Survey of the Use of Diffusion-Weighted Imaging for Cholesteatoma in the United Kingdom.

BACKGROUND: Non-echoplanar diffusion-weighted MRI (DWMRI) has a role in the surgical planning for cholesteatoma. AIMS/OBJECTIVES: The aim of the study was to assess the use of DWMRI in the management of cholesteatoma across the UK, and measure clinicians' confidence in the use of DWMRI. MATERIALS AND METHODS: Telephone survey in 139 Otolaryngology Departments in the United Kingdom between March 2017 and July 2017, and asking radiology delegates at the British Society of Head and Neck Imaging 2017 meeting. RESULTS: The response rate was 101 out of 139 Trusts (73%). Of those respondents who did have DWMRI available, 68/88 respondents (77%) use it for cholesteatoma. The mean confidence (±standard deviation) of the respondents with DWMRI in identifying cholesteatoma presence was 7.3 ± 2.1, in identifying volume of cholesteatoma was 6.8 ± 1.8, and in identifying subsites of cholesteatoma was 4.6 ± 2.1. CONCLUSIONS AND SIGNIFICANCE: DWMRI has a well-defined role in the follow-up of patients after cholesteatoma surgery, and those primary cases of cholesteatoma where the diagnosis is in question. The use of DWMRI for cholesteatoma is variable across the UK, but there are certain clinical scenarios where there is not enough awareness regarding the benefits of imaging (such as petrous apex cases of cholesteatoma).

Novel use of non-echo-planar diffusion weighted MRI in monitoring disease activity and treatment response in active Grave's orbitopathy: An initial observational cohort study.

AIM: To examine the novel use of non-echo-planar diffusion weighted MRI (DWI) in depicting activity and treatment response in active Grave's orbitopathy (GO) by assessing, with inter-observer agreement, for a correlation between its apparent diffusion coefficients (ADCs) and conventional Short tau Inversion Recovery (STIR) MRI signal-intensity ratios (SIRs). METHOD AND MATERIALS: A total of 23 actively inflamed muscles and 30 muscle response episodes were analysed in patients with active GO who underwent medical treatment. The MRI orbit scans included STIR sequences and non-echo-planar DWI were evaluated. Two observers independently assessed the images qualitatively for the presence of activity in the extraocular muscles (EOMs) and recorded the STIR signal-intensity (SI), SIR (SI ratio of EOM/temporalis muscle), and ADC values of any actively inflamed muscle on the pre-treatment scans and their corresponding values on the subsequent post-treatment scans. Inter-observer agreement was examined. RESULTS: There was a significant positive correlation (0.57, p < 0.001) between ADC and both SIR and STIR SI of the actively inflamed EOM. There was also a significant positive correlation (0.75, p < 0.001) between SIR and ADC values depicting change in muscle activity associated with treatment response. There was good inter-observer agreement. CONCLUSION: Our preliminary results indicate that quantitative evaluation with non-echo-planar DWI ADC values correlates well with conventional STIR SIR in detecting active GO and monitoring its treatment response, with good inter-observer agreement.

Using Nonechoplanar Diffusion-weighted MRI to Assess Treatment Response in Active Graves Orbitopathy: A Novel Approach with 2 Case Reports.

Two patients (68 and 71 years, both female) with sight threatening, active Graves orbitopathy but low clinical activity score underwent MRI scans before and after intravenous corticosteroid treatment. Two MRI techniques, short-term inversion recovery and nonechoplanar diffusion-weighted imaging, were used. Apparent diffusion coefficient values reduced in patient 1 who had successful medical treatment and remained elevated in patient 2 who had an inadequate treatment response. Nonechoplanar diffusion-weighted imaging provided a quantitative measure of treatment response by calculation of the apparent diffusion coefficient. The novel use of nonechoplanar diffusion-weighted imaging for monitoring treatment response in Graves orbitopathy is illustrated but requires further validation.

Classification of orbital fractures using the AO/ASIF system in a population surveillance cohort of traumatic optic neuropathy.

