Head and Neck

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 …

Clinical Otology

Pensak ML, Choo DI, eds. Clinical Otology. 4th ed. Thieme; 2014; 528 pp; 340 ill; $189.99

clin-otol_coverClose collaboration between the clinical services in the neurosciences and neuroradiology is important in all fields of our work. This is true in head/neck imaging, particularly when considering all the aspects of clinical otology. While this book, edited by Dr. Pensak and Choo (with 74 contributors), is not one a neuroradiologist would purchase for its imaging value, it is, however, one that contains valuable clinical and surgical information those who deal with a sizeable volume of temporal bone imaging will find valuable.

There are 4 basic sections of the book

  • Basic Science – concentrating on anatomy, physiology, molecular biology
  • Evaluation – including a short chapter (8 pages) on temporal bone imaging, auditory disorders, clinical evaluation of the clinical nerves, the dizzy patient
  • Management – of a whole host of disorders we frequently encounter on imaging
  • Rehabilitation – including implantable hearing devices, cochlear implants, and pulsatile tinnitus, among other topics).

Unfortunately, material on the imaging of devices is limited to nonexistent. Their inclusion and an analysis of this topic would have added value. Highly detailed MR imaging, such as 3D CISS for the small, middle, and inner ear structures, is absent, but again, the value of the book to our specialty does not lie in its imaging but rather in the clinical aspects of otology. Of note also is that in a number of chapters the legends inadequately describe all the findings or are misleading/incorrect.

Nonetheless, drawings and some of the otoscopic photographs are instructive.

For those with a keen interest in clinical otology, and for those who wish to be increasingly conversant with the temporal bone surgeons in their practice, this book is worthwhile.…

Temporal Bone CT: Improved Image Quality and Potential for Decreased Radiation Dose Using an Ultra-High-Resolution Scan Mode with an Iterative Reconstruction Algorithm

Editor’s Choice

Editor’s Comment

Patients with baseline temporal bone CT scans acquired by using a z-axis ultra-high-resolution protocol and a follow-up scan by using the ultra-high-resolution–iterative reconstruction technique were identified. Images of left and right temporal bones were reconstructed in the axial, coronal, and Poschl planes. Spatial resolution was comparable (Poschl) or slightly better (axial and coronal planes) with ultra-high-resolution–iterative reconstruction than with z-axis ultra-high-resolution. Paired t test indicated that noise was significantly lower with ultra-high-resolution–iterative reconstruction than with z-axis ultra-high-resolution.

Abstract

F3.large
Comparison of the spatial resolution of the incudomallear joint. Representative axial images of the incudomallear joint of the same patient scanned with the zUHR technique (A) and UHR-IR technique (B). The UHR-IR technique produced superior spatial resolution and lower image noise.

Background and Purpose

Radiation dose in temporal bone CT imaging can be high due to the requirement of high spatial resolution. In this study, we assessed whether CT imaging of the temporal bone by using an ultra-high-resolution scan mode combined with iterative reconstruction provides higher spatial resolution and lower image noise than a z-axis ultra-high-resolution mode.

Materials and Methods

Patients with baseline temporal bone CT scans acquired by using a z-axis ultra-high-resolution protocol and a follow-up scan by using the ultra-high-resolution–iterative reconstruction technique were identified. Images of left and right temporal bones were reconstructed in the axial, coronal, and Poschl planes. Three neuroradiologists assessed the spatial resolution of the following structures: round and oval windows, incudomallear and incudostapedial joints, basal turn spiral lamina, and scutum. The paired z-axis ultra-high-resolution and ultra-high-resolution–iterative reconstruction images were displayed side by side in random order, with readers blinded to the imaging protocol. Image noise was compared in ROIs over the posterior fossa.

Results

We identified 8 patients, yielding 16 sets of temporal bone images (left and right).

