Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_892_Библиотеки_им_академика_М_И_Перельмана
.pdf
4 Advancements and Innovations in Otologic Surgery: Endoscopic and Exoscopic Ear…
https://t.me/medicina_free
31. Pawlowski KS, Koulich E, Cuda D, Wright CG, Stabilini E, Roland PS.Effects of cochlear
drilling with piezosurgery medical device in rats. Laryngoscope. 2011;121(1):182–6. https://
doi.org/10.1002/lary.21166.
32. Cuda D, Murri A, Mochi P, Solenghi T, Tinelli N.Microdrill, CO2-laser, and piezoelectric stapedotomy: a comparative study. Otol Neurotol. 2009;30(8):1111–5. https://doi.org/10.1097/
MAO.0b013e3181b76b08.
33. Siu JM, Negandhi J, Harrison RV, Wolter NE, James A.Ultrasonic bone removal from the
ossicular chain affects cochlear structure and function. J Otolaryngol Head Neck Surg.
2021;50(1):23. https://doi.org/10.1186/s40463- 021- 00491- 4. PMID: 33810814; PMCID:
PMC8017701.
34. Ma AK, Patel N.Endoscope-assisted partial cochlectomy for Intracochlear schwannoma with
simultaneous cochlear implantation: a case report. Otol Neurotol. 2020;41(3):334–8. https://
doi.org/10.1097/MAO.0000000000002539.
35. Barber SR, Chari DA, Quesnel AM.Teaching endoscopic ear surgery. Otolaryngol Clin North
Am. 2021;54(1):65–74. https://doi.org/10.1016/j.otc.2020.09.005.
36. Kennedy DW. Functional endoscopic sinus surgery: technique. Arch Otolaryngol.
1985;111:643. https://doi.org/10.1001/archotol.1985.00800120037003.
37. Kozin ED, Lee DJ.Basic principles of endoscopic ear surgery. Oper Tech Otolaryngol Head
Neck Surg. 2017;28:2. https://doi.org/10.1016/j.otot.2017.01.001.
38. Ryan P, Wuesthoff C, Patel N.Getting started in endoscopic ear surgery [published correction
appears in J Otol. 2020 Dec;15(4):180]. J Otol. 2020;15(1):6–16. https://doi.org/10.1016/j.
joto.2018.10.002.
39. Kozin ED, Lehmann A, Carter M, etal. Thermal effects of endoscopy in a human temporal
bone model: implications for endoscopic ear surgery. Laryngoscope. 2014;124:E332–9.
40. Ito T, Kubota T, Takagi A, et al. Safety of heat generated by endoscope light sources in
simulated transcanal endoscopic ear surgery. Auris Nasus Larynx. 2016;43:501. https://doi.
org/10.1016/j.anl.2015.12.014; [Epub ahead of print].
41. Kozin ED, Lee DJ, Pollak N.Getting started with endoscopic ear surgery. Otolaryngol Clin
North Am. 2021;54(1):45–57. https://doi.org/10.1016/j.otc.2020.09.009.
42. Smith S, Kozin ED, Kanumuri VV.Initial experience with 3-dimensional exoscope-assisted
transmastoid and lateral skull base surgery. Otolaryngol Head Neck Surg. 2019;160:364.
https://doi.org/10.1177/0194599818816965.
43. Ricciardi L, Chaichana KL, Cardia A.The exoscope in neurosurgery: an innovative “point
of view”. A systematic review of the technical, surgical, and educational aspects. World
Neurosurg. 2019;S1878-8750(19):30080–4. https://doi.org/10.1016/j.wneu.2018.12.202.
44. Mamelak AN, Nobuto T, Berci G. Initial clinical experience with a high-denition exoscope system for microneurosurgery. Neurosurgery. 2010;67:476. https://doi.org/10.1227/01.
NEU.0000372204.85227.BF.
45. Garneau JC, Laitman BM, Cosetti MK. The use of the exoscope in lateral skull base surgery: advantages and limitations. Otol Neurotol. 2019;40:236. https://doi.org/10.1097/
MAO.0000000000002095.
46. Eivazi S, Afkari H, Bednarik R.Analysis of disruptive events and precarious situations caused
by interaction with neurosurgical microscope. Acta Neurochir. 2015;157:1147. https://doi.
org/10.1007/s00701- 015- 2433- 5.
