Rethinking the 'one-stop' neck lump clinic: a novel pathway beyond coronavirus disease 2019.

OBJECTIVES: UK guidelines advocate 'one-stop' neck lump assessment for cancer referrals. This paper reports the pilot of a novel pre-clinic ultrasound pathway, presents outcomes, and discusses strengths and limitations in the context of the coronavirus disease 2019 pandemic. METHODS: Two-week-wait cancer referral patients with a neck lump were allocated a pre-clinic ultrasound scan followed by a clinic appointment. Demographic, patient journey and outcome data were collected and analysed. RESULTS: Ninety-nine patients underwent ultrasound assessment with or without biopsy on average 8 days following referral. Patients were followed up on average 14.1 days (range, 2-26 days) after initial referral. At the first clinic appointment, 45 patients were discharged, 10 were scheduled for surgery, 12 were diagnosed with cancer, 6 were referred to another specialty and cancer was excluded in 19 patients. Retrospectively, four ultrasounds were performed unnecessarily. CONCLUSION: Pre-clinic ultrasound scanning is an alternative to the one-stop neck lump pathway. This study demonstrates fewer clinic visits, faster diagnosis and a low proportion of unnecessary scans, whilst minimising face-to-face consultations and aerosol-generating procedures.

The use of computed tomography as a first-line imaging modality in patients with primary hyperparathyroidism.

BACKGROUND: The success of minimally invasive parathyroidectomy (MIP) relies on accurate localization of the abnormal parathyroid glands. Concordant findings on ultrasound (US) and 99mTc-scintigraphy (sestamibi) are currently considered the 'gold standard'. Computed tomography (CT) has also recently been used in preoperative planning. We sought to assess the accuracy of CT for localization of abnormal parathyroid glands in such patients. METHODS: An audit of 75 patients with primary hyperparathyroidism (PHPT) who underwent neck US and CT between 2017 and 2019 at our center as their first-line imaging. RESULTS: All 75 patients underwent US and CT and 54 (72.0%) also had sestamibi. CT alone identified a potential target in all patients, of which the location was correct in 63 (84.0%). The overall combined sensitivity of US and CT was 88% (95% CI 78-94) and was higher than the combined sensitivity of US and sestamibi (65% [95% CI 53-76]; p < 0.001). Twenty-one patients (28.0%) had an ectopic gland, and the sensitivity of US and CT was 86% (95% CI 64-96) versus US and sestamibi (57% [95% CI 34-77]; p = 0.016). For adenomas < 1.0 g (n = 36; 48%), the accuracy of CT was 81% (95% CI 64-91) compared with 62% (95% CI 44-77) for US and sestamibi (p = 0.04). The correct preoperative diagnosis of multiglandular disease (n = 9; 12%) seemed to be the most difficult, with similar accuracy for US and sestamibi (40% [95% CI 14-73]) and US and CT (50% [95% CI 20-80]) (p > 0.99). CONCLUSION: The combination of US and CT was able to correctly identify the location of the abnormal parathyroid in 88% of patients and, in comparison with US and sestamibi, had better diagnostic accuracy, especially for smaller and ectopic adenomas. This finding suggests that US and CT could be considered as a first-line imaging modality in patients with PHPT considered for MIP.

European position paper on diagnostic tools in rhinology.

The accurate diagnosis of rhinologic disease depends on the clinical history, examination findings and, in many cases, further investigations. There are a wide variety of diagnostic tests available, the choice of which depends upon the condition being assessed. This position paper is intended to provide an up-to-date comprehensive description of the diagnostic tools available to rhinologists, allergists, general otolaryngologists and other physicians with an interest in sinonasal disease. The literature has been reviewed and evidence-based recommendations are included. The relevant history and examination techniques are described, including endoscopic assessment of the nose. General and disease-specific quality of life instruments are an important tool in assessing the impact of rhinologic disease and the response to treatment. Relevant blood tests are discussed, as well as the various methods of allergy testing. Techniques for collecting microbiological and tissue samples are described, as well as the use of more specialised tests such as nasal nitric oxide and those evaluating ciliary structure and function. Imaging techniques and their indications are included. Chemosensory (smell and taste) testing is explained, and the available techniques for objective measurement of nasal airflow and patency are reviewed. Prompt and accurate diagnosis allows appropriate management to be initiated; an understanding of the currently available diagnostic tools is a vital part of the assessment of rhinologic disease.

MRI in otology: applications in cholesteatoma and Ménière's disease.

