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We report the imaging and clinical findings in 3 patients with osteoradionecrosis of the styloid process, an uncommon consequence of radiation therapy for head and neck malignancy.

OBJECTIVE The aim of this study was to present the imaging findings of pleural metastases from head and neck cancer and correlate them with prognosis for overall survival, which to our knowledge have not received much attention in radiology literature. METHODS We reviewed 23 cases of head and neck cancer with pleural metastases that were seen on head and neck imaging. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT imaging findings were reviewed. The location and cell type of the primary cancer were studied. The effect of the pleural metastases on patient survival was analyzed. RESULTS Twelve (57%) of the 21 cases of pleural metastasis were missed initially on the neck CT but were visible in retrospect. Nine of 11 patients whom we had followed up for 1.5 years or longer have died, often within a few of months of presenting with pleural metastases. CONCLUSIONS The presence of pleural metastasis in head and neck cancer is an extremely poor prognostic indicator for survival. They are potentially missed on the neck CT. Given its significant clinical impact, head and neck radiologists should specifically look for pleural metastasis when reviewing imaging studies of patients with head and neck cancer.

BACKGROUND AND PURPOSE Human papillomavirus (HPV)-positive oropharyngeal cancers represent a distinct clinical entity with more favorable prognosis than do HPV-negative oropharyngeal cancers. However, among patients with HPV-positive oropharyngeal carcinomas, those with a significant smoking history have a much worse prognosis. Recently, imaging characteristics of oropharyngeal cancers were identified as markers of poor prognosis. The purpose of this study was to determine whether nodal imaging characteristics differ between smokers and never/light smokers with HPV-positive oropharyngeal cancer. MATERIALS AND METHODS A review of 130 pretreatment computed tomographic examinations of HPV-positive oropharyngeal cancers in smokers (>10 pack-years) and never/light smokers (10 pack-years) matched for T stage and tumor subsite was performed, with the reviewing radiologist blinded to the HPV status, smoking history, and clinical stage. Additionally 24 pretreatment computed tomographic examinations of patients with HPV-negative oropharyngeal cancers were also reviewed in a blinded fashion. Imaging characteristics of metastatic nodal disease were compared using the testing (Fisher exact testing where appropriate) and McNemar testing for the matched-pair analysis. RESULTS As expected, those with HPV-positive oropharyngeal cancer were more likely to be younger, male, non-Hispanic white, never/former smokers, and never drinkers than were those with HPV-negative oropharyngeal cancer. Furthermore, the HPV-positive oropharyngeal cancers were more likely to be in the tonsil, smaller T category, higher N category, poorly differentiated, than were the HPV-negative oropharyngeal cancers. However, among the HPV-positive oropharyngeal cancers, we could identify no obvious difference in the pretreatment imaging characteristics of paired smokers and never/light smokers. CONCLUSIONS Among the patients with HPV-positive oropharyngeal cancer, no imaging characteristics were identified to correlate with the critical prognostic feature smoking status. Cystic and necrotic nodal metastases, as described previously, were more common among the patients with HPV-positive than those with HPV-negative oropharyngeal cancers. Although cystic nodal metastases were more common among the never/light smokers with HPV-positive oropharyngeal cancer than among smokers with HPV-positive oropharyngeal cancer, however, because these results did not reach statistical significance, we concluded that the imaging results cannot serve as a surrogate for an HPV-driven phenotype.

