Marco Ravanelli

Emergency Imaging Assessment of Deep Neck Space Infections

Deep neck space infection may lead to severe and potentially life-threatening complications, such as airway obstruction, mediastinitis, septic embolization, dural sinus thrombosis, and intracranial abscess. The clinical presentation is widely variable, and often early symptoms do not reflect the disease severity. The complication risk depends on the extent and anatomical site: diseases that transgress fascial boundaries and spread along vertically oriented spaces (parapharyngeal, retropharyngeal, and paravertebral space) have a higher risk of complications and require a more aggressive treatment compared with those confined within a nonvertically oriented space (peritonsillar, sublingual, submandibular, parotid, and masticator space). Imaging has 5 crucial roles: (1) confirm the suspected clinical diagnosis, (2) define the precise extent of the disease, (3) identify complications, (4) distinguish between drainable abscesses and cellulitis, and (5) monitor deep neck space infection progression. Ultrasonography is the gold standard to differentiate abscesses from cellulitis, for the diagnosis of lymphadenitis. and to identify internal jugular thrombophlebitis in the infrahyoid neck. However, field-of-view limitation and poor anatomical information confine the use of ultrasonography to the evaluation of superficial lesions and to image-guided aspiration or drainage. Computed tomography (CT) combines fast image acquisition and precise anatomical information without field-of-view limitations. For these reasons, it is the most reliable technique for the evaluation of deep and multicompartment lesions and for the identification of mediastinal and intracranial complications. Contrast agent administration enhances the capability to differentiate fluid collections from cellulitis and allows the detection of vascular complications. Magnetic resonance imaging is more time-consuming than CT, limiting its use to selected indications. It is the technique of choice for assessing the epidural space involvement in pre- and paravertebral space infections and complements CT in the evaluation of the infections reaching the skull base.

Magnetic resonance for laryngeal cancer.

Purpose of reviewThis review summarizes the most recent experiences on the integration of magnetic resonance in assessing the local extent of laryngeal cancer and detecting submucosal recurrences. Recent findingsAdvances in magnetic resonance have been characterized by the development of technical solutions that shorten the acquisition time, thereby reducing motion artifacts, and increase the spatial resolution. Phased-array surface coils, directly applied to the neck, enable the use of parallel-imaging techniques, which greatly reduce the acquisition time, and amplify the signal intensity, being closer to the larynx. One of the most important drawbacks of this technique is the small field-of-view, restricting the imaged area to the larynx. Furthermore, diffusion-weighted imaging (DWI) has increased the set of magnetic resonance sequences. Differently from computed tomography (CT), which has only two variables (precontrast/postcontrast), magnetic resonance is based on a multiparameter analysis (T2-weighting and T1-weighting, DWI, and postcontrast acquisition). This multiparameter approach amplifies the contrast resolution. It has, also, permitted to differentiate scar tissue (after laser resection) from submucosal recurrent disease. In addition, DWI sequences have the potential of a more precise discrimination of peritumoral edema from neoplastic tissue, which may lead to improve the assessment of paraglottic space invasion. SummaryMagnetic resonance of the larynx is technically challenging. The use of surface coils and motion-reducing techniques is critical to achieve adequate image quality. The intrinsic high-contrast resolution is further increased by the integration of information from different sequences. When CT has not been conclusive, magnetic resonance is indicated in the pretreatment local assessment and in the suspicion of submucosal recurrence.

Attenuation of obstructive sleep apnea and overnight rostral fluid shift by physical activity.

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Treatment monitoring of paranasal sinus tumors by magnetic resonance imaging

Abstract Treatment monitoring of paranasal tumors is crucial, given the high rate of local and regional relapses that impairs the overall prognosis of patients. Magnetic resonance imaging (MRI) is the technique of choice to detect changes in the submucosa and deep spaces of the suprahyoid neck, inaccessible at clinical and endoscopic assessment. Correct interpretation of MRI requires detailed knowledge of the treatment applied and of the changes treatments are supposed to produce on macroscopic anatomy and tissue signals. Once such background of information is obtained, detection of recurrences is a less challenging task.

Scimitar Syndrome Comprehensive, Noninvasive Assessment With Cardiovascular Magnetic Resonance Imaging

Scimitar syndrome is a rare vascular anomaly whereby a partial anomalous pulmonary venous drainage to the inferior vena cava results in left-to-right shunt. Scimitar syndrome can be associated with congenital cardiovascular defects (dextrocardia, atrial septal defects, and right pulmonary artery hypoplasia), pulmonary anomalies (hypoplasia, sequestration), and tracheobronchial anomalies. Thus, it can manifest with heart failure and recurrent pneumonia.1,2 Diagnosis is obtained during childhood, when symptoms related to relevant shunt and other cardiovascular and pulmonary anomalies are present. When asymptomatic, scimitar syndrome can be accidentally discovered in adulthood.3 Standard chest x-ray evaluation is usually pathognomonic (Figure 1), although it is mandatory that …

Modular Endoscopic Medial Maxillectomies: Quantitative Analysis of Surgical Exposure in a Preclinical Setting.