Imaging of middle-ear cholesteatoma with diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI), and inner-ear endolymphatic hydrops (in Ménière's disease) with post-gadolinium high-resolution MRI, are reviewed. DWI MRI provides for a more specific diagnosis of tympano-mastoid cholesteatoma. There is an established and increasing role of DWI MRI in detecting both primary and postoperative cholesteatoma, localising disease, and planning surgery. The contemporary diagnostic accuracy of DWI is reviewed, pitfalls in interpretation are described, and potential future developments are highlighted. High-resolution post-gadolinium MRI of the inner ear is being explored for diagnosing endolymphatic hydrops. There is now increasing data to validate the application of three-dimensional (3D)-fluid attenuated inversion recovery (FLAIR) sequences, performed at 4 hours post-intravenous gadolinium, in the setting of potential Ménière's disease. The clinical context and the evolution of these MRI techniques are discussed. Current MRI-based grading schemes for endolymphatic hydrops are described, together with the available data on their clinical implications.

Imaging of palatal lumps.

Palatal tumours are relatively rare and of variable aetiology, rendering radiological evaluation a daunting process for many. A systematic approach to the imaging of a palatal lump is therefore essential. The hard and soft palates are oral cavity and oropharyngeal structures, respectively. They have different tissue compositions, and therefore, lesions occur with different frequencies at each site. The hard palate has the highest concentration of minor salivary glands in the upper aerodigestive tract and most tumours here are salivary in origin, whereas most tumours at the soft palate are epithelial in origin, i.e., squamous cell carcinomas, in line with other oropharyngeal subsites. The most common malignant tumours of the palate, after squamous cell carcinoma, are minor salivary gland tumours, predominantly adenoid cystic and mucoepidermoid carcinomas. These tumours have a propensity to spread perineurally; understanding the anatomy and imaging features of perineural spread is vital, as it can have significant implications for patient management and tumour resectability. When confronted with a palatal lump, it is important to consider the following: its location on the hard or soft palate; whether it is mucosal or submucosal; the frequently occurring lesions at that site; the most suitable imaging techniques (ultrasound, computed tomography, magnetic resonance imaging); whether there are typical imaging features for any of the common lesions; and whether there are aggressive features, such as bone erosion or perineural spread. This approach allows the radiologist to narrow the differential diagnosis and assist the clinicians with planning treatment.

Salivary gland FNA cytology: role as a triage tool and an approach to pitfalls in cytomorphology.

OBJECTIVE: To highlight the importance of salivary gland fine needle aspiration (FNA) cytology as a triage tool for surgery and to determine its sensitivity and specificity. To discuss the diagnostic pitfalls and potential role of ancillary techniques in diagnosis and prognosis. METHODS: The study included a total of 920 cases of salivary gland FNAs received in the cytopathology department of University College London Hospital during December 2004 to December 2012. The cases with known histological outcomes were analysed to determine the sensitivity and specificity. RESULTS: Surgery was carried out on 180 (19.6%) of 920 patients. Excluding nine with inadequate/non-diagnostic cytology, the sensitivity of FNA cytology for a malignant outcome was 89% (33/37) and the specificity was 97% (130/134). Diagnostic pitfalls are discussed with respect to eight FNAs with discrepant histology. Histological outcome was not available for 740 cases (80.4%): excluding 88 non-diagnostic FNAs, 324 (49.7%) had non-neoplastic diagnoses (not indicating surgery) and 328 (50.3%) had neoplastic diagnoses, which included recurrences/metastases of known tumours. Patients with other neoplasms on FNA were lost to follow-up and may have had surgery elsewhere. Cases with clinical concerns were discussed at weekly multidisciplinary meetings. CONCLUSION: Salivary gland FNA is crucial in the distinction of non-neoplastic from neoplastic lesions, emphasizing the fact that FNA is an excellent triage tool for surgery. Salivary gland FNA has a high sensitivity and specificity. However, it is important to interpret the cytological diagnoses in the light of clinical findings and imaging. Diagnostic pitfalls are seen in a minority of cases and could potentially be overcome with the help of recently described diagnostic and prognostic markers.

Visual loss in patients with sphenoethmoidal cells.

BACKGROUND: A sphenoethmoidal cell is a posterior ethmoid cell that pneumatises superiorly and/or laterally to the sphenoid sinus. Disease within such a cell may cause visual symptoms because of the close relationship of the optic nerve. CASE REPORTS: This paper reports four cases of chronic rhinosinusitis involving a sphenoethmoidal cell, two with visual loss. The management of such cases is discussed and the current literature is reviewed. CONCLUSION: Pathology within a sphenoethmoidal cell must be considered in cases of optic neuropathy. The presence of these cells may be relevant even in cases of seemingly uncomplicated rhinosinusitis as they are associated with a higher rate of optic nerve protrusion and dehiscence.

The role of the cytopathologist's interpretation in achieving diagnostic adequacy of head and neck fine needle aspirates.

