A comparative evaluation of the Eustachian tube cartilage between healthy and diseased ears using a 3 Tesla MRI.

PURPOSE: The purpose of this study was to prospectively assess the Eustachian tube (ET) cartilage using 3 Tesla (3T) magnetic resonance imaging (MRI) and compare the results between healthy ears and those with a middle ear disease. MATERIAL AND METHODS: The study included 56 ears with a middle ear disease as the patient group and 100 ears without a middle ear disease as the control group. The patients' age ranged from 18 to 65 years. The axial three-dimensional (3D) multiple echo recombined gradient echo (MERGE) sequence and oblique parasagittal planes were obtained. Visualisation of the ET cartilage was assessed on the MR images using a three-point numerical rating score. In the axial plane, the ET lumen's diameter was measured from the mid-portion of the cartilage. RESULTS: There was no significant difference between the patient group and the control group according to patients' age and gender, and the medial laminal thickness of the ET cartilage. In the patient group, the diameter of the ET cartilage was significantly smaller than in the control group. The ET lumen diameter was significantly lower according to each of the three scoring systems. CONCLUSIONS: 3T MRI provides an evaluation of the ET cartilage and isthmus level, which are small but important anatomical localisations and surgical landmarks. MR imaging has the potential to provide essential information on ET prior to new surgical treatments, such as balloon dilation for middle ear diseases.

Diagnostic role of ultrasound elastography on lymph node metastases in patients with head and neck cancer / Papel diagnóstico da elastografia ultrassonográfica nas metástases de linfonodos em pacientes com câncer de cabeça e pescoço

Abstract Introduction: Ultrasonography is the easiest non-invasive method to diagnose lymph node metastases in patients with head and neck cancer. However, since CT scans are often preferred in the evaluation of primary tumours of these patients, information about lymphatic metastases may also available in these patients. Therefore, ultrasound is not routinely employed in the evaluation of these patients. However, elastography technique, a recent development in ultrasound technology, could make use of ultrasonography in these patients even more widespread, even though it is still not widely used today. Objectives: The aim of this study was to evaluate the role of sonographic elastography in the diagnosis of lymph node metastasis of head and neck cancer. Methods: Twenty-three patients diagnosed with head and neck cancer and scheduled for surgical treatment including neck dissection were included in the study. All patients underwent neck examination by palpation, ultrasound elastography and computerized tomography with contrast. To compare the diagnostic performance of palpation, ultrasound elastography and computerized tomography, the findings of each examination method were compared with the histopathological examination results of neck specimens. Results: 15 (65.2%) patients had a primary tumour in the larynx; 7 (30.4%) in the oral cavity; and 1 (4.3%) in the parotid. 7 (30.4%) out of 23 patients underwent bilateral neck dissection. In total, 30 neck dissections were hereby taken into account during study. Ultrasound elastography showed higher accuracy (83.3%) and higher sensitivity (82.4%) than palpation and computerized tomography, but the specificity of ultrasound elastography was lower (84.6%) than palpation and computerized tomography. Conclusions: Ultrasound elastography is helpful for the diagnosis of lymph node metastases in patients with head and neck cancer. Due to its non-invasive character, it can be used safety in combination with other radiological techniques to support or improve their diagnostic performance.

