Head and Neck Medicine by Alexandros G.Sfakianakis: 09/27/18

Renal cell carcinoma (RCC) metastatic in the sinonasal cavity is rare. In many cases, it represents the initial presentation of RCC. We conducted a retrospective chart review to report the clinical presentation, imaging, and treatment of RCC metastases in the sinonasal cavity at two tertiary care referral centers. Our population was made up of 8 patients-6 men and 2 women, aged 55 to 86 years (mean: 66.9; median: 63.5)-who had been diagnosed with cancer in the sinonasal cavity. The most common complaints were epistaxis, nasal obstruction, and diplopia. Cancers were located in the ethmoid sinus (n = 3), nasal cavity (n = 2), sphenoid sinus (n = 2), and maxillary sinus (n = 1). Local treatment involved resection and adjuvant radiotherapy in 4 patients, surgery alone in 2 patients, and radiotherapy alone in the other 2. The lesion was embolized before surgery in 4 cases. We also performed a critical review of similar published cases. Our literature review covered 53 cases of RCC metastatic to the sinonasal cavity, including ours. Metastases were the first presentation of RCC in 24 of these cases (45.3%); in our series, the metastases led to the diagnosis of the primary RCC in 3 cases (37.5%). In the 53 reported cases, metastatic resection was performed on 35 patients (66.0%). Survival data were available for 22 of these operated patients, and 17 of them achieved a complete local response. Adjunctive radiotherapy was not associated with a better local response. Overall survival was significantly better in patients who had an isolated metastasis rather than multiple metastases (p = 0.013). There was no difference in overall survival between patients whose metastasis represented the initial presentation of RCC and those whose metastasis did not (p = 0.95). We recommend that sinonasal metastasis be suspected in the event of unilateral nasal bleeding or nasal obstruction in patients diagnosed with RCC. Embolization may prevent abundant bleeding during removal. Surgery may improve the quality of life of these patients while decreasing nasal obstruction and bleeding.

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Positivity rates of in vitro inhalant/respiratory and food allergy tests in the northern midwestern United States

Michael S. Benninger, MD; Thomas Daly, MD; Kevin Graffmiller, MD

Abstract

Rates of allergy-test positivity vary by country and by regions within countries. Several studies have looked at allergy test results to determine the most common allergens. Many of these studies have been based on surveys or on studies of small numbers of tests. Positivity rates for allergy tests are poorly defined in the northern midwestern region of the United States. We conducted a study to identify the rates of positive allergy tests for both inhalant/respiratory allergens and food allergens in the upper Midwest. We extracted from our laboratory database the results of all test samples sent for one of eight allergen panels that had been analyzed between Sept. 1, 2014, and Sept. 1, 2015. All testing was performed at The Cleveland Clinic with the Phadia ImmunoCAP system. The percentage of positive tests, the distribution of the most frequently positive tests, and the class of in vitro responses were identified. A total of 148,628 test results for 63 different allergens were identified. Of the 125,190 tests for inhalant/respiratory allergens, the most frequently positive were dog dander (24% of tests), cat dander (23%), dust mites (23% for both Dermatophagoides pteronyssinus and Dermatophagoides farinae), and June grass (21%). Of the 23,438 food tests, the most frequently positive test results were for milk (18%), peanut (17%), wheat (16%), and egg white (15%). Most of the results fell into classes 1 through 3, although there was still a notable number of very high responses (class 5 and 6). These findings suggest that there is wide variability in the positivity of in vitro allergy tests and that the likelihood of a positive result in screening panels can be estimated. Evaluating such rates will help identify the most and least common allergens and will help to cost-effectively refine allergy screening panels.

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Audiologic profile in patients with ankylosing spondylitis: A controlled study of 30 patients

Lumy Yagueshita, MD; Lucas Resende Lucinda, MD; Valderilio Azevedo, PhD; Gislaine Richter Minhoto Wiemes, PhD; Nicole Richter Minhoto Wiemes, MD; Jose Fernando Polanski, PhD

