Neck Lesions Research Articles

Tissue Parathyroid Hormone Washout: A Reliable Method for the Localization and Exclusion of Parathyroid Adenomas.

Background and objective Accurate identification of parathyroid adenoma (PA) is essential for minimally invasive treatment of primary hyperparathyroidism (PHPT). The aim of this study is to evaluate the results of parathyroid hormone (PTH) assay in aspirates of suspicious neck lesions and to clarify its reliability in determining whether the lesion is of parathyroid origin. Methods A total of 134 lesions (104 imaging-suspected PA and 30 concomitant thyroid nodules as a control group) of 101 patients were retrospectively analyzed. Patients with positive, negative, or never scintigraphy were included in our study. Ultrasound (US) was performed again and US-guided tissue fine needle aspiration with PTH washout (PTH-WO) was performed from suspicious lesions. A PTH-WO level higher than the patient's serum PTH levels is proposed for a positive test, and a PTH-WO level lower than the upper limit of the laboratory PTH level is proposed for a negative test. A definitive diagnosis was made postoperatively histopathologically. Results PTH-WO levels (median (IQR)) were significantly higher in the positive group (n = 93, 5000 (1600) ng/L) compared to the negative group (n = 11, 17 (13.1) ng/L) and thyroid nodule aspirate group (n = 30, 14 (4.3) ng/L) (p < 0.001). Among 93 PTH-WO-positive lesions, 42 lesions (45.1%) were not identified by parathyroid scintigraphy (PS), 20 (21.5%) lesions were suspiciously PS, and 33 lesions (35.4%) were negative or suspicious byfirst US findings. Of the 93 patients localized with PTH-WO, two were cystic PAsablated by aspiration. The final pathology result of 91 operated patients proved PA. The sensitivity, specificity, negative predictive value, and positive predictive value of the PTH-WO were observed as 1.00, 0.82, 0.09, and 0.91, respectively. Conclusion Comprehensive repeated US and PTH-WO from the lesion increase the accurate localization of PAs. PTH-WO is a highly reliable method for differentiating parathyroid lesions from other cervical lesions.

Laparoscopic distal pancreatectomy versus laparoscopic central pancreatectomy for benign or low-grade malignant tumors in the pancreatic neck.

Laparoscopic distal pancreatectomy (LDP) and laparoscopic central pancreatectomy (LCP) are two surgical methods that can remove pancreatic neck lesions. However, their benefits remain controversial. We aimed to compare the benefits and limitations of LDP and LCP. In total, 50 patients who underwent LDP (n = 34) or LCP (n =16) between January 2014 and November 2019 were retrospectively reviewed using our database. We analyzed their preoperative characteristics, operative data, pathological features, and postoperative outcomes. The baseline features of patients did not differ significantly between the two groups (P < 0.05). Compared with the LDP group, the LCP group showed significantly prolonged operation time (392 ± 144 vs. 269 ± 130 min, P = 0.007), time to oral intake (3.8 ± 1.3 vs. 2.8 ± 0.9 days, P = 0.017), and hospital stay (19.6 ± 5.1 vs. 15.4 ± 4.1 days, P = 0.008) as well as increased hospital expenses (10.1 ± 6.2 vs. 6.6 ± 1.5 WanRMB, P = 0.023). However, no significant differences were observed in conversion rate (0/16 vs. 0/34), blood loss (154 ± 93 vs. 211 ± 170 mL, P = 0.224), postoperative white blood cell count (10.3 ± 2.7 vs. 11.1 ± 3.1, P = 0.432), first random blood glucose level after operation (8.2 ± 2.1 vs. 8.6 ± 2.6 mmol/L, P = 0.696), and ascites amylase level on day 3 after operation (5212 [3110-14,176] vs. 3142 [604-13,761] U/L, P = 0.167) between the two groups. Moreover, no significant differences were noted in the incidence of postoperative diabetes (1/16 vs. 5/34) between the two groups. However, LCP was associated with significantly higher incidences of pancreatic fistula grades B and C (P = 0.005) and postoperative hemorrhage (P = 0.031). Compared with the LCP, LDP is a useful and safer technique for benign or low-grade malignant tumors in the pancreatic neck.

