Head and Neck Imaging: A Multi-Disciplinary Team Approach

600 Pages·2021·291.725 MB·English

by  Taranjit Singh Tatla, Joseph Manjaly, Raekha Kumar and Alex Weller

Editors
Taranjit Singh Tatla, Joseph Manjaly, Raekha Kumar and Alex Weller
Head and Neck Imaging
A Multi-Disciplinary Team Approach
1st ed. 2021
Editors
Taranjit Singh Tatla
ENT - Head and Neck Surgery, London North West University Healthcare NHS Trust, London, UK
Joseph Manjaly
ENT, Royal National ENT Hospital and University College London Hospitals, London, UK
Raekha Kumar
Radiology, West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK
Alex Weller
Radiology, St George’s Hospital NHS Trust, London, UK
ISBN 978-3-030-80895-2 e-ISBN 978-3-030-80897-6
https://doi.org/10.1007/978-3-030-80897-6
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Foreword
It should be stated from the outset that Valerie and I from the very beginning of our training in
ENT/Head and Neck grew up in an environment where multidisciplinary team working was
already established at the Royal National Throat, Nose and Ear hospital, having commenced in the
1960s. The huge bene�it and knowledge we obtained from the weekly 2-hour meeting at which all
the important Head and Neck cases were presented by the senior radiologists, senior pathologists
and senior surgeons was invaluable. Our combined surgical/radiotherapy clinic ran with all the
paramedical staff, senior specialist nurses, prosthodontists and social workers. It was immensely
bene�icial to patients and staff alike. We are, therefore, entirely supportive of this type of
multidisciplinary learning and are delighted to be asked to write this Foreword. It is fortunate that
in the United Kingdom the management of most Head and Neck patients is nowadays discussed in
a multidisciplinary team environment.
Whilst it has always been preferential to have as much understanding and exchange of
knowledge between specialities as possible, it is a fact that traditionally most information has been
gleaned from books and journals dedicated just to one’s own discipline. The multidisciplinary
approach has been adopted to improve communication and management of the patient and
nowhere is this more important than in the complex area of the Head and Neck.
In this excellent book, each topic is discussed by both surgeons and radiologists, plus important
additional specialities where appropriate, an approach which has obvious bene�its and should be
emulated in future books. Multidisciplinary working is not yet common in many countries and
indeed it is to be hoped that this book will not only assist the learning of all trainees and
consultants within the UK but help to expand the principles of multidisciplinary working to our
international colleagues.
The substantial content and quality of the illustrations in the book make it an outstanding
contribution on the subject and the inclusion of relevant case histories emphasises the key points
in many of the chapters, so that the learning process is enjoyable, clear and memorable for readers
in the many different disciplines that care for Head and Neck patients.
We personally commend the wide choice of topics and in particular, the inclusion of plain �ilm
radiology as there are still areas of the world where this is essential radiology in the absence of
more advanced imaging techniques. We wholeheartedly recommend this book. It is well thought
out, carefully compiled and is a distinct advance on many of its predecessors.
David Howard
Valerie Lund
Preface
“Let’s make a book that delivers radiology to the surgeon, and surgery to the radiologist…”
The year 2020 marks the 125th year since the accidental discovery of x-rays by Wilhelm
Roentgen, a German mechanical engineer who found that electromagnetic radiation could be used
to contrast tissue detail within the body. The �irst x-ray image created was that of his wife’s hand,
differentiating her metallic wedding ring from bony and soft tissue detail. Within the year, a
radiology department was opened in Glasgow boasting pictures of a penny lodged in a young
child’s throat and kidney stones.
Since that time, many other signi�icant developments and inventions in relation to radiological
imaging have appeared: the advent of clinical ultrasound and nuclear medicine imaging in the
1950s, the introduction of the �irst commercially viable CT scanners in 1967, and modern whole-
body magnetic resonance imaging in the late 1970s.
