Multiple Septa Research Articles

The anatomical variability of the sphenoid sinus in CBCT - a retrospective study

Summary
 The aim of this retrospective study was to assess and illustrate the anatomical variability of the sphenoid sinus (SPS) on cone-beam computed tomography (CBCT) scans. A total of 50 SPS were assessed. CBCT images were oriented in the sagittal plane to evaluate the type of pneumatization (conchal, presellar, sellar and postsellar). Size measurements (width, length and height) of the SPS as well as the septation pattern and the presence or absence of pathologies were examined in all three planes. The postsellar type (28 cases, 56%) was the most common pattern of pneumatization. Conchal, presellar, or sellar pneumatization were significantly less frequent. There was only one case (2%) with a conchal and two cases (4%) with a presellar type. Multiple septa were found in 75% of patients with postsellar pneumatization, but only in 45.5% of patients featuring conchal, presellar or sellar type. In the postsellar category, all measured dimensions were significantly higher compared to the other types of pneumatization. Pathologies in the SPS were found in 7 patients (14%). It was concluded that the anatomical structure of the SPS is highly variable. Knowledge about its radiological appearance in CBCT will help in identification of pathologies and surrounding anatomical structures.
 Accepted for publication: June 9, 2020
 Published online: June 16, 2021
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Visualization and characterization of spore morphogenesis in Paenibacillus polymyxa ATCC39564.

Paenibacillus polymyxa is a spore-forming Gram-positive bacterial species. Both its sporulation process and the spore properties are poorly understood. Here, we investigated sporulation in P. polymyxa ATCC39564. When cultured at 37℃ for 24 h in sporulation medium, more than 80% of the total cells in the culture were spores. Time-lapse imaging revealed that cellular morphological changes during sporulation of P. polymyxa were highly similar to those of B. subtilis. We demonstrated that genetic deletion of spo0A, sigE, sigF, sigG, or sigK, which are highly conserved transcriptional regulators in spore forming bacteria, abolished spore formation. In P. polymyxa, spo0A was required for cell growth in sporulation medium, as well as for the initiation of sporulation. The sigE and sigF mutants formed abnormal multiple asymmetric septa during the early stage of sporulation. The sigG and sigK mutants formed forespores in the sporangium, but they did not become mature. Moreover, fluorescence reporter analysis confirmed compartment-specific gene expression of spoIID and spoVFA in the mother cell and spoIIQ and sspF in the forespore. Transmission electron microscopy imaging revealed that P. polymyxa produces multilayered endospores but lacking a balloon-shaped exosporium. Our results indicate that spore morphogenesis is conserved between P. polymyxa and B. subtilis. However, P. polymyxa genomes lack many homologues encoding spore-coat proteins that are found in B. subtills, suggesting that there are differences in the spore coat composition and surface structure between P. polymyxa and B. subtilis.

Renal inflammatory myofibroblastic tumour presenting with a large retroperitoneal abscess

Inflammatory myofibroblastic tumour arising from the kidney is a rare occurrence. In this case report, we present a rare case of inflammatory myofibroblastic tumour arising from the kidney diagnosed after the presentation with a large retroperitoneal abscess for the first time in literature. A 55-year-old woman with diabetes mellitus presented to us with painful lump in the left lumbar region of the back for 1-week duration. On examination, there was a firm, diffuse lump in the left lumbar region of the back. Her inflammatory markers were high, but the serum creatinine and blood urea were within the normal range. Abdominal ultrasonography showed a distorted left kidney with a heterogeneous mass consisting cystic and solid components measuring approximately 7 × 9 × 8 cm in size. A contrast-enhanced computed tomography scan showed an 11 × 9 × 9 cm-sized low-density mass posterior to the left kidney with multiple contrast-enhancing septations which appeared posterior to but separate from the left kidney within the left renal fascia. There was breeching of the Gerota’s fascia with extension posteriorly up to subcutaneous tissue. Since the radiological opinion was in favour of a complex perinephric abscess, open drainage of the abscess was performed after failed attempts of ultrasound-guided drainage. The biopsy of the abscess wall was suggestive of a renal cell carcinoma and radical nephrectomy was planned. Due to tumour invasion, the radical nephrectomy was combined with a splenectomy and the specimen sent for histology. It showed an inflammatory myofibroblastic tumour or pseudotumour with the periphery showing ulceration and abscess formation. The patient had an uneventful recovery following surgery. Thus, we report the first case of renal inflammatory myofibroblastic tumour presenting with a large retroperitoneal abscess extending to the subcutaneous tissue plane. Final diagnosis was made only after radical surgery which was curative.

