Early Experience with a Novel Treatment for Menière's Disease: A Long Acting Dexamethasone Formulation for Precise Delivery to the Round Window Membrane.

OBJECTIVE: To investigate the safety and feasibility of precise delivery of a long-acting gel formulation containing 6% dexamethasone (SPT-2101) to the round window membrane for the treatment of Menière's disease. STUDY DESIGN: Prospective, unblinded, cohort study. SETTING: Tertiary care neurotology clinic. PATIENTS: Adults 18 to 85 years with a diagnosis of unilateral definite Menière's disease per Barany society criteria. INTERVENTIONS: A single injection of a long-acting gel formulation under direct visualization into the round window niche. MAIN OUTCOME MEASURES: Procedure success rate, adverse events, and vertigo control. Vertigo control was measured with definitive vertigo days (DVDs), defined as any day with a vertigo attack lasting 20 minutes or longer. RESULTS: Ten subjects with unilateral Menière's disease were enrolled. Precise placement of SPT-2101 at the round window was achieved in all subjects with in-office microendoscopy. Adverse events included one tympanic membrane perforation, which healed spontaneously after the study, and two instances of otitis media, which resolved with antibiotics. The average number of DVDs was 7.6 during the baseline month, decreasing to 3.3 by month 1, 3.7 by month 2, and 1.9 by month 3. Seventy percent of subjects had zero DVDs during the third month after treatment. CONCLUSIONS: SPT-2101 delivery to the round window is safe and feasible, and controlled trials are warranted to formally assess efficacy.

Imaging as an early biomarker to predict sensitivity to everolimus for progressive NF2-related vestibular schwannoma.

PURPOSE: NF2-related schwannomatosis (NF2) is characterized by bilateral vestibular schwannomas (VS) often causing hearing and neurologic deficits, with currently no FDA-approved drug treatment. Pre-clinical studies highlighted the potential of mTORC1 inhibition in delaying schwannoma progression. We conducted a prospective open-label, phase II study of everolimus for progressive VS in NF2 patients and investigated imaging as a potential biomarker predicting effects on growth trajectory. METHODS: The trial enrolled 12 NF2 patients with progressive VS. Participants received oral everolimus daily for 52 weeks. Brain imaging was obtained quarterly. As primary endpoint, radiographic response (RR) was defined as ≥ 20% decrease in target VS volume. Secondary endpoints included other tumors RR, hearing outcomes, drug safety and quality of life (QOL). RESULTS: Eight participants completed the trial and four discontinued the drug early due to significant volumetric VS progression. After 52 weeks of treatment, the median annual VS growth rate decreased from 77.2% at baseline to 29.4%. There was no VS RR and 3 of 8 (37.5%) participants had stable disease. Decreased or unchanged VS volume after 3 months of treatment was predictive of stabilization at 12 months. Seven of eight participants had stable hearing during treatment except one with a decline in word recognition score. Ten of twelve participants reported only minimal changes to their QOL scores. CONCLUSIONS: Volumetric imaging at 3 months can serve as an early biomarker to predict long-term sensitivity to everolimus treatment. Everolimus may represent a safe treatment option to decrease the growth of NF2-related VS in patients who have stable hearing and neurological condition. TRN: NCT01345136 (April 29, 2011).

Neurotropic Cutaneous Malignancies: Case Report on Keratinocyte Derived Malignancies of the Head and Neck With Perineural Invasion.