Acute Invasive Fungal Rhinosinusitis: A Comprehensive Update of CT Findings and Design of an Effective Diagnostic Imaging Model

Fellows’ Journal Club

Editor’s Comment

Two blinded neuroradiologists retrospectively graded 23 prespecified imaging abnormalities in the craniofacial region on CT examinations from 42 patients with pathology-proven acute invasive fungal rhinosinusitis and 42 control patients. A 7-variable model (periantral fat, bone dehiscence, orbital invasion, septal ulceration, pterygopalatine fossa, nasolacrimal duct, and lacrimal sac) was synthesized on the basis of multivariate analysis. The presence of abnormality involving a single variable in the model had an 87% positive predictive value, 95% negative predictive value, 95% sensitivity, and 86% specificity.

Abstract

Examples of established findings in AIFR. A, Axial CT image shows unilateral mucosal thickening involving the right maxillary sinus (asterisk) with soft-tissue infiltration of the right anterior periantral fat (arrow) and the posterior periantral fat (arrowhead). B, Axial image in a different patient shows unilateral right nasal cavity (white asterisk) and maxillary sinus (black asterisk) mucosal thickening. Soft-tissue infiltration through the right sphenopalatine foramen and pterygopalatine fossa (arrowhead) is seen, as well as involvement of the right posterior periantral fat (arrow). C, Coronal CT in a third patient illustrates orbital involvement of AIFR with subtle infiltration of the right medial and inferior extraconal orbital fat (arrowheads), despite the absence of bone erosion. D, Axial CT shows a surgically proved subtle ulceration along the left side of the nasal septum (arrowhead) in a fourth patient.

Background and Purpose

Acute invasive fungal rhinosinusitis carries a high mortality rate. An easy-to-use and accurate predictive imaging model is currently lacking. We assessed the performance of various CT findings for the identification of acute invasive fungal rhinosinusitis and synthesized a simple and robust diagnostic model to serve as an easily applicable screening tool for at-risk patients.…

Treatment of Benign Thyroid Nodules: Comparison of Surgery with Radiofrequency Ablation

Fellows’ Journal Club

Editor’s Comment

Two hundred patients with nodular goiter were treated with surgery, and an equal number were treated with radiofrequency ablation. Surgical resection and ablation were both effective, but ablation had fewer complications and fewer hospital days.

Abstract

A 50-year-old woman with left-neck discomfort. A, Before treatment, a 3-cm solid, left thyroid nodule is evident. B, During the RF ablation, the electrode (arrows) is placed within the nodule. C, Six months after RF ablation, the treated nodule (arrows) has decreased considerably in size and measures only 8 mm.

Background and Purpose

Nodular goiter is one of the most common benign lesions in thyroid nodule. The main treatment of the disease is still the traditional surgical resection, however there are many problems such as general anesthesia, surgical scar, postoperative thyroid or parathyroid function abnormalities, and high nodules recurrence rate in residual gland. The purpose of this study was to compare the efficacy, safety, and cost-effectiveness of 2 treatment methods, surgery and radiofrequency ablation, for the treatment of benign thyroid nodules.

Materials and Methods

From May 2012 to September 2013, 200 patients with nodular goiters who underwent surgery (group A) and 200 patients treated by radiofrequency ablation (group B) were enrolled in this study. Inclusion criteria were the following: 1) cosmetic problem, 2) nodule-related symptoms, 3) hyperfunctioning nodules related to thyrotoxicosis, and 4) refusal of surgery (for group B). An internally cooled radiofrequency ablation system and an 18-ga internally cooled electrode were used. We compared the 2 groups in terms of efficacy, safety, and cost-effectiveness during a 1-year follow-up.

