Incidental uptake of fluorodeoxyglucose in the Waldeyer’s ring and risk of oropharyngeal malignancy

Purpose Fluorodeoxyglucose (FDG) positron emission tomography (PET) is increasingly used to diagnose and stage malignancy. The aim of this article is to investigate the significance of incidental FDG uptake in the Waldeyer’s ring and to assess its value in predicting clinically occult oropharyngeal malignancy. Methods All FDG-PET/CT scans performed in Imperial College NHS Foundation Trust, UK between January 2012 and November 2018 were included. Patients with known or suspected oropharyngeal malignancy or lymphoma were excluded. Minimum follow-up was 12 months. Results A total of 724 scans revealed oropharyngeal uptake of FDG. Of these, 102 were included in the study. Most patients (62.1%) were scanned as part of staging for other malignancies. Oropharyngeal FDG uptake was asymmetrical in 57.3% of the cases. Uptake was more common in the tonsils (56.3%), followed by the tongue base (31.1%) and both sites (12.6%). In 41.7% of reports, appearance was described as likely physiological; however, 52.4% of reports advised direct visualisation, clinical correlation or ENT opinion. Only 24.3% (25/102) of patients were referred and seen by ENT, 14.6% (15/102) of which had an interval PET scan and 8.7% (9/102) proceeded to tissue diagnosis. There was one oropharyngeal cancer identified and one unexpected metastasis from esophageal cancer. Conclusion Incidental uptake on PET/CT in the oropharynx is common. However, malignancy is rare (1.9%) and, when present, is associated with high SUVmax and asymmetrical uptake. Imaging results must be correlated clinically. These patients should be seen by an ENT specialist yet most may not require further investigations.

Adenoid Hypertrophy with Deviated Nasal Septum in Young Adults

Adenoid hypertrophy is a common cause of nasal obstruction in children but relatively uncommon in adults, however adenoid hypertrophy in young adults is thought to be a persistence of untreated adenoid hypertrophy of childhood. This case series also notes that adenoid hypertrophy can be associated with deviated nasal septum. Coblation assisted endoscopic adenoidectomy usually has good result in adenoid clearance. Hence, routine endoscopic examination of nasopharynx helps in early diagnosis of adenoid hypertrophy and subsequent better management in young adults with complaints of nasal blockage. Nasopharyngeal vegetations were earlier described by Wilhelm Meyer in 1870 as forming part of Waldeyer’s ring of lymphoid tissue and he coined the term ‘adenoid’ to describe the same. In younger children, it has been thought that the adenoids may have an important role in development of an immunological memory. Physiologically it has been considered that hypertrophy of adenoid tissue occurs during 6 - 10 years and tend to regress and atrophy at 16 years. Grading of adenoid hypertrophy as described by Clemens et al. is as follows.1  Grade I: adenoid tissue filling 1/3rd. of the vertical height of choana.  Grade II: adenoid tissue filling up to 2/3rd of the vertical height of choana.  Grade III: from 2/3rd to nearly all but not completely filling the choana.  Grade IV: complete choanal obstruction We present three cases of adenoid hypertrophy with deviated nasal septums in adults who visited ENT outpatient department (OPD) at National Institute of Medical Sciences, Jaipur during COVID era of January 2021 to April 2021.

Differential Diagnosis of Sinonasal Extramedullary Plasmacytoma, Non-Hodgkin’s Lymphoma, and Squamous Cell Carcinoma Using CT Scan and MRI

Background: The imaging features of sinonasal extramedullary plasmacytoma (EMP) are non-specific and similar to those of other lesions, such as sinonasal non-Hodgkin’s lymphoma (NHL) and squamous cell carcinoma (SCC). Objectives: To analyze the computed tomography (CT) and magnetic resonance (MR) images of patients with EMP, NHL, and SCC to identify the radiological characteristics differentiating sinonasal EMP from NHL and SCC. Patients and Methods: In this cross-sectional study, the CT and MR imaging features of 37 patients with sinonasal EMP, 46 patients with NHL, and 44 patients with SCC were analyzed. Sinonasal NHL was categorized into two distinct types, namely, natural killer/T-cell lymphoma (n = 32) and diffuse large B-cell lymphoma (n = 14). The tumor volume was determined by measuring the region of interest (ROI) in the PACS program. Besides, homogeneity, apparent diffusion coefficient (ADC) in the ADC maps, degree of enhancement, adjacent bone destruction, and invasion to Waldeyer’s ring and cervical or retropharyngeal lymph nodes were evaluated. Results: Although the tumor volume was larger in the EMP group as compared to the NHL and SCC groups, the difference was not statistically significant. The NHL group showed the highest tumor homogeneity on both CT and MR images. EMP was more heterogenous than NHL, with moderate signal intensity on T1-weighted MR images. On the other hand, EMP and NHL showed significantly lower ADCs as compared to SCC. The majority of patients with sinonasal EMP, NHL, and SCC showed an avid enhancement. Also, destructive tumor growth involving the adjacent bone was more frequent in SCC than in EMP or NHL. However, there were no significant differences among sinonasal EMP, NHL, and SCC in terms of invasion to Waldeyer’s ring and cervical or retropharyngeal lymph node metastasis. Conclusion: Marked heterogeneity on T1-weighted images, low ADCs, and lack of adjacent bone destruction were the CT and MR imaging features that favored the diagnosis of EMP over NHL or SCC.

