasolacrimal duct. A, Post-contrast-enhanced CT demonstrates an enhancing tumor within the left lacrimal sac (arrow). B, At a slightly more inferior level (bone window), note the mild expansion of the lacrimal bony canal by tumor (arrow).

The purpose of this study was to present the imaging features of primary and secondary malignant lacrimal sac and nasolacrimal duct tumors and their pattern of tumor spread in 18 patients. The most common tumor histology in our series was squamous cell carcinoma. In 15/18 patients, tumor involved both the lacrimal sac and duct at the time of diagnosis. In 11/16 patients on CT, the nasolacrimal bony canal was smoothly expanded without erosive changes. The medial canthus region (16/18) was a frequent site of direct tumor spread. Two patients had intraconal orbital spread of tumor. Tumor spread to the sinus or nasal cavity was observed in 5/13 primary tumors. Only 1 patient presented with nodal metastasis. There was

Imaging Appearance of SMARCB1 (INI1)-Deficient Sinonasal Carcinoma: A Newly Described Sinonasal Malignancy

Editor’s Choice

SMARCB1 (INI1) is a tumor-suppressor gene that has been implicated in a growing number of malignancies involving multiple anatomic sites, including the kidneys, soft tissues, and the CNS (See OMIM *601607). The authors describe a case series of 17 patients collected from 6 different centers to give a comprehensive description of the appearance of these tumors on CT, MR, and PET/CT studies. SMARCB1 (INI1)-deficient sinonasal carcinoma should be included in the differential diagnosis of a central sinonasal mass demonstrating aggressive imaging features, particularly when there is associated calcification.

Atlas of Anatomy: Head, Neck, and Neuroanatomy

Schuenke M, Schulte E, Schumacher U, eds. Atlas of Anatomy: Head, Neck, and Neuroanatomy. Thieme; 2016; 600 pp; 1743 ill; $79.99

schuenke-atlas-anatomy-thieme_coverIn a beautifully illustrated 600-page softcover entitled Atlas of Anatomy: Head, Neck and Neuroanatomy, the authors describe and illustrate anatomic details we encounter on a daily basis. There are many outstanding features of the book, including the physiologic correlates and the anatomy. For example, in the excellent portions on the temporal bone, the anatomy is exquisite, even on the highly detailed drawings of small structures, and one comes away with a good understanding of how the whole assembly works to propagate and register sounds. This type of highly informative material is repeated in many sections/areas.

If one only looks at titles of the sections in the Table of Contents, it minimally spells out what lies in this book. When it comes to the neuroanatomy section, the details of functional systems, and the interconnectivity of parts of the brain, the drawings clarify many issues that are often complex and confusing. The book ends with a glossary and a synopsis to which the reader can often refer.

This book is simply wonderful. To this reviewer, the anatomy as shown in this book is the best available. Its purchase as a personal copy is highly recommended.…

Diagnostic Pathology: Neuropathology and Head & Neck Pathology

Covers of Diagnostic Pathology editions Neuropathology and Head and Neck PathologyKleinschmidt-Demasters BK, Rodriguez F, Tihan T, et al. Diagnostic Pathology: Neuropathology. 2nd ed. AMIRSYS Elsevier; 2016; 864 pp; 2800 ill; 224.99

Thompson LDR, Wenig BM, et al. Diagnostic Pathology: Head & Neck. 2nd ed. AMIRSYS Elsevier; 2017; 1192 pp; 3000 ill; $247.49

In two newly published and remarkable diagnostic pathology textbooks, both second editions, one on neuropathology and one on head and neck pathology, the neuroradiologist has access to vividly illustrated and comprehensive details relating to the histopathology and some gross pathology in a wide range of abnormalities. There are so many plaudits one could give for these books that it is difficult to know where to start.

The neuropathology text is edited by Drs. Kleinschmidt-Demasters, Rodríguez, and Tihan, with major contributions from Drs. Burger, Scheithauer, Ersen, and Rushing. The text is more encompassing in score and somewhat more descriptive in the text material than the prior edition. Interestingly, the beginning of the book starts with a 2-page run down of what is new in WHO Classifications. Highlighted are diffuse astrocytomas, oligodenrogliomas, and other tumoral redesignations. Most, as one can imagine, rely on genetic definitions and explanations. In the neuropathology text there are 2 parts—the first, on neoplastic, and the second, on non-neoplastic pathologies. The former contains (as in the 1st edition) 5 sections: Brain and Cord, Sella, Meninges, Nerves, and Tumoral Syndromes, while the latter contains 4 sections: Benign Cysts, Infections and Inflammations, Vascular Disease, and a short segment on cortical dysplasia.