Results

After radiofrequency ablation, the nodule volume decreased significantly from 5.4 to 0.4 mL (P = .002) at the 12-month follow-up. The incidence of complications was significantly higher from surgery than from radiofrequency ablation (6.0% versus 1.0%, P =

Vascular Lesions of the Head and Neck: Diagnosis and Management

Persky MS, Waner M, Blei F, et al. Vascular Lesions of the Head and Neck: Diagnosis and Management. Thieme; 2015; 168 pp; 236 ill; $99.99

Persky-vasc-lesions_ThiemeAs neuroradiologists we often diagnose various types of vascular malformations with CT, MR and/or DSA. Rarely do we actually see the patients with these abnormalities unless we are performing interventions, either as a primary treatment or as a prelude to a surgical procedure. This book (134 pages, hardcover) is edited by Drs. Persky, Waner, Blei and Berenstein. The inclusion of Dr. Berenstein, an interventional neuroradiologist, is important because it adds to the various disciplines involved in the care of these patients (Dermatology, Otolaryngology, Plastic Surgery, Pathology, and Radiology).

Drs. Shatules and Lefton contributed a short chapter on the Radiologic Evaluation of Vascular Malformations (description and illustration of the 4 types) and a separate chapter on hemangiomas alone. This book covers (14 chapters) all the critical aspects of head and neck vascular lesions, including the current classification systems and the clinical and pathologic findings in congenital vascular tumors. The pathology of congenital tumors is particularly well-written and well-illustrated chapter (many of these types are unknown to most neuroradiologists).

The chapters include information classification, genetics, pathology, natural history, various syndromes associated with vascular anomalies, imaging interventional management of these patients, and vascular neoplasms of the head and neck.

What would interest those in our specialty the most are the many pictures of patients with a variety of such lesions. Who amongst us has actually seen the clinical findings of a blue rubber bleb nevus or a proteus syndrome or an infantile Kaposioform hemogioendothelioma? And the patient illustrations go on for many more common and uncommon lesions. These are enlightening.

The endovascular treatment of these lesions is very nicely written, and as with all the other chapters, …

Orbital Lymphoproliferative Disorders (OLPDs): Value of MR Imaging for Differentiating Orbital Lymphoma from Benign OPLDs

Fellows’ Journal Club

October 2014

(3 of 3)

After retrospectively analyzing MR images of 47 patients with proven orbital lymphoproliferative disease, the authors propose that ill-defined lesion margins suggest lymphoma whereas the presence of accompanying sinusitis and intralesional flow voids suggest benign lymphoproliferative disease. Lower ADC and contrast enhancement also suggest lymphoma.

EIC signature

Abstract

BACKGROUND AND PURPOSE
Accurate discrimination of orbital lymphoma from benign orbital lymphoproliferative disorders is crucial for treatment planning. We evaluated MR imaging including DWI and contrast-enhanced MR imaging for differentiating orbital lymphoma from benign orbital lymphoproliferative disorders.

MATERIALS AND METHODS
Forty-seven histopathologically proved orbital lymphoproliferative disorders (29 orbital lymphomas and 18 benign orbital lymphoproliferative disorders) were evaluated. Two board-certified radiologists reviewed visual features on T1-weighted, fat-suppressed T2-weighted, diffusion-weighted, and contrast-enhanced MR images. For quantitative evaluation, ADC and contrast-enhancement ratio of all lesions were measured and optimal cutoff thresholds and areas under curves for differentiating orbital lymphoma from benign orbital lymphoproliferative disorders were determined using receiver operative characteristic analysis; corresponding sensitivities and specificities were calculated.

RESULTS
Multivariate logistic regression analysis showed that ill-defined tumor margin (P = .003) had a significant association with orbital lymphoma whereas the “flow void sign” (P = .005) and radiologic evidence of sinusitis (P = .0002) were associated with benign orbital lymphoproliferative disorders. The mean ADC and contrast-enhancement ratio of orbital lymphomas were significantly lower than those of benign orbital lymphoproliferative disorders (P < .01). An ADC of less than 0.612 × 10−3mm2/s and a contrast-enhancement ratio of less than 1.88 yielded areas under curves of 0.980 and 0.770, sensitivity of 94.1% and 95.5%, and specificities of 93.3% and 80.0% for predicting orbital lymphoma, respectively.

CONCLUSIONS
Some characteristic MR imaging features and quantitative DWI and contrast-enhanced MR imaging are useful in further improving the accuracy