Ercole Di Martino

Survival in second primary malignancies of patients with head and neck cancer.

Second primary tumours occur frequently in patients with a history of head and neck malignancies. Delays in making an early and correct diagnosis can seriously affect the therapy management and survival. This was a retrospective study of 120 patients with a history of head and neck cancer, presenting with a second primary tumour. Current follow-up strategies and the use of routine sonographic imaging of the head and neck regions were evaluated, and the impact that tumour chronology, the tumour site and the various treatment modalities have on the survival were assessed. Forty-two per cent of patients developed a metachronous second malignancy more than five years after diagnosis of the index tumour. The accuracy of colour-duplex sonography in detection of second primaries in the head and neck was 82.3 per cent. First and second primary tumours located in the larynx were observed to have the highest five-year survival rate. Patients who developed metachronous tumours had a five-year survival rate of 68.9 per cent for the index tumours, and a 26 per cent five-year survival rate with the occurrence of a second neoplasm. With synchronous tumours a mean survival time of 18 months and a five-year survival rate of 11.9 per cent was found (p < 0.0001). Where clinically appropriate an aggressive treatment strategy was employed and yielded the most favourable results with a five-year survival rate of 66.8 per cent and 35.9 per cent for index tumours and second primary malignancies, respectively. Since more than 40 per cent of the metachronous second primaries in patients with a history of head and neck malignancy occur beyond the five-year follow-up period, an extended protocol with individually adjusted close monitoring of high-risk patients seems appropriate. Colour-duplex sonography is a valuable screening investigation for the early detection of second primary tumours. The treatment of a second primary is often less successful than for the same malignancy occurring primarily. The prognosis of synchronous tumours is significantly lower when compared to malignancies of a metachronous nature, despite some encouraging individual results. Only the early implementation of aggressive treatment methods for second primaries is successful in terms of survival.

Fallopian canal dehiscences: a survey of clinical and anatomical findings

This survey investigates fallopian canal dehiscences in order to assess the risk of encountering an unprotected facial nerve during routine ear surgery. In a prospective non-randomized study, the intraoperative appearance of the facial canal in 357 routine ear operations was compared with 300 temporal bone specimens from 150 autopsies. Intraoperatively, a dehiscence was detected in 6.4% (23/357) of the operations, most frequently at the oval niche region (16/23 cases). The incidence increased with the number of operations (P<0.0002). Cholesteatoma surgery had the highest relative risk (RR 4.6) of exposing an unprotected facial nerve. Postoperatively, no persistent facial paralysis was observed. In four of five cases with a transient facial palsy due to local anesthetics, a bony dehiscence could be found. The anatomical study revealed fallopian canal dehiscences in 29.3% (44/150) of the autopsies. One-third (15/44) of the individuals affected displayed bilateral findings, thus resulting in 19.7% (59/300) of temporal bones affected. A total of 17/59 bones showed microdehiscences, and most (55/59) were located at the oval niche. The actual prevalence of fallopian canal dehiscences is significantly higher than intraoperative findings suggest. The oval niche is the most affected region. High-resolution computed tomography is of diagnostic value only in selected cases. Facial paralysis following local anesthesia is the most significant clinical sign. Vigilance in acute facial palsy after local anesthetics and in cholesteatoma surgery and adequate intraoperative exposure help to prevent iatrogenic injury of the uncovered nerve. In unclear cases, nerve monitoring can facilitate a safe outcome.

New method of dynamic color doppler signal quantification in metastatic lymph nodes compared to direct polarographic measurements of tissue oxygenation