Resumo Introdução: A ultrassonografia é o método mais fácil e não invasivo para diagnosticar metástases em linfonodos em pacientes com câncer de cabeça e pescoço. No entanto, como as tomografias computadorizadas são frequentemente preferidas na avaliação de tumores primários desses pacientes, as informações sobre metástases linfáticas também se tornam disponíveis. Portanto, a ultrassonografia não faz parte da avaliação de rotina desses pacientes. Entretanto, a técnica de elastografia, um desenvolvimento mais recente na tecnologia de ultrassom, poderia tornar o uso da ultrassonografia mais difundido nesses pacientes, embora atualmente ainda não seja amplamente usado. Objetivo: Avaliar o papel da elastografia ultrassonográfica no diagnóstico de metástases em linfonodos em casos de câncer de cabeça e pescoço. Método: Foram incluídos no estudo 23 pacientes diagnosticados com câncer de cabeça e pescoço e com tratamento cirúrgico programado, inclusive esvaziamento cervical. Todos os pacientes foram submetidos a exame cervical por palpação, elastografia ultrassonográfica e tomografia computadorizada com contraste. Para comparar o desempenho diagnóstico da palpação, elastografia ultrassonográfica e tomografia computadorizada, os achados de cada método de exame foram comparados com os resultados do exame histopatológico de amostras obtidas do pescoço. Resultados: Dos pacientes, 15 (65,2%) apresentaram tumor primário na laringe; sete (30,4%) na cavidade oral; e um (4,3%) na parótida. Sete (30,4%) dos 23 pacientes foram submetidos a esvaziamento cervical bilateral. Foram considerados durante o estudo 30 pescoços. A elastografia ultrassonográfica mostrou maior acurácia (83,3%) e maior sensibilidade (82,4%) do que a palpação e a tomografia computadorizada, mas a especificidade da elastografia ultrassonográfica foi menor (84,6%) do que a palpação e a tomografia computadorizada. Conclusões: A elastografia ultrassonográfica é útil para o diagnóstico de metástases de linfonodos em pacientes com câncer de cabeça e pescoço. Graças ao seu caráter não invasivo, pode ser usada com segurança em combinação com outras técnicas radiológicas para apoiar ou melhorar o desempenho diagnóstico.

Diagnostic role of ultrasound elastography on lymph node metastases in patients with head and neck cancer.

INTRODUCTION: Ultrasonography is the easiest non-invasive method to diagnose lymph node metastases in patients with head and neck cancer. However, since CT scans are often preferred in the evaluation of primary tumours of these patients, information about lymphatic metastases may also available in these patients. Therefore, ultrasound is not routinely employed in the evaluation of these patients. However, elastography technique, a recent development in ultrasound technology, could make use of ultrasonography in these patients even more widespread, even though it is still not widely used today. OBJECTIVES: The aim of this study was to evaluate the role of sonographic elastography in the diagnosis of lymph node metastasis of head and neck cancer. METHODS: Twenty-three patients diagnosed with head and neck cancer and scheduled for surgical treatment including neck dissection were included in the study. All patients underwent neck examination by palpation, ultrasound elastography and computerized tomography with contrast. To compare the diagnostic performance of palpation, ultrasound elastography and computerized tomography, the findings of each examination method were compared with the histopathological examination results of neck specimens. RESULTS: 15 (65.2%) patients had a primary tumour in the larynx; 7 (30.4%) in the oral cavity; and 1 (4.3%) in the parotid. 7 (30.4%) out of 23 patients underwent bilateral neck dissection. In total, 30 neck dissections were hereby taken into account during study. Ultrasound elastography showed higher accuracy (83.3%) and higher sensitivity (82.4%) than palpation and computerized tomography, but the specificity of ultrasound elastography was lower (84.6%) than palpation and computerized tomography. CONCLUSIONS: Ultrasound elastography is helpful for the diagnosis of lymph node metastases in patients with head and neck cancer. Due to its non-invasive character, it can be used safety in combination with other radiological techniques to support or improve their diagnostic performance.

The relation between brain MRI findings and blood manganese levels in renal transplantation, hemodialysis, and peritoneal dialysis patients.

PURPOSE: Various factors can affect blood and tissue levels of trace elements in patients with end-stage renal disease. There are a few studies showing hyperintensity of basal ganglia associated with manganese deposition in hemodialysis (HD) patients. The present study aimed to investigate the intensity changes as markers of manganese deposition in the basal ganglia and to demonstrate their association with blood manganese levels using ICP/MS technique in HD, peritoneal dialysis (PD), and renal transplant patients. METHODS: The study included 20 HD, 20 PD, 20 renal transplant patients, and 20 healthy controls. Blood manganese levels were obtained, and cranial magnetic resonance images were evaluated for basal ganglia hyperintensity. RESULTS: Blood manganese levels were similar across all study groups (p = 0.308), whereas symmetric basal ganglia hyperintensity indicating manganese deposition was detected only in HD patients (p = < 0.001). There was a significant relationship between manganese deposition and duration of dialysis (p = 0.05). CONCLUSION: Imaging findings suggesting manganese deposition in the basal ganglia being present only in HD patients suggest that manganese deposition could be caused by the hemodialysis method itself rather than uremia and renal failure. Further studies are required in this regard, as previous studies have not clearly identified the mechanisms by which hemodialysis causes these changes.

