Anna Szymańska

Evaluation of tracheal stenosis: comparison between computed tomography virtual tracheobronchoscopy with multiplanar reformatting, flexible tracheofiberoscopy and intra-operative findings.

The aim of the study was to evaluate and compare various helical CT display modes [virtual endoscopy (VE)] and multiplanar reformations (MPR), conventional flexible tracheobronchoscopy (FT) and intra-operative (IO) findings in patients with tracheal stenosis and to analyze the advantage of MPR and VE in diagnosis and treatment planning and in postoperative follow-up. Thirty-seven patients with tracheal stenosis underwent standard neck and chest CT followed by MPR and VE. Results were correlated with the results of FT and IO findings. Thirty-three of the 37 stenoses were correctly graded and measured adequately using VE. Complete correlation among CT, fiberoptic tracheoscopy, and surgery of stenosis grading, stenosis length and length of planned resection segment of the trachea was noted between 33 of 37 patients with tracheal stenosis. Correlation between VE and IO was noted in 35 of 37 patients and between FT and VE was noted in 33 of 37 patients with tracheal stenosis. The sensitivity of VE was 94–97%, specificity was 100% with comparison to IO findings. The sensitivity and accuracy of MPR was 86–89% and specificity was 100% with comparison to FT findings. The results of the study indicate that VE is an excellent, consistent, and objective technique. VE with MPR is very useful in diagnostic evaluation and treatment planning in patients with tracheal stenosis.

Extranasopharyngeal angiofibroma: clinical and radiological presentation

Nasopharyngeal angiofibroma (NA) is a rare, vascular tumor affecting adolescent males. Due to aggressive local growth, skull base location and risk of profound hemorrhage, NA is a challenge for surgeons. Angiofibromas have been sporadically described in extanasopharyngeal locations. We review ten cases of extranasopharyngeal angiofibroma (ENA) and discuss the incidence, clinical presentation and management of this pathology. The group consisted of 4 males and 5 females aged 8–49. There were 7 patients with nasal angiofibroma, 1 patient with laryngeal angiofibroma, 1 patient with oral angiofibroma and another patient with infratemporal fossa tumor. In patients with nasal angiofibroma most common presenting symptoms were nasal obstruction and epistaxis. Patients with laryngeal angiofibroma suffered from mild dysphagia and patients with the infratemporal fossa tumor had painless cheek swelling. In four patients with nasal tumor computed tomography (CT) demonstrated mass with strong to intermediate contrast enhancement. In one patient with nasal tumor carotid angiography demonstrated pathological vessels without intensive tumor blush. Infratemporal fossa tumor showed intensive contrast enhancement on CT and magnetic resonance imaging (MRI) scans, and abundant vascularity on angiography. Laryngeal and oral angiofibroma required no radiological imaging. Three nasal tumors were evaluated before introduction of CT to clinical practice. All patients underwent surgery. No recurrences developed. ENAs differ significantly from NAs regarding clinical and radiological presentations. They lack typical clinical and radiological features as they develop in all age groups and in females, may be less vascularised, arise from various sites and produce a variety of symptoms.

Extranasopharyngeal angiofibroma of the infratemporal fossa.