Tumor growth depends on sufficient blood and oxygen supply. Hypoxia stimulates neovascularization and is a known cause for radio‐ and chemoresistance. The objective of this study was to investigate the use of a novel ultrasound technique for the dynamic assessment of vascularization and oxygenation in metastatic lymph nodes. Twenty‐four patients (age 44–78 years) with cervical lymph node metastases of squamous cell head and neck cancer were investigated by color duplex sonography and 17 (age 46–78 years) were investigated additionally with polarography. Sonography was performed after contrast enhancer infusion under defined conditions. Intranodal perfusion data (color hue, colored area) were measured automatically by a novel software technique. This allows an evaluation of blood flow dynamics by calculating perfusion intensity—velocity, perfused area, as well as the novel parameters tissue resistance index (TRI) and tissue pulsatility index (TPI)—for each point of a complete heart cycle. Tumor tissue pO2 was measured by means of polarographic needle electrodes placed intranodally. The sonographic and polarographic data were correlated using Pearsons test. Sonography demonstrated a statistically significant inverse correlation between hypoxia and perfusion and significant TPI and TRI changes with different N‐stages. The percentage of nodal fraction with less than 10 mmHg oxygen saturation was significantly inversely correlated with lymph node perfusion (r = −0.551; p = 0.021). Nodes with a perfusion of less than 0.05 cm/sec flow velocity showed significantly larger hypoxic areas (p = 0.006). Significant differences of TPI and TRI existed between nodes in stage N1 and N2/N3 (p = 0.028 and 0.048, respectively). This new method of dynamic signal quantification allows a noninvasive and quantitative assessment of tumor and metastatic lymph node perfusion by means of commonly available ultrasound equipment.

Sonotubometry with perfect sequences: First results in pathological ears

Abstract Conclusion: Sonotubometry with perfect sequences (PSEQ) was able to detect eustachian tube (ET) openings in both normal and pathological ears. Impaired ears showed ET openings in almost all cases; however, these proved to be not only less frequent, but also with lower amplitude and shorter duration. Objectives: To investigate the function of impaired ET under physiological conditions, using a novel kind of sound stimulus for sonotubometry – the PSEQ. Methods: Twenty otologically healthy subjects (40 normal ears) and 32 patients with ear diseases (40 pathological ears) were examined sonotubometrically using noise signals with an ideally flat spectrum (PSEQ). Dry swallowing, water swallowing, and Toynbee maneuver were used to induce ET openings. Analysis was performed regarding the frequency of occurrence, duration, amplitude, and form of the ET openings. Results: PSEQ allowed the detection of an ET opening in all 40 normal ears (91% of the performed maneuvers) and in 87.5% of the ears with impaired ET function (but only 47% of the maneuvers). The average amplitude of the openings in healthy ears was 16.86 dB, the average duration was 363 ms. In diseased ears these values were significantly lower: 9.73 dB, p < 0.001 and 280 ms, p < 0.05.

Imaging of congenital anomalies and acquired lesions of the inner ear

Imaging of the temporal bone is under continous developement. In the recent decades the technical advances of magnetic resonance imaging and computed tomography have contributed to improved imaging quality in assessment of the temporal bone. Dedicated imaging protocols have been developed and are routinely employed in most institutions. However, imaging interpretation remains challenging, since the temporal bone is an anatomically highly complex region and most diseases of the inner ear occur with low incidence, so that even radiologists experienced in the field may be confronted with such entities for the first time. The current review gives an overview about symptoms and imaging appearance of malformations and acquired lesion of the inner ear.

Endoscopic examination of the eustachian tube: a step-by-step approach.

Objective: The aim of this study was to develop a step-by-step approach for endoscopic examinations of the eustachian tube on awake patients and to report anatomic and functional findings. Study Design: Prospective study. Setting: University hospital. Patients: Convenience sample of seven individuals without a history of ear disease. Intervention: Diagnostic transnasal-transpharyngeal videoendoscopy of the eustachian tube with 30- and 70-degree rigid Hopkins rod endoscopes, 2.5- and 0.8-mm, 0-degree flexible fiber endoscopes performed under local anesthesia in 12 eustachian tubes. Main Outcome Measures: Utility of the various endoscopes for the diagnosis in the different parts of the eustachian tube; quality of vision and the patients comfort during the procedure. Results: The 2.5-mm flexible endoscope was most useful for examination of the pharyngeal ostium and the cartilaginous lumen of the tube. The isthmus region could only be passed using an 0.8-mm fiberscope. In all cases, it was possible to insert the endoscope into the middle ear cavity. Eleven of the 12 tube examinations showed normal findings. The mobility of the tubal cartilage could be visualized with sufficient quality. In 50% of all examinations, application of local anesthesia via a tube catheter was necessary to make the procedure tolerable. Conclusion: The presented approach allows an assessment of both anatomic and functional changes to the eustachian tube in awake patients. The assessment of middle ear structures is limited. To ensure a comfortable and safe procedure, the use of topical anesthesia in a supine position and, in certain cases, additional anesthesia via eustachian tube catheter is recommended.