Modern hospitals and services are now designed and delivered, often at signi�icant expense,
with a plethora of radiological and endoscopic imaging platforms, all procured with the intent of
diagnosing and treating diseases affecting a variety of organs and tissues in the body. These
complement a whole host of other scienti�ic investigations and measurements that inform on body
organ integrity and physiological function. There are a variety of manufacturers for imaging
equipment, ranging from small enterprises and novel imaging start-ups through to multinational
medical technology powerhouses. Some may specialise and target speci�ic markets and
specialisms, even speci�ic diseases or pathologies, whereas others may be generic and cross-cut
specialty and organ distinctions.
The National Health Service in the UK, since its formation in 1948, has witnessed and evolved
itself amidst all of the aforementioned technological advances. Designed as a public service to be
free nationally at the point of delivery, based only on clinical need and not ability to pay, it has
sought to remain �inancially viable in a world of increasing technological advance, innovation and
healthcare cost. The requirement to make rational, evidence-based, cost-effective and clinically
effective decision-making, with the available diagnostic armamentarium, has necessitated the
development of national guideline forming bodies such as NICE (National Institute for Clinical
Health and Care Excellence) that advise healthcare providers and commissioners for services, as
well as healthcare professionals and the general public.
Local services are increasingly organised through interdisciplinary consensus and
multidisciplinary teams, with centralisation of specialist surgical services in technology and
manpower heavy units. In recent years for the specialty of ENT-Head and Neck (H&N), MDTs have
emerged not only for head and neck/thyroid cancer management, but also for head and neck
trauma, craniofacial disease and reconstructive surgery, anterior and lateral skull base disease,
otological disease, voice and swallow disorders, tracheostomy care, paediatric ENT, etc. Surgeons
and radiologists are core members in many of these MDTs. For each professional group, there is an
overarching requirement for shared language and knowledge base to avoid miscommunication
and error in decision-making and management, as well as necessary managerial oversight and
clinical governance arrangements. Traditionally, these professional groups have trained and learnt
the necessary core specialty knowledge in silos, that is to say, radiologists have been trained by
radiologists, surgeons by surgeons, etc; the majority of courses, conferences, training programmes,
books, etc., are designed to be delivered with focus and speci�icity to the subspecialist group. In
the evolving real world of the NHS however, the above focus for MDT discussion and consensus
seeking requires reconsideration for the training models and materials used to ensure success in
quality, patient-focused care delivery.
The H&N radiologist tasked with providing the most cost-effective, most convenient and
accessible radiological imaging solution (also radiology-guided therapy and interventions) needs
to be well versed not only in the advanced knowledge, evidence base and guidelines for radiology
imaging modalities, but also in the alternative rigid and �lexible endoscopic imaging and therapy
solutions available. They also need to be experts in the anatomy and pathophysiology of the H&N
organs, with insight and awareness of both medical and surgical interventions in disease
management, as well as minimally invasive options, i.e. radiology/endoscopy-guided interventions
with reduced morbidity and mortality for patients. Not all of these options may be available within
the local facility or organisation; knowing the options and limitations allows the suitable mapping
of suitable inter-organisational care pathways with patient safeguard and focus.
This textbook has emerged from the grassroots of daily NHS MDT practice and ongoing
evolution in the NHS for ENT-H&N services over the last 15–20 years. Its format mirrors that of
the London MDT ENT-H&N Imaging course that was set up in 2004 by two ENT core and higher
surgical trainees to address an existing regional hiatus in radiology training for surgeons. At the
outset, there was noted to be a pressing need to bridge a signi�icant gap in understanding between
doctor’s treating head and neck disease patients and radiologists who oversaw the process of scan
requests, interpretation and performance.
Trainee surgeons had little training on interpreting the various imaging modalities, and trainee
radiologists had very little clinical exposure and patient interaction (except short-lived when the
patient attended for the scan). For the latter, the interpretation of scans therefore was potentially
inaccurate and abstract as an exercise. The course (and in turn this book which has followed)
attempts to provide a clinical and illustrated context to both audiences so that learning and patient
care can be enhanced. Not dissimilar to the phenomenon of an MDT approach to service delivery,
which although increasingly popular in the UK remains relatively new or non-existent in other
parts of the world, providing training with an MDT focus too is a relatively new concept.