Antimicrobial susceptibility testing for Gram positive cocci towards vancomycin using scanning electron microscopy.

The rapid detection of resistant bacteria has become a challenge for microbiologists worldwide. Numerous pathogens that cause nosocomial infections are still being treated empirically and have developed resistance mechanisms against key antibiotics. Thus, one of the challenges for researchers has been to develop rapid antimicrobial susceptibility testing (AST) to detect resistant isolates, ensuring better antibiotic stewardship. In this study, we established a proof-of-concept for a new strategy of phenotypic AST on Gram-positive cocci towards vancomycin using scanning electron microscopy (SEM). Our study evaluated the profiling of Enterococcus faecalis, Enterococcus faecium and Staphylococcus aureus after brief incubation with vancomycin. Sixteen isolates were analysed aiming to detect ultrastructural modifications at set timepoints, comparing bacteria with and without vancomycin. After optimising slides preparation and micrographs acquisition, two analytical strategies were used. The high magnification micrographs served to analyse the division of cocci based on the ratio of septa, along with the bacterial size. Susceptible strains with vancomycin showed a reduced septa percentage and the average surface area was consequently double that of the controls. The resistant bacteria revealed multiple septa occurring at advanced timepoints. Low magnification micrographs made it possible to quantify the pixels at different timepoints, confirming the profiling of cocci towards vancomycin. This new phenotypic AST strategy proved to be a promising tool to discriminate between resistant and susceptible cocci within an hour of contact with vancomycin. The analysis strategies applied here would potentially allow the creation of artificial intelligence algorithms for septa detection and bacterial quantification, subsequently creating a rapid automated SEM-AST assay.

Growth and division mechanisms by which genetic resisters emerge from the rifampicin-surviving population of differentially antibiotic-susceptible mycobacterial subpopulations.

We recently reported the de novo emergence of unusually high numbers of antibiotic resisters from the in vitro cultures of Mycobacterium tuberculosis and Mycobacterium smegmatis surviving in the presence of minimum bactericidal concentration (MBC) of antituberculosis antibiotics. The resisters emerged due to multiple asymmetric divisions of elongated mother cells containing multiple nucleoids and multiple septae. We had earlier found a minor subpopulation of short-sized cells (SCs) and a major subpopulation of normal-sized cells (NCs) (10% and 90%, respectively, of the whole population), with significant difference in antibiotic susceptibility and resister generation frequency, in the in vitro cultures of M. tuberculosis, M. smegmatis, and Mycobacterium xenopi, as well as in pulmonary tuberculosis patients' sputum. However, the mechanisms of growth and division promoting the emergence of antibiotic resisters from these subpopulations remained unknown. Therefore, here, we took up the first-time study to find out the mechanism of growth and division by which antibiotic resisters emerge from the antibiotic-surviving population of the two subpopulations of M. smegmatis. M. smegmatis SCs and NCs were fractionated from mid-log phase cultures using Percoll gradient centrifugation; their purity was checked and exposed to 10×, 2×, and 0.4× MBC of rifampicin for 120 h. The colony-forming units (CFUs) were determined on rifampicin-free plates for the total population and on rifampicin-containing plates for scoring rifampicin resisters. The phenotype and the morphology of the cells at various stages of the exposure were determined using transmission electron microscopy. The dynamic growth and division mechanisms of the cells to emerge as rifampicin resisters were monitored using live-cell time-lapse imaging. The rifampicin resisters were sequenced for mutations in the rifampicin resistance determining region of rpoB gene. Statistical significance was calculated using two-tailed paired t-test, with *P ≤ 0.05 and **P ≤ 0.01. Multinucleated and multiseptated elongated cells emerged from their respective antibiotic-surviving populations. They produced a large number of sibling-daughter cells through multiple asymmetric divisions in short durations, showing abnormally high spurts in CFUs of antibiotic resisters. The CFUs were several-fold higher than that expected from the mass-doubling time of the subpopulations. Despite this commonality, the subpopulations showed specific differences in their response to different multiples of their respective MBC of rifampicin. Mycobacterial subpopulations come out of rifampicin stress by undergoing multiple nucleoid replications, multiple septation for nucleoid segregation, and acquisition of antibiotic target-specific mutations, followed by multiple asymmetric divisions to generate unusually a large number of rifampicin resisters. Because we had earlier shown that SCs and NCs are present in the pulmonary tuberculosis patients' sputum, the present findings have clinical relevance on the mechanism of emergence of antibiotic-resistant strains from mycobacterial subpopulations.