Abstract

Recent studies have identified sensorineural hearing loss as a possible manifestation of ankylosing spondylitis. We conducted a study of 30 patients with ankylosing spondylitis to characterize their audiologic profile and to correlate their disease activity and functional indices with their hearing thresholds. The study group was made up of 18 men and 12 women, aged 25 to 58 years (mean: 46.5), who were diagnosed with ankylosing spondylitis. We compared their findings with a socially and demographically matched group of 30 healthy controls. All 60 participants underwent an audiologic assessment, consisting of pure-tone audiometry, speech audiometry, and tympanometry. We used validated indices to assess disease activity and functional status, and we compiled information on the time of diagnosis and the types of medications used to treat the ankylosing spondylitis. We found that the average of the mean air-conduction thresholds at 0.5, 1, 2, and 4 kHz in the ankylosing spondylitis group was significantly worse than that of the controls (p = 0.004). A statistically significant difference was observed at frequencies greater than 3 kHz (p < 0.05). A subgroup of case patients who used only a tumor necrosis factor-alpha inhibitor exhibited better hearing thresholds than patients who used other drugs (p = 0.01). Differences in functional and disease activity scores between case patients with and without hearing loss were not statistically significant. We found that patients with ankylosing spondylitis did indeed have a greater prevalence of sensorineural hearing loss but that it was not correlated with either disease activity or functional status.

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Button battery insertion in nose manifested as infraorbital cellulitis

Sheng-Yao Cheng, MD; Cheng-Ping Shih, MD

Infraorbital cellulitis developing from a nasal foreign body is relatively rare and should be considered when diagnosing a child with a presentation similar to the one described in this article.

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Histoplasmosis of the head and neck in the immunocompetent patient: Report of 2 cases

Ashley P. O'Connell Ferster, MD; Aaron Jaworek, MD; Amanda Hu, MD, FRCSC

Abstract

Histoplasmosis of the head and neck is rarely seen in immunocompetent patients. We report 2 new cases of histoplasmosis of the head and neck in immunocompetent patients, one an 80-year-old man and the other a 57-year-old man. The older man presented with oral cavity histoplasmosis; his symptoms included pain, dysphagia, and ulcerative lesions. The younger man had laryngeal histoplasmosis, which resulted in hoarseness and dyspnea. We discuss the methods of diagnosis and the classic findings in histoplasmosis, including the microscopic appearance of caseating granulomas, the results of periodic acid-Schiff staining and Gomori staining, and antibody detection of histoplasmosis. We also review the treatment options with antifungals, including amphotericin B and the oral conazole drugs. With an accurate diagnosis and proper treatment, both of our patients recovered well and their symptoms resolved. Because their symptoms overlapped with those of other, more common disease processes, an accurate diagnosis of these patients was essential to treating their infection.

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Primary pleomorphic adenoma of the middle ear and mastoid

Asnake Bitew, MD; Tsion Sahle, MD; Miriam Redleaf, MD FACS

Unlike metastatic cases, primary pleomorphic adenomas tend to recur and tend to be aggressive.

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Nonarytenoid laryngeal granulomas

Marissa Evarts, DO; Jonathan Romak, MD; Robert T. Sataloff, MD, DMA, FACS

Contact and postintubation granulomas rarely are located on the middle third or anterior portion of the vocal folds, with few reported in the literature.

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Nondisseminated rhinosporidiosis with multisite involvement in the head and neck

K Devaraja, MS; Prem Sagar, MS; Chirom Amit Singh, MS; Rajeev Kumar, MS

Abstract

Rhinosporidiosis is a communicable disease prevalent in tropical countries that affects one or more mucocutaneous sites such as the nasal cavity, pharynx, skin, bronchus, genitals, and bone, in isolation or together. We report a case of multicentric rhinosporidiosis involving the nasal cavity, oropharynx, larynx, and cheek skin without disseminated disease outside the head and neck. Although the appearance of mucocutaneous lesions in our patient was similar to that of papilloma or neoplasm, the distinct clinicopathologic characteristics of the rhinosporidiosis guided us in managing the case successfully. In our own experience with 11 patients with rhinosporidiosis on whom we operated over the past 5 years, the nasal cavity and pharynx were the most commonly involved sites in the head and neck. Surgical excision of all lesions along with cauterization of the base and long-term dapsone therapy is the current standard of care for multicentric rhinosporidiosis.

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Endoscopic view of the carotid artery in the sphenoid sinus

Eiji Yanagisawa, MD, FACS; Dewey A. Christmas, MD; Joseph P. Mirante, MD, MBA, FACS

The sphenoid sinus has been described as the most variable, in shape and size, of any bilateral cavity or organ in the human body.

