Inferior Portion Research Articles

Oncoplastic surgery combining abdominal advancement flaps with volume displacement techniques to breast-conserving surgery for small- to medium-sized breasts

An abdominal advancement flap (AAF) is a flap that pulls the elevated abdominal skin up, creating the shape of the inferior portion of the breast by making a neo-inframammary fold. We used an AAF combined with volume displacement techniques to fill the defect left after breast-conserving surgery (BCS). Forty-one small- to medium-sized breast patients whose resection area included the lower portion of the breast underwent this procedure from October 2010 to December 2014. We evaluated efficacy of this procedure. The excision volume ranged from 10 to 35%. Complications after surgery were observed in two patients (partial necrosis of the nipple-areola complex and partial necrosis of the breast skin in one patient each). There was no fat necrosis of the flap in any of the patients. The cosmetic results were found to be excellent in 7 cases, good in 23, fair in 9 and poor in 2. In 11 cases with an unacceptable outcome, 9 cases were in the inner portion. In patients with the tumor in the inner portion, the proportion of unacceptable cases was 50%. In the cases other than the inner portion, the proportion of unacceptable cases was 8.7% (p<0.01). In the cases with larger breasts, unacceptable cases were more frequently observed (p<0.05). We believe that an AAF combined with volume displacement techniques may be useful following BCS in the lower portion of a small- to medium-sized breast, except in cases where the tumors is located in the inner potion.

Medical Management for the Treatment of Nontuberculous Mycobacteria Infection of the Parotid Gland: Avoiding Surgery May Be Possible.

Infection with nontuberculous mycobacteria (NTM) is uncommon in the head and neck; therefore there is no clear consensus on treating these infections. Our objective was to report our experience with a unique case of NTM infection of the parotid in an immunocompetent patient, in order to determine appropriate management through our experience with this pathology. A 57-year-old man, known for numerous comorbid diseases, presented to our institution complaining of right parotid swelling and pain. A computed tomography (CT) of the neck showed a multiloculated collection in the inferior portion of the right parotid gland, compatible with abscess formation. This abscess was drained by interventional radiology (IR) but required repeat drainage twice due to lack of initial improvement. He was treated with several antibiotics as culture results initially indicated Gram-positive bacilli and then Mycobacterium species, with final identification by a reference laboratory as Mycobacterium abscessus. Imipenem was initiated with amikacin and clarithromycin. His infection clinically and radiologically resolved after 5 months of antibiotherapy. In our case, the patient improved following intravenous antibiotic therapy. Our experience demonstrates that appropriate antibiotherapy can lead to resolution of Mycobacterium abscessus infection in the parotid without the risks associated with surgical intervention.

Capsular stroke modeling based on somatotopic mapping of motor fibers

Recently, several capsular stroke models have been reported with different targets of destruction. This study was performed to establish an accurate internal capsule (IC) target for capsular stroke modeling in rats. We injected adeno-associated virus serotype 5 (AAV)-CaMKII-EYFP into forelimb motor cortex and AAV-CaMKII-mCherry into hindlimb motor cortex (n = 9) to anterogradely trace the pyramidal fibers and map their somatotopic distribution in the IC. On the basis of the neural tracing results, we created photothrombotic infarct lesions in rat forelimb and hindlimb motor fiber (FMF and HMF) areas of the IC (n = 29) and assessed motor behavior using a forelimb-use asymmetry test, a foot-fault test, and a single-pellet reaching test. We found that the FMFs and HMFs were primarily distributed in the inferior portion of the posterior limb of the IC, with the FMFs located largely ventral to the HMFs but with an area of partial overlap. Photothrombotic lesions in the FMF area resulted in persistent motor deficits. In contrast, lesions in the HMF area did not result in persistent motor deficits. These results indicate that identification of the somatotopic distribution of pyramidal fibers is critical for accurate targeting in animal capsular stroke models: only infarcts in the FMF area resulted in long-lasting motor deficits.

Endosonographic examination of thyroid gland among patients with nonthyroid cancers.

