Detailed Radiomorphometric Analysis of the Surgical Corridor for the Suprageniculate Approach.

BACKGROUND: The suprageniculate fossa (SGF) is located between the geniculate ganglion, the middle cranial fossa (MCF) and the anterior semicircular canal (ASCC). An endoscopic transcanal approach has been recently proposed to treat the different lesions in this area. The aim of the study is to describe the anatomical pathway of this approach by measuring the dimensions of its boundaries while checking their correlation with the pneumatization of the SGF area. METHODS: This is a retrospective anatomical analysis of Cone Beam CT scans of 80 patients, for a total of 160 temporal bones analyzed. Two checkpoints were measured for the SGF route, as an internal and an external window. These are triangles between the MCF dura, the geniculate ganglion and the ASCC on parasagittal and axial planes. The pneumatization of the SGF was also assessed, classified and correlated with the measured dimensions. RESULTS: The depth of the SGF was 7.5 ± 1.8 mm. The width of the external window was 7.5 ± 1.9, 5.6 ± 2.4 and 1.6 ± 1.6 mm for the posterior, middle and anterior points of measurement, respectively. The height of the internal window was 7.6 ± 1.2, 4.5 ± 1.5 and 1.7 ± 1.7 mm for the posterior, middle and anterior points of measurement, respectively. Type A pneumatization was found in 87 cases, type B in 34 and type C in 39. The degree of pneumatization directly correlated to the depth and height of the fossa. CONCLUSIONS: The suprageniculate approach route is defined by the internal and external windows which should be evaluated during a pre-surgery imaging assessment. The detailed anatomy of the approach and the novel classification of the pneumatization of the SGF are here described which may be useful to plan a safer procedure with minimal complications.

Radiologic evaluation and clinical assessment of facial sinus in adults and children - computed tomography study.

OBJECTIVE: The facial sinus is a recess of the lateral retrotympanum located between the chorda tympani (ChT) and facial nerve (FN). Chronic otitis media with cholesteatoma often spreads from the pars flaccida to the facial sinus (FS). In stapedotomy, if an unfavorable ChT type is encountered, there is a need for removal of bone between the ChT and FN. The aim of the study was to assess FSs in adults and children according to Alicandri-Ciufelli classification, to measure FS width and depth in computed tomography scans, evaluate the correlation between measurements and different types of facial sinuses, and provide a clinical context of these findings. METHODS: Cone Beam Computed Tomography (CBCT) of 130 adults and High Resolution Computed Tomography of 140 children were reviewed. The type of facial sinus was assessed according to Alicardi-Ciufelli's classification in different age groups. Width of entrance to facial sinus (FSW) and depth of FS (FSD) were evaluated among age groups. RESULTS: Type A of FS is dominant in both adult and children populations included in the study. The average depth of FS was 2.31±1.43 mm and 2.01±0.90 in children and adults respectively. The width of FS was 3.99±0.69 and 3.39±0.98 in children and adults respectively. The depth of FS (FSD) presented significant deviations (ANOVA, p<0.05) among all three types and age groups. In 116/540 (21.5%) cases the value of FSD was below 1 mm. CONCLUSION: The qualitative classification of facial sinuses into types A, B and C, introduced by Alicandri-Ciufelli and al. is justified by statistically significant differences of depth between individual types of tympanic sinuses. Type A sinuses may be extremely shallow (<1 mm - As) or normal (>1 mm - An). Preoperative assessment of CT scans of the temporal bones gives crucial information about type and size of facial sinus. It may increase the safety of surgeries in this area and play a role in choosing an optimal approach and surgical tools.

Photobiomodulation Therapy for the Symptoms Related to Temporomandibular Joint Disk Displacement.