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Mucocele development after endoscopic sinus surgery for nasal polyposis: A long-term analysis

Hakim Benkhatar, MD; Idir Khettab, MD; Philippe Sultanik, MD, PhD; Ollivier Laccourreye, MD; Pierre Bonfils, MD, PhD

Abstract

The aim of the present study was to determine the prevalence of long-term mucocele development after functional endoscopic sinus surgery (FESS) for nasal polyposis, to search for a statistical relationship with preoperative variables and to analyze the management of this complication. A retrospective analysis of 153 patients who underwent FESS for nasal polyposis, with a minimum of 7 years of follow-up, was performed. Mucocele diagnosis was based on regular clinical and radiologic evaluation. Univariate and multivariate statistical analysis was performed. The postoperative mucocele rate was 13.1% (20 patients). The mean delay between surgery and mucocele diagnosis was 6.25 years. A high preoperative Lund-Mackay score (>19) was a risk factor for postoperative mucocele (p = 0.04). Asthma and aspirin intolerance did not increase the risk of this complication. Endoscopic marsupialization of mucoceles was successful in 19 patients, with only one recurrent frontal mucocele. One patient required external approaches for two frontal mucoceles. In conclusion, mucocele risk after FESS for nasal polyposis is significant, especially in case of a high preoperative Lund-Mackay score (>19). Long-term clinical follow-up is recommended, imaging being prescribed based on symptoms or abnormal findings on clinical examination. Endoscopic marsupialization is very effective, but frontal mucoceles are more likely to recur.

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Feasibility of carbon-fiber-reinforced polymer fixation plates for treatment of atrophic mandibular fracture: a finite element method

The objective of this study was to conduct a computer assessment of the biomechanical stability of locking fixation plates of different thicknesses, made of titanium alloy and carbon-fiber- reinforced polyetheretherkotone (CFR-PEEK) in Class III atrophic mandibular fractures. Class III atrophic mandibular models were constructed using three-dimensional finite element models. After simulation of fracture on the left side, plates with different thicknesses (1.0, 1.5, 2.0, and 2.5 mm) were adapted to the models and three locking screws on each side of the fracture were used for fixation.

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Rotation tendency of the posteriorly displaced proximal segment after vertical ramus osteotomy

Intraoral Vertical Ramus Osteotomy (IVRO) is one of the operative techniques used for orthognathic surgery. The aim of this study was to assess the posterior displacement of the proximal segment in patients undergoing IVRO at 1-year follow-up.In total, 52 hemimandibles from 26 patients who underwent IVRO in whom the proximal segment was posteriorly displaced without overlap with the distal segment at immediate post-operation (Imm) (30 cases, experimental group), and 26 patients in whom the proximal segment was not posteriorly displaced with overlap with the distal segment (Imm) (22 cases, control group) under three-dimensional computed tomography (3D CT) were included in the study.

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Photobiomodulation therapy before futsal matches improves the staying time of athletes in the court and accelerates post-exercise recovery

Abstract

This study aimed to analyze PBMT effects on futsal player's performance and recovery in a non-controlled field environment. It is a randomized, triple-blinded, placebo-controlled, crossover clinical trial. The research included six professional athletes and in each match phototherapy treatments were performed before matches (40 minutes), blood samples were collected before treatments, and samples immediately after the end of the matches and 48 h after. Furthermore, videos were analyzed to quantify the time athletes spent on the pitch and the distance they covered. PBMT was performed at 17 sites of each lower limb (40 mins before matches), employing a cluster with 12 diodes (4 laser diodes of 905 nm, 4 LEDs of 875 nm, and 4 LEDs of 640 nm, 30 J per site). The performance of the athlete could be quantified considering the time on the pitch and the distance covered; the biochemical markers evaluated were creatine kinase, lactate dehydrogenase, blood lactate, and oxidative damage to lipids and proteins. PBMT significantly increased the time of staying in the pitch and a significant improvement in all the biochemical markers evaluated. No statistically significant difference was found for the distance covered. Pre-exercise PBMT can enhance performance and accelerate recovery of high-level futsal players.

