Coronal Scans Research Articles

Hepatobiliary and Pancreatic: Large pancreatic liposarcoma

A young man, aged 24, was investigated because of progressive abdominal distension. On examination, he had a large mass in the mid-abdomen. A contrast-enhanced computed tomography (CT) scan revealed a mass, 25 x 17 x 11 cm, in the mid-abdomen as shown on the axial and coronal scans in Figure 1. The mass had a heterogeneous appearance but many areas of the mass were of low-density consistent with fat. The preoperative diagnosis was that of a retroperitoneal liposarcoma. Laparotomy revealed a relatively firm tumor with a smooth surface (Figure 2). The mass appeared to arise from the body of the pancreas with sparing of the tail of the pancreas (arrowheads). A resection of the body of the pancreas was performed with a pancreaticogastrostomy for the distal pancreatic remnant. At histology, the diagnosis was that of a myxoid pancreatic liposarcoma with surgical margins that were free of tumor. After 44 months, a second operation was performed to remove a local recurrence, 4 x 3 cm in size. He is currently asymptomatic after 3 further months of follow-up. Liposarcomas are malignant neoplasms of adipose tissue. Histologically, the most common types are the well-differentiated liposarcoma, the myxoid liposarcoma and the dedifferentiated liposarcoma. These tumors largely develop in middle-aged or older individuals. Common sites for the dedifferentiated liposarcoma include the retroperitoneum and the spermatic cord. In contrast, well-differentiated and myxoid liposarcomas usually occur in subcutaneous and intramuscular sites and are uncommon in the retroperitoneum. Retroperitoneal liposarcomas, in particular, are often relatively large at the time of diagnosis and only rarely arise from the pancreas. The behavior of liposarcomas is strongly influenced by the histology such that the dedifferentiated liposarcoma is more likely to recur locally and metastasize. The most important factor influencing prognosis is the adequacy of surgical resection at the time of primary presentation. The CT scan illustrated above is typical of a liposarcoma with low density areas consistent with fat as well as thick septae of soft tissue. Dedifferentiated neoplasms have less fat and can have a similar appearance to other sarcomas. The differential diagnosis on imaging may also need to include benign lipoma, angiomyolipoma and malignant fibrous histiocytoma.

Arthroscopic Repair of Small and Medium-Sized Bony Bankart Lesions

Background: There has been no study about treatment guidelines for arthroscopic repair according to the size of bony Bankart lesions of less than 25% of the glenoid width. Purpose: To evaluate the results of arthroscopic repair for bony Bankart lesions managed with different repair techniques based on their size. Study Design: Case series; Level of evidence, 4. Methods: Between March 2005 and February 2009, 44 of 52 consecutive patients with bony Bankart lesions with a size of less than 25% of the entire glenoid were managed with an arthroscopic approach. Of those patients, 34 (77%) were available for outcome analysis at a minimum 24 months’ follow-up (mean, 34 months; range, 24-60 months). The size of the fragment was measured by computed tomography (CT) and classified as small (<12.5% of the inferior glenoid width) and medium (12.5%-25%). Sixteen lesions were classified as small (small group), and 18 were classified as medium (medium group). For small lesions, capsulolabral repair using suture anchors without excision of the bony fragment was performed. For medium lesions, anatomic reduction and fixation using suture anchors was performed, and the adequacy of reduction was assessed by CT postoperatively. The visual analog scale (VAS) for pain score and modified Rowe score for bony Bankart repair were compared and the postoperative recurrence rate investigated. Results: One patient from the small group (6.3%) and 1 patient without anatomic reduction of the bony fragment in the medium group (5.6%) experienced traumatic redislocations. The mean VAS score improved from 1.7 preoperatively to 0.5 at final follow-up, and the mean Rowe score improved from 59 to 91 (both P < .001). The mean postoperative Rowe scores increased from 58 to 92 in the small group and from 60 to 91 in the medium group (both P < .001). Residual joint incongruity measuring ≤2 mm on both axial and coronal scans, which was considered an anatomic reduction, was present in 14 cases (77.8%) in the medium group. In the medium group, the mean postoperative Rowe scores increased from 60 to 95 in cases of anatomic reduction compared with an increase from 56 to 76 in cases of nonanatomic reduction. The Rowe score was statistically correlated with anatomic reduction of medium-sized bony fragments (P = .046). Conclusion: In small Bankart lesions, restoration of capsulolabral soft tissue tension alone may be enough, whereas in medium lesions, the osseous architecture of the glenoid should be reconstructed for more functional improvement and less pain.