Pain related to temporomandibular disorders (TMD) is a common problem that can significantly influence a patient's quality of life. Laser photobiomodulation (PBM) has been reported as a promising method in medicine for wound and bone healing, pain relief, and treatment of the temporomandibular joint (TMJ). Our clinical case aimed to demonstrate the effectivity of PBM using 1064 nm Nd:YAG laser for the treatment of pain and restricted mandible movement in a patient with anterior disk displacement of the left TMJ, using subjective (pain on visual analogue scale - VAS) and objective outcome measures [dynamic magnetic resonance imaging (MRI)]. PBM was performed on the left condyle in four sessions using a 1064 nm Nd:YAG laser with a flat-top handpiece. Results after 10 weeks showed an increase in mouth opening and a painless joint on palpation, with no reported adverse effects. An MRI of the TMJ confirmed the left disk displacement, however, with no signs of inflammation or effusion and with less pronounced disk deformity as compared with the first MRI examination. Use of PBM with Nd:YAG laser may be an efficient method for the management of orofacial pain in patients with acute and chronic TMJ disk displacements and may reduce the recovery time.

Sinus tympani revisited for planning retrofacial approach-radiologic study in pneumatized temporal bones and its surgical implications.

BACKGROUND AND PURPOSE: Retrofacial approach (RFA) is an access route to sinus tympani (ST) and it is used in cholesteatoma surgery, especially when type C ST is encountered. It may also be used to gain an access to stapedius muscle to assess the evoked stapedius reflex threshold. The primary object of this study was to evaluate the morphology of sinus tympani and its relationship to facial nerve (FN) and posterior semicircular canal (PSC) in context of planning retrofacial approach in pneumatized temporal bones. METHODS: CBCT of 130 adults were reviewed. The type of sinus tympani was assessed according to Marchioni's classification. Width of entrance to sinus tympani (STW), depth of ST (STD), distance between the posterior semicircular canal and facial nerve (F-PSC), distance between the latter plane to the floor of ST at the right angle (P-ST) were measured at level of round window (RW) and pyramidal ridge (PR). RESULTS: All of the bones were well-aerated and classified in Dexian Tan pneumatization group 3 or 4. Type B of ST is dominant (70.8%) in adult population with no history of inflammatory otologic diseases, followed by type C (22.7%) and then type A (6.5%). The depth of ST (STD) presented significant deviations (ANOVA, p < 0.05) among all three types. STW reaches greater values on the level of PR. F-PSC does not correlate with type of ST. In over 75% of examined type C sinus tympani the distance P-ST was less than 1 mm. CONCLUSIONS: The qualitative classification of the sinus tympani into types A, B and C, introduced by Marchioni is justified by statistically significant differences of depth between individual types of tympanic sinuses. The STW distance reaches greater values inferiorly-it may suggest that RFA should be performed in infero-superior manner rather than opposite direction. Preoperative assessment of temporal bones CT scans gives very important information about size of sinus tympani and distance between FN and PSC.

Temporomandibular Disk Dislocation Impacts the Stomatognathic System: Comparative Study Based on Biexponential Quantitative T2 Maps.

In this study, we aimed to assess the potential impact of temporomandibular disk displacement on anatomical structures of the stomatognathic system using biexponential T2 magnetic resonance imaging (MRI) maps. Fifty separate MRI scans of the temporomandibular joints (TMJ) of 25 patients were acquired with eight echo times. Biexponential T2 maps were created by weighted reconstruction based on Powell's conjugate direction method and divided into two groups: the TMJ without (32 images) and with (18 images) disk displacement. The disk, retrodiscal tissue, condylar bone marrow, masseter muscle, lateral and medial pterygoid muscles and dental pulp of the first and second molars were manually segmented twice. The intrarater reliability was assessed. The averages and standard deviations of the T2 times and fractions of each segmented region for each group were calculated and analysed with multiple Student's t-tests. Significant differences between groups were observed in the retrodiscal tissue, medial pterygoid muscle and bone marrow. The pulp short T2 component showed a trend toward statistical significance. The segmentation reliability was excellent (93.6%). The relationship between disk displacement and quantitative MRI features of stomatognathic structures can be useful in the combined treatment of articular disk displacement, pterygoid muscle tension and occlusive reconstruction.

A simple graded bite block for dynamic magnetic resonance imaging of the temporomandibular joint.