Deep-learning enabled ultrasound based detection of gallbladder cancer in northern India: a prospective diagnostic study

Gallbladder cancer (GBC) is highly aggressive. Diagnosis of GBC is challenging as benign gallbladder lesions can have similar imaging features. We aim to develop and validate a deep learning (DL) model for the automatic detection of GBC at abdominal ultrasound (US) and compare its diagnostic performance with that of radiologists. In this prospective study, a multiscale, second-order pooling-based DL classifier model was trained (training and validation cohorts) using the US data of patients with gallbladder lesions acquired between August 2019 and June 2021at the Postgraduate Institute of Medical Education and research, a tertiary care hospital in North India. The performance of the DL model to detect GBC was evaluated in a temporally independent test cohort (July 2021-September 2022) and was compared with that of two radiologists. The study included 233 patients in the training set (mean age, 48 ± (2SD) 23 years; 142 women), 59 patients in the validation set (mean age, 51.4±19.2 years; 38 women), and 273 patients in the test set (mean age, 50.4±22.1 years; 177 women). In the test set, the DL model had sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of 92.3% (95% CI, 88.1-95.6), 74.4% (95% CI, 65.3-79.9), and 0.887 (95% CI, 0.844-0.930), respectively for detecting GBC which was comparable to both the radiologists. The DL-based approach showed high sensitivity (89.8-93%) and AUC (0.810-0.890) for detecting GBC in the presence of stones, contracted gallbladders, lesion size <10mm, and neck lesions, which was comparable to both the radiologists (p=0.052-0.738 for sensitivity and p=0.061-0.745 for AUC). The sensitivity for DL-based detection of mural thickening type of GBC was significantly greater than one of the radiologists (87.8% vs. 72.8%, p=0.012), despite a reduced specificity. The DL-based approach demonstrated diagnostic performance comparable to experienced radiologists in detecting GBC using US. However, multicentre studies are warranted to explore the potential of DL-based diagnosis of GBC fully. None.

Outpatient management of cervical necrotizing fasciitis: A case report and literature review

Abstract Cervical necrotizing fasciitis (CNF) is a severe and life-threatening head-and-neck surgical and medical emergency characterized by rapid spreading gangrenous soft-tissue infection. Common debilitating conditions such as chronic malnutrition, uncontrolled diabetes, and others have been implicated in its pathophysiology resulting in serious morbidity and fatality. CNF often mandates aggressive medical and surgical management and prolonged hospitalization, followed by demanding reconstructive rehabilitation. We present the case report of a 25-year-old handicapped female who had a necrotic discharging lesion in the upper neck and was diagnosed with CNF managed successfully as an outpatient with aggressive serial debridement, copious irrigation, and intravenous antibiotics. The aims of this report were to describe the challenges of this management approach vis-a-vis the gold standard in the literature with possibility of exploring the variables that might have contributed to her survival.

Mpox in people with past infection or a complete vaccination course: a global case series