Interreader and intermodality reliability of standard anteroposterior radiograph and magnetic resonance imaging in detection and classification of lumbosacral transitional vertebra

Background contextDifferent types of lumbosacral transitional vertebra (LSTV) are classified based on the relationship of the transverse process of the last lumbar vertebra to the sacrum. The Ferguson view (30° angled anteroposterior [AP] radiograph) is supposed to have a sufficient interreader reliability in classification of LSTV, but is not routinely available. Standard AP radiographs and magnetic resonance imaging (MRI) are often available, but their reliability in detection and classification of LSTV is unknown. PurposeThe purpose of this study was to evaluate the interreader reliability of detection and classification of LSTV with standard AP radiographs and report its accuracy by use of intermodality statistics compared with MRI as the gold standard. Study design/settingRetrospective case control study. Patient sampleA total of 155 subjects (93 cases: LSTV type 2 or higher; 62 controls). Outcome measuresInterreader reliability in detection and classification of LSTV using standard AP radiographs and coronal MRI as well as accuracy of radiographs compared with MRI. MethodsAfter institutional review board approval, coronal MRI scans and conventional AP radiographs of 155 subjects (93 LSTV type 2 or higher and 62 controls) were retrospectively reviewed by two independent, blinded readers and classified according to the Castellvi classification. Interreader reliability was assessed using kappa statistics for detection of an LSTV and identification of all subtypes (six variants; 1: no LSTV or type I, 2: LSTV type 2a, 3: LSTV type 2b, 4: LSTV type 3a, 5: LSTV type 3b, 6: LSTV type 4) for MRI scans and standard AP radiographs. Further, accuracy and positive and negative predictive values were calculated for standard AP radiographs to detect and classify LSTV using MRI as the gold standard. ResultsThe interreader reliability was at most moderate for the detection (k=0.53) and fair for classification (wk=0.39) of LSTV in standard AP radiograph. However, the interreader reliability was very good for detection (k=0.93) and classification (wk=0.83) of LSTV in MRI. The accuracy and positive and negative predictive values of standard AP radiograph were 76% to 84%, 72% to 86%, and 79% to 81% for the detection and 53% to 58%, 51% to 76%, and 49% to 55% for the classification of LSTV, respectively. ConclusionStandard AP radiographs are insufficient to detect or classify LSTV. Coronal MRI scans, however, are highly reliable for classification of LSTV.

Isolated Sinusitis of Lateral Recesses of Sphenoid Sinus

To the Editor: An 11-y-old boy presented with acute onset headache, eye pain and fever. There was no sinus tenderness, and symptoms did not resolve with oral antibiotics and antihistaminics. The CTscan of paranasal sinuses was done which revealed acute sinusitis with fluid only within lateral recesses of bilateral sphenoid sinuses (Fig. 1). This finding was also confirmed on MRI (Fig. 2). Rests of the sinuses, particularly bilateral frontal sinuses were clear (Fig. 3). No neurological complications were seen. The child was managed with intravenous antibiotics and endoscopic sphenoidotomy. Intraoperatively, hypertrophied inflamed polypoidal mucosa was seen involving the lateral recesses of sphenoid sinuses which were excised and curetted. On histopathological examination of the excised tissue, the lamina propria and epithelial layer showed extensive edema with infiltration of neutrophils and mononuclear cells, thrombophlebitis and necrotic foci suggestive of acute inflammatory pathology. Follow-up after one month showed near complete resolution with minimal soft tissue in right lateral recess (Fig. 4). Imaging finding of an isolated acute sinusitis of lateral recess of sphenoid sinus in a child is very uncommon and has not been described in the literature. The diagnosis is often delayed until there is a neurological complication. An important differential diagnoses with similar imaging findings that should be kept in mind while treating these cases is meningocele/meningoencephalocele of the lateral recesses, due to persistence of Sternberg’s canal. These patients usually present with spontaneous cerebrospinal fluid leaks and clinical meningitis. The anatomical location of Sternberg’s canal is medial to the superior orbital fissure Fig. 1 a Axial and b Coronal non-contrast CT scan of paranasal sinuses showing fluid within bilateral lateral recesses (arrow) of the sphenoid sinus (arrowhead) and clear bilateral ethmoid sinuses (asterisk)