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Surface electromyography after lower level laser therapy application on skeletal muscles in individuals with heart failure

Abstract

The purpose of this study was to investigate the effects of low-level laser therapy (LLLT) applied before a fatigue protocol through the effects on the electrical activation in the quadriceps muscle in patients with HF. Fourteen patients with the diagnosis of heart failure (HF) were selected for this double-blind, crossover type clinical trial. These participants have attended to a familiarization, LLLT, and placebo sessions, totaling three visits. The LLLT was applied in the quadriceps muscle (850 nm, 5 J per diode). The fatigue protocol consisted of concentric and eccentric isokinetic contractions (cc/ec) until exhaustion or up to 50 cc/ec. The muscular fatigue was evaluated with surface electromyography, by the analysis of integral, median frequency, and entropy. Only one application of LLLT is not able to decrease skeletal muscle activation in patients with HF. There was no reduction of muscle fatigue among the proposed protocols. Single LLLT session has no effect on the reduction of skeletal muscle fatigue in patients with HF.

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Interaural Time Difference Perception with a Cochlear Implant and a Normal Ear

Abstract

Currently there is a growing population of cochlear-implant (CI) users with (near) normal hearing in the non-implanted ear. This configuration is often called SSD (single-sided deafness) CI. The goal of the CI is often to improve spatial perception, so the question raises to what extent SSD CI listeners are sensitive to interaural time differences (ITDs). In a controlled lab setup, sensitivity to ITDs was investigated in 11 SSD CI listeners. The stimuli were 100-pps pulse trains on the CI side and band-limited click trains on the acoustic side. After determining level balance and the delay needed to achieve synchronous stimulation of the two ears, the just noticeable difference in ITD was measured using an adaptive procedure. Seven out of 11 listeners were sensitive to ITDs, with a median just noticeable difference of 438 μs. Out of the four listeners who were not sensitive to ITD, one listener reported binaural fusion, and three listeners reported no binaural fusion. To enable ITD sensitivity, a frequency-dependent delay of the electrical stimulus was required to synchronize the electric and acoustic signals at the level of the auditory nerve. Using subjective fusion measures and refined by ITD sensitivity, it was possible to match a CI electrode to an acoustic frequency range. This shows the feasibility of these measures for the allocation of acoustic frequency ranges to electrodes when fitting a CI to a subject with (near) normal hearing in the contralateral ear.

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Dr. J. Caleb Simmons Discusses a New Treatment for Obstructive Sleep Apnea

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Odontogenic Maxillofacial Space Infections: A 5-Year Retrospective Review in Navi Mumbai

Abstract

Purpose

The aim of this study is to comprehensively review and analyse pure odontogenic maxillofacial space infections in a tertiary care hospital in Navi Mumbai over a period of 5 years.

Methods

A retrospective analysis of 315 patients treated at Dr. D. Y. Patil Dental College and Hospital at Nerul, Navi Mumbai, from January 2007 to December 2011 was done. Multiple variables were analysed. Localised infections like dentoalveolar infections without space involvement and infection of non-odontogenic cause were excluded from the study.

Results

Analysis of the records was done. Majority of patients were from lower socioeconomic background and were daily wage workers who had either consulted a general physician or a general dental practitioner or had self-medicated themselves before presenting to us with acute symptoms. Early recognition and prompt treatment involving intravenous antibiotics with extraction of involved tooth/teeth and incision and drainage helped in resolution of infections in a span of 72 h. Medically compromised patients had longer duration of hospital stay as compared to the patients who had no underlying medical condition. Majority of space infections involved multiple spaces and local anaesthesia with sedation was found to be the satisfactory mode of anaesthesia. Complications were very few.

Conclusion

We concurred that any form of odontogenic maxillofacial space infection should be rendered prompt and aggressive treatment and hospitalisation should be recommended wherever required.

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Risk Factors Associated With Unplanned Reoperation in Major Head and Neck Surgery

This cohort study uses the American College of Surgeons National Surgical Quality Improvement Program 2005-2014 database to identify risk factors associated with unplanned reoperation following major head and neck surgical procedures.

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Rapidly Enlarging Parapharyngeal Mass

A man in his 40s with Poland syndrome presented with 6-month history of left throat pain and enlarging oropharyngeal mass. What is your diagnosis?

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Patient Concerns About Nasal Reconstruction and Implications for Shared Decision Making

This study examines the concerns of patients with nonmelanoma skin cancer regarding nasal reconstruction after Mohs surgery to develop an intervention to improve the shared decision-making process of patients and practitioners.

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Hyperbaric Oxygen Therapy vs Medical Therapy Alone for Idiopathic Sudden Sensorineural Hearing Loss

This systematic review and meta-analysis of 19 studies evaluates the benefit of the addition of hyperbaric oxygen therapy for patients with sudden sensorineural hearing loss.

