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Background Whilst delayed post-gadolinium MRI has led to a shift in the diagnostic paradigm of Meniere’s Disease (MD), there remains a strong desire to develop a non-contrast enhanced MRI technique to detect and monitor MD. The endolymphatic space (ES) undergoes hydropic expansion in Ménière’s Disease (MD) and the concentration of sodium ions in the endolymph is at least 10 times lower than that in the perilymph. It was hypothesised that the lower sodium ( 23 Na) concentration in the endolymph relative to the surrounding perilymph would result in a differential reduction in 23 Na-MRI signal in inner ears with endolymphatic hydrops (EH). This proof of principle study explored the feasibility of 7-Tesla (7T) 23 Na-MRI to lateralise EH ears in unilateral MD. Methods In this prospective study, 7T 23 Na-MRI was performed in participants with both unilateral definite MD and severe vestibulo-cochlear EH on a delayed post-gadolinium real inversion recovery sequence. Two blinded independent observers qualitatively graded the visibility and anatomical compatibility of inner ear 23 Na MRI signal intensity (NaSI), before and after registering to 3D T2-weighted (T2w) MRI and determined the certainty of EH laterality. The internal auditory meatus (IAM), cochlea and vestibule were segmented using 3D Slicer and NaSI was quantified. Inner ear median NaSI were scaled to the adjacent IAM median NaSI and compared between the two ears. Results In 4 unilateral MD participants (mean age 60.3 years, 2 men), both observers correctly predicted EH laterality in 1/4 before and 3/4 participants after fusion to 3D T2w MRI. There was no incorrect lateralisation of EH by either observer, either before or after registration and fusion. In the 3 participants correctly lateralised, quantitative analysis revealed the median inner ear NaSI scaled to the ipsilateral IAM was 1.2–2.8 times higher in the normal cochlea and 1.9–2.9 times higher in the vestibule, compared to the EH ear. Intraclass correlation coefficient for inner ear median NaSI was 0.70. Conclusion This exploratory study revealed the potential for severe EH to be qualitatively and quantitatively lateralised with 7T 23 Na MRI in patients with unilateral definite MD. Trial registration NCT04370366; registered 29/4/20.

ObjectivesTo determine the frequency, morphologic and demographic characteristics, and clinical relevance of the mineralisation of six skull base ligaments (interclinoid, caroticoclinoid, petrosphenoid, posterior petroclinoid, pterygospinous, and pterygoalar).MethodsThis is a retrospective review of 240 CT scans of the paranasal sinuses (ages 6–80 years). A limited systematic review was performed primarily using Embase and Medline databases.ResultsLigamentous mineralisation was well delineated on CT and occurred at ≥ 1 location in 58.3% of patients. There was a nonsignificant trend towards a greater incidence with advancing age. The interclinoid and posterior petroclinoid ligaments were most commonly mineralised (22.1% and 18.3%, respectively); the petrosphenoid and pterygoalar ligaments were least frequently mineralised (10.8% and 6.3%, respectively). The mean age of patients with posterior petroclinoid mineralisation was significantly greater than those with interclinoid and petrosphenoid mineralisation and was not seen in patients aged 6–20 years. The literature review highlighted the clinically relevant potential for mineralised ligaments to cause barriers to surgical access (e.g. to the foramen ovale), increase the risk of neurovascular injury during surgery at the skull base (e.g. during anterior clinoidectomy), and predispose to neural impingement.ConclusionsSkull base ligamentous mineralisation is commonly encountered on CT imaging. Given the potentially significant clinical implications, an understanding of the morphological appearances is of importance to those planning interventions at the skull base. To the authors’ knowledge, this study is the first to comprehensively evaluate such a wide range of skull base ligaments using CT. For some ligaments, the incidence on CT has not been previously described.