OBJECTIVES: New solutions for the dynamic assessment of the moving structures of the temporomandibular joint (TMJ), such as the intra-articular disc and the head of the mandible, are required for magnetic resonance imaging (MRI). Therefore, we propose a simple, graded bite block for dynamic MRI examination of the TMJ. METHODS: The bite block consists of three main functional elements: a groove for the biting edges of the upper incisors, steps with bite surfaces for the biting edges of the lower incisors and a handle for easy placement and control of the device. The block is easily manufactured using commercially available 3D printers. The closed-mouth part of the study was performed without the bite block. The patient was instructed to place the central incisors' biting edges in the upper groove. The lower incisors' biting edges were placed consecutively on the first step, second step, and so on, in increasing order, until maximal opening was reached. RESULTS: Ninety-five MR examinations of TMJs were performed. The graded opening bite block was successfully applied in all but two patients. CONCLUSIONS: In conclusion, the simple and easy-to-use graded bite block may be a useful addition to the armamentarium of a radiologist performing MRI scans of the TMJ.

Radiological markers of granulomatosis with polyangiitis with nasal involvement.

INTRODUCTION: Granulomatosis with polyangiitis (GPA) is an autoimmune disease leading to necrotizing lesions in the affected tissues. Computed tomography (CT) of paranasal sinuses reveals multiple lesions in patients with GPA, for example, sinus opacification, bone / cartilage destruction, and neoosteogenesis. OBJECTIVES: We aimed to describe and compare CT lesions found in patients with GPA and those with chronic rhinosinusitis (CRS) and to propose a new radiological marker of GPA-nasal strands. PATIENTS AND METHODS: This retrospective study (2014-2019) included 53 patients with GPA (22 men, 31 women) at a median (interquartile range) age of 45 (34-60) years. Computed tomography findings of mucosal lesions in paranasal sinuses, neoosteogenesis, bony and cartilaginous lesions, and nasal strands were analyzed. Nasal strands were described as intermucosal adhesions resembling bands. A total of 71 patients with CRS (reference group) were assessed for the presence of the same parameters. RESULTS: Computed tomography scans showed mucosal lesions in the sinuses of 35 patients (66%) with GPA. Nasal septum perforation was observed in 19 patients (35.8%), neoosteogenesis in 17 (32.1%), and bone damage in 14 (26.4%). External nose deformity was present in 16 patients (30.2%). Nasal strands on CT were found in 36 patients with GPA (68%) and 32 patients with CRS (45%). The presence of 5 or more strands was more characteristic of GPA than CRS (P <0.001). A positive correlation was found between the number of strands greater than or equal to 5 and the presence of proteinase 3 antineutrophil cytoplasmic antibodies (P = 0.046). CONCLUSIONS: Nasal strands, a parameter reflecting pathologic mucus and atrophic lesions (tissue loss), should have a place in CT evaluation of the nasal cavities in patients suspected of or diagnosed with GPA.

The radioanatomical assessment of the Körner's septum.

PURPOSE OF THE STUDY: Körner's septum (KS) is a developmental remnant formed at the junction of mastoid and temporal squama, representing the persistence of the petrosquamosal suture. During mastoid surgery, it could be taken as a false medial wall of the antrum so that the deeper cells might not be explored. The aim of the study was to assess a Körner's septum prevalence and to analyze its topography. METHODS: The study was performed on 80 sets of cone-beam computed tomography (CBCT) images of temporal bone (41 male, 39 female, 160 temporal bones). Körner's septum was identified and its thickness was measured on axial sections at three points: at the level of superior semicircular canal (SCC), at the level of head of malleus (HM) and at the level of tympanic sinus (TS). RESULTS: KS was encountered at least in one point of measurements in 50 out of 80 sets of CBCT images (62.5%). The average thickness at the level of SCC was 0.87 ± 0.34 mm, at the level of HM was 0.99 ± 0.37 mm and at the level of TS was 0.52 ± 0.17 mm. CONCLUSIONS: Körner's septum is a common structure in the temporal bone-air cell complex. It is more often encountered in men. In half of the patients, it occurs bilaterally. However, in most of the cases it is incomplete with anterior and superior portions being the most constant.