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Standard Clinical Method vs Patient-Centered Tinnitus Likeness Rating

This case series assessed individual test-retest reliability of the 2-alternative forced-choice and tinnitus likeness rating approaches in patients undergoing evaluation for tinnitus.

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Suppressed descending pain modulatory and enhanced sensorimotor networks in patients with chronic low back pain

Abstract

Purpose

Although cerebral structural and functional changes were uncovered by neuroimaging in patients with chronic low back pain (CLBP), their associations remain to be clarified. We co-analyzed anatomical and functional magnetic resonance imaging data in those patients and tested whether cortical gray matter volume changes are associated with altered pain modulatory networks underlying chronification of pain.

Methods

In 16 patients with CLBP and 16 heathy controls, we performed functional magnetic resonance imaging during mechanical pain stimulation on the lower back followed by anatomical imaging. We performed voxel-based morphometry and functional connectivity analysis from the seeds with altered gray matter volume, and examined correlations between imaging and psychophysical parameters.

Results

Patients showed decreases in gray matter volume at the right dorsolateral prefrontal cortex, middle occipital gyrus, and cerebellum, and showed increases at the bilateral primary sensorimotor cortices, left fusiform gyrus, and right cerebellum compared with controls (P < 0.001). Dorsolateral prefrontal and fusiform volumes showed negative associations with affective comorbidity, whereas motor cortex volume with impaired daily activity (P < 0.05). Connectivity was decreased between the cerebellar and limbic, and increased between the bilateral sensorimotor regions (P_FDR < 0.05). Higher pain intensity and unpleasantness correlated with enhanced bilateral sensorimotor and dorsolateral–medial prefrontal networks, respectively (P < 0.05).

Conclusion

Patients showed a decreased volume of cortical center for descending pain modulation and an increased volume of sensorimotor network, in association with suppressed descending pain modulatory and cerebellum–limbic networks and enhanced sensorimotor network during pain. Such structural and functional alterations might be part of cerebral pathophysiology of CLBP.

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Interaural Time Difference Perception with a Cochlear Implant and a Normal Ear

Abstract

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Paediatric ocular super glue injuries: assessment of two cases

In this report, we elaborate the clinical findings and the optimal management of two cases with ocular glue injuries in two paediatric patients. Both the patients were presented to the ocular emergency with completely closed eyelid and periocular erythema. The eyelids were completely closed due to matting of the eyelashes with glue retention up to lash roots. Thus, in both cases, after the application of local anaesthetic agent, immediate lash trimming was performed along with the removal of crystallised glue particles. However, the ocular surface showed only congestion in absence of any added corneal complications. Patients were followed up with standard treatment protocol as per chemical injuries. Until the end of 5 months, the clinical course was uneventful.

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Comorbid presentation of syringomyelia and Guillain-Barre syndrome, attributed to mycoplasma, in a 6-year-old female patient

Syringomyelia is the development of a fluid-filled cavity or syrinx within the spinal cord that can cause loss of sensation and muscle spasticity. Guillain-Barre syndrome (GBS) is a postinfection autoimmune disease, classified as an acute polyneuropathy. This report describes the emergency admission of a 6-year-old girl presenting with sudden pallor and pain in both lower limbs. The patient's reflexes were normal, as were the results of her sonography, radiography and biochemical tests; however, spinal MRI revealed extensive compartmentalised syringomyelia extending from C2 to T3. A sensory and motor nerve conduction study revealed a demyelinating type motor polyneuropathy which, along with positive Mycoplasma pneumoniae test, was suggestive of GBS. Intravenous immunoglobulin infusion showed excellent results. In conclusion, we report a rare paediatric case of syringomyelia coexisting with GBS. It is important to bear in mind the possibility of other coexisting diseases even if MRI reveals definitive characteristics of another condition.

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Diagnosis of a tick-borne coinfection in a patient with persistent symptoms following treatment for Lyme disease

A 67-year-old woman presented with 5 days of myalgias and fevers on completion of a 21-day course of amoxicillin for Lyme disease (Borrelia burgdorferi infection). She was found to have profound thrombocytopenia, as well as new anaemia and leucopenia. Workup revealed Babesia microti as the causative agent of her symptoms. The patient quickly improved after appropriate antimicrobial therapy directed against babesiosis was started. This case illustrates the importance of basic microbiology, including epidemiology and common vectors, when creating a differential diagnosis. Because the Ixodes scapularis tick can harbour and transmit multiple parasites simultaneously, the possibility of coinfection should be considered in any patient not responding to appropriate initial medical therapy.