An Elderly Woman With Difficulty Reading and Abnormal Eye Movements

An Elderly Woman With Difficulty Reading and Abnormal Eye Movements

Is there a relationship between cribriform plate dimensions and septal deviation angle?

The aim of this retrospective study was to investigate the relationship between cribriform plate (CP) dimensions and septal deviation degree. Coronal paranasal CT scans of 99 patients were reviewed. We measured depth and width of cribriform plate on both sides and compared with septal deviation side and septal deviation degree. Deviation angles were 6.85±1.47° for right deviations; and 7.11±1.63° for the left deviations. The mean depth of CP was 5.08±1.57mm at the right side and 5.06±1.59mm at the left side; and the mean width of CP was found 4.71±1.36mm at the right side and 4.56±1.51mm at the left side. When CP dimensions were evaluated according to the septal deviation side, mean width of CP was 4.69±1.36mm at ipsilateral side (deviated side); and 4.58±1.51mm at the contralateral side. The mean depth of CP was 4.9±1.56mm at the ipsilateral side (deviated side); and 5.22±1.58mm at the contralateral side. The CP depth at the contralateral side was significantly higher than that of the ipsilateral side (deviated side). In right SD, ipsilateral and contralateral CP depth increased. As deviation angle increased, ipsilateral and contralateral CP width, right and left CP width increased. Ipsilateral and contralateral CP width; and additionally ipsilateral and contralateral CP depth increased together. In other words, right and left CP width; and CP depth increased simultaneously. It is well known that the higher incidence of intracranial penetration is on the side where the position of the ethmoid roof (ER) is lower. The presence of septal deviation, the possibility of the deeper CP at the contralateral side should be taken into consideration to avoid iatrogenic injury.

The Prevalence of Frontal Cells and Their Relation to Frontal Sinusitis: A Radiological Study of the Frontal Recess Area

Background. The frontal recess area represents a challenge to ENT surgeons due to its narrow confines and variable anatomy. Several types of cells have been described in this area. The agger nasi cells are the most constant ones. The frontal cells, originally classified by Kuhn into 4 types, have been reported in the literature to exist in 20%–41% of frontal recesses. Aim of the Study. To identify the prevalence of frontal recess cells and their relation to frontal sinus disease. Methods. Coronal and axial CT scans of paranasal sinuses of 70 patients admitted for functional endoscopic sinus surgery (FESS) were reviewed to identify the agger nasi, frontal cells, and frontal sinus disease. Data was collated for right and left sides separately. Results. Of the 140 sides reviewed, 126 (90%) had agger nasi and 110 (78.571%) had frontal cells. 37 frontal sinuses were free of mucosal disease, 48 were partly opacified, and 50 were totally opacified. There was no significant difference found in frontal sinus mucosal disease in presence or absence of frontal cells or agger nasi. Conclusions. The current study shows that frontal cells might be underreported in the literature, as the prevalence identified is noticeably higher than previous studies.

Association Between Anatomical Variations of the Sinonasal Region and Chronic Rhino-Sinusitis: A Prospective Case Series Study

SUMMARY Chronic rhinosinusitis is a chronic inflammation of the nasal and paranasal cavities. However, the main pathophysiology of these chronic conditions is poorly described and seems to be multifactorial. In the present study, we reviewed the computed tomography (CT) scans of patients with chronic rhinosinusitis to identify a probable association between the anatomical variations and chronic inflammation in the sinonasal region. Prospective study of the axial and coronal CT scans of 206 chronic rhinosinusitis patients between September 2010 and January 2012 was performed. The study population involved 100 males (48.5%) and 106 females (51.4%) with a mean age of 39 years. The ostiomeatal complex was reported patent in 43 subjects and was blocked in 36 patients. The nasal septa were significantly deviated in 117 (56.7%) patients. Turbinate hypertrophy was reported in 55 (26.6%) patients. Retention cyst was observed in 56 (27.1%) participants. Concha Bullosa and polyps were reported in 36 (17.47%) and 38 (18.44%) patients, respectively. Maxillary sinus was the most common site of involvement (67 patients). Our investigation revealed that there is a strong association between the presence of anatomical variations and chronic inflammation in the paranasal sinuses.