Novel Tyrosine Kinase-Mediated Phosphorylation With Dual Specificity Plays a Key Role in the Modulation of Streptococcus pyogenes Physiology and Virulence.

Streptococcus pyogenes (Group A Streptococcus, GAS) genomes do not contain a gene encoding a typical bacterial-type tyrosine kinase (BY-kinase) but contain an orphan gene-encoding protein Tyr-phosphatase (SP-PTP). Hence, the importance of Tyr-phosphorylation is underappreciated and not recognized for its role in GAS pathophysiology and pathogenesis. The fact that SP-PTP dephosphorylates Abl-tyrosine kinase-phosphorylated myelin basic protein (MBP), and SP-STK (S. pyogenes Ser/Thr kinase) also autophosphorylates its Tyr101-residue prompted us to identify a putative tyrosine kinase and Tyr-phosphorylation in GAS. Upon a genome-wide search of kinases possessing a classical Walker motif, we identified a non-canonical tyrosine kinase M5005_Spy_1476, a ∼17 kDa protein (153 aa) (SP-TyK). The purified recombinant SP-TyK autophosphorylated in the presence of ATP. In vitro and in vivo phosphoproteomic analyses revealed two key phosphorylated tyrosine residues located within the catalytic domain of SP-TyK. An isogenic mutant lacking SP-TyK derived from the M1T1 strain showed a retarded growth pattern. It displayed defective cell division and long chains with multiple parallel septa, often resulting in aggregates. Transcriptomic analysis of the mutant revealed 287 differentially expressed genes responsible for GAS pathophysiology and pathogenesis. SP-TyK also phosphorylated GAS CovR, WalR, SP-STP, and SDH/GAPDH proteins with dual specificity targeting their Tyr/Ser/Thr residues as revealed by biochemical and mass-spectrometric-based phosphoproteomic analyses. SP-TyK-phosphorylated CovR bound to PcovR efficiently. The mutant displayed sustained release of IL-6 compared to TNF-α during co-culturing with A549 lung cell lines, attenuation in mice sepsis model, and significantly reduced ability to adhere to and invade A549 lung cells and form biofilms on abiotic surfaces. SP-TyK, thus, plays a critical role in fine-tuning the regulation of key cellular functions essential for GAS pathophysiology and pathogenesis through post-translational modifications and hence, may serve as a promising target for future therapeutic developments.

Efficacy and safety of intrapleural streptokinase in tubercular empyema thoracis - old wine in new wineskin.

Tubercular empyema thoracis continues to be one of the leading causes of morbidity in low-income countries. Despite antitubercular therapy (ATT) and thoracostomy, empyema drainage is hampered by multiple septations, loculations, debris, and blood clots leading to complications. In a comparative experimental study to estimate the efficacy and safety of intrapleural streptokinase (IPSTK) in tubercular empyema, 30 cases of chronic multiloculated tubercular empyema were compared by radiological improvement by chest radiography, duration and volume of fluid drained, and degree of dyspnoea according to the modified Borg scale, depending on whether streptokinase was used or not. The former scored on all counts; we therefore conclude that intrapleural streptokinase is a safe, efficacious intervention in tubercular empyema. It decreases morbidity and reduces the need for surgery.

Differentiating the clinical and computed tomography imaging features of mixed epithelial and stromal tumors of the kidney to establish a treatment plan.

ObjectiveTo differentiate the clinical features and computed tomography imaging features in the two types of mixed epithelial and stromal tumor of the kidney (MESTK) and to establish a treatment plan for the MESTK types.MethodsSeventeen patients who underwent multidetector computed tomography (MDCT) before surgery and had a pathological diagnosis of MESTK were enrolled. Their clinical information (R.E.N.A.L. nephrometry score (R.E.N.A.L.‐NS), radical nephrectomy (RN), partial nephrectomy (PN), etc.) were collected. The radiological features included renal sinus fat invagination (SFI), maximal diameter (MD), capsule and septa of the tumor, etc., were also analyzed. They were divided into two types according to the MDsolid/MDtumor ratio (solid type with >60%; cystic type with ≤60%). An independent‐sample t‐test and Fisher exact test were used to assess the differences between the two groups.ResultsMESTKs demonstrated a variable multi‐septate cystic and solid components with a delayed enhancement. There were nine patients for solid type and eight patients for cystic type. Compared with solid type, the lesions in cystic type have larger MD (81.00 ± 37.91 vs. 41.22 ± 24.19, p = 0.020), higher R.E.N.A.L.‐NS (10.03 ± 0.50 vs. 8.95 ± 1.26, p < 0.001), higher RN (75.00% vs. 22.22%, p = 0.015), larger SFI (87.5% vs. 33.3%, p = 0.05), more septa (100% vs. 0%, p < 0.001), and more capsule (100% vs. 11.1%, p < 0.001).ConclusionCystic type MESTK has more hazardous features (such as larger MD, higher R.E.N.A.L.‐NS, more RN, greater SFI, multiple septa) compared with solid type, suggesting that RN is more suitable for cystic type and PN for solid type.