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Desire for lasting long in bed led to contact allergic dermatitis and subsequent superficial penile gangrene: a dreadful complication of benzocaine-containing extended-pleasure condom

Description

A 30-year-old non-atopic, non-diabetic man presented with complaints of swelling, pain and patchy blackening of penile skin for the last 3 days. He stated that for improving the duration of sexual intercourse and for better sexual performance, he recently used a new brand of condom, which contained 5% benzocaine. He, however, denied about the use of any lubricants or topical substance at the time of sexual act. There was no history of fever, inguinal or scrotal swelling, genital trauma, insect bite, known drug allergy, substance abuse or similar complaints in the past. In the past, he was using non-medicated natural rubber latex condom for contraception without any adverse effects. Local examination revealed vesicle eruption, sloughing and patchy blackening of penile skin extending from prepuce to base of penis with a clear demarcation line with non-palpable inguinal lymph nodes suggestive of allergic contact dermatitis as shown in figure 1. The underlying...

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Acromioclavicular joint cyst formation in a patient with rotator cuff-tear arthropathy: a rare cause of shoulder discomfort

We report a case of a 77-year-old man who presented to our shoulder department with a soft tissue mass on his right acromioclavicular (AC) joint. Previously attempted puncture aspiration had revealed serous fluid retention which recurred after each of several drainage attempts. Conventional radiography and MRI of the affected shoulder joint demonstrated a progressed cuff-tear arthropathy with an irreparable tear of the supraspinatus tendon, static superior migration of the humeral head, opening of the AC joint capsule and a superior joint-fluid 'eruption' and accumulation called 'Geyser sign'. Given that the patient's cuff-tear arthropathy was very well compensated, arthroscopic rotator cuff debridement and open cyst excision were performed. Closure of the superior aspect of the AC joint capsule was performed by the aid of a collagen matrix with additional closure of the deltotrapezial fascia. One year postoperatively, no cyst recurrence was noted.

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Knotted electric wire in urinary bladder: Can such complex foreign body be retrieved endoscopically!

Various types of foreign bodies have been recovered from the urinary bladder and urethra including telephone cables, pocket battery, little fish, pen tips and so on. Management of such cases include either endoscopic removal or open surgery. We report the case of an 18-year-old boy who inserted an electric wire in the urethra for eroticism and was managed by endoscopic removal following fragmentation of wire under local anaesthesia using holmium laser.

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Recurrent aseptic meningitis with PIGT mutations: a novel pathogenesis of recurrent meningitis successfully treated by eculizumab

We report the case of a patient with PIGT mutations who experienced recurrent aseptic meningitis 121 times over 16 years before developing paroxysmal nocturnal haemoglobinuria (PNH). Each episode was preceded by urticaria and arthralgia. After developing PNH, haemolysis occurred prior to meningitis. Flow cytometry revealed deficiency of the glycophosphatidylinositol (GPI)-anchored complement regulatory proteins, CD59 and CD55, and he was diagnosed with PNH. All the symptoms disappeared on administering eculizumab, an anti-C5 antibody. We did not detect mutation in PIGA, which is regarded as the cause of PNH. However, we detected a germ-line mutation and a somatic microdeletion in chromosome 20q including PIGT; PIGT is essential for transferring GPI anchor to the precursors of CD59 and CD55, which play important roles in complement regulation. Loss of these proteins leads to complement overactivation, causing inflammatory symptoms, including recurrent meningitis. PIGT mutations should be considered a novel pathogenesis of recurrent meningitis of unknown aetiology.

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Obstructive urosepsis secondary to ureteric herniation into the sciatic foramen

A 65-year-old female patient presented with a 2-day history of worsening right-sided abdominal pain and clinical signs of sepsis, on the background of a recent admission for pancolitis. Imaging revealed right ureteric herniation through the sciatic foramen with subsequent hydroureteronephrosis and radiological signs of severe pyelonephritis. The patient underwent emergency decompression with a percutaneous nephrostomy, followed by insertion of an antegrade stent to correct the ureteric hernia once the sepsis was appropriately treated. We describe the presentation and management of this unusual case of herniation of the right ureter into the sciatic foramen.

