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Reflections |
1 From the Department of Radiology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston 02114. Received December 16, 1999; revision requested January 25, 2000; final revision received June 15; accepted August 4. Address correspondence to the author (e-mail: alweber1@aol.com).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE BEGINNING OF HEAD...PROCEDURES IN HEAD AND...INTRODUCTION AND EVOLUTION OF...THE PRACTICE AND EVOLUTION...TEACHING IN HEAD AND...THE FUTURE OF HEAD...REFERENCES |
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Index terms: Head and neck • Neck, abnormalities • Neck, radiography • Skull, abnormalities • Skull, radiography
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONTHE BEGINNING OF HEAD...PROCEDURES IN HEAD AND...INTRODUCTION AND EVOLUTION OF...THE PRACTICE AND EVOLUTION...TEACHING IN HEAD AND...THE FUTURE OF HEAD...REFERENCES |
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The experiment was repeated on February 15, 1896, at the laboratory of the Western Electric Company in Chicago, Ill. A radiograph of a hand was successfully reproduced by inventor C. E. Scribner and called a "shadowgraph." Alan Campbell Swinton (1863–1930) of Great Britain, an electrician and photographer, is credited with obtaining the first radiograph of coins and also with obtaining a radiograph of his own hand on January 7, 1896. This was reported in the New York Times and The Lancet (2). A fractured ulna was successfully imaged on February 3, 1896, at Dartmouth College in Hanover, NH (3).
In these early years, x rays were being used by physicists, engineers, photographers, and a few physicians. In the last group was Walter B. Cannon, MD, who reported on motility studies in the gastrointestinal tract (4), and Francis H. Williams, MD, an internist at Boston City Hospital (Mass), who reported his clinical observations on fluoroscopy of the heart and lungs with the publication of a 532-page book on the subject in 1901 (5).
At the turn of the 20th century, glass plates were being used for obtaining images. They were heavy, expensive, and cumbersome to handle, especially for ward rounds anddemonstrations in clinics. After 1918, the glass plates were replaced with films made of cellulose acetate. This equipment was equally primitive, consisting of static machines, then a coil and mechanical interrupter, and, finally, the transformer (6).
The radiation exposures to the early investigators were excessive and shielding was inadequate; this led to radiation burns. Many early radiologists developed radiation dermatitis and eventually died of radiation-induced tumors (7). They often were mutilated from the multiple surgical procedures that were required to eradicate areas of radiation necrosis. Walter J. Dodd, MD (1869–1916), who was first a photographer, then a pharmacist, and eventually, after graduation from medical school, the first roentgenologist at Massachusetts General, underwent a total of 50 surgical procedures and in 1916 succumbed to a malignant radiation-induced tumor (8). Dr Percy Brown, the first radiologist at the Children’s Hospital in Boston, published a biography of these martyrs of radiology (7). In 1995, on the occasion of the centennial of Roentgen’s discovery, selected biographies of these early radiologists, which were extracted from Dr Brown’s book, were published in the American Journal of Roentgenology.