Whole-body [18F]-FDG-PET/MRI for staging of pediatric non-Hodgkin lymphoma: first results from a single-center evaluation

Aim In 2015, the revised International Pediatric Non-Hodgkin Lymphoma Staging System was published. It mentions [18F]-FDG-PET/MRI as the latest method to perform whole-body imaging. However, supporting data are pending. Our aim was to investigate the performance of whole-body [18F]-FDG-PET/MRI in pediatric non-Hodgkin lymphoma patients by using a limited number of MRI sequences. Materials and methods Ten pediatric patients with histologically proven non-Hodgkin lymphoma underwent whole-body [18F]-FDG-PET/MRI at staging. The retrospective analysis included three steps: First, [18F]-FDG-PET and MR scans were evaluated separately by a nuclear medicine physician and a pediatric radiologist. Nineteen nodal and two extranodal regions as well as six organs were checked for involvement. Second, discrepant findings were reviewed together in order to reach consensus. Third, [18F]-FDG-PET/MRI findings were correlated with the results of other clinical investigations. Results Of the 190 lymph node regions evaluated, four were rated controversial. Consensus was reached by considering metabolic, functional and morphologic information combined. Concordantly, [18F]-FDG-PET and MRI detected Waldeyer’s ring involvement in two patients whose Waldeyer’s ring was negative on clinical assessment. In four patients MRI showed pleural effusion. However, in only two of them an increased glucose metabolism as a reliable sign of pleural involvement was detectable. In six patients [18F]-FDG-PET and MRI detected skeletal lesions although bone marrow biopsy was positive in only one of them. Conclusion Despite the small number of cases evaluated, whole-body [18F]-FDG-PET turned out to be a valuable tool for staging of pediatric non-Hodgkin lymphoma.

Microdebrider: a painless and effective technique for adenoidectomy; comparative study with curette assisted adenoidectomy

<p><strong>Background: </strong>Adenoid is a nasopharyngeal tissue which forms Waldeyer's ring as said by Meyer, 1968. Adenoids become demonstrable with signs of CSOM with adenoid hyperplasia, recurrent rhino-sinusitis, characteristic ‘adenoid facies’, nasal obstruction, mouth breathing, snoring, drooling of saliva and speech abnormalities and dental malocclusion. Adenoidectomyis the common surgery done using various techniques like curette, microdebrider and many more. In this study we evaluate and compare the efficacy of adenoidectomy by microdebrider verses curette assisted adenoidectomy. Aim of the study was to evaluate and compare the efficacy and benefits of adenoidectomy by microdebrider with curette assisted adenoidectomy.</p><p><strong>Methods: </strong>This is a prospective randomized single-blind study done for 1 year. Total 150 patients were included which were diagnosed as adenoid hypertrophy based on clinical and radiological examination and were equally divided in 2 group for both the procedures (curette and microdebrider).</p><p><strong>Results: </strong>Patients show good response to the treatment with microdebrider assisted adenoidectomy with less complication and early recovery.</p><p><strong>Conclusions: </strong>We observe that proper examination and early surgical intervention using modern technique i.e., microdebrider reduces the time, residual tissue with less complication and promote early recovery.</p>

Surgical Anatomy of the Tonsils

The tonsils represent a circular band of mucosa associated with lymphoid tissues, Waldeyer’s ring, which is located at the entrance of the upper aerodigestive tract, with a significant role in the immune defense system. Waldeyer’s ring is composed of the pharyngeal, tubal, palatine, and lingual tonsils acting as secondary lymphoid tissues. Particularly, the palatine tonsils are the largest of the tonsils with deep branching crypts and contain B and T lymphocytes and M cell which plays a role in the uptake and transport of antigens. Because of the tonsil enlargement during childhood, upper airway obstruction and obstructive sleep apnea syndrome are mostly seen. Knowledge of the surgical anatomy of the tonsils and variations of the neurovascular and muscular structures around it allows optimal choice of surgical technique to avoid iatrogenic complications during tonsillectomy. Recent medical studies reported that a detailed understanding of the anatomic risk factors in upper airway obstruction allows to predict treatment response to surgical intervention. Due to the penetration of benign or malign lesions of the tonsil into the lateral wall of the pharynx, transoral robotic approach to this region is necessary to identify the surgical anatomic landmarks which are required to perform safe and effective surgical intervention.