Background: The recent addition of immunotherapy as a treatment modality to surgery and radiation has vastly improved disease control for patients with keratinocyte-derived carcinomas (KCs) that are incurable with local therapies alone. With the advent of immune checkpoint inhibitors (ICPis) in non-melanoma skin cancers comes diagnostic and therapeutic challenges when considering treatment strategies for patients presenting with clinical perineural invasion (cPNI) of locally advanced KC of the head and neck. Objectives: We report four cases that convey the diagnostic and therapeutic complexity of managing patients with neuropathic symptoms from cutaneous neurotropic carcinomas of the head and neck. We also discuss an updated review regarding immunotherapies and perineural invasion within KC management. Conclusion: Patients presenting with symptoms suspicious for cPNI warrant an expanded diagnostic evaluation to correlate neurological findings with neurotropic spread of disease. While nerve biopsies can be precarious in sensitive areas, a history of skin cancer and clinical presentation suggestive of neurotropism may be enough to pursue timely management in the form of surgery, radiation, and/or systemic therapy given each patient's individual priorities, comorbidities, and prognosis. When adding ICPi as a treatment modality for patients with disease not amenable to local therapies, the potential for immune-related adverse events must be considered. A multi-disciplinary review and approach to the management of patients with KC and cPNI is essential for obtaining optimal patient outcomes.

Olfactory Neuroblastoma: Re-Evaluating the Paradigm of Intracranial Extension and Cyst Formation.

The purpose of the current study was to assess the prevalence of cyst formation at the brain-tumor interface in olfactory neuroblastoma. We used the UCLA patient-based Pathology and Radiology Head and Neck Database (UPP&R HAND) to identify the largest patient cohort reported to date with imaging and pathology data. Eighteen of thirty-one patients (58.1%) had evidence of intracranial extension on MRI, while four (22.0%) demonstrated cyst formation at the brain-tumor interface. The extent of intracranial extension was by far the strongest predictor for intracranial cyst formation, regardless of Hyams tumor grade, using a binary logistics regression model (p = 0.002) and ROC curve analysis (AUC 94.6%). Cyst formation at the brain-tumor interface was an uncommon imaging finding, and tends to occur with a larger component of intracranial tumor extension.

High Resolution Three-Dimensional Delayed Contrast MRI Detects Endolymphatic Hydrops in Patients With Vertigo and Vestibular Schwannoma.

OBJECTIVE: Advances in high resolution magnetic resonance imaging (MRI) have enabled the detection of endolymphatic hydrops (EH), a pathological ballooning of the endolymphatic fluid system, known to be associated with Menière's disease. When a patient has a known diagnosis of vestibular schwannoma and develops recurrent episodic vertigo spells, many surgeons recommend surgical intervention, attributing the vestibular symptoms to the vestibular schwannoma. The aim of this study is to evaluate the clinical outcome in patients with vestibular schwannoma and EH, treated medically, for recurrent spells of vertigo. PATIENTS: Two patients with EH and vestibular schwannoma who presented with recurrent spells of vertigo are included. Both had characteristic low frequency hearing loss ipsilateral to the schwannoma. INTERVENTION: MRI sequences with 3T scanner (Skyra, Siemens Healthcare, Erlangen, Germany) using high resolution three-dimensional delayed postcontrast protocol included "cisternographic" T2 and delayed intravenous-enhanced three-dimensional fluid-attenuation inversion recovery (DIVE-3D-FLAIR) sequences, performed with 2350 ms (bright perilymph) and 2050 ms (bright endolymph) inversion times and with subtracted images. MAIN OUTCOME MEASURE: MRI FLAIR evaluation of EH and presence or absence of vestibular symptoms. RESULTS: Both patients had resolution of the disabling vertigo spells with a diuretic, and Patient 1 had unchanged EH, while Patient 2 had partial resolution of the EH and the FLAIR hyperintensity. CONCLUSION: When EH coexists with vestibular schwannoma in a patient presenting with recurrent vertigo spells, medical treatments for EH may alleviate the vestibular symptoms. We recommend that patients with small vestibular schwannomas who present with vertigo spells undergo high resolution MRI to evaluate for EH and undergo a trial of medical treatment with diuretics.

Factors Associated With Discordance Between Preoperative Parathyroid 4-Dimensional Computed Tomographic Scans and Intraoperative Findings During Parathyroidectomy.