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THE BEGINNING OF HEAD AND NECK RADIOLOGY: AN ERA OF CONVENTIONAL RADIOGRAPHY AND THE EARLY RADIOLOGISTS |
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TOPABSTRACTINTRODUCTIONTHE BEGINNING OF HEAD...PROCEDURES IN HEAD AND...INTRODUCTION AND EVOLUTION OF...THE PRACTICE AND EVOLUTION...TEACHING IN HEAD AND...THE FUTURE OF HEAD...REFERENCES |
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-year-old boy was obtained in October 1896 (10). In March 1896, Dr John J. MacIntyre of Great Britain obtained a radiograph of the larynx in a cadaver (11). An early article by Mount Bleyer of New York City titled "On the Photo-Fluoroscope" was published in 1896 (12) and also appeared in the first issue of Laryngoscope in July 1896 (13). He encouraged others to use x rays in laryngology. At the turn of the century, otolaryngologic applications expanded and dealt mainly with the assessment of laryngeal foreign bodies, diseases of the larynx, and the paranasal sinuses (14). Conventional radiographs were the only images available in the early years after Roentgen’s discovery. Special views were developed by different investigators to visualize the different parts of the head and neck, especially the temporal bones. These early investigators were radiologists, clinicians, and especially otolaryngologists who had a special interest in the applications of these new rays. In 1896, Dr Max Scheier of Berlin recognized the value of radiographs in patients with sinus disease (15), as did Dr Killian in 1903 (16) and Dr Cornelius Coakley, an otolaryngologist from New York City, in 1905 (17). The exposure time for the acquisition of these early sinus radiographs was long and not uncommonly resulted in hair loss. Another early investigator was Eugene W. Caldwell, MD (1870–1918), who became fascinated by x rays only 2 years after Roentgen’s discovery (18). He was first an electrical engineer but enrolled in medical school and received his MD degree in 1902 from New York’s Bellevue Medical School. He devoted his investigative work to radiology and introduced new equipment (a motor-driven tilting x-ray table connected with an x-ray tube underneath and a fluoroscopic screen above, a portable x-ray machine, and the first motorized radiograph viewer). In 1903, he wrote one of the first textbooks on diagnostic and therapeutic radiology. His interest in head and neck radiology is reflected by a view of the paranasal sinuses that still bears his name, "the Caldwell view," which is a depiction of the ethmoid and frontal sinuses that includes both orbits (Fig 1). Dr Caldwell is also credited with the recognition of radiology as a medical specialty that had heretofore been considered to be in the photographer’s realm. He died of radiation-induced metastatic skin cancer at the age of 48 as one of many of these early clinician-investigators. An annual lecture sponsored by the American Roentgen Ray Society in honor of this pioneer and martyr was established in 1920 (19).
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Special views had to be developed to depict individual parts of the temporal bone, especially the middle-ear cavity and mastoid bone, for the assessment of infection and cholesteatoma. Many investigators from Europe and the United States, radiologists and otolaryngologists, published articles dealing with these special views, which bear their names. In 1906, Dr Arthur Schüller (1874–1957), an Austrian neuroradiologist considered one of the founders of this subspecialty (20), described an oblique view of the mastoid bones (tube angled 25° caudally), which is used mainly for assessment of trauma and pneumatization of the temporal bones (21) (Fig 2). His name is part of a syndrome titled "Hand-Schüller-Christian disease," which is associated with the skull defects that he described. In addition, in 1905 he published a book, The Skull Base on the Radiogram, in which he described several projections of the skull base (21,22).
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In 1913, Dr Frederik Law published an article in which a lateral view of the mastoid bones, which was obtained by angling the tube 15° caudally and 15° toward the face to eliminate superimposition of both mastoid bones (24), was described. This projection found widespread application in the assessment of mastoid bone pneumatization and cell breakdown but lacked definition of the attic and middle-ear cavity.
For assessment of cholesteatoma associated with erosion of the spur and expansion of the attic, Drs E. D. Mayer (25) and G. R. Owen (26) introduced two similar projections (Fig 3). In 1917, Dr H. W. Stenver described a view for analysis of the petrous portion of the temporal bone (sagittal head plane rotated 45° away from the site of interest, with a 12° caudal tube angulation) (27).
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In 1914, a book by Dr Sonnenkalb, an otolaryngologist at the Ear Clinic in Jena, Germany, titled The Roentgen Diagnosis for the ENT [ear, nose, and throat] Physician, in which he summarized the various views and authors in skull and head and neck radiography (30), was published. This book is exhibited at the Roentgen museum in Remscheid-Lennep, Germany. One of the earliest (and most likely the first) books on otologic radiology, by Dr Ernst D. Mayer of Vienna, was published in 1930 (31). In 1912, Dr Hans Rhese, a German otolaryngologist, introduced an oblique view of the ethmoid sinuses that included the orbits, optic foramina, and sphenoid sinus. Even today, this projection is still occasionally used to survey orbital and optic foramen trauma (32).