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Atypical presentation of molar pregnancy

The classic features of molar pregnancy are irregular vaginal bleeding, hyperemesis, enlarged uterus for gestational age and early failed pregnancy. Less common presentations include hyperthyroidism, early onset pre-eclampsia or abdominal distension due to theca lutein cysts. Here, we present a case of molar pregnancy where a woman presented to the emergency department with symptoms of acute abdomen and was treated as ruptured ectopic pregnancy. The woman underwent laparoscopy and evacuation of retained products of conception. Histological examination of uterine curettage confirmed the diagnosis of a complete hydatidiform mole. The woman was discharged home in good general condition with a plan for serial beta-human chorionic gonadotropin (beta-hCG) follow-up. Complete follow-up includes use of contraception and follow-up after beta-hCG is negative for a year.

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Lupus causing small bowel obstruction

A 20-year-old female patient was admitted to hospital in 2015 with 1 year history of recurrent abdominal pain, distension, borborygmi and nausea. The patient had a background of systemic lupus erythematous (SLE) diagnosed 4 years before, with skin, joint and renal involvement. The initial investigations have shown a long segment of ileal inflammation with upstream obstruction. Differential diagnoses were mainly SLE enteritis or concomitant Crohn's. Patient failed the initial conservative management and had a laparotomy with small bowel (SB) resection and ileostomy. The histology was suggestive of autoimmune enteritis. Although bowel involvement is a frequent feature of SLE, surgery for obstruction is extremely rare. Postoperatively, she had an emergency admission and was diagnosed with SB volvulus with perforation. She underwent further resection and stoma refashioning in 2016. As a consequence, she developed short gut syndrome. Eventually, the stoma was reversed and parenteral nutrition was stopped and weight became stable.

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Idiopathic macrocheilia

A 13-year-boy presented with painless swelling of upper and lower lips accompanied with gingival enlargement. The aetiology for these symptoms included vast pathological varieties but none of them could fit in. Clinical features were similar to orofacial graulomatosis but histopathological examination revealed chronic non-specific infection. Therefore, the final diagnosis was made as idiopathic macrocheilia through exclusion criteria. Management with intralesional triamcinolone acetonide 40 mg, twice a week for 3 weeks, resulted in significant remission in lip swelling without recurrence after a 6-month follow-up.

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Massive gastric dilatation leading to acute respiratory distress 1 year after a Nissen fundoplication

Acute massive gastric dilatation (AMGD) is a recognised complication after Nissen fundoplication.¹ A 63-year-old man recently presented to our emergency department in acute respiratory distress, acute abdominal pain and distension, having had an elective umbilical port incisional hernia repair a day prior. In the year preceding his presentation, the patient had undergone a laparoscopic paraoesophageal hiatus hernia repair and excision of sac, posterior cruropexy, dual mesh reinforcement of repair and 360° fundoplication, as a day case. In between these two events, the patient was asymptomatic, and had a free diet with no further medical or surgical intervention. We hereby present successful management and discuss implications of this exceptional yet potentially life-threatening complication.

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Diabetic ketoacidosis and thyroid storm: coexistence of a double trouble

Diabetic ketoacidosis (DKA) and thyrotoxic crisis are both endocrine emergencies. Here, we present a case of a patient who presented with DKA and on further evaluation was found to also have a thyrotoxic crisis. The coexistence of both of these endocrine emergencies simultaneously is extremely rare and heralds grave prognosis unless identified and treated promptly.

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Bilateral submandibular gland nodular oncocytic hyperplasia with papillary cystadenoma-like areas

A 57-year-old man presented in 2016 with a 4-month history of a right submandibular mass, having undergone left submandibular gland (SMG) excision in 2003. Imaging suggested a benign tumour and subsequent core biopsy findings suggested a nodular oncocytic hyperplasia, similar to the tumour removed from the contralateral side. This was confirmed on histological analysis following right submandibular gland excision which showed characteristic features of nodular oncocytic hyperplasia along with an unusual diffuse papillary cystadenoma-like ductal proliferation, similar to that seen in the 2003 specimen. A diagnosis of multinodular adenomatous oncocytic hyperplasia (MAOH) was rendered in order to communicate the unique histological features that have otherwise not been described in the literature. We believe that this is the first reported case of non-synchronous multinodular oncocytic hyperplasia and the first case affecting the submandibular glands.

