The small foramina of the orbit and periorbital region: assessment with multi detector computed tomography.

BACKGROUND: Familiarity with the variants of the foramina of the orbit and periorbital region is important in planning anesthesiological blocks and during orbital and maxillofacial surgery to avoid damage to nerves and vessels. PURPOSE: To assess the visibility and the incidence of variants of the small foramina of the orbit by multidetector computed tomography (MDCT). MATERIAL AND METHODS: The MDCT scans of 400 orbits from 200 patients were evaluated retrospectively. Slice thickness of the reconstructed images were in the range of 0.5-1.0 mm. The visibility and the variants of the foramen supraorbitale, the foramen infraorbitale, the foramen zygomaticofaciale, the foramen ethmoidale anterius et posterius, and the foramen cranio-orbitale were assessed using three-dimensional reconstruction tools. RESULTS: The foramen infraorbitale (100%; n = 400), foramen supraorbitale (99.5%, n = 398), foramen zygomaticofaciale (76.5%; n = 307), and foramen zygomatico-orbitale (74.5%; n = 298) were most reliably detected by MDCT, while the foramen ethmoidale anterius (58.7%; n = 235) et posterius (56.7%; n = 225) were depicted less frequently. The foramen cranio-orbitale could not be identified in any case. Doubling was found for the foramen supraorbitale in 3.25% (n = 13), the foramen infraorbitale in 1.75% (n = 7), the foramen zygomaticofaciale in 16% (n = 64), and the foramen zygomatico-orbitale 14% (n = 56). Three foramina zygomatico-orbitale and foramina infraorbitale were found in 1.5% (n = 6) and in 0.5% (n = 2) of orbits, respectively. CONCLUSION: The foramina supraorbitale, infraorbitale, zygomatico-orbitale, and zygomaticiofaciale and their variants are well visible on MDCT. Knowledge of the exact number of these small foramina is relevant for preoperative evaluation.

Visibility of sutures of the orbit and periorbital region using multidetector computed tomography.

OBJECTIVE: Knowledge of cranial suture morphology is crucial in emergency medicine, forensic medicine, and maxillofacial reconstructive surgery. This study assessed the visibility of sutures of the orbit and periorbital region on multidetector computed tomography. MATERIALS AND METHODS: Multidetector computed tomography scans of 200 patients (127 males, 73 females; mean age 51.3 years; range, 6-92 years) were evaluated retrospectively. The slice thicknesses varied from 0.5 to 1 mm, and the tube current from 25 to 370 mAs, depending on the CT indication. The visibility of sutures was estimated according to a 4-point scale from "not visible" to "well visible". The chi-squared test was used to test the association of the visibility of sutures with the slice thickness, tube current, and age of patients. Statistical significance was assumed at p < 0.05. RESULTS: Overall, best visibility was found for the sutura frontozygomatica (98%), sutura frontonasalis (88.5%), and sutura sphenozygomatica (71.5%), followed by the sutura zygomaticomaxillaris (65.8%), sutura temporozygomatica (41.8%), sutura frontomaxillaris (44.5%), and sutura sphenofrontalis (31%). Poor visibility was found for the sutura frontolacrimalis (16.8%) and sutura frontoethmoidalis (1.3%). The sutura ethmoidomaxillaris, sutura lacrimomaxillaris, and sutura ethmoidolacrimalis were not visible. CONCLUSION: Although the sutures of the superior, lateral, and inferior orbit are well visible, those of the medial orbit are poorly visible on CT scans.

Cochlear implantation in a child with posttraumatic single-sided deafness.

Cochlear implantation has become a standard therapy for children with bilateral profound hearing loss, resulting in substantial and sustainable benefits for the development of expressive and receptive and expressive language skills and cognition. During the last few years, audiologic and otologic criteria for cochlear implantation have been expanded. Recently, patients with profound single-sided deafness with or without tinnitus have received cochlear implants despite normal to near-normal hearing on the contralateral side. This indication, however, has thus far been restricted to adult patients. Although it is known that unilateral hearing has an impact on social-emotional development in children, otologic surgeons have been reluctant to treat children with single-sided deafness with a cochlear implant. We report here on a case of successful cochlear implantation in an 8-year-old boy with acute single-sided deafness due to a lateral skull-base fracture, after an MRI showed signs of imminent fibrosis of the inner ear with possible prevention of cochlear implantation at a later stage. There was normal hearing in the contralateral ear. The child showed rapid development of speech discrimination in the implanted ear, improvements in sound localization and speech perception in noise, and a high degree of patient satisfaction. This experience may encourage using this therapeutic approach in children with chronic profound single-sided deafness.