Drs MacIntyre’s and Scheier’s investigation of the larynx with conventional radiography began soon after Roentgen’s discovery (11,14). In 1913, Dr Arthur Thost published the first Roentgen atlas of laryngeal disease (33). Between 1901 and 1956, he and others such as Drs Samuel Iglauer (1914), Behn Kiel (1901), H. Coutard (1922), and Preston Hickey (1928) wrote and had published articles on conventional radiography of the larynx (34).
Some of the early radiologists who studied the skull and head and neck were H. Pancoast, MD, E. P. Pendergrass, MD, and J. P. Schaffer, MD, from the University of Pennsylvania. They were neuroradiologists and head and neck radiologists who summarized their experiences in a book titled The Head and Neck in Roentgen Diagnosis, which was published in 1940 (35). Merrill C. Sosman, MD, chief of radiology at the Peter Bent Brigham Hospital and Harvard Medical School for more than 30 years since 1922, was probably one of the early subspecialists in neuroradiology and head and neck radiology. Dr. Sosman worked with Harvey Cushing, MD, who was one of the great neurosurgeons of this century, and in the 1920s wrote many articles that were concerned with abnormalities of the skull, optic chiasm glioma, craniopharyngioma, meningioma, tumor of the skull base, acoustic neurinoma, and aneurysm (36). Furthermore, on October 30, 1944, as a result of Dr Sosman’s efforts, the Department of Roentgenology became an autonomous department at Harvard Medical School and its name was changed from Roentgenology to Radiology (37). Dr Sosman, keenly aware of radiology as a specialty at the hospital and medical school, published poignant, witty articles highlighting many issues of the past and the evolution to the present and provided interesting perspectives (37).
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PROCEDURES IN HEAD AND NECK RADIOLOGY |
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Iodized oil (Lipiodol), created by Drs J. Forrestier and J. Sicard in 1921, was the first nontoxic contrast agent (40). It was first used for opacification of the epidural space and was later used for myelography. In otolaryngology, iodized oil was used for outlining the larynx (a procedure referred to as laryngography) and sialography. Examination with sialography was popularized in different countries in 1925 and 1926 by Drs T. Barsony and D. B. Carlsten, respectively (41,42). During the next 3 decades, technical refinements were made, including fluoroscopy with spot images, subtraction radiography, and tomography (43). At the time this article was written, sialography was limited to the evaluation of the duct system for stones and inflammatory disease.
Dacryocystography refers to opacification of the lacrimal drainage system, which is composed of the canaliculi, lacrimal sac, and lacrimal duct. In 1906, Dr J. Ewing obtained the first dacryocystogram by using iodized oil (44). Eventually, water-soluble contrast materials were used with conventional radiography. As new modalities, including tomography, computed tomography (CT), and magnetic resonance (MR) imaging with gadolinium, became available, they were applied in conjunction with dacryocystography in cases of inflammatory disease, stones, strictures, and benign and malignant tumors of the lacrimal system (45).
Laryngography, the demonstration of the internal structures of the larynx by using contrast material, was possible after the introduction of iodized oil. The procedure was first performed in 1926 by Dr Samuel Iglauer (46), who outlined a subglottic stricture (Fig 5). In 1942, after anesthetizing the larynx, Dr P. L. Farinas performed laryngography with a 40% solution of neoiodipin through a curved cannula (47). In 1950, the examination was further developed and refined through the efforts of Powers, who used oily Dionosil (propyliodone) after topical anesthesia (48). The main indication for laryngography was carcinoma of the larynx, with evaluation of mucosal spread, but chiefly of subglottic extension and involvement of the pyriform sinuses. The procedure was discontinued after CT became the modality of choice for laryngeal tumor evaluation in 1972.