IMPORTANCE: Parathyroid 4-dimensional computed tomographic scans (4D-CTs) have emerged as an accurate and cost-effective initial localization study for patients with primary hyperparathyroidism. However, potential limitations and factors affecting the accuracy of preoperative 4D-CTs remain poorly defined. OBJECTIVES: To characterize factors associated with missed parathyroid lesions on preoperative 4D-CTs and to investigate patterns of commonly observed errors. DESIGN, SETTING, AND PARTICIPANTS: A prospectively accrued patient database was analyzed from September 1, 2011, through October 31, 2016. The study was performed in a tertiary referral center. Consecutive patients with primary hyperparathyroidism undergoing preoperative 4D-CTs and subsequent parathyroidectomy were included in the study. MAIN OUTCOMES AND MEASURES: Discordance between preoperative 4D-CTs and intraoperative findings in the number and location of abnormal parathyroid lesions. RESULTS: Of 411 patients studied (mean [SD] age, 59 [14] years; 325 [79.1%] female), 123 (29.9%) had discordance between preoperative 4D-CTs and intraoperative findings. Among the 411 patients, 75 (18.2%) had major discordance, including incorrectly localized adenoma on the contralateral side of the neck, missed double adenoma, and absence of any abnormal lesion detected on 4D-CTs. Compared with concordant cases, discordant cases had higher frequencies of multigland disease (66.7% [82 of 123] vs 24.3% [70 of 288], P < .001) and multinodular goiter or thyroid nodule (40.7% [50 of 123] vs 29.2% [84 of 288], P = .02). Missed parathyroid lesions were smaller (mean [SD], 0.86 [0.29] vs 1.24 [0.50] cm; P < .001) and were more likely to be in the inferior position (65.4% [87 of 133] vs 38.1% [177 of 465], P < .001). Parathyroid lesion size of 10 mm or less (odds ratio [OR], 4.37; 95% CI, 2.24-8.54), multigland disease (OR, 7.63; 95% CI, 3.49-16.69), multinodular goiter or thyroid nodule (OR, 1.82; 95% CI, 1.01-3.28), and parathyroid lesion in the inferior position (OR, 6.82; 95% CI, 3.10-14.99) were independently associated with discordant 4D-CT results. CONCLUSIONS AND RELEVANCE: Multigland disease was most strongly associated with discordance between preoperative 4D-CTs and intraoperative findings, followed by parathyroid lesion in the inferior position and parathyroid lesion size of 10 mm or less. Awareness of these potential pitfalls may allow surgeons to better leverage this new localization technique in preoperative planning and intraoperative troubleshooting.

A Story in Black and White: Radiologic Evaluation in the Multidisciplinary Setting.

Strong engagement from expert radiologists is essential in ensuring the optimal function of a multidisciplinary group focused on the treatment of head and neck cancer. Active participation in multidisciplinary conference can be among the most rewarding roles for radiologists. Despite many benefits to radiologist involvement in multidisciplinary teams, there are obstacles and challenges that can prevent full participation. This article highlights the key issues that should be considered by radiologists and multidisciplinary team leaders when planning participation in a new or existing multidisciplinary group that focuses on the care of patients with head and neck cancer.

Anatomic Variations in Pituitary Endocrinopathies: Implications for the Surgical Corridor.

Objectives/Hypotheses Functioning pituitary adenomas may produce endocrinopathies such as acromegaly and Cushing syndrome. Both conditions lead to characteristic anatomic variations as a result of hormonally induced abnormal soft tissue deposition. We evaluate the anatomic differences between acromegalics and Cushing disease patients and compare these dimensions to controls. Design Radiographic review of preoperative magnetic resonance images (MRI) of the pituitary gland. Setting Tertiary academic medical center. Participants Patients who underwent transnasal, transsphenoidal surgery for pituitary adenomas found to have acromegaly or pituitary Cushing between January 1, 2007 and September 1, 2015. A total of 15 patients with similar MRIs and no history of pituitary or sinonasal disease were selected as controls. Main Outcome Measures Dimensions assessed were intercarotid distance; carotid canal width; piriform aperture width; distance from the piriform aperture to the anterior face of the sphenoid; sphenoid sinus height, width, and length; angle from anterior nasal spine to anteroinferior face of sphenoid sinus; choanal height; and nasal cavity height at the level of the vertical segment of the middle turbinate. Sphenoid sinus pneumatization patterns were recorded. Results There were 30 acromegalics and 31 Cushing disease patients. When compared with controls, both acromegalics and Cushing disease patients had significantly wider piriform apertures and a longer distance from the piriform aperture to the anterior face of the sphenoid sinus (p < 0.05). Acromegalics had a significantly less acute angle (19 ± 3 degrees) from the anterior nasal spine to the sphenoid (p < 0.05). Cushing disease patients had significantly lower sphenoid sinus length and shorter nasal cavity height (p < 0.05). There were no differences in intercarotid distance or carotid canal width. Conclusions As acromegalics and Cushing disease patients have known anatomic variations, the skull base surgeon should be aware of these differences and adapt their techniques and approaches as needed.

