Diagnostic accuracy of clinical visual assessment using endoscopic images for nasal cavity mass lesions.

Objectives: Discrimination of nasal cavity lesions using nasal endoscopy is challenging because of the differences in clinical manifestations and treatment strategies. We aimed to investigate the diagnostic accuracy of clinical visual assessment (CVA) of nasal cavity masses using endoscopic images and determine whether there is a difference according to pathologic class and the examiners' experience. Methods: We collected pathologically confirmed endoscopic images of normal findings, nasal polyp (NP), benign tumor, and malignant tumor (each class contained 100 images) randomly selected. Eighteen otolaryngologists, including six junior residents, six senior residents, and six board-certified rhinologists classified the test set images into four classes of lesions by CVA. Diagnostic performance according to the pathologic class and the examiner's experience level was evaluated based on overall accuracy, F1-score, confusion matrix, and area under the receiver operating characteristic curve (AUC). Results: Diagnostic performance was significantly different according to the pathological class of nasal cavity mass lesions with the overall accuracy reported high in the order of normal, NP, benign tumor, and malignant tumor (0.926 ± 0.100; 0.819 ± 0.135; 0.580 ± 0.112; 0.478 ± 0.187, respectively), F1 score (0.937 ± 0.076; 0.730 ± 0.093; 0.549 ± 0.080; 0.554 ± 0.146, respectively) and AUC value (0.96 ± 0.06; 0.84 ± 0.07; 0.70 ± 0.05; 0.71 ± 0.08, respectively). The expert rhinologist group achieved higher overall accuracy than the resident group (0.756 ± 0.157 vs. 0.680 ± 0.239, p < .05). Conclusion: CVA for nasal cavity mass was highly dependent on the pathologic class and examiner's experience. The overall accuracy was reliably high for normal findings, but low in classifying benign and malignant tumors. Differential diagnosis of lesions solely based on nasal endoscopic evaluation is challenging. Therefore, clinicians should consider further clinical evaluation for suspicious cases.

Assessment of the nasal microbiota in dogs with fungal rhinitis before and after cure and in dogs with chronic idiopathic rhinitis.

BACKGROUND: Pathogenesis of canine fungal rhinitis is still not fully understood. Treatment remains challenging, after cure turbinate destruction may be associated with persistent clinical signs and recurrence of fungal rhinitis can occur. Alterations of the nasal microbiota have been demonstrated in dogs with chronic idiopathic rhinitis and nasal neoplasia, although whether they play a role in the pathogenesis or are a consequence of the disease is still unknown. The objectives of the present study were (1) to describe nasal microbiota alterations associated with fungal rhinitis in dogs, compared with chronic idiopathic rhinitis and controls, (2) to characterize the nasal microbiota modifications associated with successful treatment of fungal rhinitis. Forty dogs diagnosed with fungal rhinitis, 14 dogs with chronic idiopathic rhinitis and 29 healthy control dogs were included. Nine of the fungal rhinitis dogs were resampled after successful treatment with enilconazole infusion. RESULTS: Only disease status contributed significantly to the variability of the microbiota. The relative abundance of the genus Moraxella was decreased in the fungal rhinitis (5.4 ± 18%) and chronic idiopathic rhinitis (4.6 ± 8.7%) groups compared to controls (51.8 ± 39.7%). Fungal rhinitis and chronic idiopathic rhinitis groups also showed an increased richness and α-diversity at species level compared with controls. Increase in unique families were associated with fungal rhinitis (Staphyloccaceae, Porphyromonadaceae, Enterobacteriaceae and Neisseriaceae) and chronic idiopathic rhinitis (Pasteurellaceae and Lactobacillaceae). In dogs with fungal rhinitis at cure, only 1 dog recovered a high relative abundance of Moraxellaceae. CONCLUSIONS: Results confirm major alterations of the nasal microbiota in dogs affected with fungal rhinitis and chronic idiopathic rhinitis, consisting mainly in a decrease of Moraxella. Besides, a specific dysbiotic profile further differentiated fungal rhinitis from chronic idiopathic rhinitis. In dogs with fungal rhinitis, whether the NM returns to its pre-infection state or progresses toward chronic idiopathic rhinitis or fungal rhinitis recurrence warrants further investigation.

Diagnostic accuracy of contrast-enhanced computed tomography for assessment of mandibular and medial retropharyngeal lymph node metastasis in dogs with oral and nasal cancer.