Evaluation of the Vestibular System and Etiology in Children with Unilateral Sensorineural Hearing Loss.

OBJECTIVE: The aim of this study was to evaluate the vestibular system of children with unilateral sensorineural hearing loss (USNHL), investigate the etiological factors of USNHL and analyze whether a genetic predisposition exists. MATERIALS AND METHODS: Thirty-three children aged less than 18 years with USNHL, who visited the ear, nose, and throat (ENT) department between January 2004 and December 2012, were included in this study. Cases with conductive hearing loss were excluded from the study. The patients were subjected to etiologic, genetic, and ophthalmologic evaluation; radiologic imaging; electronystagmography (ENG); and vestibular evoked myogenic potential (VEMP) tests. The control group, which included 25 healthy children (13 males and 12 females), had undergone audiological assessment and were subjected to ENG and VEMP tests. RESULTS: All of the patients had severe-to-profound hearing loss. Mumps immunoglobulin G was positive in 22 (66.7%) of 33 patients. The 35delG mutation was not found in any of the patients. All of the patients underwent temporal computed tomography (CT) and magnetic resonance imaging (MRI). Inner ear anomaly was present in 51.5% of the patients. Overall, 21 of 31 ENG patients had canal paresis in the affected ear. The VEMP response was absent on the affected side in three patients. The n23 latency average of the patient group was longer than that of the control group. CONCLUSION: Because USNHL causes irreversible problems in children, early diagnosis and auditory rehabilitation are very important. As USNHL is accompanied by inner ear anomaly, children with USNHL should undergo temporal bone CT and MRI. To evaluate the vestibular system, ENG and VEMP are non-invasive and diagnostic tests.

A late and extreme complication of lumboperitoneal shunt.

BACKGROUND CONTEXT: Lumboperitoneal (LP) shunting is an effective treatment modality for commmunicating hydrocephalus, pseudotumor cerebri, postoperative pseudomeningoceles, and cerebrospinal fluid fistulas. However, LP shunts are associated with some complications. Here, we report an extreme complication resulting in the formation of granulation tissue. PURPOSE: To report a late extreme complication of LP shunt. STUDY DESIGN: A case report. METHODS: A late and unusual complication of an LP shunt with unique radiologic findings is presented. RESULTS: Spinal magnetic resonance imaging studies depicted a mass on the right anterior section of the dural sac encircling the catheter throughout its course from the L3-L4 interspinous level to the catheter tip. CONCLUSIONS: The etiopathologic mechanism, the prolonged duration, and the unusual radiologic findings in this case are unique and remarkable.

The round window diameter in congenital aural atresia and comparison with sensorineural hearing loss and control group.

OBJECTIVE: The aim of this study was to measure round window (RW) diameters in patients with congenital aural atresia (CAA) or sensorineural hearing loss (SNHL) and a normal control group and to analyze whether differences exist between these groups. METHODS: Temporal bone computed tomographic scans of 12 patients with CAA (5 males, 7 females) aged 1 to 50 years (median age, 6 years), 12 patients with SNHL (8 males, 4 females) aged 2 to 32 years (median age, 5 years), and 11 patients (3 males, 7 females) aged 2 months to 53 years (median age, 8 years) randomly selected from a pool of patients with unilateral chronic otitis media or cholesteatoma were reviewed. We measured RW diameter on oblique reconstruction planes. To prevent possible individual differences, skull width was measured. RESULTS: There were no statistically significant differences between all groups for skull width. Both RW diameter and RW membrane width were found smaller in the CAA group than both SNHL group and control group with statistical significance, whereas there were no statistically significant differences between the SNHL group and the control group. CONCLUSIONS: We found that both the RW diameter and RW membrane width in CAA were smaller than those in the control group. If this finding is supported in future studies, the production of floating mass transducer with different sizes may be useful. We suggest that RW diameter should be measured in each patient before operation and thus a floating mass transducer with the appropriate caliber should be chosen.

