Amy F. Juliano

Imaging Review of the Temporal Bone: Part I. Anatomy and Inflammatory and Neoplastic Processes

From a clinical-radiologic standpoint, there are a limited number of structures and disease entities in the temporal bone with which one must be familiar in order to proficiently interpret a computed tomographic or magnetic resonance imaging study of the temporal bone. It is helpful to examine the region in an organized and systematic fashion, going through the same checklist of key structures each time. This is the first of a two-part review that provides a practical approach to understanding temporal bone anatomy, localizing a pathologic process with a focus on inflammatory and neoplastic processes, identifying pertinent positives and negatives, and formulating a differential diagnosis.

Imaging Review of the Temporal Bone: Part II. Traumatic, Postoperative, and Noninflammatory Nonneoplastic Conditions

The first part of this review of the temporal bone discussed anatomy of the temporal bone as well as inflammatory and neoplastic processes in the temporal bone region (1). This second part will first discuss trauma to the temporal bone and posttraumatic complications. The indications for common surgical procedures performed in the temporal bone and their postoperative imaging appearance are then presented. Finally, a few noninflammatory nonneoplastic entities involving the temporal bone are reviewed. They are relatively uncommon diagnoses compared with infectious or inflammatory diseases. However, because patients present with symptoms that are either common (hearing loss) or distinctive (sensorineural hearing loss in a child), they are important for the radiologist to be aware of and recognize.

Diagnostic characteristics of sinonasal organizing hematomas: avoiding misdiagnosis

Organizing hematomas of the paranasal sinuses are diagnostic dilemmas clinically and radiographically, mimicking benign or malignant neoplastic processes and causing patients and clinicians undue worry regarding these diagnoses. Diagnostic criteria for correctly identifying these lesions are not well known.

Correlation of CT, MR, and Histopathology in Incomplete Partition-II Cochlear Anomaly.

Objective: To correlate the computed tomography (CT) and magnetic resonance imaging (MR) findings in a patient with incomplete partition-type II (IP-II) anomaly with histopathology in a similar human temporal bone specimen. To discover the histologic correlate of a common finding on MR of an “apparent” interscalar septum (IS). Patients: A patient with sensorineural hearing loss and imaging findings characteristic of IP-II, and a patient with histopathologic IP-II anomaly. Intervention: High-resolution CT, MR, and review of postmortem temporal bone histopathology. Main Outcome Measure: Correlation of temporal bone histopathology with CT and MR findings. Results: Consistent findings of IP-II anomaly on CT, absence of the IS between the more distal turns and flattening of the interscalar ridge between the distal basal turn and the middle turn, were present. The signal void surrounding the cochlea on MR also demonstrated flattening of the interscalar ridge. However, a thin band-like area of low T2 signal was seen, which could be mistaken for an IS. Correlation with temporal bone histopathology revealed that the modiolus was foreshortened, and the spiral ganglion neuron dendritic processes continued toward the upper middle turn through the osseous spiral lamina, likely accounting for the MR finding. Conclusion: Correlation of CT, MR, and histopathology in IP-II shows an “apparent” segmentation representing a continuum of neurosensory elements in approximately the same location of the expected location of a normal IS. Care should be taken when interpreting MR imaging in isolation. Understanding the bony outline of the cochlea on imaging may prove to be complementary.

Anatomy and Pathology of the Facial Nerve

Clinical Presentation Symptoms of facial nerve palsy depend on the location of injury. The motor nucleus of CN VII has dorsal and ventral divisions that supply the upper and lower face, respectively. There is bilateral innervation of the dorsal division but only contralateral innervation of the ventral division. Supranuclear lesions affect upper motor neurons proximal to the motor nucleus in such locations as the cerebral cortex, internal capsule, and cerebral peduncle. This results in central facial palsy that affects the contralateral lower face but spares the forehead and brow muscles. Infranuclear lesions occur distal to the facial nerve nucleus and produce peripheral facial palsy affecting the ipsilateral upper and lower face. Within the infranuclear pathway, the presence of additional symptoms can help further localize lesions. Involvement of CN VI presents with lateral rectus palsy, or inability to abduct the eye. This suggests a lesion of the facial colliculus in the pons, in which efferent CN VII fibers encircle the CN VI motor nucleus. Involvement of CN VIII causes auditory or vestibular symptoms. This suggests a cisternal or canalicular lesion in which CN VII and VIII nerve roots course together after emerging from the cerebellopontine angle. Finally, certain branches of the facial nerve control specialized functions. The greater superficial petrosal nerve controls lacrimation, the stapedius dampens sound transmission in the inner ear, and the chorda tympani is responsible for taste. Lesions proximal to the geniculate ganglion lose all three functions, lesions between the geniculate ganglion and stylomastoid foramen have preserved lacrimation, and extracranial lesions spare all three functions. Anatomy and Pathology of the Facial Nerve

A novel thyroid cancer nodal map classification system to facilitate nodal localization and surgical management: The A to D map

To evaluate the effectiveness, reproducibility, and usability of our proposed nodal nomenclature and classification system employed for several years in our high‐volume thyroid cancer unit, for the adequate localization and mapping of lymph nodes in thyroid cancer patients with extensive nodal disease.