Primary Malignant Synovial Tumor in the Mediastinum

Primary mediastinal synovial sarcomas constitute a rare subset of mediastinal tumors. The diagnosis is often delayed at the time of presentation impacting the five-year survival rate due to its highly aggressive natural history. We report a 22-year old female with a monophasic variant of the primary mediastinal synovial sarcoma.A 22-year-old female, with a two-month history of productive cough, fever, breathlessness, was referred to our center in view of persistent right-sided hydropneumothorax despite multiple thoracocenteses. Examination revealed reduced right-sided air entry with a succussion splash. Imaging suggested a well-defined cystic lesion with fluid, air foci, and multiple septations. A provisional diagnosis of a ruptured hydatid cyst was made and exploratory thoracotomy was planned. Intraoperatively, a well-defined cystic lesion with 350 mL of hemorrhagic fluid, densely adherent to the lung and diaphragm, was found. The biopsy revealed a monophasic spindle cell variant of the primary synovial sarcoma. Follow-up positron emission tomography (PET) on postoperative day 20 showed no residual disease and evidence of metastasis. However, the patient was lost to follow up following one cycle of chemotherapy with ifosfamide.Primary mediastinal synovial sarcomas are aggressive tumors that warrant an early diagnosis for prompt treatment. They usually present with non-specific respiratory symptoms. The gold standard of diagnostic modalities is a molecular panel looking for the translocation - t(X;18)(p11;q11). However, in low-middle income countries, a biopsy may be more practical, as they are cost-effective. The treatment is surgical resection, with combined chemotherapy and radiotherapy if metastases are present.Our case emphasizes the early detection of this lesion, its mimicry with other lesions, and the impact of early diagnosis.

Mesenteric cystic lymphangioma – A rare case report; National Center for Pediatric Surgery, Gezira State, Sudan; 2021

Cystic lymphangioma is a benign congenital malformation of the lymphatic vessels. At the National Center for Pediatric Surgery, Gezira State, Sudan; 2021; a female baby of 15 months old age presented complaining of abdominal distention of 10 days duration. Patient Looks unwell, not febrile, and not pale or jaundice; abdomen was distended with full flanks, there was a palpable mass in the epigastric region, no area of tenderness and no palpable organs. Abdomino-pelvic U/S showed very huge abdomino –pelvic cystic mass with multiple thick septa. CT abdomen showed huge abdomino-pelvic mass with multiple cysts that having variable sizes measuring up to 6*7 cm. An elective explorative laparotomy was done. Intra operative findings: Multiple cystic masses arise from the root of the small bowel mesentery matted together with multiple enlarged mesenteric lymph nodes involving segment of distal jejunum with multiple adhesions. Release of adhesion, resection of the masses along with 57 cm of the involving jejunum, anastomosis was done, and homeostasis was secured. Histopathology result showed dilated cystic spaces; lined by flat endothelial cells and multiple reactive lymph nodes, no evidence of malignancy. Features are in line with lymphangioma and associated mesenteric lymphadenitis. Discussion and Conclusion: Our case was 15 months old which is the age of presentation as mentioned internationally. Mesenteric cystic Lymphangiomas are more common among male unlike our case. Ultrasonography and CT abdomen were highly recommended to achieve early diagnosis and treatment of such cases.

S3196 Diagnosis and Management of Phlegmonous Gastritis in a Young Female Without Predisposing Risk Factors