What is beautiful about this book, and also about the head and neck pathology book, is the widespread integration of the imaging and classic pathology of the same entity. Not only does one get a deep sense of the underlying causes of the familiar imaging findings, but one is also educated in virtually all …

Usefulness of Pseudocontinuous Arterial Spin-Labeling for the Assessment of Patients with Head and Neck Squamous Cell Carcinoma by Measuring Tumor Blood Flow in the Pretreatment and Early Treatment Period

Editor’s Choice

Editor’s Comment

Forty-one patients with head and neck squamous cell carcinoma were evaluated by using pseudocontinuous ASL. Quantitative tumor blood flow was calculated at the pretreatment and the early treatment periods. Pretreatment tumor blood flow in patients in the treatment failure group was significantly lower than that in patients in the local control group. The use of the percentage change of tumor blood flow combined with the percentage change of tumor volume had high diagnostic accuracy for predicting local control.

Abstract

BACKGROUND AND PURPOSE

For the assessment of the treatment response in non-surgical treatment, tumor blood flow provides the functional information of the tumor which is different from the morphological information such as tumor volume. The purpose of this study was to evaluate the diagnostic value of tumor blood flow values obtained by pseudocontinuous arterial spin-labeling in patients with head and neck squamous cell carcinoma.

MATERIALS AND METHODS

Forty-one patients with head and neck squamous cell carcinoma were evaluated by using pseudocontinuous arterial spin-labeling. Quantitative tumor blood flow was calculated at the pretreatment and the early treatment periods in all the patients, and the percentage change of tumor blood flow between the two was calculated. At the early treatment period, based on their tumor volume reduction rate, we divided the patients into stable disease and partial response groups for a subgroup analysis. The local control or failure was confirmed either by histopathology or by radiologic evaluation within the follow-up.

RESULTS

Pretreatment tumor blood flow in patients in the failure group was significantly lower than that in patients in the local control group. In the subgroup analysis of patients with stable disease, the percentage change of tumor blood flow was significantly larger (due to the tumor blood flow increase from pretreatment value) in the local control group than in

Total Otolaryngology—Head and Neck Surgery

Sclafani AP, ed. Total Otolaryngology—Head and Neck Surgery. Thieme; 2014; 1100 pp; 666 ill; $199.99

sclafani_otolaryngology_coverThis is an A-to-Z book on otolaryngology, with emphasis on the surgical aspects of that specialty. In a large (and heavy) 1100-page text edited primarily by Dr. Anthony Sclafani from Mount Sinai Medical Center in New York, the topics cover emergency management, general ENT, head and neck surgery, facial plastic and reconstructive surgery, pediatric ENT,  laryngology, rhinology, and otology.

There are portions of the book that have minimal applicability to radiology (as one would guess), but a great deal of it is directly germane to our specialty. Nearly 100 authors have contributed to this book, and they have hit the areas of greatest interest to their fellow surgeons and clinicians. However, not all the aspects a neuroradiologist would like to see in a book of this size are there, such as clinical and surgical considerations in temporal bone trauma or evaluation (clinical/imaging) of the previously operated neck, among others. That said, there are many crucial topics that allow one to appreciate and understand more fully those areas we deal with on a daily basis. As expected, there are points we infrequently, if it all, consider when dealing with ENT problems, but the reader will be disappointed to see many instances where there are no imaging correlates, such as in Bell’s Palsy, or little if any imaging, such as in paranasal sinus disease. Where imaging is included in various chapters it is generally of fair or suboptimal quality. More care should have been given to that aspect of the book.

As a general overview of ENT the book meets it goal, but detailed information in many areas of interest to the neuroradiologist is missing. That certainly is a good reason for a shorter, disease-specific book …

Postoperative Imaging Findings following Sigmoid Sinus Wall Reconstruction for Pulse Synchronous Tinnitus

Fellows’ Journal Club

Editor’s Comment

Transmastoid sigmoid sinus wall reconstruction (SSWR) is a surgical technique used for the treatment of pulsatile tinnitus arising from sigmoid sinus wall anomalies. In 13 patients, CT and MR imaging examinations were assessed for the characteristics of the materials used for reconstruction, the impact of these on the adjacent sigmoid sinus, and complications. The various materials used for reconstruction (NeuroAlloderm, HydroSet, bone pate) showed characteristic imaging appearances and could be consistently identified. In 5/13 patients, there was extrinsic compression of the sigmoid sinus by graft material. Dural sinus thrombosis occurred in 2 patients. Symptoms requiring postoperative imaging after SSWR include headaches, visual disturbances, and persistent or recurrent tinnitus.