Since May, 2022, a large global outbreak of human mpox (formerly known as monkeypox) has predominantly affected men who have sex with men. The strain responsible, Clade IIb, has mutated substantially from precursors originating from the 2017-18 outbreak in Nigeria. Immunity to smallpox, another orthopoxvirus, via previous infection or vaccination provides lifelong immunity. However, since the 2022 mpox outbreak, recent clusters were described in individuals with presumed immunity through recent infection or vaccination. We aim to describe the epidemiological and clinical characteristics of mpox in individuals with past infection or vaccination to improve the understanding of this disease in the setting of previous immunity. In this global case series, international collaborators from nine countries provided data on individuals with PCR-confirmed mpox after documented previous infection or vaccination between May 11, 2022, and June 30, 2023. We excluded cases that could not confirm vaccination status or cases with partial immunisation or any doses received before the current multi-national mpox outbreak (cutoff date May 1, 2022). Data were collected via a case report spreadsheet that reported on dates of infection and vaccination, route of immunisation, demographic characteristics, clinical findings, HIV status, concomitant sexually transmitted infections, and markers of disease severity (mpox severity score system). We describe case epidemiology, clinical course, and mpox severity scores; all analyses were descriptive. We report mpox infections in 37 gay and bisexual men who have sex with men: seven individuals had mpox reinfections, 29 individuals had mpox infections that occurred after two appropriately spaced Modified Vaccinia Ankara-Bavarian Nordic vaccine courses, and one individual had an infection that met the criteria for both reinfection and infection after vaccination. The median age of individuals was 36 years (IQR 30-45; range 21-58). Those with natural immunity after initial infection had a shorter disease course with less mucosal disease upon reinfection than with their initial infection. Infections post-vaccination were characterised by few lesions, little mucosal disease, and minimal analgesia requirements; two people received oral tecovirimat. Overall, there were no deaths, no bacterial superinfections, and all individuals were managed in the ambulatory clinic with one hospital admission for a necrotising neck lesion. The epidemiology of people with mpox reinfection or infection post-vaccination was similar to other published cohorts during the 2022 outbreak-predominantly young, sexually active gay and bisexual men who have sex with men. Clinical features and outcomes of repeat infection and infection after vaccination appear to be less clinically severe than those described in 2022 case literature. Specifically, compared with the 2022 case series, these individuals in the present study had fewer confluent lesions, less mucosal involvement, reduced analgesia requirement, and fewer admissions. Natural immunity and vaccine-induced immunity are not fully protective against mpox infection. However, in this small series both disease duration and severity appear to be reduced. None.

Clinicopathological and Demographic Characteristics of 171 Cases of Ameloblastoma: A 40-Year Retrospective Institutional Study in Maharashtra

Objectives: Ameloblastoma (AM) is the most common benign odontogenic neoplasm. Changing trends and geographic variation necessitate the conduction of periodic demographic studies to update the existing demographic data pertaining to AM. The present research aims to further append the existing yet limited demographic data available on AM in India. Materials and Method: One hundred and seventy-one cases of AM were identified out of 7862 departmental archival cases from 1980 to 2020. Demographic variables, clinical and radiographic features, as well as histopathological variants of AM were recorded and compiled. The various histopathological variants of AM were described according to their occurrence in different genders, age groups, and sites. Results: An overall incidence rate of AM among all oral lesions was found to be 2.18% of head and neck lesions. About 61.40% (n = 105) of cases comprised conventional AM (CAM), of which plexiform AM (21.64%) was the most common histopathological variant observed, whereas unicystic AM (UAM) constituted 37.43% (n = 64) of the cases. About 86% of cases occurred in the mandible, particularly, in the posterior region (83.62%). Multilocular radiolucency was the most frequent radiographic mode of presentation in about 54.97% of the cases while 36.25% of cases presented as unilocular radiolucency. Conclusion: AM constitutes about 2.24% of all head and neck lesions with a mean age of occurrence of 35.84 years. The luminal variant was found to be most common in cases of UAM, whereas plexiform was the most common variant observed in CAM. AM has a predilection to occur in the third decade and in males and exhibits a marked propensity to occur in the mandibular posterior region.

A 15-year-old Girl with a Lateral Neck Mass Turning Out to Be Papillary Thyroid Carcinoma-Lateral Ectopic Papillary Thyroid Carcinoma or Lymph Node Metastasis?

Lateral neck lesions in children are common and involve various infectious or inflammatory etiologies as well as embryological remnants such as branchial cleft cysts. Although unusual, ectopic thyroid tissue can also present as a lateral neck mass. Here, we present an unusual case of a 15-year-old girl treated for an asymptomatic lateral neck mass that after surgical removal was found to be papillary thyroid carcinoma (PTC). However, after removal of the thyroid gland, no primary thyroid tumor was found. The question arose whether the lateral neck lesion was a lymph node metastasis without identifiable primary tumor (at histological evaluation) or rather malignant degeneration of ectopic thyroid tissue. Total thyroidectomy was performed with postoperative adjuvant radioactive iodine ablation. Even though PTC in a lateral neck mass without a primary thyroid tumor has been described previously, pediatric cases have not been reported. In this report we share our experience on diagnosis, treatment and follow-up, and review the existing literature.