Juvenile angiofibroma (JA) is a benign, vascular neoplasm that accounts for less than 0.5 percent of all head and neck tumors. The characteristic triad of clinical symptoms consists of nasopharyngeal tumor, nasal obstruction, and recurrent epistaxis. JAs of extranasopharyngeal origin have been sporadically reported in the literature. Windfuhr and Remmert in a review of 65 patients with extranasopharyngeal angiofibromas found only one case of tumor located in the infratemporal fossa. We present a rare case of a patient with extensive JA that occupied infratemporal fossa and cheek, without involvement of the nasopharynx. Medical University of Lublin Review Board approved the analysis and description of the patient. A 24-year-old man was referred to our institution in January 2006 with a 9-month history of painless cheek swelling. No signs of infection were present. No lymph nodes were palpated. Biopsy taken previously in another hospital indicated capillary hemangioma. Computed tomography and magnetic resonance revealed an inhomogeneous mass in the left infratemporal fossa that caused displacement of the pterygoid muscles and anterior bowing of the posterior maxillary wall (Fig 1). The tumor spread anteriorly between alveolar process of the maxilla and ramus of the mandible and invaded the cheek. The masseter muscle was displaced posteriorly. The tumor presented intermediate signal intensity on T1and T2-weighted images with focal signal-void areas. After contrast administration, intensive inhomogeneous enhancement of the lesion was visible. There were no signs of bony destruction. A superficial part of the tumor was easily accessible for sonographic evaluation. Color-flow duplex Doppler sonography demonstrated a solid, hypoechoic mass with multiple internal vessels of low-resistance blood flow. Carotid angiography showed abundant vascularity of the tumor with blood supply from the left external carotid artery via internal maxillary artery (Fig 2). Preoperative embolization of the feeding branches with the use of polyvinyl alcohol particles was performed. Final external carotid arteriogram showed occlusion of the feeding vessels. Two days after embolization, the tumor was removed with the use of combined intraoral and infratemporal fossa approach. Apart from cheek hematoma that resolved spontaneously, postoperative course was uneventful. A threeyear follow-up revealed no recurrence and no functional deficits. Histopathologic examination showed findings characteristic for JA: multiple gaping vessels lined by a single layer of endothelial cells embedded in fibrous stroma containing spindle-shaped and stellate cells, collagen fibers, and inflammatory cells (Fig 3, http://www.journal. entnet.org).

The diagnostic value of levovist in Doppler imaging of visceral arteries in patients with abdominal angina before and after angioplasty.

PURPOSE To assess the diagnostic value of Levovist in the ultrasound imaging of visceral arteries in patients with clinical symptoms of abdominal angina, before and after percutaneous transluminal angioplasty (PTA). MATERIAL AND METHOD During a 12-month period (2000/2001) five patients with visceral arterial stenoses had ultrasound examinations and a subsequent PTA procedure. Indications for ultrasound examination were abdominal angina symptoms persisting for 3-5 years, (postprandial abdominal pain, diarrhea, and vomiting). In all patients ultrasound examinations were performed using color and spectral Doppler before and after Levovist injections. Color Doppler images and maximum blood flow velocity in stenosed visceral arteries were assessed. Patients underwent control Doppler examinations with Levovist injections to assess the effect of PTA. RESULTS In three patients conventional Doppler examination did not allow proper evaluation of visceral arteries, because of weak color and spectral Doppler signal and in two remaining patients visceral arteries were not visualized at all. In all five patients strong enhancement of color and spectral Doppler signal was observed after Levovist administration. In all these cases a hemodynamically significant stenosis was diagnosed: coeliac trunk-2 and superior mesenteric artery-3. PTA was performed successfully in these patients. In one of them ultrasound examination done before Levovist injection allowed good visualization of treated SMA and showed good PTA result. In the remaining four patients Doppler examination with the use of Levovist demonstrated visceral arteries well and confirmed successful PTA procedures. CONCLUSIONS The use of Levovist makes the diagnostic efficiency of Doppler examinations much higher. In most cases it allows an unequivocal diagnosis of visceral artery stenosis in patients with abdominal angina symptoms. The Doppler examination with the use of Levovist is the method of choice in follow-up after PTA.

Invasive growth patterns of juvenile nasopharyngeal angiofibroma: radiological imaging and clinical implications

Juvenile nasopharyngeal angiofibroma is a benign lesion with locally aggressive nature. Knowledge of its typical growth patterns is crucial for precise preoperative staging and adequate preoperative patient counseling. This pictorial essay focuses on characteristic radiological features and paths of invasive growth of this rare tumor. Also, the impact of accurate preoperative evaluation of tumor extensions on surgical planning and results of treatment are discussed.