Computed tomographic findings of X-linked deafness: a spectrum from child to mother, from young to old, from boy to girl, from mixed to sudden hearing loss.

PURPOSE: Congenital mixed hearing loss associated with fixed stapes footplate is a rare disorder transmitted through X-linked inheritance. The purpose of this study was to report the radiologic findings of X-linked deafness with middle ear anomalies in affected children and young patients and in carrier women. MATERIALS AND METHODS: The computed tomographic and audiometric findings of 7 subjects (4 affected children and young patients, 1 of whom is a girl; 2 carrier mothers; and a man who presented with sudden hearing loss) from different families were analyzed. RESULTS: Computed tomography showed bulbous dilatation of the fundi of the internal auditory canals, incomplete bony separation between the basal turn of the cochleas and the lateral ends of the internal auditory canal, deficiency of the modiolus, enlarged first part of the facial nerve, and dilatation of the superior and the inferior vestibular nerve canal and the singular canal. Besides these characteristic findings, dilatation of the vestibular aqueduct was seen except in the man. Middle ear anomalies including oval and/or round window and/or stapes abnormalities were also detected in three affected patients. The carrier mothers had milder forms of some characteristic findings. CONCLUSIONS: Because of the risks of stapes surgery in X-linked deafness, recognition of the characteristic imaging features of these disorders is important. Especially in young patients with mixed hearing loss, temporal bone computed tomography should be performed before stapes surgery to avoid the complication of stapes gusher. Middle ear anomalies might be highly associated with X-linked deafness.

Is there a connection between perivascular space and subarachnoid space?

Perivascular spaces (PVSs) surrounding the walls of arteries, arterioles, and venules do not directly communicate with subarachnoid spaces. There are a few reports exhibiting subarachnoid hemorrhage (SAH) and intracerebral hematomas extending to the PVSs by leakage of the leptomeninges that surround arteries. In this report, we present 4 patients of whom 3 had SAH extending into the PVSs in the bilateral basal ganglia and 1 had extension of contrast medium to the PVSs after injection of the contrast medium into the lumbar subarachnoid space. The hemorrhage extending to the PVSs in our 3 patients with SAH could be explained by leakage of the leptomeninges surrounding the arteries. However, how the contrast medium extends to the PVSs is not clear. We think that, although speculative, incomplete or complete defect at the leptomeninges surrounding the arteries resulting in direct continuity between the subarachnoid space and the PVS allows that blood or contrast media to extend to the PVSs.

The first report of a patient with probable variant creutzfeldt-jakob disease in Turkey.

Variant Creutzfeldt-Jakob disease (vCJD) was first reported in the UK in 1996. Here, we report the first Turkish case of vCJD. A 47-year-old man, who has never lived outside of Turkey and had had no transfusion, was admitted to the University Hospital with speech disorder, cognitive decline and ataxia following depression, irritability, and personality change. The immunoassay of the 14-3-3 protein in the cerebrospinal fluid was negative. Brain magnetic resonance imaging revealed high-signal lesions involving the bilateral caudate and lentiform nucleus on T(2)- and diffusion-weighted imaging. The patient developed akinetic mutism 10 months after disease onset. The clinical presentation and neuroimaging findings were compatible with the vCJD cases reported since 1996 and met the World Health Organization's case definition for probable vCJD.

Value of power Doppler and gray-scale US in the diagnosis of carpal tunnel syndrome: contribution of cross-sectional area just before the tunnel inlet as compared with the cross-sectional area at the tunnel.

