Cholesteatoma management includes early detection and surgical exploration. Due to its tendency to recur, it can be potentially locally aggressive. Magnetic resonance imaging (MRI), and in particular diffusion weighted imaging (DWI), plays an important role in management of these lesions.To assess the accuracy of Propeller (Periodically Rotated Overlapping ParallEL Lines with Enhanced Reconstruction) DW sequence in detecting middle ear and mastoid cholesteatomas in non-operated ears by surgical correlation.A retrospective review of 15 patients was done who underwent Propeller DWI with either clinically confirmed or suspected cholesteatomas. Surgical correlation was done in all cases.All patients had hyperintense foci on Propeller DWI. Surgical correlation performed revealed that 13 patients had cholesteatomas while two patients had mastoid abscesses. The location, extent, and size of cholesteatomas on Propeller DWI matched with the operative findings. Of the 13 patients with cholesteatomas, three patients had multiple foci of hyperintensity on Propeller DWI, which corroborated with the surgical finding of multiple cholesteatomas. The average apparent diffusion coefficient value of cholesteatoma was 0.868 × 10(-3) mm(2)/s, found to be higher than that of abscess, which was 0.425 × 10(-3) mm(2)/s.Propeller DWI was accurate in assessing the location, extent, and size of cholesteatomas as corroborated with surgical findings. Propeller DWI is useful in detecting number of cholesteatoma foci, a vital finding as it may impact the choice of surgery.
Semicircular canal dehiscence is a congenital syndrome that mainly affects the superior and, less commonly, the posterior semicircular canals. The diagnosis of superior semicircular canal dehiscence syndrome depends on the demonstration of a very small defect in the bony wall of the superior semicircular canal. Any amount of intact bone present excludes the diagnosis. The study will give an approximation of the incidence of semicircular canal dehiscence in Singapore. No specific data regarding the number of such cases exist currently. Retrospective review of CT scans of the temporal bone performed at our institution between January 2005 and July 2007 revealed a total of 10 such cases over this period, comprising 8 males and 2 females, with all cases involving the superior semicircular canal. Almost all of the patients scanned had evidence of previous or existing cholesteatoma. Three patients had bilateral superior semicircular canal dehiscence (all males), with an almost equal number of semicircular canal dehiscence on both sides for both sexes. Our study shows no significant advantage to obtaining reformatted oblique sagittal images for all temporal bone studies, unless the visualized walls show questionable defects. In these cases, reconstructed images are probably advantageous and should be obtained and reviewed.
Lymphoepithelial carcinoma (LEC) of the larynx is an extremely rare tumour which, unlike its nasopharyngeal counterpart, has shown a propensity to affect elderly Caucasian men and is not commonly associated with Epstein-Barr virus. We present a 70-year-old Chinese man who complained of hoarseness and dysphagia. Nasoendoscopy revealed a left supraglottic tumour. Preoperative MRI (in particular Diffusion Weighted Imaging) showed the possibility of two distinct components within a tumour. The patient underwent total pharyngolaryngectomy and bilateral selective neck dissection. The final histology report confirmed the presence of a tumour with two distinct components: predominant LEC with a smaller conventional (keratinising) squamous cell carcinoma component. The patient recovered well after surgery and subsequently underwent adjuvant radiotherapy. Final staging was pT3 N2c M0 (AJCC stage IVA). Follow-up over 2 years revealed no tumour recurrence.