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Gossypiboma masquerading as nephrocutaneous fistula

Nephrocutaneous fistula is a rare complication of surgical procedures involving the kidney. Fistula formation is also a complication seen in gossypiboma. We present the case of a patient who was initially suspected to have nephrocutaneous fistula after open pyelolithotomy. Later while undergoing open resection of fistula, he was found to have a retained surgical sponge (gossypiboma) near the lower pole of kidney. Gossypiboma is a term used for mass formed around a surgical sponge accidentally left in the body. It is most of the times not diagnosed by radiological imaging and thus results in unnecessary investigations to rule out other causes for the patient's symptoms. Having a high index of suspicion may lead to an earlier diagnosis. But the prevention of gossypiboma is of the utmost importance. A meticulous approach while operating by the surgeon and operating rooms staff is very important in doing so.

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Chronic urinary retention due to diabetic cystopathy masquedering as mesenteric cyst

Description

A 55-year-old previously diabetic man presented with progressive abdominal distension for the last three months. He denied any bowel/bladder complaints. His medical/surgical history was unremarkable. On examination his vitals were stable and a huge abdominal mass (10x11 cm) was palpable. The mass was having side-to-side mobility. There was no hepatosplenomegaly or clinically significant lymphadenoapathy. On evaluation with ultrasonography of abdomen and CT scan, there was evidence of huge, cystic and homogenous mass (13x11 cm) with clear margins occupying almost entire abdominal cavity (figure 1). There was no evidence of calcification, septations or nodules in the mass, and it appeared to be separate from both the kidneys and bowel. A provisional diagnosis of mesenteric cyst was made, and the patient was taken for laparotomy. A per-urethral catheter was placed intraoperatively and surgery was started. During laparotomy it came as an element of surprise that the swelling was actually chronically distended bladder...

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Fetishism in ADHD: an impulsive behaviour or a paraphilic disorder?

A boy with attention deficit and hyperactivity disorder (ADHD) presented with a fetish for and the subsequent stealing of female undergarments. He was predominantly inattentive and had been a slow learner. Psychological tests showed that he had significant cognitive and inattention problems without significant hyperactivity, and was at risk of dyslexia as well as conduct disorder.

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Pneumonia and bacteraemia caused by Gemella morbillorum in a previously healthy infant: first reported case in literature

A 5-month-old baby presented with a low-grade fever and tachypnoea and was found to have right upper lobe consolidation on chest radiograph. He was admitted with the diagnosis of bronchopneumonia and the treatment protocol for pneumonia was initiated. Blood culture samples were collected, and he was started on a course of intravenous amoxicillin–clavulanate. Blood culture results displayed pansensitive Gemella morbillorum bacteraemia and he was continued on intravenous antibiotic to which he responded in a short period and was discharged in good condition on the fourth day.

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Gastric emphysema secondary to severe vomiting: a comparative review of 14 cases

Gastric emphysema is characterised by the presence of air within the wall of the stomach. The radiographic finding of gastric emphysema with hepatic portal venous gas is classically an ominous sign, associated with a high mortality rate. We report one case from our clinical experience and undertake a review of the previously reported cases of vomiting-induced gastric emphysema retrieved from the PubMed. A total of 14 cases were found to date. The mean age at the time of diagnosis was 45.6 years (range, 9 months to 81 years). Computed tomography abdomen was the frequently used diagnostic modality. Interestingly, conservative treatment led to a clinical cure and resolution of gastric emphysema as well as the associated hepatic portal venous gas in most of the patients. This review illustrates that vomiting-related gastric emphysema entails a more benign course and surgical intervention can be avoided with a prompt aetiology establishment in these patients.

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Aneurysmal dilation of the vein of Galen and straight sinus with resultant obstructive hydrocephalus

Description

A 20-year-old woman was admitted to the emergency department on a previous occasion with tonic-clonic seizures. Her medical history was significant for headaches and hypertension. The headaches were associated with nausea and vomiting. She had no history of developmental delay or epilepsy. CT scan of the brain showed signs of obstructive hydrocephalus due to venous hypertension as a result of vein of Galen malformation, and hence a ventriculoperitoneal shunt was placed. Now on follow-up, her MRI brain demonstrates a round flow void in the suprapineal cisterns with engorged straight sinus, compatible with vein of Galen arteriovenous fistulous communication and shunting (figure 1). The resultant venous hypertension leads to mild to moderate compensated hydrocephalus.

Figure 1

(A) Axial T2, (B) axial T1 and (C) sagittal T2 MRI brain. MRI brain demonstrates a round flow void in the suprapineal cisterns with engorged straight sinus (green arrow),...

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