Diagnostyka przyzwojaków kości skroniowej

Summary Paragangliomas are rare tumours deriving from paraganglia – small bodies of neuroendocrine tissue. Approximately 3% of paragangliomas occur in the head and neck area accounting for about 0,6% of all tumours of this region. Head and neck paragangliomas are divided into two groups: neck tumours (carotid body tumor and vagal paraganglioma) and temporal paragangliomas (jugular bulb tumor and tympanic paraganglioma). Temporal paragangliomas arise from paraganglia located in the petrous part of the temporal bone. Radiological evaluation of these lesions is essential for confirming the diagnosis and surgery planning. Most useful methods are magnetic resonance imaging and computed tomography. These modalities deliver important information about tumour location, extension and the state of the surrounding structures. Carotid angiography is a second step diagnostic method, performed in patients with jugular bulb paraganglioma. It has a diagnostic value and allows palliative or preoperative embolization of the tumor. Ultrasonographic evaluation and scintigraphy also provide advantages in diagnostic management.Paragangliomas are rare tumours deriving from paraganglia--small bodies of neuroendocrine tissue. Approximately 3% of paragangliomas occur in the head and neck area accounting for about 0,6% of all tumours of this region. Head and neck paragangliomas are divided into two groups: neck tumours (carotid body tumor and vagal paraganglioma) and temporal paragangliomas (jugular bulb tumor and tympanic paraganglioma). Temporal paragangliomas arise from paraganglia located in the petrous part of the temporal bone. Radiological evaluation of these lesions is essential for confirming the diagnosis and surgery planning. Most useful methods are magnetic resonance imaging and computed tomography. These modalities deliver important information about tumour location, extension and the state of the surrounding structures. Carotid angiography is a second step diagnostic method, performed in patients with jugular bulb paraganglioma. It has a diagnostic value and allows palliative or preoperative embolization of the tumor. Ultrasonographic evaluation and scintigraphy also provide advantages in diagnostic management.

Non-paraganglioma tumors of the jugular foramen – Growth patterns, radiological presentation, differential diagnosis

OBJECTIVE Most common tumors of the jugular foramen are paragangliomas. However, other lesions, also malignant, may involve the jugular foramen and mimic radiographic presentation of paragangliomas. Therefore, a correct preoperative diagnosis is crucial for best treatment planning. This study analyzes imaging characteristics of non-paraganglioma neoplasms involving the jugular foramen, with attention given to features helpful in differential diagnosis. STUDY DESIGN A retrospective chart search. SETTING Teritary referral university centre. SUBJECTS AND METHODS During the years 1997-2010, 11 cases of jugular foramen tumors other than paragangliomas, with available imaging studies, were identified. Histopathology revealed: 3 schwannomas, 1 malignant schwannoma, 2 meningiomas, 1 hemangiopericytoma, 1 ependymoma, 1 endolymphatic sac carcinoma (ELST) and 2 nasopharyngeal carcinoma metastases. CT, MRI and angiography were assessed to determine tumor growth directions, bone involvement, tumor morphology and vascular composition. RESULTS Schwannomas were characterized by parapharyngeal space involvement, jugular foramen expansion, preservation of cortical margins, irregular contrast enhancement. Meningiomas presented diffuse bone infiltration, sclerotic changes, erosion of the cortical bone. Ependymoma showed diffuse skull base infiltration, permeative erosion, heterogeneity, abundant vascularization. Hemangiopericytoma radiologically imitated paraganglioma. ELST showed permeative/geographic bony destruction, heterogeneity, intratumoral bony fragments. Metastases were lytic, solid lesions characterized by circumferential growth, internal carotid artery encasement and stenosis. CONCLUSIONS A combination of certain radiological features including tumor epicenter, growth vectors, skull base infiltration, bony changes and tumor morphology help establish correct preoperative diagnosis and differentiate less common jugular foramen tumors, from most common paragangliomas. Hemangiopericytoma may radiologically mimic paraganglioma.

Dojście przez podniebienie do naczyniakowłókniaka młodzieńczego

Summary Introduction Juvenile nasopharyngeal angiofibromas (JNA) are highly vascular, locally invasive tumours which originate in the sphenopalatine foramen. Several surgical approaches are described for this tumour. The aim of this study was to evaluate the transpalatal approach for juvenile angiofibroma. Material and methods In a group of 22 patients with JNA transpalatal approach was employed. A retrospective patients notes review was done. Extension of tumour, complications of surgery and recurrences were analyzed. Results In 17 patients the tumour was confined to the nasal cavity and the nasopharynx. In 5 patients the tumour invaded the sphenoid sinus. No complications were observed after surgery. Two (9%) patients had recurrence. Conclusion Transpalatal approach is best suited to small tumours (Andrews grade I and II) limited to the nasopharynx, nasal cavity and sphenoid sinus.