The invited co-authors for each chapter in this book were allowed some creative freedom to
write and present on the topics as per their interpretation and local “MDT” consensus. Most if not
all the chapters have at least one surgeon and one radiologist and other multidisciplinary
professionals represented. Some already work in ENT-H&N MDT teams within their own local
hospitals across London and the UK. Others were invited for co-authorship based on established
national reputation and recognised authorities on chosen topics. For all, however, quite clear
guidelines were provided on the context for the book and the need to maintain some brevity for
text, ensuring it was “picture dominant”, presented and organised with consideration for MDT
working and guideline/evidence-based care wherever possible. This creative licence inevitably
has meant that chapters are not wholly uniform in structure and presentation. MDT practice, in
reality, varies from team to team and unit to unit, based on the active participation of varied team
members, mutual respect for inter-linked professional groups and maintenance of knowledge base
and evidence-based practices. We trust this heterogeneity for a common approach can be
appreciated and embraced by the reader.
We hope this textbook shall demonstrate itself as an invaluable multidisciplinary resource in
years to come, appealing to an international readership. We hope it succeeds in presenting the
global context of imaging for head and neck diseases, with insight and respect for the various
members of the multidisciplinary team. We also hope that it provides a strong platform for further
multidisciplinary, professional collaborations in establishing evidence-based and consensus
guidelines where they may still be missing. For developing real-world MDT audit and research
ideas where needed, evolving emerging novel imaging technologies appropriately suited for
purpose amidst the current imaging landscape and identi�ied gaps and challenges. Overarchingly
we hope it may contribute to success in efforts for improving patient-focused head and neck MDT
services and training at the loco-regional, national and international level.
This book is dedicated to our many respected teachers over the years, as well as many
enquiring and eager trainees who have ensured our knowledge base and practice has remained
evidence-based and patient-focused. During the last 7 years whilst our vision of a textbook was
realised through exhaustive efforts amidst busy career and personal life events, we have been
indebted to the many colleagues who delivered material as per their word, as well as our dear
beloved families who have sacri�iced precious and incalculable family time in support.
Taranjit Singh Tatla
Joseph Manjaly
Raekha Kumar
Alex Weller
London, UK
London, UK
London, UK
London, UK
Contents
1 On Call Modality Selection: Is the Plain Film Dead?
Jagdeep S. Virk and Ravi K. Lingam
2 Head and Neck Ultrasound for Acute Admissions and in the Lump Clinic
Dominic St Leger, Joseph Manjaly and Erin Sturdy
3 CT - The Workhorse Head and Neck Imaging Modality
Jane Adam, Enyi Ofo and Ashraf Messiha
4 Head and Neck Fascial Planes and Deep Neck Space Imaging
Taranjit Singh Tatla, Annakan Navaratnam, Daren Gibson and Alex Weller
5 Imaging the Uni�ied Airway
Romana Kuchai, Elizabeth Hodge, Daren Gibson, Ahmad Hariri and Taranjit Singh Tatla
6 Friday Night Head and Neck Trauma
Kathleen Fan and Steve E. J. Connor
7 Imaging of the Temporal Bone in Hearing Loss
Elinor Warner, Magdalena Dziedzic, Ravi Kumar Lingam and Arvind Singh
8 Radiology of Head and Neck Cancer
Steven Colley, Paul Pracy and Christopher Jennings
9 Sinonasal Radiology
Claire Hopkins and Steve Connor
10 Benign Salivary Gland Disease: Imaging, Diagnosis and Minimally Invasive Treatment
Rose Ngu