PURPOSE: In our prospective nationwide surveillance study of traumatic optic neuropathy (TON) in the United Kingdom, the prevalence of orbital fractures was found to be 39% (47/121). The prevalence of skull fractures was 7.4% (9/121). This study aims to identify the association of craniofacial-orbital fractures with the severity of visual loss. METHODS: TON patients who sustained orbital fractures were identified prospectively by population-based active surveillance through the British Ophthalmic Surveillance Unit over a 2-year period. Available CT scans were classified by a head and neck radiologist according to the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) scheme: the face was divided into 4 units; fractures in each unit were graded according to displacement (A-C) and severity (1.1-3.3). Correlation between severity of craniofacial orbital fractures and visual acuity as well as number of fractured units and visual acuity were evaluated. RESULTS: Twelve of the 25 patients (48%) with imaging available had adequate high resolution craniofacial CT imaging for review and classification using the AO/ASIF system (i.e. 48 classifiable units). Three of 48 (6%) units were undisplaced (grade A), 18 of 48 (29%) units were minimally displaced (grade B), and 4 of 48 (8%) units had largely displaced (grade C) fractures. Twenty-three units (47.9%) had no fractures; 5 patients had radiological evidence of optic canal fractures. Poor visual acuities positively correlated with severity of fractures graded using the AO/ASIF classification (Spearman's rho = 0.95, p = 0.05) and number of fractured units (Spearman's rho = 1.0, p < 0.0001). CONCLUSION: AO/ASIF classification system provides a uniform method in the assessment of orbital fractures which correlates with visual outcome in TON.

Oral cavity cancer and its pre-treatment radiological evaluation: A pictorial overview.

PURPOSE: Oral cavity cancer, primarily squamous cell carcinoma (SCC), is a prevalent malignancy globally, necessitating accurate clinical assessment and staging to enable effective treatment planning. Diagnosis requires biopsy and is followed by surgical resection and reconstruction as the primary therapeutic modality. Imaging plays a pivotal role during this process, aiding in the evaluation of tumour extent, nodal involvement and distant metastases. However, despite its value, both radiologists and clinicians must recognise its inherent limitations. METHODS: This pictorial review article aims to illustrate the application of various imaging modalities in the pre-treatment evaluation of oral cavity SCC and highlights potential pitfalls. It underscores the importance of understanding the anatomical subsites of the oral cavity, the diverse patterns of spread tumours exhibit at each site, alongside the role of imaging in facilitating informed management strategies, while also acknowledging its limitations. RESULTS: The review delves into fundamentals of current staging including nodal involvement, while, emphasising imaging strategies and potential limitations. Finally, it touches on the potential of novel radiomic techniques in characterising tumours and predicting treatment response. CONCLUSIONS: Pre-treatment oral cavity cancer staging reflects an ongoing quest for enhanced diagnostic accuracy and prognostic prediction. Recognising the value of imaging alongside its limitations fosters a multidisciplinary approach to treatment planning, ultimately improving patient outcomes.

Extraocular muscle Diffusion Weighted Imaging as a quantitative metric of posterior orbital involvement in thyroid associated orbitopathy.

OBJECTIVES: The clinical activity score (CAS) and European severity scale (ESS) are established clinical tools to assess thyroid eye disease (TED) but are limited in terms of subjectivity and their reliability in non-Caucasian individuals, and can underestimate significant disease in the posterior orbit. Preliminary data from pilot studies have shown that diffusion-weighted imaging (DWI) using extraocular muscle (EOM) apparent diffusion coefficient (ADC) measurements may provide complementary information in TED. This study expands on previous research to assess for correlations between clinical scores and EOM-ADCs in stratifying disease activity and severity in a large patient cohort from an ethnically diverse population. METHODS: A retrospective review of TED clinics between 2011 and 2021 identified 96 patients with a documented CAS and ESS and an orbital MRI that included DWI. From regions of interest manually placed on EOM bellies, the highest ADC was computed for each patient and analysed for correlations and associations with CAS and ESS using Spearman Rank correlation and Mann-Whitney U tests, and any potential discriminatory cut-offs using Receiver Operator Curve analyses. A p-value < 0.05 indicated statistical significance. RESULTS: EOM-ADCs showed a positive association with CAS (p ≤ 0.001). EOM-ADCs were higher in sight-threatening compared to mild disease (p ≤ 0.01). A cut-off of 995 mm2/s achieved AUC = 0.7744, equating to 77% sensitivity and 67% specificity for discrimination between mild-moderate and sight-threatening disease. CONCLUSION: EOM-ADCs correlate with higher scores of disease severity and activity in TED. Besides providing quantitative data to support clinical tools, EOM-ADC cut-offs may identify patients at risk of developing sight-threatening diseases. CRITICAL RELEVANCE STATEMENT: This study critically evaluates the limitations of conventional clinical assessment tools for TED and demonstrates the utility of DWI scans with ADC measurements in identifying active disease, offering valuable insights to advance clinical radiology practice. KEY POINTS: Conventional tools for TED assessment have subjective limitations. ADCs from non-echoplanar diffusion-weighted imaging correlate with clinical activity. Non-echoplanar diffusion-weighted imaging offers quantitative assessment to aid clinical practice reliability.