BACKGROUND The nomenclature adopted for endoscopic medial maxillectomies (EMMs) is exceedingly heterogeneous. The aim of this study was to objectively measure surgical exposure in a preclinical anatomic setting to validate a classification for modular EMMs. MATERIALS AND METHODS Computed tomography was used to scan 6 cadaver heads, and images were uploaded on dedicated software. A neuronavigation system was used to measure areas and volumes of surgical corridors during dissection. Differences of >10% of area exposed and >3 cm3 of volume were considered to define incremental types of EMM. Specific anatomic targets were assessed on the axial and sagittal planes. Influence of anatomic variants on surgical exposure was evaluated. RESULTS There were 4 types of EMMs (A-D), with a transseptal variant for each, identified. In the axial plane, type A exposed the vidian canal and foramen rotundum, type B exposed the foramen ovale and foramen spinosum, and transseptal type C or type D exposed the coronoid process. In the sagittal plane, type A exposed the vidian canal, and type B exposed the foramen ovale and styloid process. Transseptal type C exposed the pterygomaxillary fissure, and type D exposed the inferior border of the lateral pterygoid plate. The nasal floor limits the downward angle in transseptal approaches. The width of the piriform aperture independently influenced surgical volume of types B and C. CONCLUSIONS This modular classification of EMMs, based on quantitative analysis in a preclinical setting, should allow for better personalized preoperative surgical planning and provides standardization of nomenclature.

Mucosal melanoma of the head and neck

Mucosal melanoma of the head and neck is a very rare and aggressive malignancy with a very poor prognosis. The nasal cavity, paranasal sinuses, and oral cavity are the most common locations. One-, 3- and 5-year survival rates between 2000 and 2007 were 63%, 30% and 20%, respectively. Cigarette smoking seems to be a risk factor even though the evidence for this is very low. Clinical signs and symptoms are usually nonspecific. While surgery is considered the mainstay of treatment for most mucosal melanomas of the head and neck region, radiotherapy has a role in local control of the disease after surgery. Many new treatment options in the last years, in particular targeted therapies (i.e. inhibitors of c-KIT, NRAS/MEK or BRAF) and immunotherapies (anti CTLA-4 and anti PD-1/PD-L1 antibodies), have changed the history of cutaneous melanoma. Despite the different biology, mucosal melanoma is currently treated in the same way as cutaneous melanoma; however, patients with mucosal melanoma were excluded from the majority of recent clinical trials. Recent molecular findings offer new hope for the development of more effective systemic therapy.

Setup of a bone aging experimental model in the rabbit comparing changes in cortical and trabecular bone: Morphological and morphometric study in the femur

Bone aging was studied in an experimental model (rabbit femur) in three populations aged 0.5, 1.5, and 7.5 years. Cortical bone histology was compared with a data set from a 1.5‐month‐old population of an earlier published paper. From 0.5‐year‐old onward, the mean femur length did not increase further. Thereafter, the mean marrow area increased and the cortical area decreased significantly with aging. This was associated with a structural pattern transformation from plexiform to laminar and then Haversian‐like type. The distal meta‐epiphysis bone trabecular density of the oldest populations also was significantly lower in specific regions of interest (ROI). Percentage sealed primary vascular canals in laminar bone significantly increased with aging without variation of percentage sealed secondary osteons. Remodeling rate reflected by the density of cutting cones did not significantly change among the age populations. These data suggest that laminar bone vascular pattern is more functional in the fast diaphyseal expansion but not much streamlined with the renewal of blood flow during secondary remodeling. Bone aging was characterized by: 1) secondary remodeling subendosteally; 2) increment of sealed primary vascular canals number; 3) increased calcium content of the cortex; 4) cortical and trabecular bone mass loss in specific ROIs. Taken together, the present data may give a morphological and morphometric basis to perform comparative studies on experimental models of osteoporosis in the rabbit. J. Morphol. 276:733–747, 2015.

Superior cervical ganglion mimicking retropharyngeal adenopathy in head and neck cancer patients: MRI features with anatomic, histologic, and surgical correlation

IntroductionTo describe the unique MRI findings of superior cervical ganglia (SCG) that may help differentiate them from retropharyngeal lymph nodes (RPLNs).MethodsA retrospective review of post-treatment NPC patients from 1999 to 2012 identified three patients previously irradiated for NPC that were suspected of having recurrent nodal disease in retropharyngeal lymph nodes during surveillance MRI. Subsequent surgical exploration revealed enlarged SCG only; no retropharyngeal nodal disease was found.A cadaveric head specimen was also imaged with a 3T MRI before and after dissection. In addition, SCG were also harvested from three cadaveric specimens and subjected to histologic analysis.ResultsThe SCG were found at the level of the C2 vertebral body, medial to the ICA. They were ovoid on axial images and fusiform and elongated with tapered margins in the coronal plane. T2-weighted (T2W) signal was hyperintense. No central elevated T1-weighted (T1W) signal was seen within the ganglia in non-fat-saturated sequences to suggest the presence of a fatty hilum. Enhancement after gadolinium was present. A central “black dot” was seen on axial T2W and post-contrast images in two of the three SCG demonstrated. Histology showed the central black line was comprised of venules and interlacing neurites within the central portion of the ganglion.ConclusionsThe SCG can be mistaken for enlarged RPLNs in post-treatment NPC patients. However, there are features which can help differentiate them from RPLNs, preventing unnecessary therapy. These imaging findings have not been previously described.

Agger-bullar classification (ABC) of the frontal sinus drainage pathway: validation in a preclinical setting.

The anatomy of structures surrounding the frontal sinus drainage pathway (FSDP) is extremely complex and challenging for endoscopic sinus surgeons. The anatomical nomenclature of this area reflects this complexity and lack of agreement regarding anatomical variants of this region is present in the literature. This work presents a new classification system of the air spaces surrounding the FSDP, called the agger‐bullar classification (ABC), and compares it with the most widely used anatomical classification of the frontoethmoidal region, the modified Bent and Kuhn classification (MBKC).