Interposition of the transverse ligament of the knee into a fracture of the tibial plateau: a case report.

Interposition of the transverse ligament of the knee between fragments of an intercondylar eminence fracture was diagnosed using magnetic resonance imaging (MRI) in a 11-year-old boy after a sports injury. The interposition was confirmed and corrected during arthroscopy. We report what we believe to be the first published case of isolated interposition of the transverse ligament in a minimally displaced fracture of the tibial eminence.

Radiation awareness among dentists, radiographers and students.

OBJECTIVES: The aim of this study was to assess radiation awareness among dentists, radiographers, dentistry students and radiography students from the Medical University of Warsaw. METHODS: A questionnaire containing 13 multiple-choice questions was administered to 200 dentists, 200 radiographers, 100 dentistry students and 100 radiography students. Participants were asked about basic knowledge concerning dental radiological examinations. RESULTS: In total, 301 (50.2%) questionnaires were returned. The mean score of correct answers was 8.13 out of 13 for all responders; 8.36 for dentists, 8.11 for radiographers, 8.19 for dentistry students and 7.46 for radiography students. Range of correct answers varied from 3 to 12. Differences between the four main groups were not statistically significant. Dentists who had completed radiation protection training had significantly higher number of correct answers than untrained dentists. For radiographers, the level of education had no connection with the results. Correlation between year of the study and results was not visible in the dentistry student group. Within the radiography student group, students in the third year of the study had significantly higher number of correct answers than those in the first and second years of the study. CONCLUSIONS: Our survey shows that radiation awareness among dentists, radiographers and students is inadequate, without significant differences in the main groups. Dentists who had completed radiation protection training had better awareness than those without such training. Greater emphasis should be put on the dental radiology course in both dentistry and radiography programmes at universities.

The prevalence of pulp stones in historical populations from the middle Euphrates valley (Syria).

There are many reports in the literature concerning pulp stones in contemporary living populations, but there are no descriptions of cases of pulp stones and their prevalence in populations of the past. Here we present a study of pulp stones in a series of archaeologically derived samples from the Middle Euphrates Valley (Syria) obtained from two sites: Terqa and Tell Masaikh. The specimens were assigned to five periods: Early Bronze (2650-2350 BC); Middle Bronze (2200-1700 BC); late Roman (AD 200-400); Islamic (AD 600-1200); and Modern Islamic (AD 1850-1950). A total of 529 teeth representing 117 adult individuals of both sexes were examined. Pulp stones were identified by X-ray and 10 selected specimens were sectioned for histological study. Pulp stones were found in 99 of 117 individuals (85%) and in 271 of 529 (51%) teeth. Pulp stone prevalence was found to increase with age, for individuals of older age classes have more pulp stones than younger individuals. Intriguingly, the prevalence of single pulp stones was higher among older individuals (36-45, >46), while younger individuals (17-25, 26-35) more often possessed multiple stones. Individuals with moderate to highly advanced dental wear have pulp stones significantly more often than individuals whose tooth wear is limited to invisible or very small facets. Though there is no statistical significance in the prevalence of pulp stones across chronological periods, it appears that a high level of calcium in the diet is accompanied by a greater prevalence of pulp stones.

Shear wave elastography may add a new dimension to ultrasound evaluation of thyroid nodules: case series with comparative evaluation.

Although elastography can enhance the differential diagnosis of thyroid nodules, its diagnostic performance is not ideal at present. Further improvements in the technique and creation of robust diagnostic criteria are necessary. The purpose of this study was to compare the usefulness of strain elastography and a new generation of elasticity imaging called supersonic shear wave elastography (SSWE) in differential evaluation of thyroid nodules. Six thyroid nodules in 4 patients were studied. SSWE yielded 1 true-positive and 5 true-negative results. Strain elastography yielded 5 false-positive results and 1 false-negative result. A novel finding appreciated with SSWE, were punctate foci of increased stiffness corresponding to microcalcifications in 4 nodules, some not visible on B-mode ultrasound, as opposed to soft, colloid-inspissated areas visible on B-mode ultrasound in 2 nodules. This preliminary paper indicates that SSWE may outperform strain elastography in differentiation of thyroid nodules with regard to their stiffness. SSWE showed the possibility of differentiation of high echogenic foci into microcalcifications and inspissated colloid, adding a new dimension to thyroid elastography. Further multicenter large-scale studies of thyroid nodules evaluating different elastographic methods are warranted.