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INTRODUCTION AND EVOLUTION OF CONVENTIONAL TOMOGRAPHY, CT, AND MR IMAGING |
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TOPABSTRACTINTRODUCTIONTHE BEGINNING OF HEAD...PROCEDURES IN HEAD AND...INTRODUCTION AND EVOLUTION OF...THE PRACTICE AND EVOLUTION...TEACHING IN HEAD AND...THE FUTURE OF HEAD...REFERENCES |
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Linear tomography was performed at a number of institutions, which included the MEEI, often in conjunction with barium examination for the evaluation of laryngeal carcinoma (Fig 7a). Linear tomography was simple, inexpensive, and necessitated only an attachment to the x-ray table and overhead tube. It also was employed for assessment of diseases of the larynx, paranasal sinuses, orbits, and lungs and for assessment of the facial bones and orbits for fractures. Professors A. Vallebona and P. L. Cova of Milan were early investigators who studied the applications of linear tomography in the head and neck, as detailed in several articles (51,52).
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Because of limitations in the detail of anatomic structures that were caused by the reciprocal tube-film movements, various modifications such as circular, elliptic, and hypocycloidal tube motions were introduced. A pluridirectional hypocycloidal unit was developed by the Massiot Company, which was a subsidiary of Philips Medical Systems in the Netherlands. This unit became available commercially in 1954. With this new piece of equipment, it was possible to obtain images of variable section thickness as small as 1 mm. The major contribution of polytomography in the head and neck occurred in the detailed assessment of lesions of the temporal bones; the paranasal sinuses, including the orbits; the facial bones; and the base of the skull. In 1960, the first polytome in the United States was installed by Dr Jesse Littleton of the Guthrie Clinic in Sayre, Penn (55). This was followed by the installation of a second unit at the University of Chicago Hospital in 1960. Dr Galdino Valvassori, a staff member at the University of Chicago Hospital since 1960, worked with this new unit and conducted research on the temporal bone. Dr Lindsey, chief of otolaryngology at the University of Chicago Hospital, had set up a temporal bone bank that was available to Dr Valvassori for research on the temporal bone. Examination of the temporal bone with the polytome led to publications in which investigators addressed conditions and procedures that included cholesteatoma, the normal internal auditory canals, otosclerosis, and posterior fossa cysternography. Their experiences were summarized and published in 1966 in a book on tomography of the temporal bone and in 1973 in an atlas by Valvassori and collaborators (56,57). Other investigators applied polytomography to the temporal bone; this technique was summarized in books by Drs K. Mundnich and K. Frey (58) and Sam Brunner (59). Research findings of tomography of the skull, which included the temporal bones, orbits, and paranasal sinuses, were published by Drs K. Reisner and J. Gosepath (60), Jacqueline Vignaud (61), and Guy Potter (62).
Hearing problems are common in the everyday ENT practice. Radiologic investigation of sensory neural hearing loss consisted of measurements of the internal auditory canals for asymmetry; more than 1–2 mm was considered abnormal. This mode of evaluation changed with the introduction of posterior fossa cysternography in 1963 by Dr H. L. Baker of the Mayo Clinic in Rochester, Minn (63). During the examination of the posterior fossa, contrast material extension into the internal auditory canals was observed. This was further explored by Dr Scanlan of Los Angeles and found to be accurate in assessing small vestibular schwannomas (64) (Fig 8). Air had also been used in conjunction with polytomography to evaluate the posterior fossa (including the internal auditory canals) for vestibular schwannomas, but after 1972 it was used widely with CT (Fig 9) (65).
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CT allowed visualization of normal and abnormal soft tissue and bone structures and was optimal for demonstration of calcifications. The application of CT in the head and neck allowed wide application for the assessment of inflammation, cysts, and benign and malignant tumors. Diseases that were heretofore out of the reach of radiologic evaluation, particularly those in the orbit, could now be identified (Fig 10). Tumor staging increased in accuracy, and surgical planning achieved greater precision, with a consequent decrease in morbidity and mortality. The conspicuity of abnormalities was further increased with the administration of iodinated contrast material. The development of spiral CT in the past few years has allowed a shorter examination time and thinner sections, with the capability of three-dimensional reconstruction. Most recently, multi–detector row CT with increased spatial resolution, with a section thickness as small as 0.5 mm and aquisition capabilities of 8 images per second, has been developed (70).
