The radiological unknown primary of the head and neck: Recommendations for imaging strategies based on a systematic review.

OBJECTIVES: To develop recommendations for the radiological investigation of clinically occult primary cancer in the head and neck. DESIGN AND SETTING: In accordance with PRISMA guidelines, a search was performed on Medline, Embase and Cochrane library databases to investigate the efficacy of ultrasound guided Fine Needle Aspiration (US FNAC), contrast enhanced CT (CECT), magnetic resonance imaging (MRI) and 18F-fluorodeoxyglucose PET-CT (18F-FDG PET-CT) in the investigation of head and neck squamous cell carcinoma from an unknown primary (HNSCCUP) presenting with a metastatic cervical lymph node (s). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool and SIGN 50 guidelines were used to assess the risk of bias and quality of the included studies. PARTICIPANTS: Adult patients presenting with metastatic cervical lymph nodes from a HNSCCUP. MAIN OUTCOME MEASURES: Utility of different imaging modalities (PET-CT, MRI, CE CT and US FNAC in the management of HNSCCUP). RESULTS: Twenty-eight studies met inclusion criteria; these were meta-analyses, systematic reviews, prospective and retrospective studies. CONCLUSIONS: The optimal imaging strategy involves utilisation of various imaging modalities. US FNAC can provide the initial diagnosis and HPV status of the occult primary tumour. CECT and MRI detect up to 44% of occult tumours and guide management. FDG PET-CT is the most sensitive imaging modality for the detection of CUP and should be performed prior to panendoscopy.

Consensus statement on the management of incidentally discovered FDG avid thyroid nodules in patients being investigated for other cancers.

With the widespread use of 18F-fluorodeoxyglucose positron emission tomography (FDG PET/CT) in the investigation and staging of cancers, incidental discovery of FDG-avid thyroid nodules is becoming increasingly common, with a reported incidence in the range 1%-4% of FDG PET/CT scans. The risk of malignancy in an incidentally discovered FDG avid thyroid nodule is not clear due to selection bias in reported retrospective series but is likely to be less than 15%. Even in cases where the nodule is found to be malignant, the majority will be differentiated thyroid cancers with an excellent prognosis even without treatment. If, due to index cancer diagnosis, age and co-morbidities, it is unlikely that the patient will survive 5 years, further investigation of an incidental FDG avid thyroid nodule is unlikely to be warranted. We provide a consensus statement on the circumstances in which further investigation of FDG avid thyroid nodules with ultrasound and fine needle aspiration might be appropriate.

Frontoethmoidal mucocele following pediatric craniofacial surgery.

BACKGROUND: Mucoceles occur as a result of accumulation and retention of mucous secretions in a paranasal sinus and are uncommon in the pediatric age group. Persistent or intermittent closure of its ostium through a variety of causes, including previous surgery, is implicated in etiology. The authors report 2 cases of frontoethmoidal mucocele that followed box osteotomies for the treatment of orbital dystopia, with medical literature review and discussion of possible causal factors and events. METHODS: Case histories and radiological imaging are presented on 2 patients presenting with frontoethmoidal mucoceles following craniofacial surgery. Both had transcranial craniofacial techniques where all orbital walls and globe are moved en bloc as a "box." RESULTS: Patient 1, a 12-year-old male patient with Crouzon syndrome, developed mucoceles within 18 months of monobloc distraction surgery and box osteotomies. This was successfully marsupialized with a combined external and endoscopic surgical approach. The second patient, a 15-year-old boy with previously corrected right-sided facial cleft, developed mucocele 9 years following box osteotomies; this was successfully managed by endoscopic drainage. Of 3 other patients having similar box osteotomies in our unit, no other mucoceles were noted as complications. CONCLUSIONS: Mucoceles are a rare complication of craniofacial surgery, and literature review confirms a paucity of reports. Only 1 case has previously been alluded to of mucocele complicating box osteotomy for orbital dystopia. Our 2 cases illustrate and highlight a successful management approach in a multidisciplinary craniofacial unit.

Life-threatening laryngeal injury in Elite Rugby Union: Prevention and management laryngeal trauma in rugby.