Introduction: Phlegmonous gastritis (PG) is a rare, but serious, condition characterized by bacterial infection of the gastric wall. Since 1862, less than 500 cases of PG have been reported in the literature, limiting knowledge of its management. We discuss a case of PG in a previously healthy female who was successfully treated with a combination of medical and surgical therapies. Case Description/Methods: A 32-year-old female presented to the emergency department with 10 days of worsening epigastric pain, fever, chills, and nausea. Symptoms onset after consuming a seafood platter containing shrimp, scallops, crab, and crawfish from a local restaurant. She had no significant past medical history. CT demonstrated heterogeneously enhancing wall thickening of the distal stomach and the first portion of the duodenum with adjacent fat stranding. Lab work was significant for leukocytosis and elevated CRP. Following admission, the patient was empirically started on piperacillin-tazobactam with general surgery and gastroenterology consulted. On hospital day 2, an EGD was performed which showed a raised lesion in the antrum with central ulceration and an overlying yellow exudate. Biopsies of the lesion were consistent with active gastritis with cryptitis. No organisms, including H pylori, were visualized on routine stains. MRI revealed a 7.5 x 4.3 cm mass in the gastric antrum with central necrosis and multiple septations. EGD with EUS on hospital day 6 noted a mass in the antrum arising from the muscular layer with areas of necrosis. FNA was performed, showing gastric columnar cells, smooth muscle fragments, and a cluster of bland-appearing spindle cells. The following day, she underwent an open distal gastrectomy with Billroth I reconstruction. Significant adhesions and a desmoid reaction involving the distal stomach to the falciform ligament was present. Tissue pathology showed a perforated ulcer with perigastric abscess and acute serositis. No malignant cells were identified. The post-operative course was uncomplicated, and the patient was discharged home on hospital day 11. Discussion: This case highlights the need to consider PG in the differential diagnosis of persistent abdominal pain, although patients may lack classic risk factors for this condition, such as immunosuppression or recent intervention. Discussion should be prompted regarding the optimal treatment regimen for PG, as there are currently no guidelines regarding standardized therapy.Figure 1.: Fig 1A: An abdominal X-ray showing the faint outline of the trichobezoar impacted within the stomach and leading to the convoluted small intestinal tract. Fig 1B: An abdominal CT scan showing the trichobezoar compacted within the stomach and the small intestines. Fig 1C: Post-operative picture of the removed trichobezoar that shows it took on the form of the stomach shape along with the tapered, elongated end of the form of the small intestine.

S3224 Management of Ruptured Walled Off Pancreatic Necrosis in Disconnected Pancreatic Duct Syndrome: A Case Series

Introduction: Ruptured walled of pancreatic necrosis (WOPN) with disconnected pancreatic duct syndrome (DPDS) is a rare condition. WOPN can rupture in gastrointesinal tract or in the peritoneal cavity. Rupture of WOPN into the peritoneal cavity is difficult to treat and has dilemmas in management approach, it also has high possibilities of infections, pancreatic fistulas and carries high mortality. Methods: We present a case series of 8 patients of acute necrotizing pancreatitis with disconnected pancreatic duct syndrome (DPDS) and walled off pancreatic necrosis (WOPN) with spontaneous rupture. Results: Two patients had rupture into the GI tract (1 in the antrum and 1 in 1st part of duodeum). 2 plastic stents were placed through the luminal opening into the pseudocyst cavity to create an internal fistula and later underwent ERCP with pancreatic duct (PD) stenting. 6 patient had a rupture in the perinoteal cavity causing pancreatic peritonitis. Ascitis was aspirated for diagnosis with ascitic amylase ranging from 8945 to 25768 U/L. All patients presented with high grade fever and systemic inflammatory response syndrome (SIRS). The average size of the WOPN was 8 cms with wall thickness of 4 mm. Surgical gastrocystostomy was not possible.5 patients underwent endoscopic ultrasound guided gastrocystostomy with lumen opposing metal stent (LAMS) to drain the WOPN and create an internal fistula,followed by ERCP with PD stenting. 3 patients had clear ascitic fluid so were drained by percutaneous pigtail drainage. 2 patients had multiple internal septations in the ascitic fluid, hence were later subjected to a laparotomy with peritoneal lavage and external drain placement. One patient had a complete rupture of the WOPN with no residual collection, hence only PD stent followed by peritoneal lavage was done. All patients were on broad spectrum antibiotics and nasojejunal feeds.None of patients required endoscopic pancreatic necrosectomy. There was no mortality, no external pancreatic fistula and the average hospital stay was 10 days. Conclusion: This is the first case series of 8 patients with partially ruptured WOPN managed successfully.Figure 1.: Partially ruptured WOPN with Pancreatic ascites.