47. Capone AC, Parikh PM, Gatti ME. Occupational injury in plastic surgeons. Plast Reconstr
Surg. 2010;125:1555. https://doi.org/10.1097/PRS.0b013e3181d62a94.
48. Zhang Z, Wang L, Wei Y.The preliminary experiences with three-dimensional heads-up display viewing system for vitreoretinal surgery under various status. Curr Eye Res. 2019;44:102.
https://doi.org/10.1080/02713683.2018.1526305.
49. Wong AK, Davis GB, Joanna NT. Assessment of three-dimensional high-denition visualization technology to perform microvascular anastomosis. J Plast Reconstr Aesthet Surg.
2014;67:967. https://doi.org/10.1016/j.bjps.2014.04.001.
77
Chapter 5
https://t.me/medicina_free
Anatomic (AI) andFunctional/Molecular
Imaging (FMI) intheDiagnosis
andTreatment ofHead andNeck
Pathologies
EmilioSupsupin Jr andBoChen
Introduction
This chapter illustrates the complementary role of anatomic (AI) and functional/
molecular imaging (FMI) in the accurate diagnosis and management of head and
neck pathologies. Advances in AI and FMI have directed the workup for accurate
diagnosis of various head and neck pathologies and guided appropriate treatment.
The potential role of imaging in evaluation of treatment response and further management is also addressed.
Imaging ofHead andNeck Pathologies
This is not an exhaustive nor all-inclusive discussion of head and neck pathologies.
However, AI and FMI play a critical role in the diagnosis and/or treatment of the
representative pathologies selected in this discussion.
E. Supsupin Jr (*)
Division of Neuroradiology, Department of Radiology, University of Florida College of
Medicine - Jacksonville, Jacksonville, FL, USA
Department of Diagnostic and Interventional Imaging, UTHealth McGovern Medical School,
Houston, TX, USA
e-mail: Emilio.P.Supsupin@uth.tmc.edu; Emilio.Supsupin@jax.u.edu
B. Chen
Department of Diagnostic and Interventional Imaging, UTHealth McGovern Medical School,
Houston, TX, USA
e-mail: Bo.Chen@uth.tmc.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_5
79
80
https://t.me/medicina_free
E. Supsupin Jr and B. Chen
Atypical Skull Base Osteomyelitis (ASBO)
Skull base osteomyelitis (SBO) is rare but can be a potentially life-threatening
infection [1–5]. The diagnosis can be challenging [6]. Radiologic evaluation plays a
critical role in the diagnosis and management of SBO [6]. With aggressive management, greater than 90% survival rate in ASBO was reported at 18-month follow-up,
although up to one-third of patients had neurologic sequelae [2].
SBO occurs in two forms: typical (TSBO) and atypical (ASBO) [6]. TSBO classically occurs in elderly diabetic patients, resulting from necrotizing otitis externa
from Pseudomonas species [1, 3]. On the contrary, ASBO has a predilection to the
central skull base and is not preceded by otologic pathology [2, 3, 5]. Patients are
generally middle-aged to elderly with underlying diabetes or other immunocompromised conditions (HIV, chronic steroid use, etc.) [2]. Seventy percent of patients
with ASBO had a predisposing factor affecting bone vascularization, including diabetes (45%) [7]. Gram-positive bacteria (including Staphylococcus) are more common than Pseudomonas species [2, 3]. The most common symptoms of ASBO are
headache and cranial neuropathies [2]. Fever is uncommon and is found only in
20% of cases [2].
ASBO Imaging
Unenhanced computed tomography (CT) is often rst line in the imaging workup of
suspected head and neck infections [6]. The study of choice for nding cortical bone
erosion is high-resolution thin-slice CT with bone algorithm reformatted in multiple
planes [6].
Complementary to CT, magnetic resonance imaging (MRI) of the skull base is
superior for evaluating soft-tissue inltration, marrow involvement, and intracranial
complications related to SBO [3, 6]. To fully evaluate the skull base and surrounding structures, a combination of MR sequences is necessary [6]. This includes T1,
T2, STIR, diffusion weighted imaging (DWI), and T1-weighted fat-saturated contrast-enhanced images [6].