Objectives:There is limited endosonographic literature regarding thyroid gland pathology, which is frequently visualized during upper endoscopic ultrasound (EUS). Our objective was to assess the prevalence of benign and malignant thyroid lesions encountered during routine upper EUS within a cancer center setting.Materials and Methods:The data were prospectively collected and retrospectively analyzed. All upper EUS procedures performed between October 2012 and July 2014 were reviewed at a large referral cancer center. Data collected included patient demographics, preexisting thyroid conditions, thyroid gland dimensions, the presence or absence of thyroid lesions, and EUS morphology of lesions if present, and interventions performed to characterize thyroid lesions and pathology results when applicable.Results:Two hundred and forty-five EUS procedures were reviewed. Of these, 100 cases reported a detailed endosonographic examination of the thyroid gland. Most of the thyroid glands were endosonographically visualized when the tip of the scope was at 18 cm from the incisors. Twelve cases showed thyroid lesions, out of which three previously undiagnosed thyroid cancers were visualized during EUS (two primary papillary thyroid cancers and one anaplastic thyroid cancer). Transesophageal EUS-guided fine needle aspiration of thyroid lesions was feasible when the lesion was in the inferior portion of the thyroid gland, and the tip of the scope was at 18 cm or more from the incisors.Conclusions:Routine EUS examination may detect unexpected thyroid lesions including malignant ones. We encourage endosonographers to screen the visualized portions of the thyroid gland during routine withdrawal of the echoendoscope.

Evaluation of Partial Cut-out of Sacroiliac Screws From the Sacral Ala Slope via Pelvic Inlet and Outlet View.

An anatomic and radiographic study of placement of sacroiliac screws. The aim of this study was to quantitatively assess the risk of partial cut-out of sacroiliac screws from the sacral ala slope via inlet and outlet view. The partial cut-out of sacroiliac screws from the superior surface of sacral ala can jeopardize the L5 nerve root, which is difficult to identify on the pelvic inlet and outlet views. Computed tomography images of 60 patients without pelvic ring deformity or injury were used to measure the width (on inlet view) and height (on outlet view) of the sacral ala. The angle of the sacral ala slope was measured on lateral view. According to the measured parameters, the theoretical safe trajectories of screw placement were calculated using inverse trigonometric functions. Under fluoroscopic guidance, a sacroiliac screw was placed close to the midline on both inlet and outlet views, including posterosuperior, posteroinferior, anterosuperior, and anteroinferior regions to the midline. The incidence of screw partial cut-out from the superior surface of sacral ala was identified. The measured widths and heights of the sacral alas were 28.1 ± 2.8 and 29.8 ± 3.1 mm, respectively. The average angle between the superior aspect of the S1 vertebral body and the superior aspect of the sacral ala was 37.2 ± 2.5 degrees. The rate of partial cut-out of the screws from the superior surface of sacral ala slope was 12.5% (5/40) in posterosuperior, 0% (0/40) in posteroinferior, 70% (28/40) in anterosuperior, and 20% (8/40) in anteroinferior. To avoid the risk of partial cut-out from sacroiliac screw placement, more precise description should be added to the conventional description: the sacroiliac screws should be placed at the inferior half portion on outlet view and at the posterior half portion on inlet view. 4.

Successful Endoscopic Removal of a Kerh-Tube Placed in an Iatrogenic Esophageal Perforation: Push to Pull

Esophageal perforation is a rare complication during cervical surgery associated with high morbidity and mortality. Currently, the treatment of esophageal perforations remains controversial. The use of modified T-tube (Kerh-tube) repair can be a therapeutic option associated with a low mortality rate. The authors report a 68-year-old man with a cervical spinal cord lesion submitted to an anterior cervical surgery when a plate fixation removal complicated with an iatrogenic cervical esophageal perforation that was immediately diagnosed. A T-tube was inserted into the esophagus following debridement of adjacent wall with its inferior portion extending into the stomach. The esophageal wall was closed loosely about the tube with sutures placed in the nearest healthy submucosa (Figs. 1 and 2A and B). Two weeks later, an upper endoscopy was performed in order to remove the T-tube. Using a polypectomy snare (10 mm, Olympus) the distal end of the Kerh-tube was

Prenatal vesico-allantoic cyst outcome - a spectrum from patent urachus to bladder exstrophy.