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CT has become an important imaging modality and aided the development of functional endoscopic sinus surgery (FESS). CT enables detailed analysis of the nasal cavity, in particular, the lateral nasal wall and osteomeatal complex. The therapeutic benefits of FESS have helped a large number of patients with chronic sinus disease. These scientific accomplishments resulted from the pioneering work of Professor W. Messerklinger of Graz, Austria, in the anatomy of the lateral nasal wall, mucociliary clearance, and the application of FESS (71). This work has been continued by his successor, Professor H. Stammberger of Graz. In the United States, Dr David Kennedy of the Johns Hopkins University Medical School in Baltimore introduced FESS and built on his prior experience in microscopic endonasal ethmoidectomy and observing Drs Messerklinger and Stammberger, M. E. Wiegand of Erlangen, Germany, and Wolfgang Draf of Fulda, Germany (72,73). Dr James Zinreich, a neuroradiologist and head and neck radiologist who worked with Dr Kennedy, developed the CT algorithm for assessment of the nasal cavity and the osteomeatal complex, and of the paranasal sinuses in the coronal plane; this algorithm forms the basis for evaluation of the osteomeatal complex prior to FESS (74).
A third major milestone in radiology occurred with the introduction of MR imaging. This modality provides greater soft-tissue contrast, tissue differentiation, and marginal lesion definition. It is the modality of choice for evaluation of the globe, visual pathway, and skull base but is also helpful in a wide range of other clinical and diagnostic head and neck problems, often as a supplement to CT. Diagnostic accuracy was further increased, especially in the evaluation of malignant tumors, with the simultaneous advent of gadopentetate dimeglumine as a contrast agent that could be used in conjunction with fat suppression (75).
Other imaging modalities used in the head and neck area include positron emission tomography (PET) and ultrasonography (US). PET reflects metabolic changes in tumor cells and is indicated in the head and neck for depicting an unknown primary tumor, recurrent tumor, or metastatic disease in the lymph nodes, especially those in the neck (76). US has a long history, from its development to its present state of the art. It is useful in the evaluation of diseases of the globe and cysts and tumors of the head and neck, which include those of the thyroid gland (77).
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THE PRACTICE AND EVOLUTION OF HEAD AND NECK RADIOLOGY |
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TOPABSTRACTINTRODUCTIONTHE BEGINNING OF HEAD...PROCEDURES IN HEAD AND...INTRODUCTION AND EVOLUTION OF...THE PRACTICE AND EVOLUTION...TEACHING IN HEAD AND...THE FUTURE OF HEAD...REFERENCES |
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At the beginning of our subspecialty, radiology was practiced in general and subspecialty hospitals and private offices. In the late 19th century, several subspecialty hospitals that were devoted to the practice of eye and ENT radiology were founded in the United States. These were equipped with small radiology departments and had part-time radiologists as staff members. In addition to their hospital activity, they maintained private radiologic practices that were engaged in head and neck and limited general radiology. These eye and ear hospitals included the MEEI, the Illinois Eye and Ear Infirmary, the Pittsburgh Eye and Ear Hospital (Pa), and the Manhattan and New York Eye and Ear Infirmaries. Radiologists at these specialty hospitals made meaningful contributions to the conventional radiographic diagnosis of head and neck diseases. Some of these outstanding early head and neck radiologists include the late Dr Alexander S. MacMillan, Sr, a roentgenologist from 1920 to 1960, the late Dr Alexander S. MacMillan, Jr (MEEI), the late Dr Judah Zizmor (Manhattan Eye and Ear Infirmary), the late Dr H. Schwartz (New York Eye and Ear Infirmary), and Dr L. E. Etter of Pittsburgh. These radiologists were actively engaged in teaching ENT surgeons, ophthalmologists within their own hospitals, and general radiologists on rotation from other institutions or other parts of the country who sought additional experience in the radiologic diagnosis of head and neck diseases.