OBJECTIVE: To determine the value of gray-scale and power Doppler ultrasonography in the evaluation of carpal tunnel syndrome (CTS). MATERIALS AND METHODS: Median nerves at the carpal tunnel were evaluated by using gray-scale and power Doppler ultrasonography and by using accepted and new criteria in 42 patients with CTS (62 wrists) confirmed by electromyogram and 33 control subjects. We evaluated the cross-sectional area of the nerve just proximal to the tunnel inlet (CSAa), and at mid level (CSAb). We then calculated the percentage area increase of CSAb, and area difference (CSAb-CSAa). We measured two dimensions of the nerve at the distal level to calculate the flattening ratio. The power Doppler ultrasonography was used to assess the number of vessels, which proceeded to give a score according to the vessel number, and lastly evaluated the statistical significance by comparing the means of patients with control subjects by the Student t test for independent samples. Sensitivities and specificities were determined for sonographic characteristics mentioned above. We obtained the receiver operating characteristic (ROC) curve to assess the optimal cut-off values for the diagnosis of CTS. RESULTS: A statistically significant difference was found between patients and the control group for mean CSAb, area difference, percentage area increase, and flattening ratio (p < 0.001, p < 0.001, p < 0.001, p < 0.05, respectively). From the ROC curve we obtained optimal cut-off values of 11 mm(2) for CSAb, 3.65 for area difference, 50% for the percentage of area increase, and 2.6 for the flattening ratio. The mean number of vessels obtained by power Doppler ultrasonography from the median nerve was 1.2. We could not detect vessels from healthy volunteers. Mean CSAbs related to vascularity intensity scores were as follows: score 0: 12.3 ± 2.8 mm(2), score 1: 12.3 ± 3.1 mm(2), score 2: 14.95 ± 3.5 mm(2), score 3: 19.3 ± 3.8 mm(2). The mean PI value in vessels of the median nerve was 4.1 ± 1. CONCLUSION: Gray-scale and power Doppler ultrasonography are useful in the evaluation of CTS.

Septo-optic dysplasia plus: a patient with diabetes insipidus.

The association of septo-optic dysplasia and cortical dysplasia is described as septo-optic dysplasia-plus. Reports on patients with septo-optic dysplasia-plus have been rare. We describe a 4-year-old girl with septo-optic dysplasia-plus syndrome, characterized by septo-optic dysplasia with schizencephaly, pachygyria, and diabetes insipidus.

Multiple intradural-extramedullary ependymomas: proven dissemination by genetic analysis.

This 45-year-old woman was admitted with neck and back pain and difficulty in ambulation that had been progressively worsening for 2 years. Admission MR imaging revealed a cervicomedullary junction tumor and 2 intradural-extramedullary spinal tumors located separately at the levels of T5-6 and T8-9. All masses were successfully resected in a 2-stage operation. Histopathological examination of the surgical specimens revealed that all the lesions were ependymomas. Genetic analysis was performed to determine if the tumors were related. Conventional cytogenetics, multiplex fluorescence in situ hybridization (M-FISH), interphase-FISH specific to 22q11, and epidermal growth factor receptor loci analyses of the tumor samples revealed that the lesions originated from the same primary tumor. Although 3 simultaneous tumors in different compartments of the neural axis were diagnosed as ependymoma by histopathological examination, it was not possible to be sure if their multiplicity was due to spread of tumor cells via CSF or if it was due to multicentric foci. Thus, genetic analysis of the tumor samples is essential to confirm the exact mechanism of development of multiple ependymomas.

Evaluation of the size and area of the corpus callosum with the Osiris method in Alzheimer's disease.

BACKGROUND/OBJECTIVE: Significant corpus callosum (CC) atrophy has been demonstrated in patients with Alzheimer's disease (AD). The aim of this study is to evaluate the size and the area of the CC with the Osiris method. The correlation between the CC measurements and Mini-Mental Status Examination (MMSE) scores in AD patients was also investigated. METHODS: The results of the topographic measurements included the cross-sectional area of entire CC, body, rostral portion of the genu and splenium from a midsagittal magnetic resonance imaging section. The results of the topographic measurements of CC on MRI with the Osiris method were compared between AD (n = 29) and control subjects (n = 27). RESULTS: In AD patients the mean value of the splenium was 9.2 +/- 1.5 mm, the width of the CC body was 3.9 +/- 0.2 mm, the rostral portion of the genu was 7.9 +/- 0.2 mm, and the total CC area was 47.2 +/- 0.9 mm(2). In the control group the mean values were 12.2 +/- 2.1 mm, 5.9 +/- 0.2 mm, 11.2 +/- 0.2 mm and 56.1 +/- 0.6 mm(2), respectively. Significant reduction was detected in the splenium, the CC body and the rostral part of the genu and CC area in AD patients. The MMSE score was 18.9 +/- 4.5 in the AD patients and 29.1 +/- 0.9 in the control subjects. A significant positive correlation between the MMSE scores and each CC measurement was seen in the AD patients. CONCLUSION: The results of this study suggest that callosal atrophy in AD may suggest the severity of the disease. The Osiris method for CC measurements may be used as an easy and reliable technique to assess the severity of the disease.