The purpose of this study is to assess the prognostic significance of a cystic vesico-allantoic communication discovered on prenatal ultrasound in terms of its effect on the developing urinary tract. Multi-institution review of prenatal screening ultrasound was performed between 2004 and 2015 to identify cases of in utero communication between the fetal urinary bladder and a cystic dilatation of the umbilical cord. Gestational age at diagnosis, perinatal evolution, and eventual urinary tract outcome are described and compared with existing literature. Five cases of cystic vesico-allantoic communication were identified on second-trimester screening ultrasound. Serial ultrasounds showed an increase in the size of the umbilical cystic component with gestational age, followed by its eventual rupture prior to delivery. All neonates had urinary leakage through the inferior portion of the umbilicus with bladder prolapse ranging from patent urachus to partial bladder exstrophy. An isolated prenatal ultrasound finding of an hourglass communication between the fetal bladder and a cyst of the umbilical cord should be considered predictive of a spectrum from patent urachus to bladder exstrophy. Given the significant ramications on the developing urinary tract, the prenatal finding of vesico-allantoic cyst warrants referral to a high-risk obstetrical center with urologic consultation.

Microsurgical Approaches to the Ambient Cistern Region: An Anatomic and Qualitative Study

We used microscopy to conduct qualitative and quantitative analysis of 4 surgical approaches commonly used in the surgery of the ambient cistern: infratentorial supracerebellar (SC), occipital interhemispheric, subtemporal (ST), and transchoroidal (TC). In addition, we performed a parahippocampal gyrus resection in the ST context. Each approach was performed in 3 cadaveric heads (6 sides). After the microscopic anatomic dissection, the parahippocampal gyrus was resected through an ST approach. The qualitative analysis was based on anatomic observation and the quantitative analysis was based on the linear exposure of vascular structures and the area of exposure of the ambient cistern region. The ST approach provided good exposure of the inferior portion of the cistern and of the proximal segments of the posterior cerebral artery. After the resection of the parahippocampal gyrus, the area of exposure improved in all components, especially the superior area. A TC approach provided the best exposure of the superior area compared with the other approaches. The posterolateral approaches (SC/occipital interhemispheric) to the ambient cistern region provided similar exposure of anatomic structures. There was a significant difference (P < 0.05) in linear exposure of the posterior cerebral artery when comparing the ST/TC and ST/SC approaches. This study has demonstrated that surgical approaches expose dissimilarly the different regions of the ambient cistern and an approach should be selected based on the specific need of anatomic exposure.

Broca’s Aphemia: The Tortuous Story of a Nonaphasic Nonparalytic Disorder of Speech

Broca coined the neologism “aphemia” to describe a syndrome consisting of a loss of the ability to speak without impairment of language and paralysis of the faciolingual territories in actions unrelated to speech, such as protruding the tongue or pursing the lips. Upon examining the brains of patients with aphemia, Broca concluded that the minimum possible lesion responsible for aphemia localized to the posterior left inferior frontal gyrus and lower portion of the middle frontal gyrus. A review of Broca’s writings led us to conclude that (a) Broca localized speech, not language, to the left hemisphere, (b) Broca’s aphemia is a form of apraxia, (c) Broca’s aphemia is not, therefore, a terminological forerunner of aphasia, and (d) Broca was an outspoken equipotentialist concerning the cerebral localization of language. Broca’s claim about the role of the left hemisphere in the organization of speech places him as the legitimate forebear of the two most outstanding achievements of Liepmann’s work, namely, the concepts of apraxia and of a left hemisphere specialization for action.

Pancreatitis by Compression

Diverticula are a rare cause of pancreatitis. We present a case of acute pancreatitis secondary to compression from a periampullary duodenal diverticulum (PAD). A 38-year-old male presented with acute epigastric abdominal pain. He denied other symptoms and had no history of alcohol intake, trauma, or taking any medications. He was afebrile and hemodynamically stable. On exam, his abdomen was tender to palpation in the epigastrium. His labs were notable for a WBC 11.5 k/mm3, lipase 5,410 IU/L, AST 87 IU/L, ALT 72 IU/L, ALP 126 IU/L, total bilirubin 0.5mg/dL, normal triglycerides and calcium levels. He was admitted with suspected biliary pancreatitis and medical management was initiated with intravenous fluids, bowel rest, and pain control. His liver enzymes subsequently increased to an AST 469 IU/L, ALT 503 IU/L and total bilirubin 1.4 mg/dL. An abdominal ultrasound done prior to admission for similar symptoms was negative for gallbladder stones or sludge. Computed Tomography Scan showed mild common bile duct and pancreatic duct dilatation with an edematous pancreatic head consistent with pancreatitis. An Endoscopic Retrograde Cholangiopancreatography showed a large diverticulum with food impaction obscuring the major duodenal papilla. Some food particles were removed from the diverticulum using a grasping snare and a Roth net. Due to remnant food debris, the ampulla could not be located to allow for cannulation within the large diverticulum. Magnetic Resonance Cholangiopancreatography revealed an enlarged pancreatic head with a large 3cm duodenal diverticulum compressing its inferior portion at the ampulla of Vater with no evidence of biliary stones. The patient's symptoms and laboratory abnormalities improved after ERCP, and he was discharged with surgical follow-up for possible intervention in event of recurrent pancreatitis attacks. Duodenal diverticula rarely cause pancreatitis, but should be kept in mind as a potential etiology. About 70-75% of duodenal diverticula occur in the periampullary region. Factors that contribute to the development of these diverticula include age, weakening of intestinal smooth muscles, and increased intraduodenal pressure. Mechanical pressure from the diverticulum and diverticular inflammation from narrowing at the duodenal papilla leads to complications of PAD. Surgical intervention is not indicated for asymptomatic patients. Patients who are symptomatic may necessitate surgical or endoscopic intervention, such as sphincterotomy. We present a rare case of acute pancreatitis caused by compression from a periampullary duodenal diverticulum.Figure 1Figure 2Figure 3