Objectives The primary objective was to determine whether the narrowest dimensions of the labyrinthine facial nerve (LFN) canal on the symptomatic side in patients with unilateral recurrent Bell's palsy (BP) differ from those on the contralateral side or in asymptomatic, age‐ and gender‐matched controls on computed tomography (CT). The secondary objectives were to assess the extent of bony covering at the geniculate ganglion and to record inter‐observer reliability of the CT measurements. Methods The dimensions of the LFN canal at its narrowest point perpendicular to the long axis and the extent of bony covering at the geniculate ganglion were assessed by two radiologists. Statistical analysis was performed using the Wilcoxon signed‐rank and Mann‐Whitney U tests (LFN canal dimensions) and the Chi‐squared test (bony covering at the geniculate ganglion). Inter‐observer reliability was evaluated using Intra‐Class Correlation (ICC) and Cohen's kappa. Results The study included 21 patients with unilateral recurrent BP and 21 asymptomatic controls. There was no significant difference in the narrowest dimensions of the ipsilateral LFN canal when compared to the contralateral side or controls (P = .43‐.94). Similarly, there was no significant difference in the extent of bony covering at the geniculate ganglion when compared to either group (P = .19‐.8). Good inter‐observer reliability was observed for LFN measurements (ICC = 0.75‐0.88) but not for the bony covering at the geniculate ganglion (Cohen's kappa = 0.53). Conclusion The narrowest dimensions of the LFN canal and the extent of bony covering at the geniculate ganglion do not differ in unilateral recurrent BP, casting doubt over their etiological significance. Level of Evidence Level IV. Two observers evaluated the narrowest dimensions of the labyrinthine facial nerve canal and the extent of bony covering at the geniculate ganglion on computed tomography (CT), in 21 patients with unilateral recurrent Bell's Palsy and 21 matched asymptomatic controls. There was no significant difference in the dimensions of the ipsilateral (symptomatic) labyrinthine facial nerve canal or the geniculate ganglion bony covering in patients with unilateral recurrent Bell's Palsy, either when comparing to the contralateral side or to asymptomatic controls. This casts doubt over their aetiological significance of these CT findings in cases of recurrent BP.

A 19-year-old patient presented with slowly enlarging, painless, left-sided cervical mass. She had a background of multiple endocrine neoplasia 2B and had undergone a total thyroidectomy for medullary thyroid carcinoma during childhood. A cervical recurrence was therefore suspected. Ultrasonographic and MRI examination revealed a well-defined lesion within the left sternocleidomastoid muscle. Further evaluation with sestamibi and single-photon emission CT revealed elevated tracer uptake within the lesion. Cytological analysis, following ultrasound-guided sampling, revealed absent staining for calcitonin and blood samples confirmed a normal serum calcitonin level; however, the serum parathyroid hormone level was elevated. Overall, summative findings were consistent with a diagnosis of a parathyroid adenoma arising within the left sternocleidomastoid muscle. Given that this is not a location for a physiological parathyroid tissue, the adenoma might have arisen within the autotransplanted parathyroid tissue, injected into the muscular sheath during thyroidectomy. The clinical, radiological and pathological features are considered in this article.

Objectives To evaluate the diagnostic performance and reliability of MRI descriptors used for the detection of Ménière’s disease (MD) on delayed post-gadolinium MRI. To determine which combination of descriptors should be optimally applied and whether analysis of the vestibular aqueduct (VA) contributes to the diagnosis. Materials and methods This retrospective single centre case-control study evaluated delayed post-gadolinium MRI of patients with Ménièriform symptoms examined consecutively between Dec 2017 and March 2023. Two observers evaluated 17 MRI descriptors of MD and quantified perilymphatic enhancement (PLE) in the cochlea. Definite MD ears according to the 2015 Barany Society criteria were compared to control ears. Cohen’s kappa and diagnostic odds ratio (DORs) were calculated for each descriptor. Forward stepwise logistic regression determined which combination of MRI descriptors would best predict MD ears, and the area under the receiver operating characteristic curve for this model was measured. Results A total of 227 patients (mean age 48.3 ± 14.6, 99 men) with 96 definite MD and 78 control ears were evaluated. The presence of saccular abnormality (absent, as large as or confluent with the utricle) performed best with a DOR of 292.6 (95% confidence interval (CI), 38.305–2235.058). All VA descriptors demonstrated excellent reliability and with DORs of 7.761 (95% CI, 3.517–17.125) to 18.1 (95% CI, 8.445–39.170). Combining these saccular abnormalities with asymmetric cochlear PLE and an incompletely visualised VA correctly classified 90.2% of cases (sensitivity 84.4%, specificity 97.4%, AUC 0.938). Conclusion Either absent, enlarged or confluent saccules are the best predictors of MD. Incomplete visualisation of the VA adds value to the diagnosis. Clinical relevance statement A number of different MRI descriptors have been proposed for the diagnosis of Ménière’s disease, but by establishing the optimally performing MRI features and highlighting new useful descriptors, there is an opportunity to improve the diagnostic performance of Ménière’s disease imaging. Key Points • A comprehensive range of existing and novel vestibular aqueduct delayed post-gadolinium MRI descriptors were compared for their diagnostic performance in Ménière’s disease. • Saccular abnormality (absent, confluent with or larger than the utricle) is a reliable descriptor and is the optimal individual MRI predictor of Ménière’s disease. • The presence of this saccule descriptor or asymmetric perilymphatic enhancement and incomplete vestibular aqueduct visualisation will optimise the MRI diagnosis of Ménière’s disease.