Apparent diffusion coefficients for detection of postoperative middle ear cholesteatoma on non-echo-planar diffusion-weighted images.

PURPOSE: To determine whether there is a difference between the apparent diffusion coefficients (ADCs) of postoperative middle ear cleft cholesteatoma and noncholesteatomatous tissue on half-Fourier acquisition single-shot turbo spin-echo diffusion-weighted (DW) images and to determine, with interobserver agreement, a predictive accuracy for diagnosis of postoperative middle ear cleft cholesteatoma. MATERIALS AND METHODS: Patients who underwent DW magnetic resonance (MR) examination before repeat explorative surgery for postoperative cholesteatoma were included in this study. There were 72 patient episodes and 56 patients. DW MR images were acquired with b values 0 and 1000 sec/mm(2) and 2-mm section thicknesses. Two observers assessed images qualitatively for presence of cholesteatoma and recorded ADCs. Surgery with histologic confirmation established final diagnosis of abnormal middle ear cleft soft tissue. ADCs between cholesteatoma and noncholesteatomatous tissue were compared with Mann-Whitney test. Effects of ADCs and confidence intervals to indicate presence of cholesteatoma were examined by using receiver operating characteristic (ROC) curve analysis, logistic regression analysis, and interobserver agreement. RESULTS: Forty-six patients had cholesteatoma and 25 patients did not; sensitivity and specificity were 0.91 and 0.88, respectively, for the qualitative diagnosis of postoperative cholesteatoma by using a five-point confidence scale. ADC of cholesteatoma (median, 707 × 10(-6) mm(2)/sec; interquartile range, 539-858 × 10(-6) mm(2)/sec; P < .001) was significantly lower than that of noncholesteatomatous tissue (median, 1849 × 10(-6) mm(2)/sec; interquartile range, 1574-1982 × 10(-6) mm(2)/sec; P < .001). There was good accuracy (area under the ROC curve, 0.97) and interobserver agreement for detecting postoperative cholesteatoma with ADC threshold less than 1300 × 10(-6) mm(2)/sec. CONCLUSION: The ADC value of postoperative middle ear cleft cholesteatoma is significantly lower than that of noncholesteatomatous tissue and has good accuracy for detecting cholesteatoma.

Improving access in borderline therapy for difficult-to-engage patients: a clinical description.

Debate about suitability or clinicians' low expectations has led to patients with personality disorders being labeled as difficult and being socially excluded from pathways of care. Traditional psychotherapeutic treatments in borderline personality disorder demand too much of these patients' fractured ego structures for meaningful (long-term) therapeutic engagement. However, these patients cause clinicians anxiety and are a burden in health care systems. This article describes the challenge for clinical care teams working in partnership arrangements-psychotherapy and psychiatry services-to provide a containing framework of care. Early access to a pragmatic psychoanalytically oriented group treatment in borderline personality disorder is aimed at offering these patients an opportunity to make transitions in borderline treatment and thus alter the trajectory of their (self-) destructive pathway. A clinical and theoretical case is made for clinicians and health strategists to re-engage in the process of making meaningful early contact with borderline vulnerability. The group-based treatment model in borderline disturbance described in this article has helped forge partnerships between psychotherapy and psychiatric teams in providing in-depth diagnostic and prognostic information early in the patients' journey.

Imaging of pharyngeal pathology.