At the MEEI, Dr MacMillan, Sr, was a legend, and I witnessed his work during and after my residency in radiology at Massachusetts General Hospital in the early 1960s. He would begin reporting his examinations at 7:00 AM; these consisted of conventional radiographs of the paranasal sinuses, mastoid bones, and lateral neck, and an occasional view of the skull base, mandible, or skull. Chest radiographs, routinely obtained before surgery, were interpreted in seconds, usually with one word—"normal"— in more than 90% of cases. A few barium examinations were added, along with preoperative chest radiographs. Interpretations were rendered at banks of four or eight viewing boxes, since viewing alternators were not yet available. The reports were brief—on average, three to four sentences—and written by hand, to be typed later by a secretary who was also a receptionist. Invariably, the small interpretation room, which also served as an office, was filled with ENT residents, who were radiologists from other hospitals in and outside of Boston. Teaching was brief and to the point. We were awed by this master’s descriptions of the radiographic findings that escaped most of us (78).
Dr MacMillan, Sr, was one of the first true devoted subspecialists who limited his practice to head and neck radiology, as were the other radiologists in ENT hospitals. Dr MacMillan, Sr, was a humble and kind man and a keen observer and clinician-radiologist. He was in the operating room almost daily to correlate his reported x-ray interpretations with the surgical findings. Between 1:00 and 2:00 PM, he left the hospital to attend to his private practice, which served as a referral center for Boston otolaryngologists and ophthalmologists.
The x-ray department consisted of one radiography room that contained a fluoroscope with a table and overhead tube and a chest stand. In the 1960s, a linear tomographic attachment was added. This was used chiefly for tomography of the temporal bone, sinuses, and larynx. A polytome unit was finally acquired when a new hospital was built in 1972 under the able leadership of Mr Charles Wood, former director of the MEEI, who was instrumental in getting the project underway.
This brief description is intended to highlight the beginnings of head and neck radiology in a subspecialty hospital. Dr MacMillan, Jr, followed in his father’s footsteps and, until his death in 1978, continued the high level of radiology practiced and taught at the MEEI. The field of head and neck radiology has expanded in the past 4 decades because of the efforts of many clinical and basic investigators. Dr W. Compere, a radiologist at the House Group (otology) in Los Angeles, and Dr Etter of Pittsburgh were active proponents of conventional radiography of the head and neck through publication and teaching (79,80). Dr Herman Wilbrand of Uppsala, Sweden, was one of the early subspecialists in head and neck radiology in Europe who engaged in research on the temporal bone, especially the vestibular and cochlear aqueducts (81). Dr Arnold Noyek, an otolaryngologist in Toronto, has been a tireless clinical investigator of the applications of radiology in patients with ENT diseases and written several articles on the history of head and neck radiology in collaboration with the late Dr Zizmor (13,34).
Dr Glyn Lloyd was an early subspecialist at the Moor’s Eye Hospital in London who contributed substantially to ophthalmologic and ENT radiology by writing scientific articles and two books in collaboration with Dr Eric Samuel of Edinburgh, Scotland, and Dr Peter Phelps, another well-respected head and neck radiologist, of Coventry, England (82). A book edited by Drs Galdino Valvassori, Guy Potter, Barbara Carter, and R. A. Buckingham that encompasses the ear, nose, and throat was published in 1982 and is now in its third edition, with the addition of Mahmood Mafee, MD, a prolific writer and scientific contributor to head and neck radiology (83). This was followed in 1983 by a textbook by Drs Tom Bergeron, Ann Osborn, and Peter Som, which is now in its third edition and edited by Drs Som and Hugh Curtin (84). Drs Joel Schwartz and Ric Harnsberger published a book on CT and MR imaging of the temporal bone and continue the work of the authors previously mentioned (85).