Compartmental Innervation of the Superior Oblique Muscle in Mammals.

Intramuscular innervation of mammalian horizontal rectus extraocular muscles (EOMs) is compartmental. We sought evidence of similar compartmental innervation of the superior oblique (SO) muscle. Three fresh bovine orbits and one human orbit were dissected to trace continuity of SO muscle and tendon fibers to the scleral insertions. Whole orbits were also obtained from four humans (two adults, a 17-month-old child, and a 33-week stillborn fetus), two rhesus monkeys, one rabbit, and one cow. Orbits were formalin fixed, embedded whole in paraffin, serially sectioned in the coronal plane at 10-μm thickness, and stained with Masson trichrome. Extraocular muscle fibers and branches of the trochlear nerve (CN4) were traced in serial sections and reconstructed in three dimensions. In the human, the lateral SO belly is in continuity with tendon fibers inserting more posteriorly on the sclera for infraducting mechanical advantage, while the medial belly is continuous with anteriorly inserting fibers having mechanical advantage for incycloduction. Fibers in the monkey superior SO insert more posteriorly on the sclera to favor infraduction, while the inferior portion inserts more anteriorly to favor incycloduction. In all species, CN4 bifurcates prior to penetrating the SO belly. Each branch innervates a nonoverlapping compartment of EOM fibers, consisting of medial and lateral compartments in humans and monkeys, and superior and inferior compartments in cows and rabbits. The SO muscle of humans and other mammals is compartmentally innervated in a manner that could permit separate CN4 branches to selectively influence vertical versus torsional action.

Evaluation of Cortical Thickness after Traumatic Brain Injury in Military Veterans.

Military service members frequently sustain traumatic brain injuries (TBI) while on active duty, a majority of which are related to explosive blasts and are mild in severity. Studies evaluating the cortical gray matter in persons with injuries of this nature remain scarce. The purpose of this study was to assess cortical thickness in a sample of military veterans with chronic blast-related TBI. Thirty-eight veterans with mild TBI and 17 veterans with moderate TBI were compared with 58 demographically matched healthy civilians. All veterans with TBI sustained injuries related to a blast and were between 5 and 120 months post-injury (M = 62.08). Measures of post-traumatic stress disorder (PTSD) and depression were administered, along with a battery of neuropsychological tests to assess cognition. The Freesurfer software package was used to calculate cortical thickness of the participants. Results demonstrated significant clusters of cortical thinning in the right hemispheric insula and inferior portions of the temporal and frontal lobe in both mild and moderate TBI participants. The TBI sample from this study demonstrated a high incidence of comorbid PTSD and depression symptoms, which is consistent with the previous literature. Cortical thickness values correlated with measures of PTSD, depression, and post-concussive symptoms. This study provides evidence of cortical thinning in the context of chronic blast-related mild and moderate TBI in military veterans who have comorbid psychiatric symptoms. Our findings provide important insight into the natural progression of long-term cortical change in this population and may have implications for future clinical evaluation and treatment.

Evaluation of lamina cribrosa thickness and depth in ocular hypertension.