The challenge of localizing the anterior temporal face area: A possible solution

Humans recognize faces exceptionally well. However, the neural correlates of face recognition are still elusive. Accumulated evidence in recent years suggests that the anterior temporal lobe (ATL), in particular face-selective region in the ATL, is a probable locus of face recognition. Unfortunately, functional MRI (fMRI) studies encounter severe signal drop-out in the ventral ATL, where that ATL face area resides. Consequently, all previous studies localized this region in no more than half of the subjects and its volume was relatively small. Thus, a systematic exploration of the properties of the ATL face area is scarce. In the current high-resolution fMRI study we used coronal slice orientation, which permitted us to localize the ATL face area in all the subjects. Furthermore, the volume of the area was much larger than was reported in previous studies. Direct within subjects comparison with data collected with the commonly used axial slice orientation confirmed that the advantage of the coronal slice orientation in revealing a reliable and larger face-selective area in the ATL. Finally, by displaying the face-selective activations resultant from coronal and axial scanning together, we demonstrate an organization principle of a chain of face-selective regions along the posterior–anterior axis in the ventral temporal lobe that is highly reproducible across all subjects. By using the procedure proposed here, a significant progress can be made in studying the neural correlates of face recognition.

HEADACHE--A SINONASAL SYMPTOM AND MORE… A REVIEW ARTICLE

Headaches and facial pain are common complaints. In many cases, patients are referred to an otolaryngologist to determine if head pain is sinus related. In the absence of other nasal or sinus symptoms, some rhinogenic headaches can be overlooked or misdiagnosed. A complete history and thorough ENT examination, including nasal endoscopy with or without coronal CT scans is key to the correct diagnosis.1 Headache resulting from disease of the nose or paranasal sinuses are usually associated with symptoms (congestion, fullness, discharge, obstruction) that point to the site of origin. Occasionally, however nasal or sinus disease can be manifested solely as headache.

A Study of Anatomy of Frontal Recess in Patients Suffering from ‘Chronic Frontal Sinus Disease’

A study designed to describe the anatomical features of the frontal recess area in patients suffering from chronic frontal sinusitis. A prospective study done in adult patients admitted in our hospital between July 2009 to June 2011. Tertiary level, private ENT care centre. 50 adult patients of chronic frontal sinusitis who did not have history of previous sinus surgery. The frontal recess anatomy was studied by 2mm slice CT scans pre-operatively. CT findings were confirmed intra operatively by meticulous dissection in frontal recess area endoscopically with aid of image guided system. A chart prepared for each patient of different anatomical variations present in frontal recess on each nasal side and analyzed. Agger nasi cell was found in 94% of cases. The superior attachment of the uncinate was to the lamina papyraceae in 82% of cases. Type 1 frontal recess cells were found in 44%, type 2 in 8%, type 3 in 48% and type 4 in 2% of the cases. Over all 74% of cases had frontal recess cells. The management of frontal sinusitis is a challenge to endoscopic surgeon and as more and more rhinologists got expertise in endoscopic sinus surgery skills; the next challenge is management of frontal sinus. Hence, the need arises for more precise study of frontal recess anatomy. Detailed studies of anatomic features of the frontal recess by coronal and sagittal CT scans are very important and helpful for endoscopic frontal sinus surgery. Our study suggests that there is high prevalence of frontal recess cells in Indian population suffering from frontal sinusitis.