The diagnostic accuracy of contrast-enhanced CT for detection of cervical lymph node metastasis in dogs is unknown. The purpose of this retrospective, observational, diagnostic accuracy study was to assess the efficacy of CT for detection of mandibular and medial retropharyngeal lymph node metastasis in dogs. Histopathology of dogs with cancer of the head, CT and bilateral mandibular and medial retropharyngeal lymphadenectomy was reviewed. A single radiologist measured lymph nodes to derive short axis width and long-short axis ratios. Two blinded radiologists separately assessed lymph node margins, attenuation and contrast enhancement and each provided a final subjective interpretation of each node site as benign or neoplastic. Where radiologists' opinions differed, a consensus was reached. Sensitivity, specificity and accuracy were calculated for mandibular and medial retropharyngeal sites. Agreement between radiologists was assessed. Fisher's exact test and the Kruskal-Wallis H-test were used to assess associations between variables. Forty-one primary tumours were recorded in 40 dogs. Metastasis to mandibular or retropharyngeal lymph nodes occurred in 16 out of 40 dogs (43/160 nodes). Agreement between radiologists was almost perfect for margination, attenuation and enhancement, strong for interpretation of mandibular lymph node metastasis, and weak for interpretation of medial retropharyngeal lymph node metastasis. Sensitivity of CT was 12.5% and 10.5%, specificity was 91.1% and 96.7%, and accuracy was 67.5% and 76.3% for mandibular and medial retropharyngeal lymph nodes respectively. No individual CT findings were predictive of nodal metastasis. Given the low sensitivity of CT, this modality cannot be relied upon alone for assessment of cervical lymph node metastasis in dogs.

HPV Virus Transcriptional Status Assessment in a Case of Sinonasal Carcinoma.

Human Papilloma Virus (HPV) can play a causative role in the development of sinonasal tract malignancies. In fact, HPV may be the most significant causative agent implicated in sinonasal tumorigenesis and is implicated in as many as 21% of sinonasal carcinomas. To date, there are no definitive, reliable and cost-effective, diagnostic tests approved by the FDA for the unequivocal determination of HPV status in head and neck cancers. We followed an exhaustive algorithm to correctly test HPV infection, including a sequential approach with p16INK4a IHC, viral DNA genotyping and in situ hybridization for E6/E7 mRNA. Here, we report a case of sinonasal carcinoma with discordant results using HPV test assays. The tumor we describe showed an irregular immunoreactivity for p16INK4a, and it tested positive for HPV DNA; nevertheless, it was negative for HR-HPV mRNA. We discuss the possible meaning of this discrepancy. It would be advisable to test HPV transcriptional status of sinonasal carcinoma on a diagnostic routine basis, not only by p16INK4a IHC assay, but also by HPV DNA genotyping and HR-HPV mRNA assessment.

Assessment of the prognostic capacity of pretreatment, interim, and post-therapy (18)F-FDG PET/CT in extranodal natural killer/T-cell lymphoma, nasal type.

OBJECTIVE: Although the prognostic value of positron emission tomography/computed tomography (PET/CT) using [(18)F]-fluorodeoxyglucose ((18)F-FDG) has been widely confirmed for diffuse large B cell lymphoma, its value for extranodal natural killer/T-cell lymphoma, nasal type (ENKTL), is still controversial. Therefore, we designed a prospective study to investigate the prognostic value of (18)F-FDG PET/CT in patients with ENKTL. MATERIALS AND METHODS: Thirty-three patients with newly diagnosed, untreated ENKTL, were enrolled in this study. Interim and post-therapy PET/CT scans were analyzed by visual evaluation, in accordance with the criteria set forth by the International Harmonization Project. Patients were classified as either positive or negative. Pretreatment maximum standardized uptake values (SUVmax) of (18)F-FDG were recorded in the most (18)F-FDG-intense lesions. The pretreatment (18)F-FDG SUV as well as the interim and post-therapy PET/CT results were assessed for the ability to predict progression-free survival (PFS) and overall survival (OS). RESULTS: On the pretreatment scan, the SUVmax of the indicator lesion was >10.00 in 81.8% of patients who were treatment-resistant and ≤10.00 in 86.4% of patients who were treatment non-resistant (mean SUVmax, 12.93 and 8.10, respectively). Univariate analyses revealed that pretreatment SUVmax is a significant predictor (P < 0.01, P < 0.01) of PFS and OS, respectively. Multivariate analyses revealed that pretreatment SUVmax (P < 0.01, P = 0.01) and post-therapy PET/CT result (P < 0.01, P = 0.04) are independent predictors of PFS and OS, respectively. CONCLUSIONS: (18)F-FDG uptakes prior to treatment and post-therapy PET/CT results can predict unfavorable outcomes following treatment in patients with ENKTL, but interim PET/CT results have little value in predicting survival.