Camptocormia phenotype of FSHD: a clinical and MRI study on six patients.

Recently it has been postulated that there is an atypical facioscapulohumeral muscular dystrophy (FSHD) phenotype with isolated axial myopathy. Involvement of paraspinal and limb muscles was evaluated in six patients with molecularly proven FSHD and a predominant bent spine phenotype. Consistent with the camptocormia phenotype, the most severely affected muscles in all six patients were the thoracic and lumbar spinal tract together with hamstrings. MRI disclosed severe axial muscle degeneration but mostly subclinical involvement of limb muscles. The involvement of hip extensor muscles in FSHD might considerably contribute to the clinical phenotype of camptocormia due to axial muscle involvement.

Development of fMRI tests for children with central auditory processing disorders.

The term 'central auditory processing disorder' (CAPD; in German-speaking countries: 'auditive Verarbeitungs- und Wahrnehmungsstörung', AVWS) embraces various complex disorders of central auditory function. The purpose of this preliminary study was to develop a functional magnetic resonance imaging (fMRI) test set in order to extend the diagnostic work-up to include imaging, and thus to improve both diagnostic performance and the monitoring of treatment outcome. fMRI was performed in 11 healthy children ranging in age from 7 to 10 years and in 11 healthy adults (age range: 23 to 31 years). Three tests, used for diagnosis of CAPD, served as the basis for fMRI paradigms: the Hannover phoneme discrimination test (HPDT); the auditory memory span test (MST) and the dichotic listening test (DLT). In the HPDT, activations in the dorsal part of the superior temporal gyrus (STG) were found on both sides, in the Broca area and in the left middle temporal gyrus, typical for phonemic tasks. The MST showed bilateral activations of the STG, typical for processing of pseudo-words. In addition, bilateral activation of the hippocampus was found. However, there was no clear activity in the left supramarginal gyrus, where the phonological store is thought to be located. The DLT showed activations of the bilateral STG and of the left inferior frontal gyrus. Predominantly, the paradigms showed typical activation patterns of the examined central auditory functions. These results can serve as a reference for future examinations in children with AVWS/CAPD.

Invasive aspergillosis of the paranasal sinuses and the skull base.

Invasive aspergillosis (IA) originating from the paranasal sinuses can cause an intracranial growth mainly along the skull base and larger vessels. This study reports our experience in the diagnosis and treatment of a series of patients with IA. A retrospective chart review of four patients with chronic invasive intracranial aspergillosis was performed. Clinical signs, physical examinations, radiographs, histological samples, and outcome were demonstrated. The patients demonstrated different symptoms like exophthalmus, ophthalmoplegia, loss of vision, and hypaesthesia of the ophthalmic and maxillary nerve. Computed tomography and MRI revealed extensive sino-orbital and skull base lesions. The patients were treated with aggressive endonasal debridement, intravenous antifungal agents and daily irrigations with antimycotic suspensions. Furthermore, we applied hyperbaric oxygenation. Two patients died from complications due to subarachnoidal hemorrhage and accompanied complications respectively. Despite the high mortality rate patients with an invasive aspergillosis can be effectively treated in some cases by an early and rigorous treatment schedule using all surgical and conservative therapeutic options.

Imaging and clinical findings in large endolymphatic duct and sac syndrome.

OBJECTIVE: Large endolymphatic duct and sac syndrome (LEDS) is known as the most common kind of inner ear malformations, which is radiologically detectable. Nevertheless, nowadays many questions are not fully cleared and LEDS is relatively unknown among general radiologists. The aim of this study was to evaluate the incidence of LEDS in the own patient population and to present our experiences regarding imaging findings, clinical presentation and follow up. MATERIALS AND METHODS: Based on a complete recording of all patients, sent from ENT department to radiology, we identified all radiological diagnosed cases of inner ear malformations including LEDS and all patients in whom an inner ear malformation was clinically suspected. The retrospective study included clinical records, HR-CT and MRI performed between 1994 and 2002. RESULTS: Among 169 patients (338 ear), 17 of patients (median age: 12 years) and 28 ears, respectively, had enlarged endolymphatic structures. In 10 patients - 6% - (15 ears), no other abnormalities were detected, called isolated LEDS, seven patients showed additional inner ear abnormalities. One patient showed a labyrinthine hemorrhage after sudden hearing loss. Audiometric data revealed sensorineural hearing loss in 22 ears, deafness in 5 ears and normal hearing in 1 case of 28 ears. In 10 (67%) of 15 ears with isolated LEDS, the hearing loss was downward-fluctuating progressive. Twelve patients (eight with isolated LEDS) had partly repeated sudden hearing losses. A trigger for worsening of hearing was found in five patients. A correlation between the severity of morphological changes on imaging and the degree of hearing disturbances could not be detected. Only four young patients underwent a radiological examination within the first or second year after onset of hearing loss. Three patients received a cochlear implant. CONCLUSIONS: LEDS might be the cause of progressive hearing loss and repeated acute hearing losses in children and young adults. Imaging plays an important role in making the diagnosis.