Image-Guided Biopsies of Superficial and Deep Head and Neck and Skull-Base Lesions.

Percutaneous image-guided biopsy has largely replaced open surgical biopsies for many head and neck (H&N) lesions, being very safe and minimally invasive. Although the radiologist plays the primary role in these cases, it requires a multidisciplinary approach. Depending upon numerous factors, these biopsies can be either fine-needle aspiration or core needle biopsy, using ultrasound for superficial lesions and computed tomography for deep neck lesions. The most crucial part of H&N biopsies is planning a trajectory to avoid injury to critical anatomic structures. This article outlines the standard biopsy approaches and key anatomical considerations for H&N procedures.

Some uncommon cystic lesions in the anterior head and neck region: Pitfalls to be avoided on cytology.

Cystic lesions of the anterior head and neck region are a challenging and frequent finding on cytological smears. The scant amount of cellular material in cystic slides poses the greatest difficulty to interpretation, so that frequently they are diagnosed as inadequate or with minimal cellular component. Despite the majority of cystic lesions being benign, a minor portion consist of malignant cystic entities. In these latter cases, the evidence of very scant malignant cells can be misdiagnosed and/or underestimated, leading to a false negative diagnosis. Many papers have already described and detailed the range of possible benign and malignant cystic lesions in head and neck. In the current review we have focused on the less common entities that often lead to serious misinterpretation.

Incidental findings on preoperative head and neck MRI for orthognathic surgery in jaw deformity patients

ObjectiveImaging is a critical component of orthognathic treatment. Magnetic resonance imaging (MRI) is a non-invasive method for observing the temporomandibular joint (TMJ). At our institution, MR images of the TMJ are also used when planning treatment for jaw deformities, head and neck screening images are also acquired using a head coil during MR imaging of the TMJ to confirm the presence of incidental findings (IFs) of head and neck lesions. IFs may require additional examination and/or treatment, even if the lesion is asymptomatic. This article presents a review of diseases detected as IFs during MR imaging. Case reports are also presented in which the detection of an IF affected the management of the jaw deformity. MethodsReports of 401 patients with jaw deformities who underwent TMJ MR imaging including head and neck screening before preoperative orthodontic treatment were retrospectively reviewed. ResultsAsymptomatic IFs were detected in 89 patients on screening images performed simultaneously with the TMJ MR imaging. The most common site was the maxillary sinus, and the most common lesions were inflammatory lesions. Although most of the IFs were not clinically significant, 10 required treatment prior to orthognathic treatment or required more detailed examination. ConclusionsAlthough small in number, some of the IFs detected in this study required the use of non-conventional treatment strategies. Our approach of combining TMJ MR imaging with head and neck screening assists not only in evaluating the TMJ but also in detecting lesions that are difficult to detect in radiographic images.

Congenital heterotopic gastrointestinal duplication cyst of the face: a rare case report

