Radiology of the head and neck

Various imaging techniques are used in the staging and follow-up of head and neck cancer and evaluating patients presenting with a neck mass. The workhorses in imaging the neck are ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) with positron emission tomography CT (PET-CT) increasingly being requested. Plain radiographs, contrast studies, video fluoroscopy, angiography, and cone beam CT have limited but important roles. This chapter discusses the role of some of these modalities.

Quantification of fluoroscopic fundoplication anatomy: inter- and intraobserver reliability

SUMMARY The etiology of postfundoplication dysphagia remains incompletely understood. Subtle changes of gastroesophageal junction (GEJ) anatomy may be contributory. Barium swallows have potential for standardization to evaluate postsurgical anatomical features. Using structured barium swallows, we aim to identify reproducible, objectively measured postfundoplication anatomical features that will permit future comparison between patients with/without dysphagia. At 6–12 months of postfundoplication, 31 patients underwent structured barium swallow with video–fluoroscopy recording: standing anteroposterior; standing oblique (×2); prone oblique (×2); and prone oblique with continuous free drinking. A primary observer recorded 11 variables of GEJ anatomy for each view, repeated 3 months later, forming two datasets to assess intraobserver consistency. Interobserver reliability was determined using a dataset each from the primary observer and two medical students (after training). Intraclass correlation coefficients (ICC) were based on two-way mixed-effects model (ICC agreement: 0.40–0.59 ‘fair’; 0.60–0.74 ‘good’; 0.75–1.00 ‘excellent’). Interobserver reliability was good–excellent for 47 of 66 measurements. Measures of maximal esophageal diameter cf. wrap opening diameter and posterior esophageal angle showed high interobserver reproducibility on all views (ICC range 0.84–0.91; 0.68–0.80, respectively). Interobserver agreement was good–excellent for 5/6 views when measuring anterior GEJ displacement and axis deviation (ICC range 0.56–0.79; 0.41–0.77, respectively). Measures of wrap length showed lower reproducibility. Prone oblique measurements showed highest reproducibility (good–excellent agreement in 19/22 measurements). Intraobserver consistency was excellent for 98% of measurements (ICC range 0.74–0.99). Objective measurements of postfundoplication GEJ anatomy using structured barium swallow are reproducible and may allow further interrogation of anatomical features contributing to postfundoplication dysphagia.

The global end-ranges of neck flexion and extension do not represent the maximum rotational ranges of the cervical intervertebral joints in healthy adults - an observational study

Background In clinical diagnosis, the maximum motion of a cervical joint is thought to be found at the joint’s end-range and it is this perception that forms the basis for the interpretation of flexion/extension imaging studies. There have however, been representative cases of joints producing their maximum motion before end-range, but this phenomenon is yet to be quantified. Purpose To provide a quantitative assessment of the difference between maximum joint motion and joint end-range in healthy subjects. Secondarily to classify joints into type based on their motion and to assess the proportions of these joint types. Study design This is an observational study. Subject sample Thirty-three healthy subjects participated in the study. Outcome measures Maximum motion, end-range motion and surplus motion (the difference between maximum motion and end-range) in degrees were extracted from each cervical joint. Methods Thirty-three subjects performed one flexion and one extension motion excursion under video fluoroscopy. The motion excursions were divided into 10% epochs, from which maximum motion, end-range and surplus motion were extracted. Surplus motion was then assessed in quartiles and joints were classified into type according to end-range. Results For flexion 48.9% and for extension 47.2% of joints produced maximum motion before joint end-range (type S). For flexion 45.9% and for extension 46.8% of joints produced maximum motion at joint end-range (type C). For flexion 5.2% of joints and for extension 6.1% of joints concluded their motion anti-directionally (type A). Significant differences were found for C2/C3 (P = 0.000), C3/C4 (P = 0.001) and C4/C5 (P = 0.005) in flexion and C1/C2 (P = 0.004), C3/C4 (P = 0.013) and C6/C7 (P = 0.013) in extension when comparing the joint end- range of type C and type S. The average pro-directional (motion in the direction of neck motion) surplus motion was 2.41° ± 2.12° with a range of (0.07° -14.23°) for flexion and 2.02° ± 1.70° with a range of (0.04°-6.97°) for extension. Conclusion This is the first study to categorise joints by type of motion. It cannot be assumed that end-range is a demonstration of a joint’s maximum motion, as type S constituted approximately half of the joints analysed in this study.