The soft-tissue abnormality in the nasopharynx may be the dominant feature,
which can be indistinguishable from an inltrative neoplasm [6]. In osteomyelitis
affecting the bone marrow, loss of normal fat signal in the marrow space causes T1
hypointensity and STIR hyperintensity [4, 6, 8, 9]. The affected marrow shows heterogeneous gadolinium enhancement [4, 6, 8, 9].
Nuclear medicine imaging served as a cornerstone for evaluation of SBO before
CT and MRI [10]. The various radionuclide studies supply functional and metabolic
information that can help conrm and localize infection of the skull base and can be
complementary to clinical ndings and anatomic imaging to monitor treatment
response [6].
[18F] Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET)
detects increased glucose metabolism [6]. FDG is nonspecific and accumulates
5 Anatomic (AI) and Functional/Molecular Imaging (FMI) in the Diagnosis…
https://t.me/medicina_free
81
at sites of high glucose demand, including active infection, inflammatory, postoperative, or neoplastic processes [6, 8]. Advantages of FDG- PET/CT over
other nuclear medicine studies include wider availability, shorter imaging time,
and higher spatial resolution [6]. It can complement other modalities in determining the extent of infection in confirmed cases of SBO and maybe useful for
evaluation of treatment response [6, 8]. A recent study showed similar diagnostic sensitivity of [18F] FDG-PET/CT and MRI [11]. However, PET-CT had better specificity (71.0% vs. 28.5%) in finding infection [11].
Technetium Tc99m methylene diphosphonate (Tc99m MDP) can show increased
osteoblastic bone activity that occurs in response to infection [6]. There is abnormal
increased tracer uptake in bone on all three phases (immediate blood ow, blood
pool [5–10min], and delayed phase [3–4h]) [6]. Isolated soft-tissue infection will
be differentiated by a normal delayed phase [6]. Delayed-phase single photon emission computed tomography (SPECT) improves anatomic localization [6]. However,
a bone scan lacks specicity for infection and may show abnormal activity in noninfectious processes such as malignancy, trauma, recent surgery, and noninfectious
inammatory conditions [6]. In the setting of osteomyelitis, a bone scan can remain
abnormal even after satisfactory treatment due to bone healing and remodeling [1,
2, 12, 13].
Gallium-67 citrate (Ga-67) scan targets acute-phase reactants like lactoferrin and
bacterial siderophores [6]. It has a high specicity for infection and complements
bone scan [6]. Gallium-67 citrate (Ga-67) binds to white blood cells engaged in the
immune response to infection [6]. A normal Ga-67 scan reliably excludes SBO,
even with an abnormal bone scan. An increased uptake on a Ga-67 scan conrms
infection [6].
Ga-67 scan plays an important role in monitoring of treatment response, converting to normal ndings after successful treatment [6]. Persistent increased uptake
suggests residual infection [6]. The scan can be repeated to monitor antibiotic
response until ndings become normal [12, 14]. Long scan time requiring delayed
images up to 48–72h is the major limitation of a Ga-67 scan [6].
A technetium-labeled white blood cell scan is less commonly used. However,
like a Ga-67 scan, it has a high specicity in the initial diagnosis of SBO [1, 6, 15,
16]. A tagged white blood cell study can conrm healing after completion of antibi-
otic therapy [1, 6, 15, 16].
The imaging ndings in ASBO are illustrated in Fig.5.1a–d and summarized in
Box 5.1. Stroke can be a devastating complication of ASBO when left untreated or
when diagnosis is delayed or missed (Fig.5.2).
Box 5.1 Imaging Findings in ASBO
• Loss of normal fatty marrow signal in the central skull base
• Periclival soft tissue inltration and abnormal enhancement
• Mastoid effusion from Eustachian tube obstruction
• Slight increase in DWI signal
82
a
(arrow)
Slightly increased signal on diffusion weighted
https://t.me/medicina_free
E. Supsupin Jr and B. Chen
Nasopharyngeal Carcinoma (NPCA)
NPCA (nasopharyngeal carcinoma) is a leading form of cancer in certain regions of
the world such as the Cantonese population of Southern China and Hong Kong
where the reported incidence is as high as 20 cases per 100,000 person-years [17,
18]. It is a rare cancer worldwide with incidence rates of less than 1 case per 100,000
person-years in north America and Europe [17, 18]. It is an aggressive head and
neck cancer with high incidence of locoregional spread and of distant metastasis at
presentation. NPCA has a relatively high incidence of systemic metastasis (up to
41%) when compared to other head and neck cancers [18]. NPCA may spread into
the parapharyngeal soft tissues, skull base, or intracranial structures [18]. The nasopharynx has a rich lymphatic plexus. Seventy-ve percent of patients present with
enlarged cervical nodes, 80% of whom have bilateral involvement [18].