Bilateral Endolymphatic Hydrops in a Patient With Migraine Variant Without Vertigo: A Case Report.

OBJECTIVE: To use modern high-resolution inner ear imaging modalities to evaluate for endolymphatic hydrops (EH) in a patient with migraine-associated fluctuating hearing loss without vertigo spells or dizziness. BACKGROUND: EH has been well described in patients with Meniere's disease on both human temporal bone studies and modern high-resolution imaging; however, there is no study to date, to our knowledge, that examines the presence of EH in a patient with migraine and bilateral hearing loss. We present the MRI findings using a sequence for detecting EH in a unique case of a patient experiencing migraine headaches accompanied by fluctuating hearing loss without vertigo. METHODS: Magnetic resonance imaging sequences included "cisternographic" three-dimensional T2, and delayed intravenous-enhanced three-dimensional fluid-attenuation inversion recovery (DIVE-3D-FLAIR) sequences, performed with 2350 ms (bright perilymph) and 2050 ms (bright endolymph) inversion times. The bright endolymph images were subtracted from bright perilymph images to create a composite image with bright perilymph, dark endolymph, and intermediate bone signals. RESULTS: A 40-year-old female presented with a left-sided sensorineural hearing loss and severe migraine headaches that began at age 12. For the past year, she experienced severe migraines with right-sided fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Audiometry confirmed a drop of right-sided hearing at times of migraines and increased symptom severity. Vestibular testing was within normal limits. MRI demonstrated the presence of severe bilateral vestibular and cochlear EH. CONCLUSIONS: EH of both the cochlea and vestibule can be present in patients without Meniere's disease or vertigo. The relationship between migraine and Meniere's disease may be complex, as demonstrated in this patient with migraine-associated bilateral hearing loss with MRI documentation of severe bilateral EH. The fact that migraine can be associated with EH is important and demonstrates a potential relationship between the pathophysiology of migraine and that of EH. Given this patient's previous association of migraine and hearing loss at age 12, it appears that migrainous attacks occur simultaneously with the hearing loss, and may be potentially causative of the fluctuating hearing loss, mediated possibly through the development of EH. New imaging modalities allow for studies into the field of inner ear pathology, with significant implications for future research.

Facial nerve stimulation following cochlear implantation for X-linked stapes gusher syndrome leading to identification of a novel POU3F4 mutation.

We report a case of a nine-year-old male who presented with facial nerve stimulation four years after cochlear implantation. Computed tomography was performed revealing a dilated internal auditory meatus and the cochlear implant electrode was found to be protruding into the fallopian canal at the level of the geniculate ganglion. Subsequent genetic analysis demonstrated X-linked deafness type 2 (DFNX2) caused by a novel c.769C > T nucleotide change in the POU domain, class 3, transcription factor 4 gene (POU3F4). Inactivation of electrodes 1 and 19-21 successfully abated facial nerve stimulation.

High Resolution MRI Shows Presence of Endolymphatic Hydrops in Patients Still Symptomatic After Endolymphatic Shunt Surgery.