Congenital cavernous hemangioma of the calvaria. Case report.

The authors present the case of a 6-month-old infant with a cavernous hemangioma of the parietal bone and discuss the radiological, operative, and pathological features and differential diagnosis of these extremely rare lesions in infants. Only 1 case of an infant with a calvarial cavernous hemangioma without intracranial invasion has previously been reported, and that case involved a 4 month old. Although a cavernous hemangioma of the calvaria is extremely rare in the newborn, this condition should be included in the differential diagnosis of calvarial lesions. During surgical treatment of calvarial cavernous hemangiomas, utmost attention should be paid to avoid blood loss, which could be fatal in infants.

The estimation of cerebral asymmetries in schizophrenia by the Cavalieri principle.

OBJECTIVE: To demonstrate hemispheric asymmetry in patients with schizophrenia using a cheap, simple stereologic method on the basis of standard CT scans of the brain. METHODS: To demonstrate hemispheric asymmetry, standard CT scans of 30 schizophrenic patients (14 males, 16 females) were compared with 39 (13 male, 26 female) control subjects at Eskisehir Osmangazi University, Eskisehir, Turkey in 2005. Brain volumes were investigated by using a cheap, simple stereologic method, namely, Cavalieri. RESULTS: In patients with schizophrenia, we found that as age increases, right and left hemisphere volumes decrease. However, in the control group there was no relationship found between age and hemisphere volumes. In the control group, the left hemisphere was significantly bigger in males compared to females. There was a significant difference in both right and left hemisphere volumes between the control group and the schizophrenic group. In the schizophrenic group, a significant difference was observed in right hemisphere volumes between genders (p=0.002), while there was no difference in the control group. There was a difference in left hemisphere volumes between genders in both groups. Right and left hemispheric volumes of the schizophrenic group were smaller than those of control group. CONCLUSION: Cerebral asymmetry is an arguable subject for the diagnosis of schizophrenia. The method that we used in this study will be useful in estimating hemispheric volumes.

Post-traumatic pneumocele of the frontal sinus.

A pneumocele is an abnormal dilatation of a paranasal sinus, most commonly affecting the frontal sinus. Although the etiology of pneumocele is not entirely known, several causative factors have been suggested including trauma, surgery, tumor and infection. We report here a case of post-traumatic pneumocele of the frontal sinus following a head trauma.

Cochlear implantation in cases with incomplete partition type III (X-linked anomaly).

Incomplete partition-type III anomaly (X-linked deformity) is no common finding in a prospective candidate for cochlear implantation. In this paper, the problems about the cochlear implantation in cases with incomplete partition-type III anomaly (X-linked deformity) and profound sensorineural hearing loss is discussed. High-resolution multidedector computed tomography (MDCT) and magnetic resonance imaging were performed preoperatively in all patients. MDCT revealed that there was bulbous dilatation at the lateral ends of internal auditory canals (IAC) in all patients. There were also enlargements of labyrinthine segments of facial and superior vestibular nerve canals. Patients with the basal turns of cochlea incompletely separated from IAC were also presented. Patients with IP-type III (X-linked deformity) and profound SNHL were implanted. Standard transmastoid-facial recess approach was used and cerebrospinal gusher was encountered after the cochleostomy in all cases. Postoperative performance was very good in all patients. Two patients had complications, which are facial nerve stimulation and device failure. Both patients were reimplanted. Cochlear implantation is a good choice in the patients with IP-type III. However, this anomaly may have special potential risk than the other inner ear abnormalities. Therefore, the surgeon should be aware of them and must be ready to inform the patient and parents.

Bilateral narrow duplicated internal auditory canal.

Internal auditory canal (IAC) anomalies are rare malformations that may include alterations of shape, size or orientation of the IAC. Bilateral duplication of IAC is a very rare malformation and only one case has been described in literature. We report a case of bilateral duplicated IAC together with other inner ear anomalies.