Timothy Beale’s research while affiliated with University College London Hospitals NHS Foundation Trust and other places

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.

Introduction: The facial nerve is a small structure that can be displaced into unexpected positions by tumors growing within the parotid gland. Hololens2 is an augmented reality headset which allows the holographic projection of images onto the wearers view of their surroundings creating a mixed image. In this study we assessed the ability of 3T MRI and Hololens2 to visualise the path of facial nerve around parotid tumors and the impact on surgical planning. Methods: 18 patients with parotid neoplasms underwent 3T MRI imaging. MRI images were subsequently segmented using 3D slicer software and uploaded into a mixed reality device (Microsoft HoloLens2) using ApoQlar software. This created a 3D hologram of the facial nerve and the relations to the surrounding structure.Images were later compared to observations made intraoperatively. Results: 18 patients with parotid neoplasms were included in this study. 14 females and 4 males between the ages of 18 and 66. This included 13 benign and 5 malignant neoplasms. Identical match of projected 3D hologram images to the surgical findings was present in 100% of the patients. Age, sex, tumor type, size, site did not make a change in the predicted images. Conclusions: The facial nerve can be faithfully visually traced in 3D hologram as it passes through the parotid gland and weaves its way past resident tumors. This allows surgeons to be forewarned of unusual configuration of the facial nerve and also opens up the opportunity to plan and execute operations in a way that minimizes nerve contact.

Diffusion MRI characteristics assessed by apparent diffusion coefficient (ADC) histogram analysis in head and neck squamous cell carcinoma (HNSCC) have been reported as helpful in classifying tumours based on diffusion characteristics. There is little reported on HNSCC lymph nodes classification by diffusion characteristics. The aim of this study was to determine whether pretreatment nodal microstructural diffusion MRI characteristics can classify diseased nodes of patients with HNSCC from normal nodes of healthy volunteers. Seventy-nine patients with histologically confirmed HNSCC prior to chemoradiotherapy, and eight healthy volunteers, underwent diffusion-weighted (DW) MRI at a 1.5-T MR scanner. Two radiologists contoured lymph nodes on DW (b = 300 s/m2) images. ADC, distributed diffusion coefficient (DDC) and alpha (α) values were calculated by monoexponential and stretched exponential models. Histogram analysis metrics of drawn volume were compared between patients and volunteers using a Mann–Whitney test. The classification performance of each metric between the normal and diseased nodes was determined by receiver operating characteristic (ROC) analysis. Intraclass correlation coefficients determined interobserver reproducibility of each metric based on differently drawn ROIs by two radiologists. Sixty cancerous and 40 normal nodes were analysed. ADC histogram analysis revealed significant differences between patients and volunteers (p ≤0.0001 to 0.0046), presenting ADC distributions that were more skewed (1.49 for patients, 1.03 for volunteers; p = 0.0114) and ‘peaked’ (6.82 for patients, 4.20 for volunteers; p = 0.0021) in patients. Maximum ADC values exhibited the highest area under the curve ([AUC] 0.892). Significant differences were revealed between patients and volunteers for DDC and α value histogram metrics (p ≤0.0001 to 0.0044); the highest AUC were exhibited by maximum DDC (0.772) and the 25th percentile α value (0.761). Interobserver repeatability was excellent for mean ADC (ICC = 0.88) and the 25th percentile α value (ICC = 0.78), but poor for all other metrics. These results suggest that pretreatment microstructural diffusion MRI characteristics in lymph nodes, assessed by ADC and α value histogram analysis, can identify nodal disease.

Purpose: Various 'positive-contrast' neurographic methods have been investigated for imaging the extracranial course of the facial nerve. However, nerve visibility can be inconsistent with these sequences and may depend on the composition of the parotid gland, limiting consistent identification. To address this, we describe and evaluate a negative-contrast method for imaging of the extracranial facial nerve using three-dimensional variable flip angle turbo spin echo (VFA-TSE) imaging. We investigate strategies for further optimization, including parotid-specific VFA-TSE optimization and the use of gadolinium-based contrast agent (GBCA). Methods: 6 healthy volunteers and 10 patients with parotid tumors underwent VFA-TSE and double echo steady state (DESS) imaging of the extracranial facial nerve at 3 Tesla. The main trunk, divisions and branches of the extracranial facial nerve were manually segmented by three radiologists, enabling CNR and Hausdorff distance computation and confidence scoring. CNR, Hausdorff distance and confidence scores were compared between sequences and between pre- and post-contrast imaging to evaluate the effect of GBCA. Results: CNR, Hausdorff distances and confidence scores were superior for VFA-TSE compared to DESS imaging. GBCA administration produced a further increase in CNR of nerve against parotid and improved differentiation of nerve from tumor. Conclusion: Imaging of the extracranial facial nerve with VFA-TSE depicts the nerve as a low signal structure ('black nerve') against the high signal parotid parenchyma ('white parotid') and outperforms positive-contrast DESS imaging in terms of CNR, segmentation consistency and confidence. The use of GBCA further increases negative contrast and improves differentiation of nerve from tumor.

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.ResultsAll 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.

Although US is one of the most used modalities for head and neck imaging, its use in the diagnosis of laryngeal abnormalities is much less widespread. The standard assessment of laryngeal abnormalities currently involves direct laryngoscopy and cross-sectional imaging (either CT or MRI) but rarely US. US is readily available, noninvasive, and radiation free, and it allows real-time imaging (with video for dynamic assessment), higher resolution than that of cross-sectional imaging, and the performance of targeted fine needle aspiration cytology or biopsy. This modality, particularly with the advent of high-resolution US, has been found to be at least comparable to CT or MRI for diagnosis of malignant lesions and benign abnormalities such as vocal nodules, polyps, cysts, and Reinke edema. Furthermore, it has been found to be more sensitive for diagnosis of abnormalities such as small glottic tumors, and its dynamic capability can be used to identify functional abnormalities such as vocal cord palsy. The authors outline the technique of laryngeal US, which includes strategies to avoid calcified laryngeal cartilage by imaging through the thyrohyoid and cricothyroid membranes with a five-sweep strategy supplemented by cine film of the technique. They also provide US images of common laryngeal abnormalities such as tumors with and without extralaryngeal extension; vallecular, thyroglossal, and vocal cord cysts; laryngeal mucoceles; and vocal cord palsy. Online supplemental material is available for this article.©RSNA, 2020.