Impact of tumor control and presence of visible necrosis in head and neck cancer patients treated with radiotherapy or radiochemotherapy.

PURPOSE: Tumor volume after the lymph node involvement is one of the most important single prognostic factor in patients of head and neck cancers treated with radiotherapy. We have recently demonstrated that the hypoxic subvolume is more important than the total tumor volume. We therefore propose the hypothesis that the presence of visible necrosis might be an important factor for cure by radiotherapy in squamous cell cancers of the head and neck. METHODS: A total of 51 patients with locally advanced inoperable (T3-4 or N2-3) squamous cell cancers of the head and neck (mean age 57 years, range 41-75 years) were prospectively investigated with regard to a possible impact of tumor volume. All patients received CT examination of the head and neck according to a standardized protocol (spiral CT, contrast enhancement after automatic injection), and the total tumor volume was calculated as the sum of volumes of all visible macroscopic tumor sites. Poorly perfused and necrotic areas (no contrast enhancement) within macroscopic tumor sites were also calculated. Patients were then treated with accelerated-hyperfractionated radiotherapy in about 6 weeks. Seventeen patients were treated with only radiation. Patients without contraindications to cisplatin chemotherapy received cisplatin chemotherapy or a combination of cisplatin and paclitaxel (N=34). The allocation of patients to certain treatment regimens was based on individual decisions in each case and not randomized. RESULTS: In patients treated with radiation alone, 12/17 (71%) got recurrence whereas in patients treated with radiation plus cisplatin, only 14/34 (41%) recurred (P=0.05). The 2-year overall survival was for radiation alone versus radiation plus cisplatin 0% vs. 62% (P<0.0008). Tumors with smaller amount of necrosis (necrosis volume<4 cm3) had a good prognosis irrespective of type of treatment (radiation alone or radiation plus cisplatin). However, patients with tumors with a larger amount of necrosis (necrosis volume> or =4 cm3) had a significantly better outcome if they were treated with radiation plus cisplatin as compared to patients treated with radiation alone. In a multi-variate analysis using a Cox-regression model the type of treatment (radiotherapy plus versus without cisplatin) was the only independent prognostic factor for event-free survival (P<0.03) in the whole group. CONCLUSIONS: In this non-randomized retrospective investigation with limited sample size, radiation plus cisplatin was superior to radiation alone. This resulted mainly from a higher efficacy of the radiochemotherapy regimen in patients with large and especially necrotic tumors. The prognostic and predictive impact of visible necrosis should be further evaluated.

Vascular anomalies, sutures and small canals of the temporal bone on axial CT.

PURPOSE: Subtle bony structures, small canals and fine sutures cause sometimes problems in the analysis of CTs of the temporal bone. The aim of this study was: to analyze the visibility of subtle structures and to estimate the incidence of vascular anomalies. PATIENTS AND METHOD: We retrospectively analyzed axial scans of 223 high-resolution CTs of the temporal bone obtained as single slice or spiral CT with 1mm slice thickness. All CTs had clinical indications. Two experienced radiologists studied CTs regarding the visibility of the fine sutures, fissures and small canals and the occurrence of vascular anomalies. RESULTS: The following structures were seen commonly: sphenosquamosal suture (76%), arcuate artery canal (93%), vestibular aqueduct (89%), mastoid emissary vein (82%), singular canal (56%). Not so commonly were observed: tympanosquamosal suture (31%), mastoid canaliculus (28%), lateral sigmoid sinus (28%), petrotympanic fissure (24%), tympanomastoid suture (10%). Seldom we identified: the inferior tympanic canaliculus (6%), high jugular bulb (6%), anterior sigmoid sinus (5%), dehiscent internal carotid artery canal (2%), persistent petrosquamosal sinus (1%), dehiscent jugular bulb (1%). Persistent stapedial artery, aberrant internal carotid artery, dehiscent jugular bulb, high jugular bulb with diverticulum, anterior and dehiscent sigmoid sinus were detected in below 1% of the analyzed temporal bones. The frequency of asymmetry of the jugular foramen, which varied between 3% and 42%, depended on different criterions of size. CONCLUSION: A profound knowledge of normal anatomy and anomalies of the temporal bone avoids misinterpretation as pathological lesions and iatrogenic bleedings.