Frontal sinus outflow tract evaluation by sagittal computed tomography in frontal sinus fracture

The status of the frontal sinus outflow tract is important in the management of frontal sinus fractures. Anatomic and mucosal obstruction of the FSOT leads to mucociliary stasis with consequent infectious complications. This has been evaluated by routine CT scan. ObjectivesThe aim of this study was to determine the ability of MPR mainly the sagittal CT images assessing the patency of FSOT in frontal sinus fractures. Patients and methodsA prospective study was carried out from December 2008 to May 2012 on 19 patients with frontal sinus fractures. Reformatted sagittal views were done besides the routine axial, coronal CT scan views as part of facial trauma workup. These views were assessed to determine the status of the nasofrontal ducts (NFD) and compared with the operative findings. ResultsThe patency of FSOT by sagittal CT reformatted images was the same as that of the operative finding in all cases (specificity and PPV were 100%) even in patients in whom FSOT in the axial and/orcoronal views were doubtful. ConclusionSagittal reformatted CT images are helpful in evaluating FSOT in frontal sinus fractures due to their ability to evaluate the frontal sinus in anteroposterior and superoinferior dimensions, thus aiding the surgical approach.

A Targeted Approach to a Giant Gastrointestinal Stromal Tumor of the Esophagus

Sir, Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, accounting for 0.1 %–3.0 % of all gastrointestinal malignancies. GISTs can arise anywhere in the gastrointestinal tract: 50–70 % in the stomach, 20–40 % in the small bowel, 5–15 % in the colon and rectum and rarely in the mesentery or retroperitoneum. Esophageal GISTs are extremely uncommon, representing approximately 5 % of GISTs with a majority occurring at the esophagogastric junction (GEJ). [1, 2] We report a case of a borderline resectable GIST of the lower esophagus, treated with neoadjuvant imatinib mesylate (IM) which ultimately resulted in a successful R0 resection. A 50-year-old lady with no co-morbid conditions was referred to us for progressively worsening dysphagia of 6 months. An upper gastrointestinal endoscopy revealed a circumferential ulcerated growth in the lower end of the esophagus, from 30 to 36 cm, which was seen extending to the GEJ. An endoscopic biopsy was suggestive of a spindle cell neoplasm, which on immunohistochemistry correlation (CD117 and CD34 positive, Ki-67–30 %) was suggestive of a high grade GIST. Computerized tomography (CT) scan of the chest and abdomen revealed a large lobulated, hetero-dense, poorly enhancing mass (10.9 × 7.4 × 16 cm) in the thoraco-abdominal region, involving the lower end of the esophagus, GEJ, posterior stomach and extending along the retroperitoneum to infiltrate the body and tail of pancreas, causing a mass effect on the left kidney. (Figures 1a and ​and2a2a) Fig. 1 a- Axial CT scan at presentation (Maximal diameter-10.9 cm). b- Axial CT scan following 6 months of Imatinib Mesylate (Maximal diameter-4.2 cm) Fig. 2 a- Coronal CT scan at presentation. b- Coronal CT scan following 6 months of Imatinib Mesylate After thorough discussion of the issues of borderline resectability/unresectability, the patient consented to attempt to downstage the tumor by neoadjuvant treatment with IM. (400 mg/day) An interim CT scan at two months revealed a regression of the tumor diameter, IM was hence continued for another 4 months. A follow-up CT at 6 months revealed a regression of the tumor diameter from 10.2 cm to 4.2 cm. (Figures 1b and ​and2b)2b) Resection of the residual tumor was deemed feasible and the patient was taken up for an exploratory laprotomy. The residual tumor was found to be densely adherent to a portion of the distal body of the pancreas; a distal pancreatico-spleenectomy had to be combined with an esophago-gastrectomy via a transhiatal approach to attain a R0 resection. (Figures 3 and ​and4)4) The bowel continuity was restored using a gastric tube conduit through the posterior mediastinum. Histopathological examination of the resection specimen confirmed a GIST with extensive post treatment changes and clear margins. The postoperative course was uneventful, after recovery the patient continued adjuvant therapy with IM for 6 more months, she is currently disease free. Fig. 3 Specimen photograph (Esophago-gastrectomy along with distal pancreatico spleenectomy) Fig. 4 a- H& Ex 40- Shows tumor composed of fascicles and sheets of spindle cells with dark staining nuclei in a myxoid background. b- IHCX40- Tumor cells showing immunopositivity to CD-117. c- IHCX40- Tumor cells showing immunopositivity to CD-34. ... GISTs are thought to arise from the intestinal cells of Cajal, which are intestinal pacemaker cells that regulate peristalsis. Considerable progress has been made recently in our understanding of the natural history, risk stratification, and molecular biology of GIST. The vast majority of GISTs contain an activating mutation in either the KIT or platelet-derived growth factor-A gene. GIST is highly responsive to several selective tyrosine kinase inhibitors. Despite the efficacy of targeted therapy, surgery remains the only curative primary treatment and cures >50 % of GIST patients who present with localized disease. Many authors agree that loco regionally advanced tumors or those poorly positioned which require an extended/multi-organ resection should be considered for neoadjuvant treatment with IM and should be re-evaluated for a possible curative resection. [3–5] This approach has been proven to be safe and feasible even in the management GIST of the esophagus as was also seen in our patient. In conclusion a multimodal approach with neoadjuvant administration of IM is emerging as a viable treatment strategy for borderline resectable esophageal GIST, although the dose and duration have not been clearly established. The long-term impact of this approach on survival is presently under investigation in multicenter prospective randomized trials.