Dehiscence of the superior and/or posterior semicircular canal: delineation on T2-weighted axial three-dimensional turbo spin-echo images, maximum intensity projections and volume-rendered images.

The purpose of this study was to compare the ability of T2-weighted three-dimensional turbo spin-echo (TSE) images, maximum intensity projections and three-dimensional volume-rendered images for delineation of semicircular canal dehiscence. In 26 patients with dehiscence of the superior and/or posterior semicircular canal and 26 control patients, TSE images were obtained with two different resolutions and maximum intensity projection (MIP) and 3D volume-rendered images reconstructed. All images were evaluated by two radiologists in consensus regarding the visualization of anatomical structures and dehiscence of the semicircular canals. Computed tomography was used to confirm or exclude dehiscence. Dehiscence of the semicircular canals was delineated on axial MR images and on 3D volume-rendered images, but not on MIP images. The number of false positive cases was reduced from 3 to 0 with an increase in matrix, rendering results similar to those obtained with CT. Dehiscence of the semicircular canals can be assessed on high resolution MR images. Volume-rendered 3D images allow for immediate perception of the location of defects in semicircular canal dehiscence. These images may facilitate understanding of the extent and location of the defects.

Evaluation of tumor oxygenation by color duplex sonography: a new approach

OBJECTIVE: Description of a new noninvasive method for the evaluation of tissue oxygenation in head and neck cancer. STUDY DESIGN AND SETTING: Prospective nonrandomized controlled study in an academic medical center on 20 patients with neck metastases of head and neck cancer. Metastases were investigated using color duplex sonography and pO2 histography. The vascularization in sonography was quantitatively evaluated by color pixel density and compared to the pO2 values of the same nodes. RESULTS: The correlation between vascularization and flow velocity was 0.71. For the mean/median pO2-values and for the pO2 readings < 10.0 mmHg correlations were r = 0.65/0.76 and 0.71. CONCLUSION: This sonographic method allows a safe and reliable evaluation of oxygenation in metastases of head and neck cancer. SIGNIFICANCE: The new approach is an alternative to pO2 histography and may play a future role in the planning of radiotherapy in the neck. (Otolaryngol Head Neck Surg 2005;132:765-9.)

A new otological diagnostic system providing a virtual tube model

Sonotubometry allows for the detection of the dynamic Eustachian tube function under physiological conditions, whether the eardrum is intact or perforated. Quality and reliability of state-of-the-art sonotubometry have been substantially improved by a new real-time system for otological diagnostics. Moreover, this diagnostic system provides a time-variant virtual model of the Eustachian tube as a new feature, which opens up entirely new possibilities in monitoring Eustachian tube openings. In this work we investigate the correlation of the virtual model to the human anatomy.

Dynamic Sonographic Tissue Perfusion Measurement with the PixelFlux Method

Publisher Summary This chapter provides an introduction to a novel technique (the PixelFlux technique) of color Doppler sonographic perfusion measurement, which allows the quantification of tumor tissue perfusion along with a normal ultrasound investigation of the tumor. The procedure for this technique involves the scanning of a relevant structure such as tumor with a suitable presetting of all available specifications of the ultrasound equipment and transducer using as high a frequency as possible to achieve a high resolution and to depict color Doppler signals as sensitively as possible. An imaging plane is selected, the transducer is held in this plane, and a video clip with duration of at least one full heartbeat is recorded. The video clip is transferred to a PC with installed PixelFlux software and the clip is opened by PixelFlux and the calibration of distances as well as color bar are carried out automatically with DICOM clips. A picture archiving and communication system (PACS) function is included in PixelFlux that allows review of clips, region of interest (ROI), and all measurements, as well as export of measurements to a statistical software. With the PixelFlux technique the parameters that are calculated from a video sequence recording at least one full heart cycle include mean flow velocity throughout the entire region of interest (ROI), mean perfused area in relation to the ROI, area of the ROI, perfusion intensity throughout the entire ROI, and tissue resistance index (TRI) of velocity/of area/of perfusion intensity. When contrast enhancers (CE) are used to enhance color signals in a tumor, care should be taken to avoid blooming artifacts that are color signals massively splashed across vessel borders and thus cause errors in perfusion quantification.