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TEACHING IN HEAD AND NECK RADIOLOGY AND THE BEGINNING OF THE AMERICAN SOCIETY OF HEAD AND NECK RADIOLOGY |
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TOPABSTRACTINTRODUCTIONTHE BEGINNING OF HEAD...PROCEDURES IN HEAD AND...INTRODUCTION AND EVOLUTION OF...THE PRACTICE AND EVOLUTION...TEACHING IN HEAD AND...THE FUTURE OF HEAD...REFERENCES |
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In 1955, for the first time, at the initiative of Drs George Guillen and M. Portmann (an otolaryngologist) of Bordeaux, France, Dr G. L. Dulac of Belgium, and Professor P. L. Cova of Milan, a group of radiologists and ENT surgeons met in Brussels to discuss imaging issues in ENT radiology. This informal group decided to meet every 4 years to discuss subjects related to ENT radiology. The next meeting took place in 1959 in Milan under the sponsorship of Professor Cova. This was followed by a meeting in Bordeaux in 1963, which was organized by Professor Portman of the same city. Present at the meeting were Drs Vignaud of the Fondation A-de Rothschild in Paris; Dr Ramon Ruenes of Mexico City; Professor Horst Wullstein (an otolaryngologist) of Wurzburg; Dr Brunner of Copenhagen; Dr Truijo-Peco of Madrid; Dr Frey of Munich; and Dr Valvassori of Chicago. All of the participants, who were radiologists as well as otolaryngologists, made meaningful contributions through books and scientific articles in the early years, most notably in tomography of the temporal bone. They recognized the need and importance of a subspecialty that dealt with imaging of head and neck diseases and thereby laid the foundation of head and neck radiology. At that meeting, the loosely structured organization was named the "International Collegium of Radiology in Otolaryngology," with the resolution to meet every 3 or 4 years.
The next meeting of the International Collegium convened in Acapulco, Mexico, in 1967 and was sponsored by Dr Ruenes, who was one of the first head and neck radiologists in Mexico and South America. This was followed by meetings in 1970 in Wurzburg (president, Professor Wullstein); in 1973 in Santiago de Compostela, Spain (president, Dr Truijo-Peco); in 1976 in Copenhagen (president, Dr Brunner); in 1979 in New Orleans, Louisiana (president, Dr Valvassori); in 1982 in Abbaye de Fontevraud, France (president, Dr Vignaud); in 1988 in Uppsala (president, Dr Wilbrand); and in 1991 in Zurich (president, Professor A. Valvanis).
Stimulated by these international meetings, Dr Valvassori, at the University of Illinois Eye and Ear Infirmary since 1965, started a 2-day postgraduate course in Radiology of Otolaryngology and Ophthalmology on the Friday and Saturday preceding the 1968 meeting of the RSNA. This course was given every year for 10 years, with an invited faculty. In 1973, the course was renamed "Radiology of the Head and Neck" and continued until 1976.
Because of the expansion of head and neck radiology as a subspecialty, which was reflected by the increased number of publications that was partly based on the introduction of CT in 1972, Dr Valvassori decided to form a new organization. In a meeting with Drs William Hanafee, Potter, and Daniel Johnson in 1976, it was decided to establish the American Society of Head and Neck Radiology (ASHNR), which became a legal nonprofit organization in February 1977.
The first meeting of the ASHNR was held at the Hotel Bonaventure in Los Angeles in May 1977, with Dr Valvassori as president. This was followed by a meeting in 1978 in New York, with Dr Potter as president. Subsequent meetings were held annually and consisted of 30-minute lectures by invited speakers, presentation of scientific papers, and brief case and poster presentations. The late Dr Kenneth Dolan of Iowa City, Iowa (86) and Dr Barbara Carter of Boston were active supporters of the society in the early stages of its development. A second course in otolaryngologic and ophthalmologic radiology was conducted by Dr Potter of Columbia University (New York City) annually for 6 years beginning in 1971. Dr Juan Taveras, former chief of radiology at Massachusetts General Hospital, conducted a 5-day course in neuroradiology beginning in 1956. Recognizing the close relationship between neuroradiology and head and neck radiology, Dr Taveras and I changed the format of the course in 1974 to 3 days of neuroradiology and 2 days of head and neck radiology.