[Cutaneous malignancies in occupationally-induced scars]. / Maligne Hauttumoren in beruflich verursachten Narben.

BACKGROUND: The occurrence of neoplasms in injury scars--as consequence of occupational accidents--may lead to compensation according to the statutory accident insurance regulations. According to newer regulatory attempts in occupational dermatology, certain criteria have to be met before the diagnosis of a neoplasm induced by a scar is accepted and compensation is due. MATERIAL AND METHODS: Based on a retrospective analysis of 217 dermatological claim files between 2007 and 2009 of the IPA (including 22 follow-ups), medical opinions on neoplasms developing in possible occupational scars were re-evaluated using criteria of the German social accident insurance and the Bamberg medical bulletin, part II (Bamberger Merkblatt, BM II) to see how well they qualified for recognition as an occupational or accident-related disorder. RESULTS: Three cases were identified where a neoplasm was suspected of having developed in an occupationally-related scar. One of the insured events entitled for compensation. Following the guidelines of the BM II, this case was approved as an occupational disease secondary to injuries with resultant reduction in earning capacity, whereas the others did not meet the requirements. CONCLUSIONS: Two problems in evaluating malignant tumors in occupational scars are the long latency period and the documentation of a scar. The tumor excision specimen should be histologically re-examined to document the presence of an associated scar.

Assessment of nasal fibroscopy to explore olfactory cleft.

OBJECTIVE: To assess whether flexible nasoendoscopy can be used to visualize all parts of the olfactory cleft (OC) without morbidity. STUDY DESIGN: Single-center, prospective, observational study. SETTING: French tertiary referral center. SUBJECTS AND METHODS: 100 consecutive patients were divided in 2 groups of 50. Group 1 underwent nasal fibroscopy without vasoconstriction or local anesthesia with an endosheath- protected endoscope. Group 2 was examined by a fiberscope without an endosheath after application of naphazoline Xylocaine. Each OC was divided in 16 items recorded as visualized or not. Four scores were compared between both groups: out of 16 (1 side), out of 32 (both sides), out of 12 concerning only the narrowest and highest bilateral spaces, and out of 4 to divide these specific areas in anterior, middle, and posterior parts. Length of procedure, pain, epistaxis, blood mark on the endosheath, sneezing, rhinorrhea, and causes of failure were recorded. RESULTS: There was no significant difference between both groups concerning score out of 16 or 32. The visibility of the narrower and higher spaces was better in group 2: scores out of 12 were significantly different between the groups (P = .025), as were scores out of 4 for the anterior and middle parts of the OC (P = .02 and .01 respectively). Morbidity was low without differences between the groups. Deviated nasal septum was the only cause of failure and increased the patients' pain during the examination (P = .045). CONCLUSION: Nasal fibroscopy could be used to explore the different portions of the OC efficiently and with low morbidity.

Assessment of nasal and paranasal sinus masses by diffusion-weighted MR imaging.

PURPOSE: To assess nasal and paranasal sinus masses by diffusion-weighted echoplanar magnetic resonance imaging (MRI). PATIENTS AND METHODS: This prospective study included 55 consecutive patients (34 males, 21 females; aged 14-64 years, mean 39 years) with nasal and paranasal sinus masses. All underwent diffusion-weighted MRI using single-shot echoplanar imaging (EPI) with a b factor of 0.500 and 1000 s/mm2. Apparent diffusion coefficient (ADC) maps were constructed, allowing ADC values of the mass to be calculated and correlated with histopathological findings. RESULTS: The mean ADC value of nasal and paranasal sinus malignant lesions (1.10+/-0.25x10(-3) mm2/s) was significantly different (P=0.001) from that of benign lesions (1.78+/-0.41x10(-3) mm2/s). Also, there was a significant ADC difference between carcinoma and sarcoma (P=0.01) as well as between well differentiated and poorly differentiated malignancies (P=0.005). Using an ADC value of 1.53x10(-3) mm2/s as the threshold value for differentiating malignant from benign lesions, the best result obtained had an accuracy of 93%, sensitivity of 94%, specificity of 92%, a positive predictive value of 92% and negative predictive value of 94%. However, the use of 0.97x10(-3) mm2/s and 1.16x10(-3) mm2/s as threshold values to differentiate carcinomas from sarcomas and poorly differentiated malignancy, respectively, gave the best results. CONCLUSION: The ADC value is a non-invasive imaging parameter that can be used to assess nasal and paranasal sinus masses, as it can help in the differentiation of malignant tumors from benign lesions, and in the characterization and grading of malignancies.

[Expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust]. / Aktualisierung der Hinweise zur Begutachtung holzstaubassoziierter sinunasaler Adenokarzinome (BK 4203)1.

BACKGROUND: Adenocarcinomas of the nasal cavity and the paranasal sinuses after occupational exposure to sawdust from oak and beech have been listed as occupational diseases in Germany since 1988. Given that modes of treatment have changed, we analyzed the guidelines based on the recommendations of Hartung et al. for developing an expert assessment on reduced earning capacity. MATERIALS AND METHODS: A retrospective analysis of 43 cases which had been evaluated between March 1994 and February 2007 for an occupational disease #4203, in the Ear-Nose-Throat clinic of the Münster University Hospital, Germany. RESULTS: Following the guidelines of Hartung et al., it was impossible to formally classify 21 of 43 cases (48.8 %) in an unambiguous manner. This was primarily due to the assessment of the results of radiotherapy, either adjuvant or therapeutic, as well as the grading of postoperative dysfunction in the area of the sinuses operated on (Rhinitis, Ozaena). Suggestions for a revision of the classification system include a modified assessment of radiotherapy as well as evidence for grading post-therapeutic inflammations of the sinus operated on based on the need for further care. These changes enable all cases in question to be classified unambiguously. CONCLUSIONS: The use of the revised guidelines is recommended for expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust.

Radiographic assessment of inverted papilloma.

CONCLUSION: Both CT and MRI defined the extent of histologically proven recurrent disease, although it was impossible to radiographically distinguish recurrent disease from postoperative scar tissue or mucoperiosteal thickening. OBJECTIVE: A retrospective analysis of radiographic findings of patients with known inverted papilloma (IP) was performed to identify those characteristics that should prompt preoperative biopsy in patients with polypoid nasal masses. MATERIALS AND METHODS: The radiologic studies from a group of 77 patients with biopsy-proven IP of the nasal cavity or paranasal sinuses were reviewed. Fifty-three computed tomography (CT) scans, 17 cases of plain sinus radiography and 7 cases of magnetic resonance imaging (MRI) were analyzed. RESULTS: Although no preoperative MRI examinations were available for comparison, CT was the most helpful study for evaluation of primary, nonrecurrent inverted papilloma. CT demonstrated disease-related abnormalities in 90% of studies. The finding of frequent unilateral bony remodeling was demonstrated in 43% of scans. Plain sinus X-rays were abnormal in 70% of cases of primary tumor, with all positive studies showing nonspecific unilateral opacification of the maxillary antrum.

Extramedullary plasmacytoma of the nasal cavity: treatment perspective in a developing nation.

Extramedullary plasmacytomas are uncommon tumors, with a worldwide annual incidence of 3 per 100,000 population. They account for 1% of all tumors of the head and neck and 4% of all nonepithelial tumors of the nasal tract. A variety of treatment options has been suggested. These treatments vary according to the site of presentation, the presence of locoregional spread, and the histologic picture. Radiotherapy has been widely used as a treatment modality, but little has been written about surgery as a single management modality. However, such an option assumes importance in a developing nation, where patient follow-up is erratic and treatment costs must be kept low. We discuss the feasibility of surgery in such a circumstance, and we describe our surgical treatment of a case of extramedullary plasmacytoma in an elderly woman who presented to our hospital in India.

Imaging and surgical approach of nasal dermoids.

OBJECTIVE: Determine the most accurate and cost effective radiographic evaluation for nasal dermoids. Determine the best surgical approach for excision of nasal dermoids. DESIGN: Retrospective chart review. SETTING: Division of Pediatric Otolaryngology, Children's Hospital and Health Center, San Diego, California. PARTICIPANTS: All patients with nasal dermoids evaluated and treated from 1990 to 2000. INTERVENTION: Preoperative radiographic evaluation and surgical excision. OUTCOME MEASURES: Accuracy of CT and MRI correlated with surgical findings and results. RESULTS: Ten patients were identified with the diagnosis of nasal dermoid. The age at diagnosis ranged from 0 to 24 months, with a mean of 3 months. Six children presented with masses located at the glabella, three patients presented with masses located at the nasal dorsum and one presented with a mass at the nasal tip. Six children underwent a computed tomogram with contrast of the head. Seven children underwent a MRI study of the head. Three children underwent an initial CT followed by MRI. Twenty percent of children were found to have intracranial extension. CT scan accurately diagnosed intracranial extension in one case, was indeterminate in a second case and falsely positive in a third case. MRI correctly diagnosed intracranial extension in two cases and had no false positive or false negative results. No children were found to have associated intracranial anomalies. In the early years of the review, a simple excision was made over the mass with blunt and sharp dissection for removal. (An external rhinoplasty incision is now used with better exposure and improved cosmetic results.) In cases with intracranial communication, a combined approach of external rhinoplasty and craniotomy was used. CONCLUSIONS: MRI alone is the most cost effective and accurate means of evaluating nasal dermoids and is essential for preoperative planning. The surgical approach of choice is external rhinoplasty for both cosmetic reasons and exposure of nasal dermoids with and without intracranial extension.