OBJECTIVE: Endolymphatic hydrops has been well described in patients with Ménière's syndrome; however, causation has not been established. Decompression of the endolymphatic sac has been proposed as a means to relieve hydrops and improve vertigo symptoms, but the efficacy of the surgery is debated. Until recently, there have been few objective measures of efficacy other than patients' subjective symptoms. Recent archival human temporal bone studies have shown that patients continue to have hydrops after shunt surgery. We propose using high-resolution magnetic resonance imaging (MRI) to determine the efficacy of endolymphatic shunt surgery (ELS) in patients who continue to experience vertigo. PATIENTS: Four patients presented with continued vertigo after ELS. INTERVENTIONS: Magnetic resonance imaging sequences included "cisternographic" three-dimensional T2, and delayed intravenous-enhanced three-dimensional fluid-attenuation inversion recovery (DIVE-3D-FLAIR) sequences, performed with 2350 ms (bright perilymph) and 2050 ms (bright endolymph) inversion times. The bright endolymph images were subtracted from bright perilymph images to create a composite image with bright perilymph, dark endolymph, and intermediate bone signals. MAIN OUTCOME MEASURES: MRI finding of endolymphatic hydrops. RESULTS: In all five affected ears in four patients who continued to experience severe vertigo, hydrops was found on high resolution MRI on the operated ear. The appearance on MRI was no different than in patients with endolymphatic hydrops (EH) who have not had surgery. CONCLUSIONS: The present study demonstrates the persistence of endolymphatic hydrops in patients who have failed ELS. Future studies evaluating for the presence or absence of endolymphatic hydrops in patients who claim to obtain relief from ELS.

Head and neck Epstein-Barr virus mucocutaneous ulcer: Case report and literature review.

OBJECTIVES/HYPOTHESIS: To report the clinical presentation, treatment, and management outcomes of patients with Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) of the head and neck, which is a newly characterized pathologic entity with aggressive morphology but follows an indolent, self-limiting clinical course. STUDY DESIGN: Case report and literature review. METHODS: A case of EBVMCU of the base of tongue is reported and a retrospective review of all cases of EBVMCU of the head and neck at a single academic institution was conducted between January 1, 1986 and April 1, 2015. The MEDLINE database was additionally queried from January 1, 1950 to April 1, 2015 for all reports of EBVMCU of the head and neck, and all pertinent clinical data were extracted. RESULTS: The clinical presentation, treatment, and response of a patient with EBVMCU of the base of tongue are presented. Interim follow-up of the patient has revealed a complete remission with discontinuation of immunosuppression and rituximab therapy. A review of the literature supports conservative management and reduction of immunosuppression. Overall, 96.6% of patients with follow-up greater than 2 months achieved complete remission with conservative management. The current study is the largest series to report on the clinical presentation and treatment outcomes of EBVMCU of the head and neck. CONCLUSIONS: EBVMCU tends to follow an indolent and self-limiting clinical course, responding to reduction of immunosuppression and conservative treatment. It is imperative for clinicians to consider EBVMCU in the differential diagnosis of mucocutaneous ulcers of the head and neck to avoid excessive treatment. LEVEL OF EVIDENCE: Laryngoscope, 126:2500-2504, 2016.

Hypopharyngeal venous malformation presenting with foreign body sensation and dysphagia.

OBJECTIVE: Review the importance of imaging selection and clinicoanatomic correlation for a vascular malformations presenting with unique symptomatology. METHODS: Case study and literature review. RESULTS: A 64-year-old female presented with globus and dysphagia ongoing for 40 years. Esophagogastroduodenoscopy discovered a hypopharyngeal mass. A CT scan showed a soft tissue mass with shotty calcifications. Flexible laryngoscopy revealed a bluish compressible mass. MRI showed T2 hyperintensity with heterogeneous enhancement resulting in the diagnosis of a low-flow vascular malformation. CONCLUSIONS: All globus is not equal. Attention to symptoms, anatomy, and imaging selection is crucial for the diagnosis and treatment of vascular malformations uniquely presenting with dysphagia.

Osteochondroma of the Hyoid Bone: A Previously Unrecognized Location and Review of the Literature.