Laryngeal trauma is a life-threatening injury in contact sports. Due to its potentially devastating consequences, the prevention, diagnosis, and management of neck trauma both pitch side and at the hospital are essential for athletes.

Assessing Changes in Airflow and Energy Loss in a Progressive Tracheal Compression Before and After Surgical Correction.

The energy needed to drive airflow through the trachea normally constitutes a minor component of the work of breathing. However, with progressive tracheal compression, patient subjective symptoms can include severe breathing difficulties. Many patients suffer multiple respiratory co-morbidities and so it is important to assess compression effects when evaluating the need for surgery. This work describes the use of computational prediction to determine airflow resistance in compressed tracheal geometries reconstructed from a series of CT scans. Using energy flux analysis, the regions that contribute the most to airway resistance during inhalation are identified. The principal such region is where flow emerging from the zone of maximum constriction undergoes breakup and turbulent mixing. Secondary regions are also found below the tongue base and around the glottis, with overall airway resistance scaling nearly quadratically with flow rate. Since the anatomical extent of the imaged airway varied between scans-as commonly occurs with clinical data and when assessing reported differences between research studies-the effect of sub-glottic inflow truncation is considered. Analysis shows truncation alters the location of jet breakup and weakly influences the pattern of pressure recovery. Tests also show that placing a simple artificial glottis in the inflow to a truncated model can replicate patterns of energy loss in more extensive models, suggesting a means to assess sensitivity to domain truncation in tracheal airflow simulations.

Sinonasal inflammatory disease.

Inflammatory sinus disease is ubiquitous. Patients with recurrent or unilateral disease and those who do not respond to treatment require imaging. Computed tomographic scanning is the mainstay of investigation; magnetic resonance imaging is used as a problem-solving tool. The imaging characteristics of sinonasal inflammatory conditions are varied. The role of imaging is to identify patterns of disease, provide a roadmap for the endoscopist, identify anatomical variants that impact on drainage, and exclude aggressive pathology.

Differential diagnosis in sinonasal disease.

This article summarizes the imaging features that aid in distinguishing inflammatory from neoplastic disease and benign from malignant conditions. Diagnostic pitfalls are highlighted.

Imaging of the paranasal sinuses and nasal cavity: normal anatomy and clinically relevant anatomical variants.

Anatomy is the foundation on which the understanding of pathological processes in radiology is based. This article describes the anatomy of the sinonasal region and the clinically relevant anatomical variants, highlighting the need for multiplanar reconstructions as a routine part of the examination when reviewing this region.

Imaging of sinonasal tumors.

This article reviews the role of imaging in the diagnosis of sinonasal tumors, illustrating the diversity of tumors affecting this region. The symptoms of sinonasal tumors are nonspecific; imaging plays a critical role in distinguishing benign and malignant disease and may occasionally illustrate characteristic radiological features of specific tumors. The patterns of local and distant spread of sinonasal malignancy are demonstrated and the respective roles of computed tomography and magnetic resonance imaging are explained. Critical imaging review areas are discussed together with accurate staging, including orbital and intracranial involvement, which determine the appropriate surgical approach. The sites and patterns of tumor recurrence and the imaging features of recurrent tumor are also discussed.

Anatomy of the salivary glands.

This article describes the anatomy of the salivary glands highlighting those anatomical features that are relevant to the radiologist. Magnetic resonance images with super-imposed line illustrations have been used to aid the understanding of the anatomy of this region.

Inflammatory conditions of the salivary glands.

Inflammatory conditions are the most common pathology to affect the salivary glands, of which sialolithiasis is the most frequent etiology. This article reviews the role of all imaging modalities in the management of inflammatory salivary disease. The technique for performing salivary gland ultrasound is described with some common pitfalls. The typical features of a comprehensive range of pathology including obstructive and infective sialadenitis, Sjogren's syndrome, sarcoidosis, HIV sialopathy, and their complications are described.

Tumors of the salivary glands.

This article reviews the role of imaging in the management of tumors of the salivary glands, discussing tumor localization, extent, and, where possible, characterization. The relative benefits of the different modalities and the typical features of benign and malignant lesions are discussed for each modality. Characteristic appearances of specific tumors are highlighted.