Improved sleep MRI at 3 tesla in patients with obstructive sleep apnea

To describe a real-time MR imaging platform for synchronous, multi-planar visualization of upper airway collapse in obstructive sleep apnea at 3 Tesla (T) to promote natural sleep with an emphasis on lateral wall visualization. A real-time imaging platform was configured for sleep MR imaging which used a cartesian, partial k-space gradient-echo sequence with an inherent temporal resolution of 3 independent slices every 2 s. Combinations of axial, mid-sagittal, and coronal scan planes were acquired. The system was tested in five subjects with polysomnography-proven obstructive sleep apnea during sleep, with synchronous acquisition of respiratory effort and combined oral-nasal airflow data. Sleep was initiated and maintained to allow demonstration of sleep-induced, upper airway collapse as illustrated in two subjects when using a real-time, sleep MR imaging platform at 3T. Lateral wall collapse could not be visualized on mid-sagittal imaging alone and was best characterized on multiplanar coronal and axial imaging planes. Our dedicated sleep MR imaging platform permitted an acoustic environment of constant "white noise" which was conducive to sleep onset and sleep maintenance in obstructive sleep apnea patients at 3T. Apneic episodes, specifically the lateral walls, were more accurately characterized with synchronous, multiplanar acquisitions.

Dislocation of the mandibular condyle into the middle cranial fossa: a case report

A 32-year-old woman was admitted to our hospital following a motor vehicle accident. Her chief complaint was severe limited mouth opening and unilateral open bite on the left. Axial and coronal CT scans showed penetration of right condyle into the middle cranium through the fractured roof of glenoid fossa. A craniotomy exactly above the glenoid fossa was done. The condyle was reduced and the glenoid fossa was reconstructed. On postoperative follow-up at 6 months, the patient had no complaint, but there was a small deviation to the affected side on opening.

Intranasal contact points as a cause of facial pain or headache: a systematic review

There is a body of opinion in the clinical literature advocating the removal of intranasal contact points to treat facial pain. To review the evidence that intranasal mucosal contact points cause facial pain or headache and their removal is therapeutic. Systematic review. A systematic search of the available literature was performed using MEDLINE, EMBASE, Cochrane library and NHS Evidence from inception to September 2011. Terms used include facial pain and contact point (3628), rhinologic headache (6) contact point and surgery/endoscopy (38). Inclusion criteria applied. Assessment of papers were undertaken by one reviewer and checked by the second. A narrative review of each study was performed and results recorded in tables. In one study, 973 consecutive patients with a provisional diagnosis of rhinosinusitis were divided into groups with (42%) and without facial pain. There was a 4% prevalence of nasal contact in both groups, which was unrelated to the presence of facial pain. In another study of 100 patient's coronal paranasal sinus CT scans, 29% had headache and 55% had a contact point but their presence was inversely related to the presence of pain.(1) In a further study, ten healthy volunteers had palpation, adrenaline, substance P and placebo applied to different areas throughout the nasal cavity and none of these stimuli caused facial pain. Nineteen studies were identified where nasal mucosal contact points had been removed surgically for the treatment of facial pain. They were small case series, not randomised and subject to selection bias, had no control group, a limited follow-up and were open to observer bias with level IV evidence. Seven studies had a statistically significant improvement in pain postoperatively compared with preoperative questionnaire results but the majority had residual facial pain. The majority of people with contact points experience no facial pain. The presence of a contact point is not a good predictor of facial pain. The removal of a contact point rarely results in the total elimination of facial pain making the theory that a contact point is responsible unlikely. The improvement in postoperative symptoms following the removal of contact points in some patients may be explained by cognitive dissonance or neuroplasticity. A randomised, controlled and blinded trial with a followed up period of over 12 months is needed to assess the place of surgery in the removal of a contact point for the treatment of facial pain.