To investigate the differences in thickness and depth of the lamina cribrosa (LC) between ocular hypertension (OH) patients and normal control subjects, using enhanced depth imaging (EDI) spectral-domain optical coherence tomography (SD-OCT). EDI-OCT data were obtained from the subjects in a cross-sectional analysis of data from a retrospective study. After IOP correction according to central corneal thickness (CCT), we divided the OH patients into two groups based on the corrected IOP (cIOP)--OH with lower IOP (OH-L; cIOP < 23 mmHg) and OH with higher IOP (OH-H; cIOP ≥ 23 mmHg). Comparisons of LC thickness and depth among three groups were performed. Seventy-four OH patients and 45 normal control subjects were included in the analysis. Among the 74 OH patients, 41 were included in the OH-L group and 33 were included in the OH-H group. LC thickness was thicker in the OH-H group compared to normal controls both in superior (P = 0.02) and inferior (P = 0.01) portions. However, no difference was found in LC depth among the three groups in any portion (P = 0.36; P = 0.44; P = 0.31, respectively). OH patients may have a thicker LC than normal control subjects, especially in OH with definite high IOP.

Chondrocytes Directly Transform into Bone Cells in Mandibular Condyle Growth

For decades, it has been widely accepted that hypertrophic chondrocytes undergo apoptosis prior to endochondral bone formation. However, very recent studies in long bone suggest that chondrocytes can directly transform into bone cells. Our initial in vivo characterization of condylar hypertrophic chondrocytes revealed modest numbers of apoptotic cells but high levels of antiapoptotic Bcl-2 expression, some dividing cells, and clear alkaline phosphatase activity (early bone marker). Ex vivo culture of newborn condylar cartilage on a chick chorioallantoic membrane showed that after 5 d the cells on the periphery of the explants had begun to express Col1 (bone marker). The cartilage-specific cell lineage–tracing approach in triple mice containing Rosa 26tdTomato (tracing marker), 2.3 Col1GFP (bone cell marker), and aggrecan CreERT2 (onetime tamoxifen induced) or Col10-Cre (activated from E14.5 throughout adult stage) demonstrated the direct transformation of chondrocytes into bone cells in vivo. This transformation was initiated at the inferior portion of the condylar cartilage, in contrast to the initial ossification site in long bone, which is in the center. Quantitative data from the Col10-Cre compound mice showed that hypertrophic chondrocytes contributed to ~80% of bone cells in subchondral bone, ~70% in a somewhat more inferior region, and ~40% in the most inferior part of the condylar neck (n = 4, P < 0.01 for differences among regions). This multipronged approach clearly demonstrates that a majority of chondrocytes in the fibrocartilaginous condylar cartilage, similar to hyaline cartilage in long bones, directly transform into bone cells during endochondral bone formation. Moreover, ossification is initiated from the inferior portion of mandibular condylar cartilage with expansion in one direction.

P17.09: In polyhydramnios investigation: don't forget trachea!

We examined a 35 years old pregnant G5 P3 for a polyhydramnios (Great cisterna 9 cm) in one of the twin (monochorionic biamniotic), with no sign of Twin–twin transfusion. At 28 Week of gestation stomach was seen with normal filling, the profile was normal and fetal movements were present. Esophagus was not well identified as the tracheo aortic space. No but pouch sign were found during 20 mn ong examination. We only notice an unusual wide trachea at 4.9 mm. The MRI did not find direct or indirect esophagus atresia signs but noticed also the wide trachea diameter. 2 weeks later, a control scan found again the wide trachea (5 mm) but found also the 2 unusual wide bronchus on the first millimeters. One of them seems to continue with the esophagus normally seen in its inferior portion. A brief filling objectives the prolongation between trachea and esophagus and allowed to exclude the possibility of a pouch sign. Meanwhile we couldn't demonstrate the normal space between trachea and aorta normally occupied by esophagus. More, we found a very thin distance between trachea and vertebral echogenicity. These elements led to propose the diagnostic of laryngo diastema and was confirmed. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Clinical and radiological outcomes of arthroscopic subacromial decompression for stage-II impingement of shoulder