The pharynx plays a significant role in swallowing and speech, and this is reflected in both its complex anatomy and degree of physiological motility. Patients who present with pharynx-related symptoms such as sore throat, globus, dysphagia or dysphonia will usually undergo visual and nasal endoscopic examination in the first instance. Imaging is frequently required to supplement clinical assessment and this typically involves MRI and CT. However, fluoroscopy, ultrasound and radionuclide imaging are valuable in certain clinical situations. The aforementioned complexity of the pharynx and the myriad of pathologies which may arise within it often make radiological evaluation challenging. In this pictorial review, we aim to provide a brief overview of cross-sectional pharyngeal anatomy and present the radiological features of a variety of pharyngeal pathologies, both benign and malignant.

Analysing lateral soft tissue neck radiographs.

A lateral soft tissue neck radiograph is a useful adjunct in diagnosing and managing the patient presenting with upper airway symptoms but is often inadequately reviewed. We present some common findings and robust systems to improve analysis of these radiographs.

Imaging the floor of the mouth and the sublingual space.

A wide range of pathologic processes may involve the floor of the mouth, the part of the oral cavity that is located beneath the tongue. They include lesions that arise uniquely in this location (eg, ranula, submandibular duct obstruction) as well as various malignancies, inflammatory processes, and vascular abnormalities that may also occur elsewhere in the head and neck. Some lesions that arise in superficial tissues such as the mucosa may be easily diagnosed at physical examination. However, computed tomography, magnetic resonance imaging, or ultrasonography may be necessary for a reliable assessment of lesion extension to deeper structures. In such cases, knowledge of the complex muscular, vascular, glandular, ductal, and neural anatomy of the region is important for accurate diagnosis and treatment planning. Familiarity with the radiologic imaging appearances of the floor of the mouth and recognition of anatomic landmarks such as the mylohyoid and hyoglossus muscles are especially useful for localizing disease within this region.

Imaging of Acute and Chronic Skull Base Infection.

Skull base infections are uncommon but can be life threatening without timely recognition. Imaging plays a crucial role because symptoms can be vague and nonlocalizing. Necrotizing otitis externa in diabetic or immunocompromised patients is the commonest cause of skull base osteomyelitis (SBO), followed by sinogenic infections and idiopathic central SBO. Multiparametric magnetic resonance (MR) and high-resolution CT are the mainstays for establishing a diagnosis and estimating disease extent, with MR being superior in ascertaining marrow and soft tissue involvement. Monitoring treatment response, of which imaging is a fundamental part, is challenging, with emerging promising imaging tools.

Detecting causes of pulsatile tinnitus on CT arteriography-venography: A pictorial review.

Pulsatile tinnitus (PT) can be a mild or debilitating symptom. Following clinical examination and otoscopy, when the underlying aetiology is not apparent, radiological imaging can be used to evaluate further. CT arteriography-venography (CT A-V) of the head and neck has recently been introduced as a single 'one catch' modality for identifying the many causes of PT including those which are treatable and potentially serious whilst also providing reassurance through negative studies or studies with benign findings. CT A-V is performed as a single phase study allowing both arterial and venous assessment, hence limiting radiation exposure. Additional multiplanar reformats and bone reconstructions are desirable. Understanding the limitations of CT A-V is also required, with an awareness of the scenarios where other imaging modalities should be considered. The causes of PT can be divided into systemic and non-systemic categories. Non-systemic aetiologies in the head and neck should be carefully reviewed on CT A-V and include a variety of vascular causes (arteriovenous malformations/fistulas, venous or arterial aetiologies) and non-vascular causes (tumours and bony dysplasias). Venous causes (dominant, aberrant, stenosed or thrombosed venous vessels) are more common than arterial aetiologies (aberrant or stenosed internal carotid artery, aneurysms or a persistent stapedial artery). Glomus tumours that are not visible on otoscopy and osseous pathologies such as bony dehiscence and otospongiosis should also be excluded. Careful assessment of all the potential vascular and non-vascular causes should be reviewed in a systematic approach, with correlation made with the clinical history. A structured reporting template for the reporting radiologist is provided in this review to ensure all the potential causes of PT are considered on a CT A-V study. This will help in providing a comprehensive radiological evaluation, hence justifying the radiation dose and for patient assessment and prognostication.

Imaging of IgG4-related disease in the extracranial head and neck.