Efficacy of NUTRI's Softia S product in patients with dysphagia.

Background: Dysphagia of various origins is widespread. There is a high risk of developing formidable complications: malnutrition, dehydration, weight loss, airway obstruction, aspiration pneumonia. The product Softia S is used to solve the problems of swallowing liquids. The Ministry of Agriculture, Forestry and Fisheries of Japan financed this study within the framework of the 8-Point Cooperation Plan presented by the Prime Minister of Japan S. Abe to the President of the Russian Federation V.V. Putin in May 2016. Aims: assessment of the efficacy and safety of NUTRI's Softia S product for patients with dysphagia of various origins. Materials and methods: Complex assessment of dysphagia included speech therapy, video fluoroscopy and video laryngoscopy with assessment of swallowing function (Rosenbek (PAS) and FEDSS scales). Patients were divided into 2 groups (experiment and control). The study lasted 14 days. Examination by a speech therapist and a nutritionist was carried out daily. On the 1st and 14th days, laboratory parameters were monitored, and the patient's body weight was determined. Results: The study included 30 patients with mild dysphagia. By the end of the study, 8 people in the experimental group showed a restoration of the swallowing function, residual effects in the form of choking persisted in 7 people. In the control group, a slight improvement was observed in 2 patients, 13 had no changes. The most significant changes were found in the experimental group for the indicators "Time of eating " ("Breakfast", on average, 3.7 minutes, P = 0.0033; "Lunch", on average, 6.9 minutes, P0.0001); "The number of chokes after hydration" ("Breakfast" by an average of 7.0, P0.0001; "Lunch" by an average of 8.1, P0.0001; "Dinner" by an average of 6.8, P 0.0001); "The number of chokes during hydration" ("Breakfast" by an average of 8.8, P0.0001; "Lunch" by an average of 12.1, P0.0001; "Dinner" by an average of 8.7, P0.0001). The number of dysphonia cases with sputum significantly decreased only in the experimental group. Conclusions: Softia S can be used in complex therapy for dysphagia by reducing the amount of choking after and during hydration and time of eating and dysphonia cases with sputum.

Clinical Feeding Evaluation and Videofluoroscopy: An Integrative Approach to Feeding Management in Children With Suspected Aspiration

BackgroundVideo fluoroscopy swallow studies (VFSS) are considered gold standard for the diagnosis of aspiration in children but require resources and radiation compared to clinical feeding evaluation (CFE). We evaluated their added value for diagnosis, feeding management and clinical status.MethodsA retrospective single-center cohort study of children aged 0-18 years, referred for VFSS at a tertiary pediatric hospital. Results 113 children, median age (range) 2.2 years (0.1-17.9) successfully completed VFSS. Forty-six (41%) had oropharyngeal aspiration, 9 (8%) overt alone and 37 (33%) including silent aspirations. Underlying medical conditions included clinically suspected aspiration lung disease (ALD), 87 (77%); neurologic disease, 73 (64%); gastrointestinal disease, 73 (64%) and congenital heart disease, 42 (37%), not mutually exclusive. Those with ALD or cerebral palsy were more likely to have aspiration by VFSS, OR 3.2 and 9.8 respectively. Sensitivity and specificity of CFE for VFSS diagnosis of aspiration were 71% and 84% respectively. Feeding recommendations after VFSS differed significantly from those based on prior CFE, p<0.001: The rate of exclusively orally fed children increased from 65% to 79%, p=0.006 and exclusively enterally fed children from 10% to 14%; p=0.005. During the following year, there were significantly less antibiotic courses, as well as total and respiratory admissions. Conclusions In this population of children with a high prevalence of clinically suspected ALD, VFSS refined diagnosis and altered feeding management compared to CFE, with subsequent clinical improvement.