Gastrointestinal duplication (GDC) cysts have various synonyms; choristoma, enterocystoma, and duplication cyst. They are infrequent congenital benign lesions diagnosed mainly in children in the first decade of life, comprising approximately less than 5% of the pediatric population with a predilection for the male sex. It is exceedingly rare in the oral cavity but it is possible, particularly on the tongue, floor of the mouth, and pharynx. From 1895 until 1994, 30 cases of this lesion in the oral cavity were reported. Nowadays, none of the authors reported a GDC in the facial region. We report an exceptional case of heterotopic gastrointestinal duplication cysts (HGDC) in the facial region of a 13 -years -old male teenager who was referred to our medical department for an evaluation of a painless progressive facial asymmetry. In the first instance, the ultrasound facial soft tissue was made with a 6.5 MHz convex transducer, reporting a big anechoic image with regular borders to a 60 x 26 x 56 mm diameter with a 46cc approximate volume. Following this, a non-contrast magnetic resonance image was executed with an open Philips PanoramaⓇ machine performed at 3T, reporting a hyperintense image in T2-weighted (repetition time msec/echo time msec: 5,500/112) sagittal sequence and FLAIR-weighted (5,714/80) axial sequence; and an isointense image in T1-weighted (24/80) coronal sequence to 54 x 30 x 51 mm diameter compatible with space occupant lesion with interior walls. A complete tumor resection was achieved under balanced general anesthesia, and the specimen was sent for histological examination. Microscopic examination showed a cystic cavity lined mostly by mucous secretory gastrointestinal epithelium and other areas by stratified squamous epithelium. The cystic wall was composed of fibrous connective tissue and contains abundant gastric cells. Its deepest portion exhibits a smooth muscle layer. In summary, HGDC is an unusual congenital head and neck lesion, but it should be considered in the differential diagnosis of neonates and children. The diagnosis of gastrointestinal tract duplications may be suggested by imaging studies; however, the correct diagnosis is defined by histopathologic analysis. Due to the risk of destruction potential and malignant transformation, HGDC should be treated surgically by complete excision.

Cytomorphological Spectrum of Head and Neck Lesions by Fine Needle Aspiration Cytology in a Tertiary Care Center.

Fine needle aspiration cytology (FNAC) is considered the first line investigation of choice for evaluating head and neck swellings as it is a quick, safe, and rapid diagnostic procedure. This is a retrospective study that included 242 cases of head and neck lesions in the Department of Pathology, Maharaja Agrasen Medical College, Agroha. FNAC was performed by aspiration and non aspiration techniques, and cytological diagnosis was given and correlated with clinical findings and investigations. The most common age group affected was 21-30 years. Male to female ratio was 1:1.49. Out of 242 cases, maximum lesions were found in lymph nodes (128 cases), followed by thyroid gland in 81 cases, salivary gland in 23 cases, and miscellaneous group in 10 cases. Maximum number of cases reported were inflammatory (55.37%), followed by benign (29.33%) and malignant (11.15%) cases. Most swellings occurring in the head and neck region are inflammatory in nature. Our study concluded that FNAC is a simple, safe, and minimal invasive technique that differentiates between neoplastic and non neoplastic lesions and avoids unnecessary surgeries.

P16 Cutaneous renal cell carcinoma metastasis with scrofuloderma as the initial presentation of metastatic renal cell carcinoma: a diagnostic challenge

Abstract Renal cell carcinoma (RCC) with cutaneous metastasis is uncommon and accounts for approximately 3–5% of metastatic RCC, with an unfavourable prognosis. We present an unusual and difficult case of advanced RCC presenting initially with cutaneous metastasis and scrofuloderma, with identical morphology of the lesions. It also highlights the importance of dermatologists in the early diagnosis and management of such cases. A 50-year-old man presented with gradually progressive, multiple erythematous discharging nodules over the right side of his neck of 3 months’ duration. He described a weight loss of 10 kg, intermittent undocumented fever with headache and two episodes of uninvestigated transient haematuria in the last 6 months. He had received multiple courses of antibiotics without any relief. A skin biopsy and immunohistochemistry confirmed cutaneous RCC metastasis with a primary advanced metastatic left RCC, involving the brain as well. A total left nephrectomy was done and he was started on lenvatinib, everolimus and radiotherapy, following which there was suboptimal response and he started developing similar nodular lesions over the left axilla and chest wall, and a puckered crusted plaque over the left lateral abdomen 1 week post treatment. Follow-up at 8 weeks revealed a significant response in the neck lesions; however, the new lesions on the left side did not respond, following which a dermatology consultation was sought again. A skin biopsy from the new lesions confirmed scrofuloderma. Tissue polymerase chain reaction and culture were positive for mycobacterium tuberculosis. He was diagnosed as having scrofuloderma and started on daily isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months followed by daily isoniazid and rifampicin for 4 months. Follow-up at 6 months revealed well-healed lesions, and the systemic symptoms and discharge had abated. The cutaneous metastatic lesions had also healed completely. Here, we present an interesting case of cutaneous RCC metastasis with coexisting scrofuloderma as the initial manifestation of an advanced RCC, posing a diagnostic challenge due to similar morphology. On this background, a recurrence of cutaneous metastasis was the first possibility considered for the new skin lesions. The delay in diagnosis led to significant morbidity in our patient, emphasizing the role of early dermatology consultation in the management of such cases. A high index of suspicion for conditions masquerading as cutaneous metastasis, as well as a lower threshold for skin biopsy, may improve the prognosis dramatically.