Ovarian cysts

Ovarian cysts

Disseminated Phaeohyphomycotic Lymphadenitis with Cladophialophora Species

Objective: This study describes a case of disseminated phaeohyphomycotic lymphadenitis in a young female with delayed diagnosis and good clinical response after appropriate treatment. Methods: A 32-year-old female presented with erythematous to violaceous papules with oozing discharge bilaterally in her inguinal region for a few months. History revealed tuberculous meningitis 4 years earlier treated with first line anti-tuberculous therapy for 18 months, and 2 years previously she developed pigmented discharging lymph nodes bilaterally in her axillae. The histopathology of the biopsy of the axillary nodes showed chronic granulomatous inflammation with multiple branching septate fungal hyphae. She received amphotericin B for 21 days but without improvement. Biopsy from the inguinal lesions was sent for histopathology and culture. Results: Histopathology of the biopsy material showed chronic granulomatous inflammatory process with multinucleate giant cells, epithelioid cells, histiocytes, and lymphocytes with multiple branching septate fungal hyphae. Gram stain revealed moderate septate hyphae with numerous pus cells. Culture on Sabouraud dextrose agar yielded velvety olive–black colonies in the fourth week. Microscopic slide examination of culture material was suggestive of Cladophialophora species. The patient was started on voriconazole, which was continued for 6 months, and showed clinical improvement. Conclusion: Incomplete investigation of infectious lesions may delay diagnosis. Furthermore, clinical presentations are greatly influenced by the immune status of the host. Both histopathological and microbiological assessments are equally important for making a conclusive diagnosis. Anti-fungal therapy may delay the growth of fungi that normally grow within a week; thus, a longer incubation time may be warranted for fungal smear-positive samples.

Lymphangioma of popliteal fossa masquerading as Baker\u2019s cyst

BackgroundLymphatic malformations are the second most common vascular malformations after venous malformations. These slow-flow lesions occur most often in the paediatric population and seldom in the extremities. We report a case of lymphangioma at the popliteal fossa in an adult who underwent complete surgical resection.Case presentationA 30-year-old male presented to the department of orthopaedics with a swelling in the right calf region. Clinically, it was suspected to be a Baker’s cyst. Ultrasound showed a multiloculated anechoic cystic lesion in the inferior aspect of popliteal fossa along the intermuscular plane with multiple internal septations. Infected Baker’s cyst was considered, and MRI was suggested for further evaluation. On MRI, the lesion measured 7.2 × 4.6 × 5.8 cm, appeared as a low signal on T1 and high signal on STIR and T2, with multiple internal septations and was situated in the inferior aspect of the right popliteal fossa along the intermuscular plane between the lateral head of gastrocnemius and soleus muscles. No obvious synovial extension. A post-contrast study showed minimal peripheral and septal enhancement. Neither internal enhancing solid components nor significant internal derangement of the knee was observed. Diagnosis of lymphangioma was considered based on the imaging features and ruling out the common differentials for cystic lesions around the knee. Wide local excision was performed. Histopathological evaluation showed multiple irregularly dilated lymphatic channels lined by flatted epithelium. The lymphatic channels were seen to be surrounded by thick fibro collagenous cyst wall with scattered congested blood vessels, skeletal muscle fibre and chronic inflammatory cells.ConclusionLymphangioma must be included in the differential diagnosis of any cystic lesion if the lesion appears multiseptated and/or infiltrative. At the popliteal fossa, it presents as a multiseptated cyst with no synovial continuity or internal derangement of the knee.

The anatomical variability of the sphenoid sinus in CBCT - a retrospective study.

The aim of this retrospective study was to assess and illustrate the anatomical variability of the sphenoid sinus (SPS) on cone-beam computed tomography (CBCT) scans. A total of 50 SPS were assessed. CBCT images were oriented in the sagittal plane to evaluate the type of pneumatization (conchal, presellar, sellar and postsellar). Size measurements (width, length and height) of the SPS as well as the septation pattern and the presence or absence of pathologies were examined in all three planes. The postsellar type (28 cases, 56%) was the most common pattern of pneumatization. Conchal, presellar, or sellar pneumatization were significantly less frequent. There was only one case (2%) with a conchal and two cases (4%) with a presellar type. Multiple septa were found in 75% of patients with postsellar pneumatization, but only in 45.5% of patients featuring conchal, presellar or sellar type. In the postsellar category, all measured dimensions were significantly higher compared to the other types of pneumatization. Pathologies in the SPS were found in 7 patients (14%). It was concluded that the anatomical structure of the SPS is highly variable. Knowledge about its radiological appearance in CBCT will help in identification of pathologies and surrounding anatomical structures.