OBJECTIVE: We aimed to assess the potential role of interpretation by cytopathologists on the level of diagnostic adequacy of head and neck fine needle aspirations (FNAs). METHODS: An audit ('first audit') was performed between 1 May 2007 and 30 April 2008 using data from three different hospitals (A, B and C). The specimens were interpreted by two cytopathologists with specific experience in head and neck pathology in hospitals A and B, and by any of the eight cytopathologists (only two of whom were experienced in head and neck cytopathology) in hospital C. Following the analysis of the initial findings, there was a change in practice in hospital C, after which specimens were also read only by two experienced cytopathologists. A new audit ('second audit') was then performed between 20 January 2011 and 20 December 2012 in the same three hospitals. RESULTS: During the first audit, the diagnostic adequacy of FNAs from hospital C was 84.2% compared with 96.6% in hospital A and 97.7% in hospital B (P = 0.000). No significant difference in the diagnostic adequacy rate of the FNAs performed in hospitals A and B was found when comparing the first and second audits. The FNA diagnostic adequacy for hospital C increased significantly in the second relative to the first audit (95.5% versus 84.2%, P = 0.000). CONCLUSIONS: Our study confirms that expert cytology interpretation is important in achieving optimal diagnostic adequacy of head and neck FNAs.

Computed tomography features of luetic osteitis (otosyphilis) of the temporal bone.

OBJECTIVE: We report a missed case of otosyphilis presenting as otic capsule lucencies on temporal bone computed tomography. METHODS: A 58-year-old woman presented with a 15-year history of bilateral, mixed hearing loss together with otic capsule lucencies, subsequently confirmed as otosyphilis. A literature review of otosyphilis was undertaken based on a PubMed search of studies published between 1988 and 2012, using the key words 'otosyphilis', 'otodystrophy', 'otic capsule lucencies' and 'luetic osteitis'. RESULTS AND CONCLUSION: Although rare, otosyphilis is important to recognise as it is one of the few treatable causes of deafness when diagnosed early. The differentiating computed tomography features of luetic osteitis (otosyphilis) of the temporal bone have only rarely been described. We emphasise how these imaging features can be used to distinguish the rare but treatable condition of luetic osteitis from other, more common conditions with similar imaging findings.

Sinonasal bony changes in nasal polyposis: prevalence and relationship to disease severity.

BACKGROUND: Nasal polyposis is characterised by opacification of the nasal cavities, paranasal sinuses and ostiomeatal complexes on computed tomography scanning. Sinonasal bony changes have been reported as disease sequelae. OBJECTIVES: To assess the prevalence of sinonasal bone expansion, erosion and thickening in patients with nasal polyposis, and to correlate disease severity with the prevalence of bony changes. METHODS: A retrospective radiological study was conducted comprising pre-operative computed tomography scans of 104 patients with nasal polyposis and scans of 44 age- and gender-matched individuals (control group) without sinonasal disease. Lund­Mackay scores and bony changes were quantified. RESULTS: Ninety-three per cent of the study group scans showed sinonasal bony change, with no changes in the control group. Radiological severity of nasal polyposis correlated positively with the prevalence of bony changes (rs = 0.31; p < 0.01). CONCLUSION: Sinonasal bony changes were common in the study group. This highlights the importance of pre- and intra-operative imaging, which can help to prevent intra-operative complications. As bony changes may mimic invasive disease, the importance of histological assessment of polyps is emphasised.

MR spectroscopy for assessment of memantine treatment in mild to moderate Alzheimer dementia.

OBJECTIVES: Magnetic Resonance Spectroscopy (MRS) may provide a precise and reliable assessment of the extent and severity of neural tissue loss caused by various diseases. In particular, the N-Acetyl Aspartate (NAA) and Creatine (Cr) ratio has been found to be an indicator of the degree of neuronal loss in Alzheimer's disease (AD). Memantine is thought to benefit the AD brain by stabilizing the NMDA receptors on neurons in turn reducing excitotoxicity. Despite its effectiveness in treating moderate to severe AD, memantine has not had similar success in the treatment of mildly demented AD patients. The objective of this study was to test whether memantine would slow or prevent the loss of neurons in mild to moderate AD patients. METHODS: A double-blind placebo-controlled study was designed to measure the effect of a year-long course of memantine in patients with a probable AD diagnosis with mild to moderate dementia. The primary outcome measure was stipulated to be change in MRS NAA/Cr ratio in inferior parietal cortex in memantine relative to the placebo treatment condition. The secondary outcome measures were changes in cognitive and function scale scores. RESULTS: This pilot study failed to demonstrate a benefit of memantine on the primary outcome measure, the inferior parietal NAA/Cr ratio, or the secondary outcome measures. CONCLUSIONS: More studies are needed to determine the effect of memantine on regions of the brain significantly affected by AD pathology.