PURPOSE: Immunoglobulin G4-related disease (IgG4-RD) is a newly defined fibro-inflammatory multisystemic condition defined by a triad of diagnostic criteria based on clinical presentation, biochemical and histopathological findings. Whereas some subsites of this disease have been well described in the literature so far (e.g. pancreas, kidneys, retroperitoneum, salivary glands), more recently identified anatomical sites of involvement in the head and neck are less well understood (e.g. nose, paranasal sinuses). METHOD: This pictorial review details the imaging appearances of extracranial IgG4-RD in the Head & Neck. Multimodality imaging appearance and features are presented, with reference to the published literature to date. RESULTS: Following a subsite-based approach, we present both the most common and the more rarely encountered imaging patterns of IgG4-RD in the extracranial head and neck, along with the relevant differential diagnoses to consider. Our institutional experience not only cements what is already known in the existing literature on this topic, but also reveals new imaging features of IgG4-RD, notably in the sinonasal tract. CONCLUSIONS: This pictorial review of extracranial head & neck IgG4-RD will enable radiologists to recognise the features of this condition and propose it as a differential diagnosis to include alongside other probable entities. It establishes the place of the radiologist in the diagnosis and management of IgG4-RD.

Questionnaires used in complex trauma intervention evaluations and consideration of their utility for autistic adults with mild intellectual disability: A systematic review.

INTRODUCTION: Research suggests some trauma symptoms e.g. avoidance are difficult to recognise in autistic people with intellectual disability while arousal/emotional and interpersonal difficulties may be useful signals. This review aims to (i) identify questionnaires used in general population complex trauma interventions to measure emotional and interpersonal difficulty and (ii) evaluate their psychometric properties to inform selection of a potential measure/s for use and/or adaptation for autistic people with mild intellectual disability and trauma related mental health conditions. METHODS: Stage 1: we searched Medline, Cinahl, Embase and PsycInfo for general population and clinical complex trauma intervention studies. Stage 2: we used a search filter in Embase to identify psychometric evaluations of relevant questionnaires used in Stage 1 studies and assessed these with the COnsensus based Standards for the selection of health based Measurement Instruments (COSMIN) checklist. RESULTS: five studies were identified in Stage 1 utilising three measures of emotion dysregulation and interpersonal difficulties. Thirty-three articles on their psychometric properties were identified in Stage 2. Strongest psychometric evidence was found for the Emotion Regulation Questionnaire (ERQ) and Difficulties in Emotion Regulation Scale (DERS). CONCLUSIONS: Evaluating content validity/acceptability of the ERQ and DERS for autistic people with mild intellectual disability and trauma-related mental health conditions are useful next steps.

Imaging the facial nerve: A contemporary review of anatomy and pathology.

PURPOSE: The facial nerve is the seventh paired cranial nerve which anatomically can be divided into six distinct segments. There are a wide range of pathologies that may occur along each segment of the nerve. The aim of this pictorial review is to untangle the complex appearances of the facial nerve, both in its normal anatomical course and when affected by pathology. METHOD: This review takes an evidence-based segmental approach to the evaluation of the facial nerve in terms of its anatomy and clinical features of common pathologies affecting specific segments of the nerve. The typical multimodal radiological findings of common facial nerve pathologies are included in the review using imaging from select pathologically confirmed cases. RESULTS: A wide range of pathologies ranging from congenital abnormalities to inflammatory, infective and neoplastic processes can affect the facial nerve. As select segments of the nerve are better evaluated on certain imaging modalities a clear understanding of the anatomy and clinical features associated with specific facial nerve pathologies enables the radiologist to tailor the imaging test to best answer the clinical question. CONCLUSIONS: This review provides a segmental clinical-radiological approach to imaging the facial nerve. In addition, recent developments in facial nerve imaging that may come into mainstream use in the near future are touched upon.

Surgical mapping of middle ear cholesteatoma with fusion of computed tomography and diffusion-weighted magnetic resonance images: Diagnostic performance and interobserver agreement.