Normal Variations in Sphenoid and Their Significance Regarding Endoscopic Sinus Surgeries: Multislice Computed Tomographic Study

Background:Sphenoid sinus (SS) is one of the most variables of all sinuses and its relation to vital vascular and nervous elements as optic nerve (ON), cavernous sinus, pituitary gland, and internal carotid arteries. This makes its transsphenoidal approach a challenge for functional endoscopic sinus surgeries (FESS). We aimed to delineate SS radiologically using multislice computed tomography (MSCT), to show normal variations in pneumatization pattern, septation, intercarotid distance, bony covering of carotid artery and ON, to provide successful and safe FESS -transsphenoidal surgeries and to decrease morbidity and mortality during its surgeries. Methods and materials: A prospective observational study on 210 patients from May 2017 to July 2019 was conducted and included all cases requiring MCTS, with free sphenoid sinus. We excluded patients who have pathology in SS, or previous SS surgery. Results: Onodi cells presented in 67 of cases case (31.9%) from whom 30 cases (14.3%) were bilateral, and 143 cases were absent (68.1%). Pneumatization of SS, sellar (adult) type is the most common type of pneumatization that presented in 160 cases (76.2%), presellar (juvenile) type in 48 cases (22.9%), then conchal (fetal) type only in 2 cases (0.95%). The relation between pneumatization of anterior clinoid process (ACP) and dehiscence of ON showed that among 168 cases who had absent ACP pneumatization, 159 of them showed no ON dehiscence (94.6%). Pneumatization of greater wing of sphenoid was in 28 cases (41.8%). Type I ON presented in 321 cases (76.4%), type II was in 54 (12.8%), type III was in 21 (5%), and type IV was in 24 cases (5.7%). Inter sphenoid septum was found in 119 cases (56.7%), multiple septa were found in 87 (41.4%), and no septum in 4 cases (1.9%). Dehiscence in carotid artery occurred in 17% of cases. Conclusion: We concluded SS variations, septation pattern, type of pneumatization, and onodi cells. All that will help preoperative regarding transsphenoidal surgeries, as that decrease morbidity and mortality by avoiding injury of important structures.

Case study: low grade dysplasia of intraductal papillary mucinous neoplasm progression to metastatic pancreatic adenocarcinoma despite complete pathologic resection

Presenter: Dena Steiner MD | Saint Elizabeth's Medical Center Background: Intraductal Papillary Mucinous Neoplasm (IPMN) management has been closely monitored due to the potentially high morbidity of unnecessary resection and the high mortality of delayed diagnosis of pancreatic cancer. Methods: This case study demonstrates a newly developed pancreatic cancer from the bed of a minimally symptomatic 4x3 cm low grade IPMN found on imaging with pancreatic dilation, mucin, a 15 x 10 mm mural nodule and multiple septations. Endoscopic ultrasound cytology was inconclusive for malignant cells, and a subsequent whipple procedure was revealing for mixed duct IPMN with low grade dysplasia, negative margins and 14 negative nodes. Results: One year later, he presented with bloating and subsequent imaging revealed metastatic cancer at the pancreatic bed and liver. He underwent chemotherapy and received palliative care following this diagnosis. Conclusion: Typically, low grade dysplasia in IPMNs subjugates them to a benign categorization, however this case challenges that determination. Malignant potential remains in these lesions with low grade dysplasia; and the mere presence of an IPMN may be a marker that all the patient’s pancreatic cells are at risk for malignant degeneration. Additionally, subcategorization into gastric, intestinal, pancreaticobiliary and oncocytic subtypes and determination of MUC13 expression may provide improved risk stratification.

Giant multilobular lipoma of neck - A case report

Rationale:Presenting a rare case report of a giant multilobular lipoma in submandibular and submental spaces of anterior and lateral aspect of neck.Patient's Concerns:The patient's main concern was persistent diffuse swelling in right lower face and neck region for 5–6 years.Diagnosis:The lesion was diagnosed as multiple septate lipoma measuring 11.5 cm × 10.5 cm × 6.5 cm involving submandibular region and anterior triangle of the right neck following fine-needle aspiration cytology and radiological imaging.Treatment:Extraorally complete surgical excision was carried out through submandibular approach under general anesthesia.Outcomes:The patient's postoperative recovery was uneventful. The patient was followed up on a monthly basis for 6 months. No recurrence was observed. The patient was satisfied with the treatment.Lessons:Lipomas should be considered as a rare differential diagnosis for anterior neck swelling. Biopsy is not necessary to confirm the diagnosis. Surgical excision remains the mainstay of treatment following final diagnosis through imaging modalities.