Orbital cellulitis is a potentially sight and life-threatening complication of acute sinusitis, and the association with osteomyelitis is rare in the era of antibiotic-use. A 13-year-old girl presented with coryzal symptoms and severe headache, with a CT head being consistent with a diagnosis of pansinusitis and orbital cellulitis with abscess formation. She proceeded to have surgical drainage through a combined endoscopic and external approach to intraorbital abscess drainage with frontal trephine. She was also diagnosed with progressive calvarial osteomyelitis involving the right frontal bone, treated with a prolonged course of intravenous antibiotics. Our case highlights the importance of a high index of suspicion for complications of sinusitis. Multimodal imaging is essential to establish the extent of infection, and a multi-disciplinary approach is integral to manage this rare complication.

Objectives To compare the performance and optimal combination of MRI descriptors used for the diagnosis of Ménière’s disease (MD) between a real-IR sequence with “zero-point” endolymph (ZPE), and an optimised real-IR sequence with negative signal endolymph (NSE). Materials and methods This retrospective single-centre cross-sectional study evaluated delayed post-gadolinium ZPE and NSE real-IR MRI in consecutive patients with Ménièriform symptoms (8/2020–10/2023). Two observers assessed 14 MRI descriptors. “Definite MD” (2015 criteria) and “all MD” ears (wider clinical criteria) were compared to controls. Cohen’s kappa and risk ratios (RR) were evaluated for each descriptor. Forward stepwise logistic regression established which combination of descriptors best predicted MD. Results The study included 132 patients (57 men; mean age 57.7 ± 13.6), with 87 “all MD” (56 “definite”) and 39 control ears. The NSE sequence demonstrated increased perilymph SNR, and improved both diagnostic performance and reliability for 9/14 descriptors. However, ZPE demonstrated superior diagnostic performance for the best descriptor of “saccule absent, large as or confluent with the utricle” (RR 6.571, ZPE; 6.300, NSE) and that of “asymmetric perilymphatic enhancement” (RR 3.628, ZPE; 2.903, NSE). Both sequences combined these two descriptors in the optimal predictive model for “definite MD”, with “grade 2 cochlear hydrops” also significant for NSE. ZPE and NSE descriptor combinations both correctly classified 95.8% of ears. The ZPE descriptor combination performed better for “all MD” (ZPE, AUC-ROC 0.914; NSE, AUC-ROC 0.893). Conclusion Parameter optimisation with NSE Real-IR influenced the optimal selection of MRI descriptors but did not improve their diagnostic performance in definite MD. Key Points Question Delayed post-gadolinium ZPE (FLAIR) and NSE (REAL-IR) sequences are widely applied for diagnosing MD, but their relative benefits remain unclear . Findings Optimised NSE sequences improve perilymphatic depiction and influence the selection of the optimal MRI descriptors, but do not improve diagnostic performance . Clinical relevance Radiologists may continue to apply either ZPE or NSE sequences since they offer similar diagnostic abilities, but the choice of the sequence will influence which MRI features should be evaluated to support the diagnosis of MD .