Anatomical margins of uncinectomy in endoscopic sinus surgery

BackgroundEndoscopic sinus surgery is a common and generally safe ENT procedure. Orbital injury is a rare but devastating complication. The distance between the uncinate process and the lamina papyracea is the safety margin to avoid entering the orbital cavity and has not been measured previously. MethodsThe authors reviewed 330 consecutive coronal CT scans of the paranasal sinuses to measure this distance and identify variation. ResultsThe distance can be as narrow as 0.1 mm and varies between sides. An air cell lateral to the uncinate is not uncommon; it increases the distance considerably p < 0.001 but is frequently unilateral (22%). Gender does not have an effect on this distance p = 0.90. ConclusionIt is essential to carefully examine the area on a CT scan especially when performing front-to-back uncinectomy during endoscopic sinus surgery. The variation between the right and left sides should be considered to avoid unsafe assumptions.

Primary tracheobronchial amyloidosis

Primary tracheobronchial amyloidosis (PTBA) is a localized form of amyloidosis. The clinical signs of this condition are non-specific and diagnosis before bronchoscopic examination with multiple biopsies is uncommon. We present three cases of PTBA and compare findings between the thoracic imaging and fiberoptic bronchoscopy. Radiographic findings often had uncharacteristic features. The relatively specific coronal section CT preceded findings in transverse sections, and showed an irregular mucosal surface with diffuse prominent nodes and/or calcification of the tracheobronchus, which we called the "wavy path sign". In conclusion, coronal CT scan can provide ample clues for the early diagnosis of PTBA.

Combined Aplasia of Sphenoid, Frontal, and Maxillary Sinuses With Hypoplasia of The Ethmoid Sinus