T1-weighted MRI depicting loss of normal fatty marrow signal in the central skull base with
periclival soft tissue infiltration (arrows)
b
T2-weighted MRI showing right mastoid
effusion due to Eustachian tube obstruction
Fig. 5.1 (a–d) 62-year-old male with uncontrolled diabetes (DM 2) with neck pain
imaging (arrow)
c
Pe
postcontrast MRI
SPECT/CT with tagged
right retropharyngeal soft tissue compatible with infection – atypical skull base osteomyelitis.
5 Anatomic (AI) and Functional/Molecular Imaging (FMI) in the Diagnosis…
https://t.me/medicina_free
riclival soft tissue infiltration with abnormal enhancement in the central skull base on T1
d
83
WBC scan: Fused images show the location of the abnormality in the
Fig. 5.1 (continued)
Fig. 5.2 Massive bilateral hemispheric strokes as a complication of untreated atypical skull base
osteomyelitis (ASBO)
84
https://t.me/medicina_free
Determination of tumor extension and delineation of target volume rely on imaging [17, 18]. The main treatment of NPCA is radiotherapy and chemotherapy
because of its specic anatomic location and excellent response to radiation [18].
Staging of patients with NPCA is the basic step to successful treatment [18]. TNM
stage is the major prognostic factor of patient survival in NPCA [18]. The correct
diagnosis of tumor extension and the delineation of target volume depend on imaging [18].
E. Supsupin Jr and B. Chen
NPCA Imaging
MRI and FDG-PET have complementary roles. MRI contributes to T staging,
whereas FDG-PET/CT has greater efcacy for N and M staging [17, 18]. In the
future, PET/MRI may play a signicant role in the treatment of NPCA by combining the benets of PET and MRI [17].
MRI plays a signicant role in diagnosis, staging, treatment planning, and prognostication. It has a high sensitivity, specicity, and accuracy of 100%, 93%, and
95%, respectively, in diagnosing NPCA [19]. These gures are comparable to
endoscopy with biopsy, with corresponding values of 95%, 100%, and 98% [19].
MRI can provide a more accurate evaluation of the extent of primary tumor [17, 18].
Because of its superior spatial and soft-tissue contrast resolution, MRI is the imaging modality of choice to delineate the extent of the primary tumor [20, 21]. MRI
can identify retropharyngeal lymph nodes misdiagnosed on CT as soft-tissue inltration [18].
The various metabolic parameters from FDG-PET scans gathered before treatment provide valuable prognostic information [17]. FDG-PET and FDG-PET/CT
have the potential to change management in patients with NPCA when compared to
conventional imaging because of their superior ability to detect nodal and distant
metastases [22, 23]. FDG-PET/CT is limited by its lack of contrast resolution in
identifying retropharyngeal nodes that merged with adjacent primary tumor or to
discriminate direct tumor invasion from retropharyngeal metastasis [17] [18].
However, for nding cervical lymph node metastasis, FDG-PET/CT may be more
accurate than MRI [17, 18].
A combination of Epstein–Barr virus (EBV) DNA levels and FDG-PET can
effectively monitor patients during follow-up to detect recurrence and can help in
planning treatment and assessing prognosis in recurrent cases [17].
Fig. 5.3a–c illustrate the role of PET/CT in the accurate staging of NPCA.
Carotid Body Tumors (CBTs)
The carotid body (CB) is a structure within the adventitia of the common carotid
artery at the inferomedial aspect of the carotid bifurcation [24]. CB has several
functions, including regulation of heart rate and blood pressure, and acts as a chemoreceptor and baroreceptor [25].