BackgroundShoulder impingement is described as a mechanical impingement of the rotator cuff tendon beneath the antero inferior portion of the acromion, especially when the shoulder is placed in the forward-flexed and internally rotated position. It is a common cause of recurrent shoulder pain and disability. AimThe aim of the present study was to study the clinical and radiological outcomes of arthroscopic sub acromial decompression for stage II impingement of the shoulder. MethodsAll adults with type 2 impingement of the shoulder having positive impingement signs and unimproved pain after a course of conservative treatment of at least 3 months were included in the study. Glenohumeral arthroscopy was performed under general anaesthesia in lateral position followed by subacromial decompression. Postoperatively a sling was given initially for support but to prevent adhesions, passive mobilization of the shoulder was initiated as early as possible. Active exercises were started at 2 weeks’ time and cuff strengthening exercises at 6 weeks’ time.Patients were followed up at 3 weeks, 6 weeks, 9 weeks, 3 months and 6 months. Post-operative assessment was performed using the UCLA shoulder rating scale and radiological assessment of acromiohumeral distance was made. Results and conclusionThose patients who had failed conservative treatment were benefited by the procedure. The pain decreased, functional capacity of the shoulder increased, range of motion increased, strength of forward flexion increased and almost 90% patient reported that their symptoms had improved and were feeling better and satisfied. The cost of the treatment was low because no implants were used. Duration of procedure was short. Post-operative return to activities was quick. Number of days absent from work was less as patients returned to normal activities soon and were discharged either next day or a day after surgery. Pre, intra and post-operative complications were nil in our study and are also otherwise rare.

Physiological noise compensation in gradient-echo myelin water imaging

In MRI, physiological noise which originates from cardiac and respiratory functions can induce substantial errors in detecting small signals in the brain. In this work, we explored the effects of the physiological noise and their compensation methods in gradient-echo myelin water imaging (GRE-MWI). To reduce the cardiac function induced inflow noise, flow saturation RF pulses were applied to the inferior portion of the head, saturating inflow blood signals. For the respiratory function induced B0 fluctuation compensation, a navigator echo was acquired, and respiration induced phase errors were corrected during reconstruction. After the compensations, the resulting myelin water images show substantially improved image quality and reproducibility. These improvements confirm the importance and usefulness of the physiological noise compensations in GRE-MWI.

There Is No Such Thing as a “Mid-Pole”

In ordinary English, one meaning of the word pole refers to either of two opposite ends of an axis running through a sphere or similarly shaped object, or to two thoughts or functional opposites (like the poles of a battery) [ 1 Webster’s third new international dictionary of the English language, unabridged. Merriam-Webster, Springfield, Massachusetts1991: 1753 Google Scholar ]. In biology or medicine generally, there are similar usages, such as the animal and vegetal poles of an ovum, which have very different functions [ 2 Dox I. Melloni B. Eisner G. Melloni J. Melloni’s illustrated medical dictionary. 4th ed. Parthenon, London, United Kingdom2002: 519 Google Scholar ]. In radiology, referring to the superior and inferior portions of the kidney, for instance, as the upper and lower poles is understandable [ 3 Etter L. Glossary of words and phrases used in radiology, nuclear medicine and ultrasound. 2nd ed. Charles C. Thomas, Springfield, Illinois1970: 271 Google Scholar ] because the normal kidney’s bean shape may be thought of as somewhat similar to a sphere, and the two ends do seem to be opposite each other.

Spontaneous Temporomandibular Joint Herniation into the External Auditory Canal through a Persistent Foramen Tympanicum (Huschke): Otologic Features

A persistent foramen tympanicum (Huschke) is an anatomic variation located in the anterior inferior portion of the bony external ear canal. We present a case of symptomatic temporomandibular joint (TMJ) herniation into the right external auditory canal though an enlarged osseous defect. The herniated retrodiscal temporo-mandibular joint (TMJ) tissue moved backward when the patient’s mouth was closed, and forward, when opened. Imaging findings were useful for differentiating TMJ herniation from salivary fistula or a true granuloma of the anterior bony canal wall near the tympanic membrane. The purpose of this presentation is to alert otologists that a large granuloma near the anterior inferior or anterior superior portion of the bony ear canal adjacent to the anterior superior tympanic membrane can be a herniation of either the parotid gland or in this case, the temporomandibular joint capsule. Several attempts at removal of this through the ear canal failed because of the initially incorrect diagnosis of a primary lesion of the ear canal. Only after considerable thought was it realized that this was a rare herniation of the temporomandibular joint capsule through a patent foramen of Huschke.

Mo1496 Endoscopic Ultrasound Guided (EUS) Fiducial Marker Placement Without Fluoroscopy - Safety and Technical Feasibility

Mo1496 Endoscopic Ultrasound Guided (EUS) Fiducial Marker Placement Without Fluoroscopy - Safety and Technical Feasibility