Osteochondroma is a benign cartilaginous neoplasm and the most common benign tumor of bone. Osteochondromas occur primarily in the axial skeleton with a predilection for the distal femur, and relatively few cases occur in the head and neck region. The majority of cases of osteochondromas in the head and neck region affect the mandibular condyle, with fewer cases reported in the skull base and the neck. To our knowledge, there is no reported case of osteochondroma of the hyoid bone documented in the English literature. We thus report the first case of a hyoid bone osteochondroma, presenting as an asymptomatic mass in a young woman.

Parathyroid Adenomas and Hyperplasia on Four-dimensional CT Scans: Three Patterns of Enhancement Relative to the Thyroid Gland Justify a Three-Phase Protocol.

PURPOSE: To describe the prevalence of three relative enhancement patterns of parathyroid lesions on four-dimensional (4D) computed tomographic (CT) scans. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study and waived the need for informed consent. The authors retrospectively reviewed preoperative 4D CT scans obtained from November 2012 to June 2014 in 94 patients with pathologically proven parathyroid adenomas or hyperplasia. Lesions were classified into one of three relative enhancement patterns. All patterns required lesions to be lower in attenuation than the thyroid on non-contrast material-enhanced images, but patterns differed in the two contrast-enhanced phases. Type A lesions were higher in attenuation than the thyroid in the arterial phase, type B lesions were not higher in attenuation than the thyroid in the arterial phase but were lower in attenuation than the thyroid in the delayed phase, and type C lesions were neither higher in attenuation than the thyroid in the arterial phase nor lower in attenuation than the thyroid in the delayed phase. The prevalence of the relative enhancement patterns was compared. The t test was used to compare mean attenuation differences in Hounsfield units between the relative enhancement patterns. RESULTS: Ninety-four patients had 110 parathyroid lesions, including 11 patients with multigland disease. The sensitivity for single-gland disease was 94% (78 of 83) and that for multigland disease was 59% (16 of 27). Type B enhancement was most common, with a prevalence of 57% (54 of 94), followed by type C (22% [21 of 94]) and type A (20% [19 of 94]). Five lesions were interpreted incorrectly as parathyroid adenoma (false-positive), and all lesions had the type C pattern. Relative to the thyroid, lesions categorized as type A by readers had mean attenuation difference (± standard deviation) of 39 HU ± 13 in the arterial phase, and type B lesions had a difference of -58 HU ± 26 in the delayed phase. These values differed from the mean attenuation difference of lesions not in these categories (P < .001). CONCLUSION: Parathyroid adenomas and hyperplasia can be grouped into three relative enhancement patterns based on a protocol with a non-contrast-enhanced and two contrast-enhanced phases. The type B pattern is most common and could be diagnosed with two contrast-enhanced phases. However, almost one quarter of lesions have the type C pattern and thus could be missed without the non-contrast-enhanced phase.

Quantitative multiparametric MRI in uveal melanoma: increased tumor permeability may predict monosomy 3.

INTRODUCTION: Uveal melanoma is a rare intraocular tumor with heterogeneous biological behavior, and additional noninvasive markers that may predict outcome are needed. Diffusion- and perfusion-weighted imaging may prove useful but have previously been limited in their ability to evaluate ocular tumors. Our purpose was to show the feasibility and potential value of a multiparametric (mp-) MRI protocol employing state of the art diffusion- and perfusion-weighted imaging techniques. METHODS: Sixteen patients with uveal melanoma were imaged with mp-MRI. Multishot readout-segmented echoplanar diffusion-weighted imaging, quantitative dynamic contrast-enhanced (DCE) MR perfusion imaging, and anatomic sequences were obtained. Regions of interest (ROIs) were drawn around tumors for calculation of apparent diffusion coefficient (ADC) and perfusion metrics (K (trans) , v e , k ep , and v p ). A generalized linear fit model was used to compare various MRI values with the American Joint Commission on Cancer (AJCC) tumor group and monosomy 3 status with significance set at P < 0.05. RESULTS: mp-MRI was performed successfully in all cases. MRI tumor height (mean [standard deviation]) was 6.5 mm (3.0). ROI volume was 278 mm(3) (222). ADC was 1.07 (0.27) × 10-3 mm(2)/s. DCE metrics were K (trans) 0.085/min (0.063), v e 0.060 (0.052), k ep 1.20/min (0.32), and v p 1.48 % (0.82). Patients with >33 % monosomy 3 had higher K (trans) and higher v e values than those with disomy 3 or ≤33 % monosomy (P < 0.01). There were no significant differences between ADC (P = 0.07), k ep (P = 0.37), and v p with respect to monosomy 3. CONCLUSION: mp-MRI for ocular tumor imaging using multishot EPI DWI and quantitative DCE perfusion is technically feasible. mp-MRI may help predict monosomy 3 in uveal melanoma.