Petrosektomia subtotalna z wszczepieniem implantu ślimakowego w przewlekłym zapaleniu ucha środkowego

Summary Chronic otitis media can lead to deafness and it is one of the indications for cochlear implantation. However the presence of chronic perforation or discharge from the ear requires specific management. We present two patients with bilateral deafness due to chronic otitis media in whom cochlear implantation and subtotal petrosectomy were carried out as a one stage procedure. One patient had a recurrent perforation of the drum despite repeated myringoplasties in different centers. The other patient had been operated 15 years before using open technique. We describe the technique and results of the procedure. The combination of subtotal petrosectomy and cochlear implantation in a one stage procedure offers a safe method of the disease eradication and cochlear implantation.

Ocena zgodności progów słyszenia w badaniach potencjałów słuchowych stanu ustalonego (ASSR), audiometrii tonalnej i słuchowych potencjałów wywołanych pnia mózgu (ABR) u młodych osób z prawidłowym słuchem

Summary Introduction One of the basic audiological parameter in estimation of hearing sensitivity is hearing threshold. The need for an objective tool to efficiently predict the audiogram caused that the use and importance of ASSR method is growing in recent times. However, the technique is quite new and needs to be still improved. Aim of the study was the estimation of behavioral audiogram in comparison with ABR and ASSR threshold of young adults with normal hearing. Material and methods The study sample included 9 subjects with normal hearing (18 ears) with no abnormalities in otoscopy. Behavioral hearing thresholds and ASSRs to carrier frequencies of 0.5, 1, 2, and 4 kHz were obtained. The ASSRs were assessed with Bio-logic MASTER system by the use of four sinusoidal tones both frequency – and amplitude – modulated given simultaneously to every ear for each carrier frequency. The potentials are collected, averaged and analyzed in this method by the fast Fourier transform to yield statistically significant responses. Electrophysiologic threshold responses for click ABR stimuli for the same carrier frequencies for right and left ear were obtained by the use of Bio-logic Navigator Pro unit. Differences and correlations between the ASSRs, ABRs and the behavioral thresholds were determined. Results We discovered that the values of pure tone audiograms and ABRs thresholds values differ from ASSRs considerably. We could also observed that the difference between behavioral and ABRs threshold is less than for behavioral and ASSRs threshold. Conclusion To conclude, this study shows that auditory steady-state responses technique is not useful method in estimating of hearing threshold of young adults with normal hearing.INTRODUCTION One of the basic audiological parameter in estimation of hearing sensitivity is hearing threshold. The need for an objective tool to efficiently predict the audiogram caused that the use and importance of ASSR method is growing in recent times. However, the technique is quite new and needs to be still improved. Aim of the study was the estimation of behavioral audiogram in comparison with ABR and ASSR threshold of young adults with normal hearing. MATERIAL AND METHODS The study sample included 9 subjects with normal hearing (18 ears) with no abnormalities in otoscopy. Behavioral hearing thresholds and ASSRs to carrier frequencies of 0.5, 1, 2, and 4 kHz were obtained. The ASSRs were assessed with Bio-logic MASTER system by the use of four sinusoidal tones both frequency--and amplitude--modulated given simultaneously to every ear for each carrier frequency. The potentials are collected, averaged and analyzed in this method by the fast Fourier transform to yield statistically significant responses. Electrophysiologic threshold responses for click ABR stimuli for the same carrier frequencies for right and left ear were obtained by the use of Bio-logic Navigator Pro unit. Differences and correlations between the ASSRs, ABRs and the behavioral thresholds were determined. RESULTS We discovered that the values of pure tone audiograms and ABRs thresholds values differ from ASSRs considerably. We could also observed that the difference between behavioral and ABRs threshold is less than for behavioral and ASSRs threshold. CONCLUSION To conclude, this study shows that auditory steady-state responses technique is not useful method in estimating of hearing threshold of young adults with normal hearing.