5 Anatomic (AI) and Functional/Molecular Imaging (FMI) in the Diagnosis…
https://t.me/medicina_free
a
Primary left nasopharyngeal soft tissue mass crossing the midline (red arrow), abutting the left medial
pterygoid plate (blue arrow) without discrete invasion of the prevertebral muscles or skull base
b
85
c
Fig. 5.3 (a) PET/CT depicting a biopsy proven EBV + nasopharyngeal cancer in a 53-year-old
East Asian male with palpable left-sided lymphadenopathy. (b) PET/CT showing the extent of
nodal disease ipsilateral to the primary mass. (c) PET showing the extent of nodal disease with no
distant metastasis
86
https://t.me/medicina_free
E. Supsupin Jr and B. Chen
Paraganglioma (carotid body tumor) is the most common pathology of the
carotid body [26]. Carotid body tumor (CBT) is rare [27]. They are mostly benign,
but malignant forms can be seen in up to 5% of patients [28]. Despite being rare,
CBTs constitute most of the head and neck paragangliomas [29]. Accurate staging
of CBT is particularly important because the malignant potential of tumor is not
predictable from histology [30]. Malignancy is proved based on locoregional or
distant metastasis [30].
CBT Imaging
Conventional imaging like ultrasound, CT, MRI, and arteriography are used for
diagnosis of CBTs [30]. CBT is depicted on imaging as an avidly enhancing softtissue mass at the carotid bifurcation. Larger lesions have typical ndings of splaying of the carotid bifurcation, avid enhancement, and characteristic “salt and pepper”
appearance due to slowly owing blood products and vascular ow-voids [27].
These tumors are readily visualized with current CT and MR imaging modalities
[27]. However, distant metastases can be missed in malignant forms [30].
123
I-MIBG and
mas, in whole body scanning with high specicity [30]. However, the sensitivity
was low in smaller lesions because of limitations in the spatial resolution of gamma
cameras [30]. Recently, 68Ga-DOTA peptides, PET tracers for somatostatin receptor
imaging, have been used in neuroendocrine tumors with higher sensitivity and specicity, providing better resolution and quantication by PET technology [31, 32].
A small study showed that 68Ga-DOTATATE PET–CT is a valuable diagnostic
tool for staging of CBTs, detecting unknown lesions and changing the management
of patients [30]. It is also useful in showing expression of somatostatin receptors
and opportunity for peptide receptor radionuclide therapy (
both metastatic CBT and pheochromocytoma [30].
Fig. 5.4a and Box 5.2 illustrate and summarize the imaging ndings of CBT,
respectively. Fig.5.4b shows the role of 68Ga-DOTATATE PET–CT in the accurate
diagnosis of malignant (metastatic) CBT.
111
In-pentetreotide scintigraphy have been used in paraganglio-
177
Lu-DOTATATE) for
Box 5.2 Imaging Findings in CBT
• Avidly enhancing, hypervascular mass at the carotid bifurcation
• Splaying of the internal and external carotid arteries (“Lyre sign”)
• Classic salt (bright signal from slow ow and blood products) and pepper
(ow-voids) appearance
• Uptake of somatostatin-rich metastatic disease on 68Ga-DOTATATE
PET-CT scan
5 Anatomic (AI) and Functional/Molecular Imaging (FMI) in the Diagnosis…
https://t.me/medicina_free
a
b
87
Fig. 5.4 (a) 20-year-old female with neck mass. (b) Metastases in malignant carotid body tumor
Squamous Cell Carcinoma (SCC) withPerineural Tumor
Spread (PTS)
Many cutaneous, mucosal, and salivary malignancies carry high potential of perineural spread of disease. The most common nerves affected are the trigeminal and
facial nerves (85% and 25%, respectively) due to the larger surface that they innervate [33]. The most affected trigeminal nerve branch is V2, but multiple branches of
different cranial nerves can be involved due to anatomic contiguity. Certain tumor
types such as mucoepidermoid carcinoma, adenoid cystic carcinoma, desmoplastic
variant of melanoma, and squamous cell carcinoma are the most common culprits.
Based on ACR (American College of Radiology) criteria, MRI of the skull base and
brain with contrast are considered appropriate for evaluation of cranial neuropathy
due to superior soft-tissue contrast, as well as less artifact from potential dental
hardware. Typical primary MRI appearance of perineural spread of tumor is
enhancement along the course of a thickened nerve with obliteration of fat at
Соседние файлы в папке Библиотека им академика М.И. Перельмана