Lymphatic leakage is a rare complication of thyroid surgery, the risk of which increases in the presence of malignancy and correlates with the extent of surgery. Although primarily associated with left-sided thoracic duct injuries, lymphatic leaks may occur following right-sided neck dissections for metastatic thyroid cancer. However, the development of a lymphocele following a right-sided lobectomy for benign disease is exceptionally rare. The authors present the case of a patient who developed a cervical lymphocele 10 days after a re-operative right thyroid lobectomy for a multinodular goitre. The patient was successfully managed conservatively with a combination of dietary modification and high-dose octreotide. The reason for her presentation was most likely the result of an occult injury to a congenitally-aberrant lymphatic duct, brought into the operative field by postsurgical adhesions. The case serves to highlight the importance of subtle variations in lymphatic anatomy in the context of a re-operative thyroidectomy.

Aim Pharyngeal leak (PL) and pharyngocutaneous fistula (PCF) are serious complications following total laryngectomy and their incidence is higher in the salvage setting. The aim of this study is to describe the accuracy of water soluble swallow (WSS) to rule out salivary postoperative leak after salvage total laryngectomy (STL) to expedite start of oral intake. Material and methods Retrospective study including patients undergoing STL between 2008 and 2021 at Guy’s Hospital. WSS was routinely performed within 15 days post operation. Results Sixty-six patients underwent STL. Nine developed clinically diagnosed PCF; one died before having WSS. Fifty-six patients underwent WSS post STL. WSS was performed within 15 days after STL when no postoperative complications occurred (76.8%). Among patients undergoing WSS with no clinical suspicion for fistula (56), PL was identified in 15 cases (26.8%). They were managed conservatively; PCF was avoided in 7(46.7%) cases. Three patients (7.3%) developed PCF after having started oral intake with a negative WSS. These three cases were further analysed, 2 cases where recorded at the beginning of the studied period when less experience was available possibly leading to incorrect results. Sensitivity and negative predictive value (NPV) for fistula prediction were 72.7% and 92.7%, respectively. Conclusion Taking into account the high NPV of WSS, it is safe to start oral intake after negative WSS. Further studies to evaluate its accuracy earlier on after SLT are justified taking into account the results and the impact that delayed feeding has on patient’s quality of life.

Purpose To compare the calibre of the cochlear (CN), superior vestibular (SVN) and inferior vestibular (IVN) nerves on magnetic resonance imaging (MRI), both between Ménière’s Disease (MD) ears and clinical controls, and between inner ears with and without endolymphatic hydrops (EH) on MRI. Methods A retrospective case–control study evaluated patients undergoing MRI for suspected hydropic ear disease from 9/2017 to 8/2022. The CN, SVN, IVN and facial nerve (FN) diameters and cross-sectional areas (CSA) were measured on T2-weighted sequences whilst EH was evaluated on delayed post-gadolinium MRI. Absolute nerve calibre (and that relative to the FN) in unilateral definite MD ears (2015 Barany criteria) was compared to that in both asymptomatic contralateral ears and clinical control ears. Nerve calibre in ears with severe cochlear and vestibular EH was compared to ears without EH. t tests or Wilcoxon signed-rank test/Mann–Whitney U test were applied ( p  < 0.001). Results 173 patients (mean age 51.3 ± 15.1, 65 men) with 84 MD (62 unilateral) and 62 clinical control ears were studied. Absolute and relative CN dimensions were decreased in both MD ears (CSA and diameter) and the contralateral asymptomatic ears (CSA) when compared to clinical controls ( p  < 0.001). Absolute nerve dimensions were reduced in both severe vestibular EH (CN, IVN and SVN) and severe cochlear EH (CN) ( p  < 0.001), however this was not evident when adjusted according to facial nerve calibre. Conclusion There is decreased absolute CN calibre in both symptomatic and asymptomatic MD ears as well as ears with severe cochlear and vestibular EH on MRI.