We would like to highlight the need to reduce intraoperative frozen section (FS) during diagnostic hemithyroidectomy performed on thyroid nodules with Bethesda III cytology.Thyroid nodules are increasingly diagnosed and subjected to fine needle aspiration cytology.Bethesda III is a cytological category that consists of atypia or follicular lesion of undetermined significance, and carries a 6-30% risk of malignancy. 1 Hemithyroidectomy is commonly performed on Bethesda III nodules to obtain a definitive histological diagnosis.FS during hemithyroidectomy allows some thyroid cancers-predominantly papillary thyroid carcinoma (PTC)-to be diagnosed intraoperatively. 2 Such a diagnosis may prompt the surgeon to perform a total thyroidectomy and/or central neck dissection.However, the routine use of FS on Bethesda III nodules is controversial considering the low probability of a diagnosis of malignancy on FS, 2 and such a diagnosis would not necessarily alter the extent of surgery. 3Until 2016, we practised FS routinely on Bethesda III nodules followed by total thyroidectomy with or without elective central neck dissection, if thyroid carcinoma was diagnosed on FS-except for papillary thyroid microcarcinomas.In view of recent guidelines recommending hemithyroidectomy without elective central neck dissection to be an acceptable treatment of well-differentiated intrathyroidal papillary carcinomas that are ≤4cm, 3 we reviewed our experience to determine how FS in Bethesda III nodules may be reduced.After obtaining ethics approval from our institution in Singapore, we studied the preoperative clinical, sonographic and pathologic characteristics associated with the diagnosis of malignancy or suspicion of malignancy on FS in 98 Bethesda III nodules from 98 patients.These patients underwent hemithyroidectomy and FS in our department from 2010 to 2016.Sonographic characteristics were retrieved from the radiologist's report and suspicion of malignancy, defined by the presence of any of these featuresmicrocalcification, marked hypoechogenicity, tallerthan-wider configuration, irregular margin, extrathyroidal extension or abnormal cervical lymph nodes-was considered present if it was so specified by the radiologist.Cytologic nuclear atypia was diagnosed when nuclear enlargement, pale or clear chromatin, grooves or pseudoinclusions were seen in various combinations in the follicular cells, but were insufficient
The incidence of otosclerosis in nonendemic patients is low, and preoperative diagnosis can be challenging. The aim of this study was to evaluate computed tomography (CT) findings in patients with otosclerosis and determine their correlation with audiometric findings and surgical outcome in a nonendemic population. We retrospectively reviewed 17 patients from August 2011 to August 2013 with surgically confirmed otosclerosis who underwent preoperative high-resolution CT scans and pre- and postoperative audiometry. Otosclerotic foci were identified on the scans. The density ratio of these foci was calculated and compared with pre- and postoperative audiometric parameters. One patient with Paget disease was excluded from the study. A total of 19 ears were operated on and included in the data analysis. CT scans were normal in 4 ears (21.1%). Hypodense lesions were detected in the remaining 15 (78.9%) ears and the region of interest mapped out. The density ratio was obtained between the hypodense area and adjacent normal labyrinthine bone. No statistically significant correlation was found between the density ratio and any of the audiometric parameters tested (p > 0.05). The diagnosis of otosclerosis in nonendemic areas is challenging. A preoperative CT scan can be useful when otosclerotic foci are present. However, the density ratio of the otosclerotic foci did not correlate with audiometric parameters or surgical outcome.
Nasopharyngeal cancer (NPC) is a unique disease that shows clinical behaviour, epidemiology and histopathology that is different from that of other squamous cell carcinomas of the head and neck. Magnetic resonance imaging (MRI) is now the preferred imaging modality in the assessment and staging of NPC, especially in relation to its superior soft tissue contrast, ability to demonstrate perineural tumour spread, parapharyngeal space, bone marrow involvement and its ability to show the involvement of adjacent structures, such as the adjacent paranasal sinuses and intracranial extension. An understanding of its patterns of spread and the criteria used in the AJCC TNM staging system is important to relay the relevant information to the referring clinician, so that appropriate treatment planning decisions may be made. In this article, the various features of NPC that are pertinent to staging and treatment planning will be discussed, inclusive of locoregional spread, nodal involvement and metastatic disease.
MR imaging can detect nasopharyngeal carcinoma that is hidden from endoscopic view, but for accurate detection carcinoma confined within the nasopharynx (stage T1) must be distinguished from benign hyperplasia of the nasopharynx. This study aimed to document the MR imaging features of stage T1 nasopharyngeal carcinoma and to attempt to identify features distinguishing it from benign hyperplasia.
MATERIALS AND METHODS:
MR images of 189 patients with nasopharyngeal carcinoma confined to the nasopharynx and those of 144 patients with benign hyperplasia were reviewed and compared in this retrospective study. The center, volume, size asymmetry (maximum percentage difference in area between the right and left nasopharyngeal halves), signal intensity asymmetry, deep mucosal white line (greater contrast enhancement along the deep tumor margin), and absence/distortion of the adenoidal septa were evaluated. Differences were assessed with logistic regression and the χ2 test.
RESULTS:
The nasopharyngeal carcinoma center was lateral, central, or diffuse in 134/189 (70.9%), 25/189 (13.2%), and 30/189 (15.9%) cases, respectively. Nasopharyngeal carcinomas involving the walls showed that a deep mucosal white line was present in 180/183 (98.4%), with a focal loss of this line in 153/180 (85%) cases. Adenoidal septa were absent or distorted in 111/111 (100%) nasopharyngeal carcinomas involving the adenoid. Compared with benign hyperplasia, nasopharyngeal carcinoma had a significantly greater volume, size asymmetry, signal asymmetry, focal loss of the deep mucosal white line, and absence/distortion of the adenoidal septa (P < .001). Although size asymmetry was the most accurate criterion (89.5%) for nasopharyngeal carcinoma detection, use of this parameter alone would have missed 11.9% of early-stage T1 nasopharyngeal carcinomas.
CONCLUSIONS:
MR imaging features can help distinguish stage T1 nasopharyngeal carcinoma from benign hyperplasia in most cases.
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