[Tumors of the nose, paranasal sinuses and facial bones: the role of computerized tomography and MRI in the assessment of the damage]. / Tumori del naso, dei seni paranasali e delle ossa facciali: apporto della tomografia computerizzata e della risonanza magnetica nell'accertamento della estensione della malattia.

The authors examine the use of CT and MR comparatively in tumours of nose, paranasal sinuses and facial bones. Both CT and MR are much more useful to assess the real extent of the pathology than to give specific diagnose. The resolution of the images and the possibility of examining them on many different planes give evident advantage to MR as regards the evaluation of tumors in this region. Nevertheless, CT with bone algoritme gives better details about bone structure.

[Magnetic resonance and computed tomography compared in the staging of rhinosinusal neoplasms. A cost-effectiveness evaluation]. / Risonanza Magnetica e Tomografia Computerizzata a confronto nella stadiazione delle neoplasie rino-sinusali. Valutazione costo-efficienza.

This study was aimed at comparing CT and MRI in the preoperative staging of sinonasal malignancies and at developing the most cost-effective diagnostic strategy to determinate resectability and choice of surgery and to assess surgical demolition extent. Forty-nine patients with sinonasal tumors were examined during a 10 years' period, with CT (20 patients), MRI (13 patients) and combined CT and MRI (16 patients); 42/49 patients underwent surgical resection (16 patients with craniofacial resection and 6 with orbital exenteration). Cost-effectiveness of the two techniques was assessed comparing five protocols using CT and MRI either alone or combined. In 40/98 orbits the tumor was in contact with a bone wall. MRI was more accurate than CT in assessing orbital invasion (100% sensitivity, 94% specificity, 86% positive predictive value and 100% negative predictive value, vs. 50%, 93%, 75% and 82%, respectively, for CT). MRI showed the tumor in contact with the skull base in 24/49 patients and CT in 23/49 patients, with no statistically significant difference between the two techniques. Dural infiltration, however, was better demonstrated with MRI in 3 patients with minimal bone erosion of the nasal vault. In 5 patients CT and MRI showed pterygopalatine fossa invasion (4 true positives and 1 false positive for both techniques). Since the final decision about orbital exenteration needs accurate surgical mapping, CT appears to yield all the pieces of information necessary for surgical planning. The most cost-effective protocol seems to be a CT examination for all patients. MRI is needed only for better prognostic assessment in the patients with minimal bone erosion of the floor of anterior cranial fossa. In fact, dural invasion, which is a markedly negative factor for survival, may be missed by CT.

CT and MR assessment of tumors of the nose and paranasal sinuses, the nasopharynx and the parapharyngeal space using ROC methodology.

Neoplastic disease of the nose and paranasal sinuses, the nasopharynx and the parapharyngeal space requires thorough assessment of location and extension in order to plan appropriate treatment. This study evaluates computer tomography and magnetic resonance imaging in the workup of malignant and non-malignant tumors of the nose and paranasal sinuses, the nasopharynx and the parapharyngeal space in 76 patients. An attempt is made to characterize histopathology on magnetic resonance images by analyzing the signal intensities on T1- and T2-weighted images relative to muscle and brain tissue. The test performance of computer tomography and magnetic resonance imaging in the assessment of tumor extension are compared with receiver operating characteristic methodology. Although no definitive conclusions can be made as to the histopathology on the basis of the signal intensities on magnetic resonance imaging, some tumors show characteristic images. Receiver operating characteristic analysis of the performance of computer tomography and magnetic resonance imaging in the assessment of extension of neoplastic disease of the nose and paranasal sinuses, the nasopharynx and the parapharyngeal space, demonstrates no statistically significant difference in overall test performance. However, in evaluating regions involving predominantly soft tissue structures and comparatively large bony structures magnetic resonance imaging is superior to computer tomography, whereas in evaluating regions involving thin bony structures, computer tomography performs better than magnetic resonance imaging.