Dear Editor, Paranasal sinuses are prone to a great diversity of anomalies. Aplasia of the frontal sinus is a relatively common phenomenon and may be accompanied with hypoplasia of the maxillary sinus, but combined aplasia or underdevelopment of the paranasal sinuses is unusual (1, 2).These developmental pathologies may be misdiagnosed as sinusitis or neoplasm (2). Computerized Tomography (CT) is an excellent imaging technique that is used to map sinus anatomy (3). Here, we present a 23-years old male patient who has combined aplasia of sphenoid, frontal, and maxillary sinuses accompanied by ethnocide sinus hypoplasia, which is the second reported case to our knowledge. Twenty three years old male patient presented with complaints of headache and nasal obstruction to the Otorhinolaryngology outpatient clinic. Axial and Coronal CT scans (5mm slice thickness) delineated lack of pneumatization in the frontal, sphenoid and maxillary sinuses and minimal pneumatization in the ethmoid cells eg. Total aplasia of the frontal, sphenoid and maxillary sinuses and hypoplasia of the ethmoid sinuses. (Figure 1) No other craniofacial anomaly was observed. He had no previous history of facial trauma, irradiation or systemic diseases affecting the skeletal system such as Paget’s disease, osteopetrosis, or fibrous dysplasia. No other abnormality was found on clinical and laboratory examinations, including cystic fibrosis. The paranasal sinuses begin their development as an evagination of the mucosa from the nasal cavities during the third and fourth fetal months. They undergo major expansion after birth, along with the development of the facial cranium and teeth (1) The underdevelopment or aplasia of the paranasal sinuses is a rare phenomenon that refers mainly to the frontal (12%) and secondarily to the maxillary sinuses (5% and 6%). Agenesis of the sphenoid sinuses is extremely rare (4). The agenesis of the paranasal sinuses occurs more frequently in syndromes of craniosynostosis, osteodysplasia (Melnick-Needles), as well as in cases of Down’s syndrome (hypoplasia of the frontal sinus) (3). Developmental anomalies of paranasal sinuses in cystic fibrosis patients is significantly high compared to normal population (3). The developmental pathologic abnormalities may be misdiagnosed as sinusitis or neoplasm (4). The maxillary sinus is the first of the paranasal sinuses to develop in the human fetus and is present at birth. Development of the maxillary sinus may become arrested in children with recurrent chronic rhino sinusitis (4). For many authors there is a connection between reduced nasal ventilation and abnormal maxillary growth, but Diner et al observed normal development of maxillary sinus in 11 patients with unilateral choanal atresia. Chronic obstruction due to narrow infundibular passage and absence of natural osmium leads to thick effusion in hypo plastic sinuses (2, 4)Maxillary sinus hypoplasia may be misdiagnosed as chronic sinusitis. The sphenoid sinus develops embryo logically from the skull base. By the age of 12, the sphenoid pneumatization reaches its final form to a size equivalent to that of an adult. Sphenoid sinuses vary in size and shape. The average measurements of the sphenoid sinus are as follows: vertical height, 2 cm; transverse breadth, 1.8 cm; and anterosuperior depth, 2.1 cm. Hypoplasia of the sphenoid sinuses is shown frequently in patients with cystic fibrosis. However, agenesis of the sphenoid sinus is highly uncommon (4). Based on their anatomical studies, Wertheim and Grunwald reported in the early 1900s that agenesis of the sphenoid sinuses can indeed occur in 1–1.5% of cases. The diagnosis of sphenoid sinus hypoplasia is potentially important in patients in whom trans-spheroidal hypophysectomy is contemplated. In conclusion this patient seems to be the second case to have combined aplasias of the sphenoid, frontal, and maxillary sinuses with hypo plastic ethmoid cells without any systemic or skeletal disease. This extremely rare anomaly should also be kept in mind to prevent complications during endoscopic sinus surgery. Figure 1 Paranasal Sinus CT, Coronal Section, Indicating Aplasia of the Maxillary Sinus and Minimal Pneumatization in the Ethmoid Cells.

A Rare Condition with a Common Presentation: NK/T-Cell Lymphoma Presenting as Recurrent Sinusitis and Facial Cellulitis

Journal of Case Reports in Medicine,2013,2,1,1-4.Published:April 2013Type:Case ReportAuthors:Danny K. C. Wong, Angus Shao, and Michael Davison Author(s) affiliations:Danny K. C. Wong, Angus Shao, and Michael Davison Department of Otolaryngology – Head and Neck Surgery, Northshore Hospital, Private Bag 93503, Takapuna 0622, Auckland, NEW ZEALAND. Abstract:Extranodal natural killer (NK)/T-cell lymphomas are rare tumors that account for 1.5% of all non-Hodgkin-type lymphomas in the United States and almost 7–10% of all non-Hodgkin’s lymphomas in Asia and South America. The nasal type commonly presents with facial cellulitis, nasal obstruction or proptosis. Occasionally, local extension from the nasal cavity causes destruction of the hard palate, previously known as “lethal midline granuloma.” We present a case of a 37-year-old male who presented with recurrent right-sided facial swelling, periorbital cellulitis and sinusitis. There was some delay in confirming the diagnosis but he was eventually diagnosed with stage 1e NK/T-cell lymphoma (nasal type). Disease diagnosed at an early stage confers a very favorable curative remission rate. Therefore, clinicians should be aware of the possibility of an NK/T-cell lymphoma when facing a presentation of recurrent sinusitis associated with atypical presentation such as periorbital cellulitis. Keywords:NK/T-cell lymphoma; Nasal type; Periorbital cellulitis; Sinusitis; Facial swellingView:PDF (1.11 MB) PDF Images Figure 2: Coronal CT scan of patient representing with recurrent right sided facial cellulitis and predominantly right sided sinusitis on the 2nd presentation.