Lumbar Intervertebral Kinematics During an Unstable Sitting Task and Its Association With Standing-Induced Low Back Pain

People developing transient low back pain during standing have altered control of their spine and hips during standing tasks, but the transfer of these responses to other tasks has not been assessed. This study used video fluoroscopy to assess lumbar spine intervertebral kinematics of people who do and do not develop standing-induced low back pain during a seated chair-tilting task. A total of 9 females and 8 males were categorized as pain developers (5 females and 3 males) or nonpain developers (4 females and 5 males) using a 2-hour standing exposure; pain developers reported transient low back pain and nonpain developers did not. Participants were imaged with sagittal plane fluoroscopy at 25 Hz while cyclically tilting their pelvises anteriorly and posteriorly on an unstable chair. Intervertebral angles, relative contributions, and anterior–posterior translations were measured for the L3/L4, L4/L5, and L5/S1 joints and compared between sexes, pain groups, joints, and tilting directions. Female pain developers experienced more extension in their L5/S1 joints in both tilting directions compared with female nonpain developers, a finding not present in males. The specificity in intervertebral kinematics to sex-pain group combinations suggests that these subgroups of pain developers and nonpain developers may implement different control strategies.

Cervical End-Range Joint Motion Does Not Indicate Maximum Cervical Joint Motion In Healthy Adults. An Observational Study

BackgroundIn clinical diagnosis, the largest motion associated with cervical range of motion is thought to be found at end-range and it is this perception that forms the basis for the interpretation of flexion/extension studies. There have however, been representative cases of joints producing their maximum motion before end-range, but this phenomenon is yet to be quantified. PurposeTo provide a quantitative assessment of the difference between maximum motion and end-range in healthy subjects. Secondarily to classify joints into type based on their motion and to assess the proportions of these joint types. Study designThis is an observational study. Subject sampleThirty three healthy subjects participated in the study. Outcome measuresMaximum motion, end-range motion and surplus motion in degrees were extracted from each cervical joint. MethodsThirty-three subjects performed one flexion and one extension motion excursion under video fluoroscopy. The motion excursions were divided into 10 percent epochs between the initial upright position and the end-range position, from which maximum motion, end-range and surplus motion were extracted. Surplus motion was then assessed in quartiles and joints were classified into type according to end-range. ResultsFor flexion 48.9% and for extension 47.2% of joints produced maximum motion before end-range (type Surplus). For flexion 45.9% and for extension 46.8% of joints produced maximum motion at end-range (type Classic) and 5.2% of joints in flexion and 6.1% of joints in extension concluded their motion anti-directionally (type Anti-directional). Mann-Whitney U tests produced significant results for C2/C3, C3/C4 and C4/C5 in flexion and C1/C2, C3/C4 and C6/C7 in extension when comparing end- range motion for type Classic and type Surplus. The average contributions to cervical range-of-motion (ROM) (C0 to C7) for flexion and extension were 60.23֯ and 67.86֯ for type Classic and 42.22֯ and 49.05֯ for type Surplus respectively. Thus, the average contribution to cervical ROM was larger for type Classic than for type Surplus. The average pro-directional surplus motion was 2.41֯ ± 2.12֯ with a range of range (0.07֯ -14.23֯) for flexion and 2.02֯ ± 1.70֯ with a range of 0.04°-6.97° for extension.ConclusionThis is the first study to categorise joints by type of motion. Type Surplus constituted approximately half of the joints analysed in this study. Therefore, end-range motion cannot be assumed to be a demonstration of a joint´s maximum motion.