Abstract

Figure from Raghavan et al -- Fellows' Journal Club
CT features of sigmoid wall anomalies. A, Axial CT image of the temporal bone demonstrates dehiscence of the left sigmoid sinus wall (arrow). B, Axial CT image of the temporal bone in a different patient demonstrates a small left sigmoid sinus diverticulum (arrow). Both patients presented with left pulse synchronous tinnitus.

BACKGROUND AND PURPOSE

Transmastoid sigmoid sinus wall reconstruction is a surgical technique increasingly used for the treatment of pulsatile tinnitus arising from sigmoid sinus wall anomalies. The imaging appearance of the temporal bone following this procedure has not been well-characterized. The purpose of this study was to evaluate the postoperative imaging appearance in a group of patients who underwent this procedure.

MATERIALS AND METHODS

The medical records of 40 consecutive patients who underwent transmastoid sigmoid sinus wall reconstruction were reviewed. Thirteen of 40 patients underwent postoperative imaging. Nineteen CT and 7 MR imaging examinations were assessed for the characteristics of the materials used for reconstruction, the impact of these on the adjacent sigmoid sinus, and complications.

RESULTS

Tinnitus resolved in 38 of 40 patients. Nine patients were imaged postoperatively for suspected complications, including dural sinus

Accuracy of Preoperative Imaging in Detecting Nodal Extracapsular Spread in Oral Cavity Squamous Cell Carcinoma

Fellows’ Journal Club

Editor’s Comment

A group of 111 consecutive patients with untreated oral cavity squamous cell carcinoma and available preoperative imaging and subsequent lymph node dissection was studied. Twenty nine subjects had radiographically determined extracapsular spread. Imaging sensitivity and specificity for extracapsular spread were 68% and 88%, respectively. Necrosis, irregular borders, and gross invasion were independently correlated with pathologically proved extracapsular spread.

Abstract

A, A right level IIA lymph node (arrow) in a patient with OCSCC. This rounded low-attenuation node has irregular borders and fat stranding. Imaging prospectively diagnosed ECS, which was confirmed with pathologic examination (true-positive result). B, A right level IIA lymph node (arrow) in a patient with OCSCC. This small 1-cm lymph node shows subtle fat stranding. Imaging prospectively diagnosed ECS, which was confirmed with pathologic examination (true-positive result). C, A right level IIA lymph node (arrows) in a patient with OCSCC. This large necrotic node demonstrates invasion of the adjacent sternocleidomastoid muscle. Imaging prospectively diagnosed ECS, which was confirmed with pathologic examination (true-positive result).
A, A right level IIA lymph node (arrow) in a patient with OCSCC. This rounded low-attenuation node has irregular borders and fat stranding. Imaging prospectively diagnosed ECS, which was confirmed with pathologic examination (true-positive result). B, A right level IIA lymph node (arrow) in a patient with OCSCC. This small 1-cm lymph node shows subtle fat stranding. Imaging prospectively diagnosed ECS, which was confirmed with pathologic examination (true-positive result). C, A right level IIA lymph node (arrows) in a patient with OCSCC. This large necrotic node demonstrates invasion of the adjacent sternocleidomastoid muscle. Imaging prospectively diagnosed ECS, which was confirmed with pathologic examination (true-positive result).

Background and Purpose

The increasing impact of diagnosing extracapsular spread by using imaging, especially in patients with oropharyngeal squamous cell carcinoma, highlights the need to rigorously evaluate the diagnostic accuracy of imaging. Previous analysis suggested 62.5%–80.9% sensitivity and 60%–72.7% specificity. Our goals were to evaluate the accuracy of imaging in diagnosing extracapsular spread in a cohort of patients with oral cavity squamous cell carcinoma (pathologic confirmation of extracapsular spread routinely available), as a proxy for oropharyngeal squamous cell carcinoma, and to independently assess the reliability of imaging features (radiographic lymph node necrosis, irregular borders/stranding, gross invasion, and/or node size) in predicting pathologically proven extracapsular spread.

Materials and Methods

One hundred eleven consecutive patients with untreated oral cavity squamous cell carcinoma and available …