Multiloculated Hydrocephalus: Surgical Techniques

Objective: Hydrocephalus shunt remains as the most common treatment choice for nonobstructive hydrocephalus, but in some cases multiloculated hydrocephalus (MH) remains a difficult neurosurgical disease despite of the different therapeutic options available. In children with MH multiple shunt procedures combined with neuroendoscopy may be required.(1) The rationale for neuroendoscopy in such complex cysts and multiloculated hydrocephalus is also to open several compartments to the normal fluid-filled spaces, minimize the number of isolated/loculated CSF spaces, and decrease shunt dependency and the number of proximal shunt catheters.(2) In such cases our major objective is keep the children with one or no one shunt and with one normal intracranial pressure (ICP).&#x0D; Most patients with multiloculated hydrocephalus are infants with a severe disability who present with high intracranial pressure. Multiple shunting was a routine practice so far to normalize the intracranial pressure, but in these cases shunt complications could be quite common including shunt infection, malposition and malfunction which needed more shunt revision surgeries.(1, 3)&#x0D; Neuroendoscopy has changed the treatment options for complex multiloculated hydrocephalus. The possibility to do several fenestrations and change multiples cysts in one simple cyst or ventricle was one important improvement in MH treatment.(4-6)&#x0D; In this review we will discuss aspects related to etiology, surgical techniques, and results in multiloculated hydrocephalus.&#x0D; &#x0D; Methods: The authors carried out a literature review on multiloculated hydrocephalus and evaluated a series of personal cases operated in the recent years.&#x0D; The keywords loculated hydrocephalus and surgical technique were used in Pubmed database website. Fifty-two articles were obtained and reviewed. From these publications we select the most relevant ones for the presentation. The articles were divided according to the main subject, with articles on etiology, surgical techniques and outcomes were selected.&#x0D; We also reviewed some difficult cases with MH from personal experience. In all of those cases endoscopy procedures were performed associated to shunt procedures in all cases. The authors described some different techniques of cyst fenestration and the association to shunt or not.&#x0D; Results/Discussion: Neuroendoscopy has changed the treatment in MH. This is a very difficult and interesting disease. Common risk factors for the development of MH include intraventricular hemorrhage, bacterial meningitis, shunt infection, and cerebrospinal fluid (CSF) overdrainage from shunt placement (rare). The magnetic resonance imaging (MRI) or computerized tomography (CT) scan with evidence of septations causing marked nonuniform compartmentalization and enlargement within the ventricular system are the most important ways to do the diagnosis of MH. Predisposing factors include low birth weight, prematurity, perinatal complications, and congenital malformation.&#x0D; Although the full pathogenesis of MLH remains unclear, it is known that inflammation leads to subependymal gliosis, which produces glial tufts and septations that occlude the normal ventricle system. Septations also develop via organization of intraventricular exudate and debris from ventriculitis.&#x0D; Despite os clinical history of poor outcome, head circuference increase and prior infection or brain bleeding, we need image to perform the diagnosis. Types of loculated hydrocephalus could be divided in: multiloculated and uniloculated. The most important classification was done by Spennato.(5) He divided in five types:&#x0D; 1) hydrocephalus with multiple intraventricular septations;&#x0D; 2) isolated lateral ventricle/unilateral hydrocephalus;&#x0D; 3) entrapped temporal horn;&#x0D; 4) isolated fourth ventricle;&#x0D; 5) expanding cavum septi pellucidi/cavum vergae&#x0D; Using the endoscope to treat MH has some advantages.(7, 8) This is a less invasiveness and this is very important in kids.(6) Avoidance of brain retraction, less blood loss, faster operation time, and shorter hospital stay. But endoscopy has some risk and possible complications. It also has several disadvantages. A subdural hematoma and/or hygroma may form, but the incidence of this is lower than with open craniotomy. The risk of ventriculitis, CSF leakage (subcutaneous CSF collection), and hemorrhage are reported to be like that with open craniotomy. Intraoperative bleeding can usually be easily managed by irrigation or coagulation. However, handling of significant intraoperative bleeding is not as easy in endoscopy as in open craniotomy.(9)&#x0D; Some new technologies could improve the outcome and avoid risk and complications.(10, 11) Navigation could be used in two forms:&#x0D; &#x0D; Navigation system is used to planning the entry point and the endoscopy trajectory&#x0D; Endoscopy guided and navigation during all surgical time.&#x0D; &#x0D; The evaluation of results is presented in different ways in the literature. The main outcomes observde for measuring results were: hydrocephalus control or not, number of surgery performed and number of catheters used.(4) Shunt Independence is rare.&#x0D; Conclusion: Multiloculated hydrocephalus is one difficult disease to treat.(4) Neuroendoscopy cyst fenestration was one great improvement in treatment of MH, but after this new procedure the clinical outcome still no so good. Endoscopy is important to decrease the number of shunts and surgeries.&#x0D;