11 Radiological Imaging for Non-traumatic Paediatric ENT Conditions
Jahangir Ahmed, Yogesh Bajaj and Curtis Of�iah
12 Evidence-Based Imaging for Thyroid and Parathyroid Disease Management
Taranjit Singh Tatla, Elena Boyd and Hassan Hirji
13 Imaging of the Lateral Skull Base and Cochlear Implants
Fiona McClenaghan and Robert Nash
14 Anterior Skull Base and Sinonasal Surgery: Dilemmas and Complexities in
Management
Jagdeep S. Virk, Luke Dixon, Gitta Madani and Peter Clarke
15 Imaging in Swallow Disorder
Taranjit Singh Tatla, Ramkishan Balakumar, Roganie Govender, Jamal Hayat, Daren Gibson and
Evgenia Mainta
16 The Problematic Middle Ear and Cholesteatoma
Andrew Hall, Ravi K. Lingam and Arvind Singh
17 Challenges in Sinonasal and Anterior Skull Base Imaging
Mohiemen Anwar, Gitta Madani, Hesham Saleh and William Grant
18 Dysphagia Following Treatment for Head and Neck Cancer
Mohiemen Anwar, Justin Roe, Margaret Coffey and Peter Clarke
19 Imaging Considerations for Laryngeal Cancer Surgery
Taranjit Singh Tatla, Raekha Kumar, Francesca Fiorini and Alex Weller
20 3D Imaging, 3D Printing and Additive Manufacture in Complex Reconstruction and
Craniofacial Surgery Planning
Jason Watson, Nadine Hachach-Haram, Niall Kirkpatrick and Dilip Srinivasan
21 Imaging for Anterior Neck Trauma
Taranjit Singh Tatla, Charlotte McIntyre, Heide Mills, Zi Wei Liu and Roy Farrell
Index
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
T. S. Tatla et al. (eds.), Head and Neck Imaging
https://doi.org/10.1007/978-3-030-80897-6_1
1. On Call Modality Selection: Is the
Plain Film Dead?
Jagdeep S. Virk1 and Ravi K. Lingam2
(1) Head and Neck Consultant, London, UK
(2) Northwick Park & Central Middlesex Hospitals, London North West University Healthcare
NHS Trust, London, UK

Keywords Lateral soft tissue neck radiograph – OPG – CT – Paediatric differentials – Anatomical
correlation – Foreign body ingestion – Deep soft tissue neck infection – Retropharyngeal
collection – Modi�ied Stenvers projections
Introduction
Despite the availability of potentially more sophisticated imaging modalities, plain radiographs of
the spine, airway and upper aerodigestive tract still remain useful adjuncts in the evaluation and
management of upper airway problems. Plain �ilm imaging is readily accessible, quick to perform
and incurs low radiation doses. The most commonly performed radiograph in otolaryngology is
the single lateral soft tissue neck view, while oro-maxillofacial surgeons often employ the
orthopantomogram (OPG). In the UK, the main caveat remains that the radiographs are often sub-
optimally reviewed and provisionally reported in the emergency department and outpatient clinic
settings [1].
Lateral Soft Tissue Neck Radiograph
A lateral soft tissue neck radiograph is a relatively cheap and readily available investigation that
provides good clinical value. It has a role in both acute and chronic scenarios. In the emergent
setting, it adds value in the assessment of impacted foreign bodies, food boluses, deep neck space
infections (DNSI) and trauma. On an outpatient basis, these �ilms can help to assess in grading
adenoidal hypertrophy, particularly in the paediatric subgroup. Crucially, correlating imaging
�indings with clinical evaluation is required [1].
Normal Anatomy and Calci�ications
Important radiological landmarks include the C3 vertebra (denotes the level of the hyoid bone)
and the C6 vertebra (denotes the transition point of the pharynx and larynx to the oesophagus and
trachea, respectively). Prevertebral soft tissue has variable thickness depending upon the
vertebral level, neck positioning and patient age. Some studies suggest absolute normal
measurements less than 7 mm at the level of C2 and up to 14 mm at the level of C6. However, as a
reasonable rule-of-thumb in adults, above the level of C3/4 the soft tissue thickness should be less