Safety of sonographically guided aspiration of intramuscular, bursal, articular and subcutaneous hematomas.

OBJECTIVE: To evaluate the safety and efficacy of sonographically guided aspiration of intramuscular, bursal and subcutaneous hematomas. MATERIALS AND METHODS: One hundred eleven interventions were performed in 75 patients at a single institution from January 2005 to December 2009. In all cases the target of interest was identified with ultrasonography. RESULTS: Ninety-six procedures (87.3%) were successful, 14 procedures (12.7%) were unsuccessful due to excessive density and/or viscosity of the content. No significant complications were encountered during or immediately after any procedure. Clinical follow-up records were available for 73 (75%) procedures in 45 (66%) patients, 30 patients did not return for follow-up after hematoma evacuation. No septic or hemorrhagic complications or cases of neurovascular compromise were recorded. CONCLUSIONS: Sonographically guided hematoma evacuation is a safe procedure. However, the proportion of unsuccessful evacuations and hematoma recurrence is substantial.

Value of modern sonography in the assessment of meniscal lesions.

The aim of this prospective study was to assess the accuracy of modern ultrasonography in diagnostic imaging of meniscal tears. One hundred and sixty menisci were evaluated in 80 patients (42 females, 38 males, mean age=36.2 years, range=16-70 years). Inclusion criteria for the study were twofold: clinical suspicion of meniscal injury and clinical indication for arthroscopy. Knee examination was performed with the Voluson 730 Expert ultrasound system (General Electric). After sonographic examination, all patients underwent arthroscopic procedures within 1-4 days. The final diagnosis of meniscal tears was taken from surgical reports. The overall sensitivity, specificity, positive predictive value and negative predictive value of sonographic examination in the assessment of meniscal tears amounted to 85.4%, 85.7%, 67.3% and 94.4%, respectively. The statistical parameters were not statistically different in medial and lateral menisci. Age, sex, body mass index (BMI), weight, physical activity, mechanism on injury, and time lapse from injury did not have a statistically significant impact on the usefulness of ultrasonography. The highest sensitivity (>90%) was obtained in medial menisci and in patients with a BMI>25. The highest specificity (>90%) was obtained in lateral menisci, in patients after twisting injuries, in sports injuries, and in recent injuries (time lapse from the injury <1 month). The positive predictive value (PPV) of sonographic examination was higher than 90% only in recent injuries (<1 month), however, the negative predictive value of ultrasound is high, being less than 90% in males with lesions of lateral menisci and in sequelae of sports injuries.

Traumatic detachment of the inferior angle of the scapula in a 5-year-old boy--a sonographic diagnosis.

A complete slip of the cartilage of the inferior angle of the scapula was diagnosed in a 5-year-old boy who fell inside a wooden construction at a kindergarten playground. Radiographs of the scapula were normal, and ultrasound demonstrated complete cartilage detachment, which was displaced deep and laterally. Computed tomography (CT) additionally demonstrated a thin rim of bone displaced along with the detached cartilage. Radiologic findings were confirmed during surgery. We report what we believe to be the first published case of traumatic detachment of the cartilaginous lower angle of the scapula in a child demonstrated by ultrasound.

Advantages and disadvantages of 3D ultrasound of thyroid nodules including thin slice volume rendering.

