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E. Supsupin Jr and B. Chen
foraminal openings or the pterygopalatine fossa [34]. Secondary MRI signs include denervation atrophy of the innervated muscles with edema and enhancement during the early part of the process and muscular atrophy with fat replacement in the chronic phase. While perineural tumor spread may be asymptomatic, uncontrolled disease can carry signicant debilitating clinical presentation such as neuropathic pain or motor dysfunction due to the affected nerve. The prognostic value of peri­neural spread of disease varies along histologic types and location with worse prog­nosis in certain scenarios [35, 36]. Both anterograde and retrograde tumor spread can occur [37] Retrograde spread of disease into the skull base foramina are more difcult to treat [38].
Imaging SCC withPTS
FDG-PET/CT is often used for initial and subsequent imaging for therapeutic response of head and neck tumors including melanoma, parotid tumors, and squa­mous cell carcinoma [39]. PET/CT has greater accuracy than either CT or MRI for assessment of nodal involvement and distant disease and synchronous primary. It can alter both staging and therapy planning in substantial number of cases [40]. Following therapy, PET/CT enables early detection of recurrent disease [41]. In the setting of head and neck cancers, linear or curvilinear FDG uptake within the head and neck region should be investigated, particularly along the anatomical course of the trigeminal and facial nerves due to their increased likelihood for involvement. MIP (maximum intensity projection) in all three planes should be examined. If not already performed, the radiologist can alert the referring physician for subsequent MRI evaluation of the area of abnormality on PET/CT to delineate the affected nerve and potential for local treatment.
Fig. 5.5 illustrates the role of MRI and FDG-PET/CT in the anatomic and func­tional depiction of perineural spread of squamous cell carcinoma along the trigemi­nal nerve.
Fig. 5.5 Perineural spread of disease along the trigeminal nerve in a patient with squamous cell carcinoma
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FDG-PET/CT does require patient preparation. The patient’s blood glucose level must be controlled through diet, temporary refraining from exercise, and medica­tions because the FDG molecule is a glucose analog.
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Papillary Thyroid Cancer (PTC): Imaging andTreatment
Well-differentiated thyroid cancers including papillary and follicular and Hurthle cell variants constitute over 90% of the primary thyroid cancers [42]. The well­differentiated cell types carry an excellent prognosis. Most of these are discovered incidentally on cross-sectional evaluation of the neck with CT or MRI.For the ini­tial evaluation of the thyroid abnormalities, neck ultrasound and CT of the neck are considered appropriate by the ACR.Neck ultrasound offers superior spatial resolu­tion with the ability for real-time intervention (such as a primary mass and nodal biopsy without radiation). The classic sonographic appearance is a solid mass with irregular margins and internal vascularity with punctuate calcication [43]. CT evaluates the regional nodal disease, which can have variable appearance including cystic or solid feature or calcication [44]. The primary treatment is surgical resec­tion with possible cervical nodal dissection.
After surgical treatment, majority of the patients undergo further evaluation for potential radioactive iodine ablation, which has been in practice since the 1940s. The purpose of the radioactive iodine treatment is to ablate the residual thyroid tis­sue to facilitate cancer surveillance via thyroglobulin and to treat iodine avid dis­ease, which may be microscopic [45]. After surgery, iodine-based imaging with either low dose I-131 or low dose I-123 can be performed to evaluate for residual local and whole-body abnormalities and deemed appropriate for suspected recur­rence of differentiated thyroid cancer and appropriate for early imaging after treat­ment of differentiated thyroid cancer.
The iodine-based functional studies have the advantage to assess the amount of residual disease after surgery and allow for dose calculation for the I-131 therapy, which carries the beta radiation, allowing for the local destruction of the cells that take up iodine. Iodine-based therapy can be performed for various stages of papil­lary thyroid cancer but particularly the advanced stages, which confer better sur­vival [46].
Taking advantage of the long half-life and larger dose of the I-131 for treatment, post ablation images with gamma radiation offer a complete evaluation of the bur­den of disease in the body, as illustrated by the case example (Fig.5.6a, b). Excellent anatomic details can be delineated with SPECT/CT. Surveillance whole-body iodine-based imaging can be performed and correlated with serum thyroglobulin and sonographic evaluation.
Iodine-based imaging requires several inconvenient preparations including dis­continuation of certain thyroid medications or Thyrogen shots to achieve the proper thyroid-stimulating hormone (TSH) level, special low-iodine diet, evaluation of interfering medications including iodinated contrast for CT, and caution in the set­ting of potential pregnancy.