Measurement for Detection of Incomplete Partition Type II Anomalies on MR Imaging

BACKGROUND AND PURPOSE: Incomplete partition type II of the cochlea, commonly coexisting with an enlarged vestibular aqueduct, can be a challenging diagnosis on MR imaging due to the presence of a dysplastic spiral lamina–basilar membrane neural complex, which can resemble the normal interscalar septum. The purpose of this study was to determine a reproducible, quantitative cochlear measurement to assess incomplete partition type II anomalies in patients with enlarged vestibular aqueducts using normal-hearing ears as a control population. MATERIALS AND METHODS: Retrospective analysis of 27 patients with enlarged vestibular aqueducts (54 ears) and 28 patients (33 ears) with normal audiographic findings who underwent MR imaging was performed. Using reformatted images from a cisternographic 3D MR imaging produced in a plane parallel to the lateral semicircular canal, we measured the distance (distance X) between the osseous spiral lamina-basilar membrane complex of the upper basal turn and the first linear signal void anterior to the basilar membrane. RESULTS: The means of distance X in patients with normal hearing and prospectively diagnosed incomplete partition type II were, respectively, 0.93 ± 0.075 mm (range, 0.8–1.1 mm) and 1.55 ± 0.25 mm (range, 1–2.1 mm; P < .001). Using 3 SDs above the mean of patients with normal hearing (1.2 mm) as a cutoff for normal, we diagnosed 21/27 patients as having abnormal cochleas; 4/21 were diagnosed retrospectively. This finding indicated that almost 20% of patients were underdiagnosed. Interobserver agreement with 1.2 mm as a cutoff between normal and abnormal produced a κ score of 0.715 (good). CONCLUSIONS: Incomplete partition type II anomalies on MR imaging can be subtle. A reproducible distance X of ≥1.2 mm is considered abnormal and may help to prospectively diagnose incomplete partition type II anomalies.

Temporal bone computed tomography findings associated with feasibility of endoscopic ear surgery

PURPOSE There are no formal radiologic criteria to stratify patients for transcanal (TEES) or transmastoid endoscopic ear surgery for resection of cholesteatoma. We aim to determine 1) whether standard preoperative computed tomography (CT) findings are associated with the need for conversion to a transmastoid approach and 2) the amount of time added for conversion from TEES to transmastoid techniques. MATERIALS AND METHODS Retrospective chart review of consecutive pediatric and adult cases of TEES for primary cholesteatoma from 2013 through 2015 (n=52). TEES cases were defined as endoscope-only procedures that did not require a transmastoid approach (n=33). Conversion cases were defined as procedures that began as TEES however, required conversion to a transmastoid approach due to the inability to complete cholesteatoma removal (n=19). Preoperative CT findings and total operating room (OR) times of TEES and conversion cases were compared. RESULTS Preoperative CT scan characteristics that were associated with conversion included tegmen erosion (p=0.026), malleus erosion (p<0.001), incus erosion (p=0.009), mastoid opacification (p=0.009), soft tissue opacification extending into the aditus ad antrum (p=0.009) and into antrum (p=0.006). Total OR time for TEES cases was significantly shorter than conversion cases (median 143min versus 217min, p<0.001). CONCLUSIONS Preoperative CT findings, notably extension of soft tissue in the aditus ad antrum, antrum and mastoid, are associated with need for conversion to transmastoid technique to achieve removal of cholesteatoma. Endoscope-only cases were significantly faster than cases that required conversion to a transmastoid approach.

Intraoperative Ultrasound in Oral Tongue Cancer Resection: Feasibility Study and Early Outcomes:

The current standard of care in oral tongue cancer surgery is complete resection with a target of 5-mm microscopic clearance at all margins on final pathologic review. While current methods of resection are often successful at determining the mucosal margins of the lesion, they may be limited when attempting to achieve an adequate deep margin. A number of previous studies suggested that ultrasound is superior to manual palpation and other imaging modalities (computed tomography, magnetic resonance imaging) at demarcating the margins of tongue lesions. Recent clinical reports of the intraoperative use of this modality have used an invasive method to mark the proposed deep resection margin. In this communication, we report our initial experience with the use of intraoperative ultrasound as an adjunct to oral tongue cancer surgery without the use of an invasive method to mark the deep resection margin.

Computed Tomography Versus Magnetic Resonance in Head and Neck Cancer: When to Use What and Image Optimization Strategies

This article provides a practical overview of head and neck cancers, outlining an approach to evaluating these lesions and optimizing imaging strategies. Recognition of key anatomic landmarks as suggested by American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) criteria is emphasized. Further, the recently updated eighth edition of the AJCC staging manual has introduced some modifications that influence the TNM staging. These modifications are discussed throughout the article to provide an updated review on head and neck cancer.