Peter D. Phelps

Juvenile angiofibroma: the lessons of 20 years of modern imaging

Seventy-two patients with juvenile angiofibroma have been investigated by computerized tomography (CT) and/or magnetic resonance imaging (MRI) over a period of 20 years. The evidence from these studies indicates that angiofibroma takes origin in the pterygo-palatine fossa at the aperture of the pterygoid (vidian) canal. An important extension of the tumour is posteriorly along the pterygoid canal with invasion of the cancellous bone of the pterygoid base, and greater wing of the sphenoid (60 per cent of patients). Distinctive features of angiofibroma are the high recurrence rate, and the rapidity with which many tumours recur. It is postulated that the principal determinant of recurrence is a high tumour growth rate at the time of surgery coupled with incomplete surgical excision. The inability to remove the tumour in toto is principally due to deep invasion of the sphenoid, as described above. In this series 93 per cent of recurrences occurred with this type of tumour extension. A contributory cause in these patients is the use of pre-operative embolization. The treatment implications of these findings are examined.

Magnetic resonance imaging in the evaluation of nose and paranasal sinus disease.

Fifty patients with a wide range of sinus disease have been examined by magnetic resonance. These included congenital conditions, inflammatory and allergic sinus disease, fungus infection, and both necrotising and non-necrotising granulomas. A variety of benign and malignant tumours have been investigated, including eight examples of juvenile angiofibroma and 19 malignant sinus tumours. This experience of magnetic resonance scanning has shown that it is superior to computed tomography in showing the extent of malignant disease and, provided the correct pulse sequences are employed, it is always possible to distinguish tumour from retained secretion or inflamed mucosa. The extent of intracranial invasion can also be optimally demonstrated. One of the advantages of the method is the direct three-plane imaging and multislice technique, which gives total coverage of the head and neck for the assessment of malignant disease. Tissue diagnosis in the paranasal sinuses is less important than the demonstration of tumour extent and distribution. Only one tumour (juvenile angiofibroma) showed diagnostic spin-sequence characteristics, and no differentiation was observed between malignant tumours of epithelial and mesenchymal origin. The major drawback of magnetic resonance is the poor demonstration of bone and calcification in the sinuses, so that in some patients the scans need to be augmented by computed tomography studies.

Involution of residual juvenile nasopharyngeal angiofibroma

The apparent tendency of juvenile nasopharyngeal angiofibroma to involute with age has been known for many years but firm evidence of this has been lacking. This case report uses computerized tomography to provide the first documented evidence of this involution.

The basal turn of the cochlea

The coils of the cochlea are now readily demonstrated by thin-section high-resolution computed tomography (CT) in the axial plane. This assessment has become important in severely deaf patients who are candidates for cochlear implant surgery. The commonest abnormality shown in these cases is post-meningitic or tympanogenic labyrinthitis ossificans, which can obstruct the passage of the electrode. Severe otosclerosis can cause a similar problem. Congenital deformities of the labyrinth are rarely suitable for implantation, but the procedure may be indicated for the true Mondini deformity. Implantation is contraindicated for severe dysplasia of the cochlea and for the recently described variety of x-linked deafness with deficient bone at the fundus of the internal auditory meatus.

Osteomas of the temporal Bone: A report of three cases

Osteomas of the petrous temporal bone, inaccessible to clinical examination are rare. Three such cases are reported, one in the internal acoustic meatus, one in the middle ear, and the other on the posterior surface of the petrous ridge, emphasizing the role of radiology in their diagnosis evaluation, and as an aid to management.

Vascular masses in the middle ear

High resolution computed tomography (CT) is of great value in demonstrating soft tissue masses in the middle ear cavity. However, tissue characterisation even for vascular masses after contrast enhancement has proved disappointing. Differentiation therefore depends upon the site and anatomical configuration of the mass, and in many cases angiography is mandatory for diagnosis. Examples of high ectopic jugular bulb, glomus jugulare and glomus tympanicum tumours and aberrant internal carotid artery are presented and their differential diagnosis considered. The value of CT and more traditional techniques, particularly lateral tomograms to show the spur of bone between the jugular bulb and internal carotid artery, are discussed.

Deformity of the labyrinth and internal auditory meatus in congenital deafness

In congenital deafness it is important that the radiological examination should exclude any deformities of the bony labyrinth or internal auditory meatus as well as demonstrating lesions of the middle and external ears. Radiological assessment of inner ear abnormalities should be used as a guide both to the feasibility of reconstructive surgery to the middle and external ears and for the future training of the child. Inner ear abnormalities demonstrated by tomography in 56 patients are discussed in relation to the cochlea function. The importance of demonstrating the central bony spiral of the cochlea and of assessing the size and shape the internal auditory meatus is stressed.

Imaging for cochlear implants

All patients in the Birmingham Cochlear Implant Programme underwent computerized tomography (CT) scanning and were assessed and images interpreted by the main author. Of the first 100 cases, 20 were considered to have abnormalities of the inner ears by CT imaging. It is concluded that the commonest abnormality was cochlear otospongiosis followed by labyrinthitis ossificans. Otospongiosis is well shown by CT which gives a good predicator of luminal patency. However, labyrinthus obliterans, although usually apparent on CT, is not reliably shown in all cases and T2 weighted magnetic resonance imaging (MRI) is better.

Diagnostic imaging of the ear

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Congenital cerebrospinal fluid fistula through the inner ear and meningitis

Congenital deformities of the labyrinth of the inner ear can be associated with a fistulous communication between the intracranial subarachnoid space and the middle ear cavity. We describe seven such cases, six confirmed by high resolution CT and one by postmortem histological section. The seven patients all presented with meningitis although a cerebrospinal fluid fistula was demonstrated at subsequent surgery or postmortem. The lesions were bilateral in three patients, unilateral in three and probably bilateral in the postmortem case although only one temporal bone was obtained. In every case there was a dilated sac instead of the normal two and a half turn cochlea on the affected side and this was confirmed at surgery. The demonstration of the basal cochlear turn is of paramount importance in any deaf child presenting with meningitis. A true Mondini deformity with a normal basal turn and some hearing is not at risk of developing a fistula.