BACKGROUND: The purpose of this study was to assess the advantages and disadvantages of 3D gray-scale and power Doppler ultrasound, including thin slice volume rendering (TSVR), applied for evaluation of thyroid nodules. METHODS: The retrospective evaluation by two observers of volumes of 71 thyroid nodules (55 benign, 16 cancers) was performed using a new TSVR technique. Dedicated 4D ultrasound scanner with an automatic 6-12 MHz 4D probe was used. Statistical analysis was performed with Stata v. 8.2. RESULTS: Multiple logistic regression analysis demonstrated that independent risk factors of thyroid cancers identified by 3D ultrasound include: (a) ill-defined borders of the nodule on MPR presentation, (b) a lobulated shape of the nodule in the c-plane and (c) a density of central vessels in the nodule within the minimal or maximal ranges. Combination of features provided sensitivity 100% and specificity 60-69% for thyroid cancer.Calcification/microcalcification-like echogenic foci on 3D ultrasound proved not to be a risk factor of thyroid cancer.Storage of the 3D data of the whole nodules enabled subsequent evaluation of new parameters and with new rendering algorithms. CONCLUSIONS: Our results indicate that 3D ultrasound is a practical and reproducible method for the evaluation of thyroid nodules. 3D ultrasound stores volumes comprising the whole lesion or organ. Future detailed evaluations of the data are possible, looking for features that were not fully appreciated at the time of collection or applying new algorithms for volume rendering in order to gain important information. Three-dimensional ultrasound data could be included in thyroid cancer databases. Further multicenter large scale studies are warranted.

Sonographic diagnosis of carpal tunnel syndrome--diagnostic value of the triangular cross-section sign.

BACKGROUND AND PURPOSE: Carpal tunnel syndrome (CTS) is a common neuropathy resulting from compression of the median nerve at the carpal tunnel. Sonographic diagnosis of this condition relies on enlargement, flattening and/or demonstration of impaired mobility of the median nerve, as well as bowing or thickening of the flexor retinaculum. In most patients the cross-section of the median nerve at the level of the carpal tunnel has an oval or elliptical shape. We have noticed, however, that in a number of cases the cross-section of the median nerve at the inlet of the carpal canal was deformed, assuming a triangular shape. The purpose of this study was to assess the diagnostic value of the triangular median nerve cross-section sign. MATERIAL AND METHODS: One hundred and thirty-nine sonographic examinations in 76 patients with clinical signs of CTS, and 25 examinations in 14 healthy volunteers were performed. Standard electrodiagnostic studies were performed in all symptomatic patients. RESULTS: Triangular shape of the median nerve cross-section in the carpal canal was observed in 13/118 (11.0%) median nerves with abnormal result of the electrodiagnostic study, and in 2/21 (9.5%) cases with a normal electrodiagnostic examination result. No such deformation was seen in the control group. CONCLUSIONS: The triangular cross-section sign has high specificity (0.90) and positive predictive value (0.87) in dia-gnosis of CTS.

US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls.

Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas. In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. The US features of advanced Sjögren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow. Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications; Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow. However, US appearances of some diseases may overlap, thus producing diagnostic pitfalls.

Gray-scale three-dimensional sonography of thyroid nodules: feasibility of the method and preliminary studies.

The aim of the study was differential evaluation of new and classical sonographic features of benign thyroid nodules and thyroid cancer with three-dimensional gray-scale sonography and evaluation of the effectiveness of the thin-slice surface rendered images in comparison with multiplanar reformation (MPR) presentation. Fifty-four thyroid nodules were interactively evaluated with thin-slice smooth surface rendering: shape in the c-plane (parallel to the probe) and evaluation of echogenicity, margins and calcification/microcalcification-like echogenic foci in the a-plane (plane of the probe). Evaluation of the level of agreement in readers' interpretation and between sonographic techniques was performed using the kappa statistic. Surface rendering permitted visualization of the shape of the nodule in the c-plane in all cases, in contrast to only up to 48% of cases in MPR evaluation. Lobulated nodule shape in the c-plane was 82-100% sensitive and 47-53% specific in diagnosis of carcinoma. Surface rendered images showed more calcification/microcalcification-like echogenic foci than MPR ones. The level of agreement between the observers in the evaluation of features of thyroid nodules and the agreement between features of thyroid nodules on MPR and surface-rendered images showed at least moderate reproducibility (kappa>or=0.41). Three-dimensional thin-slice surface rendering sonography appears to be a feasible and effective method for thyroid nodule evaluation.