Carcinoma ex-pleomorphic adenoma of the parotid gland consisting of high-grade salivary duct carcinoma and keratinizing squamous cell carcinoma.

Carcinoma ex-pleomorphic adenoma (CXPA) is a rare salivary gland malignancy that presents diagnostic difficulties partly because of its wide range of histologic presentations. We report a case of a 77-year-old man, who presented with a 6-year history of a parotid mass that had undergone rapid growth within weeks. Magnetic resonance imaging revealed an infiltrative mass in the parotid gland, and the fine-needle aspiration (FNA) biopsy result was highly suspicious for carcinoma. Subsequent excision of the tumor demonstrated a poorly differentiated epithelial neoplasm consisting of keratinizing squamous cell carcinoma (SCC) and adenocarcinoma with regions of both ductal carcinoma in situ and invasive salivary duct carcinoma (SDC). Only focal areas exhibited a benign pleomorphic adenoma component. To our knowledge, this is the first case of a CXPA that consists of both a high-grade SDC and a keratinizing SCC in the parotid gland.

Meniere's disease: histopathology, cytochemistry, and imaging.

Meniere's disease is a poorly understood, disabling syndrome causing spells of vertigo, hearing fluctuation, tinnitus, and aural fullness. In this paper, we present a review of the histopathology, cytochemistry, and imaging of Meniere's disease. Histopathology is significant for neuroepithelial damage with hair cell loss, basement membrane thickening, and perivascular microvascular damage. Cytochemical alterations are significant for altered AQP4 and AQP6 expression in the supporting cell, and altered cochlin and mitochondrial protein expression. Current developments include imaging techniques to determine the degree and presence of endolymphatic hydrops, and future studies will endeavor to correlate the observance of hydrops with clinical findings.

Dynamic Parathyroid Computed Tomography (4DCT) Facilitates Reoperative Parathyroidectomy and Enables Cure of Missed Hyperplasia.

BACKGROUND: Four-dimensional computed tomography (4DCT) is an emerging imaging modality in the evaluation of primary hyperparathyroidism (PHPT). We assessed the role of 4DCT in patients presenting for reoperative parathyroidectomy. METHODS: A prospective database of patients with persistent or recurrent PHPT undergoing reoperative parathyroidectomy during the years 2006-2014 was analyzed. Patients treated before versus after the advent of 4DCT were compared for operative eligibility, operative success, operative time, and concordance of imaging results with surgical findings. RESULTS: Ninety patients were included in the study (61 before 4DCT, 29 after 4DCT). The post-4DCT group had a higher rate of surgical concordance with imaging results (63 vs. 90 %, p < 0.01) and shorter operative time (114 vs. 76 min, p < 0.05). The operative success rate was not different (87 vs. 86 %). A similar pattern was observed in the subset of sestamibi-negative patients, with post-4DCT patients having a higher rate of surgical concordance (12 vs. 83 %, p < 0.0001) and shorter operative time (181 vs. 89 min, p < 0.05). Among patients ultimately found to have parathyroid hyperplasia, 4DCT correctly identified multiple enlarged glands in 80 % (4 of 5) and correctly lateralized one or more glands in 100 % (5 of 5) of cases, facilitating successful subtotal parathyroidectomy in the reoperative setting. CONCLUSIONS: 4DCT enables successful and efficient reoperative parathyroidectomy. These benefits extend to difficult cases, including sestamibi-negative patients and those with missed hyperplasia.