Purpose The goal of this study was to describe computed tomographic findings in patients with clinically proven temporal bone (TB) osteoradionecrosis (ORN) (TB-ORN). Materials and methods Computed tomographic scans of 20 patients were retrospectively evaluated for bony and soft tissue abnormalities. Clinical severity was graded based on level of therapy administered: mild (observation), moderate (antibiotics/hyperbaric oxygen), or severe (surgery). Results Radiation dose to the primary tumor ranged from 30 to 75.6 Gy. Time to onset of ORN from completion of radiation therapy was 2 to 22 years (median, 7 years). Clinical findings exposed bone, 20 of the 20 patients; otorrhea, 17 of the 20 patients; hearing loss, 11 of the 20 patients; otalgia, 10 of the 20 patients; facial nerve paralysis, 2 of the 20 patients; gait imbalance, 2 of the 20 patients. Computed tomographic findings: external auditory canal erosions, 18 of the 20 patients; mastoid effusion, 18 of the 20 patients; mastoid bony coalescence, 5 of the 20 patients; enhancing soft tissue, 6 of the 20 patients; soft tissue gas, 6 of the 20 patients; temporomandibular joint/condylar erosion, 3 of the 20 patients.Three patients developed an abscess. Conclusion Mastoid effusion and external auditory canal erosions are commonly seen with TB-ORN. Clinically moderate or severe cases of TB-ORN are more likely to demonstrate enhancing soft tissue (P = 0.002), soft tissue gas (P = 0.002), and temporomandibular joint involvement (P = 0.07).

Our purpose was to present 3 cases of perineural tumor spread (PNS) to the oculomotor (CN III) nerve. To our knowledge, PNS to CN III has not been previously reported. In the course of advanced PNS, typically with involvement of the cavernous sinus, tumor may spread in a retrograde fashion to involve CN III in the interpeduncular fossa and can even invade the brainstem.

Perineural spread along the nasociliary branch of the ophthalmic nerve has not been previously described, to our knowledge. One case of cutaneous squamous carcinoma at the medial canthus and another of melanoma of the nasal ala, with nasociliary nerve perineural spread, are illustrated here. Whereas magnetic resonance imaging is preferred to search for perineural spread, computed tomography may also demonstrate perineural thickening and enhancement. Awareness of the computed tomography appearance of perineural spread will aid in avoiding misdiagnosis.

We reviewed MR and CT myelographic studies in patients with the Klippel-Feil syndrome (KFS) to determine the patterns of associated congenital and acquired abnormalities of the spine and spinal cord and to correlate these radiologic findings with the manner of clinical presentation. Twenty-four consecutive patients with radiologically definite KFS were evaluated by a cross-sectional imaging technique (CT or MR) over a 6 year period. Radiologic images were blindly interpreted by a panel of three experienced neuroradiologists and then correlated with clinical history. Cervical spondylosis or disk herniations were the most common radiologic abnormalities encountered, seen in 10 (42%) of the 24 patients. While some clustering of these secondary degenerative changes occurred at levels immediately adjacent to the fused vertebrae, in most patients spondylotic changes were seen widely distributed throughout the lower cervical region. Coexisting congenital defects of the spinal cord or brain were encountered in seven patients, six of whom were female, consisting of cervical cord dysraphism or diastematomyelia (n = 5) and Chiari I malformations (n = 2). In only eight patients (33%) had the diagnosis of KFS been suspected clinically prior to imaging by the presence of short neck, limited cervical mobility, or low occipital hairline. In the remaining 16 patients, mostly adolescents or adults being evaluated for cervical sensory or motor syndromes, the diagnosis of KFS was made radiologically at the time of the imaging referral.

Imaging plays an important role in the staging of carcinoma of the nasopharynx. Accurate staging is necessary as the treatment is directly dependent on stage. Clinical examination provides information on mucosal involvement but is unable to determine the deep extension or presence of skull base invasion or intracranial spread. The 1997 International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC) staging manuals were a collaborative project that provided a unified classification for nasopharyngeal carcinoma (NPC). The majority of staging can be identified only on imaging and not by clinical examination. The intent of this article is to provide information on the specific imaging findings that will directly affect the stage and treatment of NPC.

Temporal bone involvement in Paget disease can result in hearing loss by a variety of mechanisms. One such mechanism is compression of neural structures within the internal auditory canal. This report describes such a case. Magnetic resonance imaging characteristics are discussed, including the appearance of Paget disease following Gd-DTPA administration.

We describe the imaging and clinical features of a patient presenting with a posterior cervical space mass. The only abnormality identified on CT was a variant muscle, the levator claviculae. Radiologists are cautioned to be familiar with this muscle and its appearance to avoid misdiagnosing it as pathologic.