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SPECT/CT at different levels:
Iodine avid bilateral level II cervical nodes (red arro and iodine avid soft tissue with low density at the r thyroidectomy bed (green arrow) correlating with the foci seen on planar images
Fig. 5.6 (a) Postablation I-131 scan after 7days. (b) Postablation SPECT/CT
Parathyroid Adenoma: Imaging andLocalization
Parathyroid Adenoma is the most common cause of primary hyperparathyroidism, accounting for vast majority of cases, (75–85%) [47]. Preoperative identication of the abnormality has altered the approach of curative parathyroidectomy [48]. Majority of adenomas are posterior to the thyroid gland, but ectopic adenoma can be seen in the mediastinum, retropharyngeal region, carotid sheath, or intrathyroid. Based on the current ACR appropriateness criteria, initial evaluation of primary, secondary and tertiary, and recurrent primary hyperparathyroidism can be per­formed with neck ultrasound, CT of the neck with and without contrast (4D proto­col) and functional imaging with SPECT/CT, which are all deemed appropriate.
right thyroid lobe with enhancement on arterial phase (red arrow) and washout on delayed phase (blue arrow)
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Typical parathyroid adenoma on 4D CT: hypoattenuating nodule (white arrow) below the inferior pole of the
Fig. 5.7 Parathyroid adenoma
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The abnormality appears on ultrasound as a hypervascular homogeneously hypoechoic nodule distinct from the thyroid gland with feeding vessel seen on Doppler. On 4D CT, the classic pattern is a hypodense soft tissue mass separate from the thyroid gland in the noncontrast images with avid arterial enhancement and washout in the delayed phase (Fig.5.7).
Various protocols of radiotracer with SPECT/CT can be performed including dual time Tc-99m Sestamibi, dual tracer techniques with Tc-99m Sestamibi with I-123, and Tc-99m Sestamibi and Tc-99m Pertechnetate. The dual time Tc-99m Sestamibi is the most employed technique (Fig.5.8a, b). While the protocol can vary, our institution performs a planar image of the skull base to the superior medi­astinum at 20min and 2h, and a SPECT/CT is done of the same region at 20min for anatomical localization of the abnormality. PET/CT is novel modality for inves­tigation of this pathology.
With the improving accuracy of preoperative imaging, the earlier surgical para­digm has shifted to minimally invasive parathyroidectomy, which yields superior results [49].
In addition to the anatomical evaluation of SPECT/CT, the abnormal gland can be localized intraoperatively with a handheld probe if both the study and the operation are planned closely in time. The relative duration of functional imaging and the heterogeneous quality of the CT portion of the functional study can be improved.
Just as the advent of the functional imaging and 4D CT has changed the surgi­cal planning, the imaging paradigms remain in ux and constantly challenged by data. Recent studies have advocated for the use of 4D CT over functional imag­ing [50].
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Fig. 5.8 (a) Parathyroid localization by Tc-99–Sestamibi. (b) Parathyroid localization by SPECT/CT
Conclusion
We highlighted the complementary role of AI and FMI in the accurate diagnosis and management of various head and neck pathologies. The advantages and limitations of imaging modalities are addressed. Appropriate use of imaging may help improve patient outcomes.
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Chapter 6
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Advancements andInnovations inSleep Surgery
StanleyYung-ChuanLiu andAhmedA.Al-Sayed
Introduction
Obstructive sleep apnea (OSA) is a complex condition that aficts all ages. Upper airway surgery is an important treatment option. Sleep surgery has evolved with improved understanding of facial skeletal development and sleep physiology. Evolving skeletal techniques and upper airway stimulation (UAS) are effective extrapharyngeal interventions with high success rate. With more emphasis on the timing of interventions in growing individuals, there is also the likelihood of reduc­ing risk of OSA in adulthood [1].
Another advance in the treatment paradigm of sleep surgery is focus on preci­sion. The selection and sequence of procedure(s) should follow a systematic and organized method [2]. The Powell–Riley protocol [3] was introduced in the early 1990s to limit unnecessary surgery through physical examination including pha­ryngoscopy, polysomnography (PSG), and lateral cephalometry. The protocol acknowledged the commonality of multi-level airway collapse in OSA patients. Surgical options in Phase I of the protocol consisted of nasal surgeries,
S. Y.-C. Liu (*) Division of Sleep Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA e-mail: ycliu@stanford.edu
A. A. Al-Sayed Division of Sleep Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
Department of Otolaryngology–Head and Neck Surgery, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia e-mail: alsayed@stanford.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. C. Melville et al. (eds.), Advancements and Innovations in OMFS, ENT, and Facial Plastic Surgery, https://doi.org/10.1007/978-3-031-32099-6_6
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tonsillectomy, uvulopalatopharyngoplasty, genioglossus advancement, and hyoid myotomy with suspension. Phase II, which is maxillomandibular advancement (MMA), was reserved for incompletely treated OSA after re-evaluation by PSG 6-months following Phase I.The rationale behind the protocol was based on a 60% surgical response with Phase I surgery, and therefore, a majority not needing MMA.
The Stanford sleep surgery protocol since 2015 [4] reects the reality that all treatment modalities, from medical to surgical, are on a continuum of care (Fig.6.1). Classic Phase I procedures can follow MMA in indicated patients. Surgery to relieve nasal obstruction can help improve adherence to medical management such as posi­tive airway pressure therapy. More important than individual surgical success is the overall treatment efcacy for every patient. The aim of this chapter is to provide an overview of this updated protocol and discuss the latest innovations in sleep surgery. A few highlights include the role of drug-induced sedation (sleep) endoscopy (DISE), the advent of UAS, and precision in both patient selection and procedure accuracy in skeletal surgery.
Fig. 6.1 The updated Stanford sleep surgery protocol
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