Through technical advances (polytome), scientific publications, and meetings of the International Collegium of Radiology in Otolaryngology in Europe, head and neck radiology had become firmly established as a subspecialty. In the ensuing years (1960–1979), a close relationship between the Intercollegium of Radiology and the ASHNR developed and culminated in the first joint meeting in 1979 in New Orleans. The establishment of the ASHNR in 1977 was followed by the founding of the European Society of Head and Neck Radiology (ESHNR) in 1983 by Drs Vignaud and Wilbrand, with the support of the ASHNR. At that meeting, two representatives from each attending western European country were present and selected Dr Wilbrand as their first president for a period of 4 years, followed by Drs Reisner of Germany and A. Chiesa of Italy. The international status and cooperation of the ASHNR and ESHNR was further strengthened by the creation of the Japanese Society of Head and Neck Radiology by Professor Takahashi of Kumamoto, Japan, in 1990. This society was expanded to the Asian and Oceanic Society in 1994. All three societies conducted an international meeting in Kumamoto in October 2000 under the sponsorship of Professor Takahashi.
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THE FUTURE OF HEAD AND NECK RADIOLOGY |
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TOPABSTRACTINTRODUCTIONTHE BEGINNING OF HEAD...PROCEDURES IN HEAD AND...INTRODUCTION AND EVOLUTION OF...THE PRACTICE AND EVOLUTION...TEACHING IN HEAD AND...THE FUTURE OF HEAD...REFERENCES |
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What is the future of head and neck radiology? Like all of medicine, radiology included, we are part of a general society in constant change. The demands for improved health care are greater than ever. Financial constraints demand greater efficiency with the same or a better level of care. Technologic advances, especially in radiology, have led to cost savings with improved productivity and, with the introduction of new equipment and procedures, have simultaneously improved our diagnostic capabilities. Information technology has promoted better communication and dissemination of knowledge.
In line with cost savings, subspecialty hospitals have closed or become part of adjoining general hospitals. Because of a shift from inpatient to outpatient care, a substantial percentage of patients in ENT and ophthalmology departments are ambulatory, which obviates hospital beds. Subspecialty radiology departments have been integrated into general radiology departments as sections. The ongoing research and development of new equipment have demanded large capital investments that are not affordable for subspecialty hospitals. Head and neck radiology as a subspecialty in a hospital is practiced either within neuroradiology or as an independent section that is closely affiliated with neuroradiology.
The status of head and neck radiologists also has changed in relation to the foregoing discussion. The special knowledge required for the interpretation of head and neck diseases is unquestioned. Furthermore, research, either basic or clinical, is mandatory for the advancement of our specialty and optimal patient care. The American Journal of Neuroradiology became the official journal of the ASHNR in 1992. Dr Curtin was the first editor of the section of head and neck radiology within the American Journal of Neuroradiology and was followed by William P. Dillon, MD, of San Francisco.
There are full- and part-time head and neck radiologists in the United States. They practice in university and general hospitals and in private offices. A close link has developed between neuroradiology and head and neck radiology, since both specialties overlap in the diagnosis of head and neck diseases, especially with the introduction of CT, MR imaging, and angiography. Rotation programs through head and neck radiology sponsored by those departments are in place for neuroradiologists during their 2-year fellowship at the MEEI and for residents in general radiology at the Harvard teaching hospitals. In future years, head and neck radiologists, for the most part, will be recruited from the specialty of neuroradiology, with 6–12 months of their 2-year fellowship spent in the subspecialty of head and neck radiology. A smaller number of potential candidates will choose a fellowship that is limited to diseases of the head and neck. In the years to come, the acquisition of new equipment, introduction of new procedures, demand for high-level medical care, postgraduate teaching requirements, and increase in malpractice litigation will make it necessary for radiologists to have special expertise.
In conclusion, I would like to remind all of us that medicine is not a business. It is a noble profession that addresses the most precious possession, namely, the well-being of the human body. It is our task as physicians to uphold this ideal without regard to political or financial pressures exerted on us in this commercial environment. The history of medicine is long and has many role models, beginning with Hippocrates, and, with respect to radiology, includes Wilhelm Conrad Roentgen and many radiologists who gave their lives for humankind.
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ACKNOWLEDGMENTS |
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