OBJECTIVE: To assess the diagnostic performance in detecting primary cholesteatoma at various anatomical subsites using Computed Tomography (CT), Diffusion-weighted Magnetic Resonance Imaging (DWMRI) and Fusion of CT and DWMRI (Fusion CT-MRI) images. STUDY DESIGN: A retrospective study of 22 children identified from a prospective database of surgically treated cholesteatoma cases over a five year period. All cases underwent pre-operative CT, non-echo planar DWMRI and Fusion CT-DWMRI, and with clearly documented surgical findings. For each imaging modality, two radiologists scored for the presence or absence of cholesteatoma with confidence levels at different anatomical subsites. The radiologists were blinded to the surgical findings to which their findings were compared. SETTING: Large Teaching Hospital in London. PATIENTS: 22 children with cholesteatoma confirmed surgically. INTERVENTION: CT, DWMRI imaging and fusion CT-MRI. MAIN OUTCOME MEASURE: Diagnostic performance of subsite localisation of cholesteatoma by CT, DWMRI and fusion CT-MRI imaging with intra-operative findings. RESULTS: Twenty-two patients were included (12 women and 10 men). The median age of patients was 11 years. When considering all subsites combined, the result for all imaging methods suggested 'good' agreement between both observers. When all subsites were examined together, all methods had relatively high sensitivity values (87% for CT vs 84% for DWMRI vs 85% for fusion CT-DWMRI). Specificity was highest with fusion CT-DWMRI (46% for CT vs 76% for DWMRI vs 97% for fusion CT-DWMRI), as was accuracy (66% for CT vs 80% for DWMRI vs 91% for fusion). CONCLUSIONS: Our study has demonstrated that fusion CT-DWMRI is superior to DWMRI or CT separately in localizing cholesteatoma at various middle ear cleft subsites and bony relations, making it a valuable tool for surgical planning.

British Thyroid Association 2014 classification ultrasound scoring of thyroid nodules in predicting malignancy: Diagnostic performance and inter-observer agreement.

OBJECTIVES: To assess the inter-observer agreement amongst five observers of differing levels of expertise in applying the British Thyroid Association (2014) guidelines for ultrasound scoring of thyroid nodules (BTA-U score) in the management of thyroid cancer, and to assess the U-score diagnostic performance in predicting malignancy. METHOD: A total of 73 consecutive patients were included over a two-year period (July 2012 to July 2014), after referral to a tertiary head and neck oncology centre for ultrasound plus fine needle aspiration and cytology. Our five observers retrospectively and independently reviewed static ultrasound images on PACS and scored the thyroid nodules according to BTA-U classification. The observers were blinded to each other's scoring, cytology and histology results. Either the Kappa-statistic or intra-class correlation was used to assess the level of inter-observer agreement, plus agreement between the radiological and cytological diagnoses. The diagnostic performance of U-scoring for predicting final histological diagnosis was assessed with sensitivity, specificity, positive and negative predictive values. RESULTS: A Kappa-value of 0.73 (95% CI: 0.68-0.77) confirmed substantial inter-observer agreement amongst the five observers. All 17 histology confirmed malignant nodules were correctly classified as potentially malignant by all observers. The sensitivity and negative predictive value of BTA-U score in detecting and predicting malignancy were 100%, whereas the specificity and positive predictive values were 34% and 32%, respectively. CONCLUSIONS: There is good inter-observer agreement in using the BTA-U score amongst different observers at differing levels of expertise. Adhering to BTA-U scoring can potentially achieve 100% sensitivity in selecting malignant nodules for sampling.

Inflammation of the Temporal Bone.

Temporal bone and ear structure inflammation is commonly due to infection. It can be associated with a variety of complications and postinflammatory sequelae. Where the ear is easily inspected, clinical evaluation suffices. At the deeper aspect of the temporal bone, clinical evaluation is limited. High-resolution computed tomography scanning is suited for temporal bone imaging and is the modality of choice. MR imaging is useful to characterize disease, define the extent and spread of disease, or as a surveillance tool. MR imaging can be used with high-resolution computed tomography scanning to give a comprehensive evaluation of a complex disease process.

Conductive hearing loss with a "dry middle ear cleft"-A comprehensive pictorial review with CT.

Conductive hearing loss (CHL) commonly results from middle ear fluid and inflammation (otitis media). Less commonly in patients with CHL, the middle ear cleft is well aerated or 'dry' with absence of soft tissue or fluid clinically and on imaging. There are numerous causes for this but they can be clinically challenging to diagnose. This pictorial review aims to illustrate and discuss the CT features of both common and less common causes of CHL in patients with a "dry middle ear cavity".