Antiferromagnetically spin polarized oxygen observed in magnetoelectric TbMn2O5.

We report the direct measurement of antiferromagnetic spin polarization at the oxygen sites in the multiferroic TbMn2O5, through resonant soft x-ray magnetic scattering. This supports recent theoretical models suggesting that the oxygen spin polarization is key to the magnetoelectric coupling mechanism. The spin polarization is observed through a resonantly enhanced diffraction signal at the oxygen K edge at the commensurate antiferromagnetic wave vector. Using the fdmnes code we have accurately reproduced the experimental data. We have established that the resonance arises through the spin polarization on the oxygen sites hybridized with the square based pyramid Mn3+ ions. Furthermore we have discovered that the position of the Mn3+ ion directly influences the oxygen spin polarization.

RASOR: an advanced instrument for soft x-ray reflectivity and diffraction.

We report the design and construction of a novel soft x-ray diffractometer installed at Diamond Light Source. The beamline endstation RASOR is constructed for general users and designed primarily for the study of single crystal diffraction and thin film reflectivity. The instrument is comprised of a limited three circle (theta, 2theta, and chi) diffractometer with an additional removable rotation (phi) stage. It is equipped with a liquid helium cryostat, and post-scatter polarization analysis. Motorized motions are provided for the precise positioning of the sample onto the diffractometer center of rotation, and for positioning the center of rotation onto the x-ray beam. The functions of the instrument have been tested at Diamond Light Source, and initial test measurements are provided, demonstrating the potential of the instrument.

Head and neck cancer in the UK: what is expected of cytopathology?

OBJECTIVE: This review highlights the role of cytopathology in cancer management within UK Head and Neck Cancer Networks and informs on the issues raised by recent UK Department of Health documents and other UK professional guidance. UK guidance requires the formal involvement of cytopathologists within multidisciplinary cancer teams, with medical and non-medical cytopathology staff setting up and running rapid access lump clinics, and support for image-guided fine needle aspiration cytology (FNAC) services. UK guidance also makes recommendations for training, resources and quality control. This review also highlights the resource gap between best practice evidence-based guidance for head and neck (HN) cancer services and existing UK provision for cytopathology, as evidenced by lack of availability of experienced staff and adequacy of training and quality control (QC). Finally, it stresses the importance in the UK of the Royal College of Pathologists' guidance, which defines the need for training, the experience needed for new consultants, the requirements for audit and QC. The implications for the additional resources required for HN cancer cytopathology services are discussed. Recent professional guidance specifying the provision of HN cancer services in the UK includes a cytopathology service for cancer networks, such as rapid access FNAC clinics. Although these clinics already operate in some institutions, there are many institutions where they do not and where the provision of cytopathology services would have to be restructured. This would need the support of local cancer networks and their acceptance of the detailed requirements for cytopathology, including resources, training and QC. The standards are not defined locally, as Strategic Health Authorities and Primary Care Trusts have been instructed by the Department of Health to support, invest and implement them.

Full polarization analysis of resonant superlattice and forbidden x-ray reflections in magnetite.

Despite being one of the oldest known magnetic materials, and the classic mixed valence compound, thought to be charge ordered, the structure of magnetite below the Verwey transition is complex and the presence and role of charge order is still being debated. Here, we present resonant x-ray diffraction data at the iron K-edge on forbidden (0, 0, 2n+1)(C) and superlattice [Formula: see text] reflections. Full linear polarization analysis of the incident and scattered light was conducted in order to explore the origins of the reflections. Through simulation of the resonant spectra we have confirmed that a degree of charge ordering takes place, while the anisotropic tensor of susceptibility scattering is responsible for the superlattice reflections below the Verwey transition. We also report the surprising result of the conversion of a significant proportion of the scattered light from linear to nonlinear polarization.

Nature of the magnetic order and origin of induced ferroelectricity in TbMnO3.

The magnetic structures which endow TbMnO(3) with its multiferroic properties have been reassessed on the basis of a comprehensive soft x-ray resonant scattering (XRS) study. The selectivity of XRS facilitated separation of the various contributions (Mn L(2) edge, Mn 3d moments; Tb M(4) edge, Tb 4f moments), while its variation with azimuth provided information on the moment direction of distinct Fourier components. When the data are combined with a detailed group theory analysis, a new picture emerges of the ferroelectric transition at 28 K. Instead of being driven by the transition from a collinear to a noncollinear magnetic structure, as has previously been supposed, it is shown to occur between two noncollinear structures.