BI15 (P16) Cutaneous renal cell carcinoma metastasis with scrofuloderma as the initial presentation of metastatic renal cell carcinoma: a diagnostic challenge

Abstract Renal cell carcinoma (RCC) with cutaneous metastasis is uncommon and accounts for approximately 3–5% of metastatic RCC, with an unfavourable prognosis. We present an unusual and difficult case of advanced RCC presenting initially with cutaneous metastasis and scrofuloderma, with identical morphology of the lesions. It also highlights the importance of dermatologists in the early diagnosis and management of such cases. A 50-year-old man presented with gradually progressive, multiple erythematous discharging nodules over the right side of his neck of 3 months’ duration. He described a weight loss of 10 kg, intermittent undocumented fever with headache and two episodes of uninvestigated transient haematuria in the last 6 months. He had received multiple courses of antibiotics without any relief. A skin biopsy and immunohistochemistry confirmed cutaneous RCC metastasis with a primary advanced metastatic left RCC, involving the brain as well. A total left nephrectomy was done and he was started on lenvatinib, everolimus and radiotherapy, following which there was suboptimal response and he started developing similar nodular lesions over the left axilla and chest wall, and a puckered crusted plaque over the left lateral abdomen 1 week post-treatment. Follow-up at 8 weeks revealed a significant response in the neck lesions; however, the new lesions on the left side did not respond, following which a dermatology consultation was sought again. A skin biopsy from the new lesions confirmed scrofuloderma. Tissue polymerase chain reaction and culture were positive for mycobacterium tuberculosis. He was diagnosed as having scrofuloderma and started on daily isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months followed by daily isoniazid and rifampicin for 4 months. Follow-up at 6 months revealed well-healed lesions, and the systemic symptoms and discharge had abated. The cutaneous metastatic lesions had also healed completely. Here, we present an interesting case of cutaneous RCC metastasis with coexisting scrofuloderma as the initial manifestation of an advanced RCC, posing a diagnostic challenge due to similar morphology. On this background, a recurrence of cutaneous metastasis was the first possibility considered for the new skin lesions. The delay in diagnosis led to significant morbidity in our patient, emphasizing the role of early dermatology consultation in the management of such cases. A high index of suspicion for conditions masquerading as cutaneous metastasis, as well as a lower threshold for skin biopsy, may improve the prognosis dramatically.

Endoscopic Suture With Chemocauterization: An Effective Treatment of Congenital Pyriform Sinus Fistula.

Endoscopic cauterization is an effective method for treating pyriform sinus fistula (PSF). However, these approaches sometimes result in a higher failure rate. We present an effective technique utilizing suture combined with chemocauterization as first-line treatment in patients with PSF and evaluate the safety and efficacy of its use in 126 patients. Retrospective study. Tertiary referral center. Retrospective case review of patients treated between March 2012 and June 2021 at our institution with descriptive statistical analysis. A total of 126 patients with PSF were included in this study with a mean age of 14.7 years. There was no sex predilection. The majority of patients presented with a left-sided neck lesion (89.7%). Ten patients presented following prior attempts at the surgery of the PSF at another institution; 8 via open surgery and 2 following endoscopic CO2 laser cauterization; other patients only had a history of repeat incision and drainageor antibiotic treatment. The success rate of obliteration of the internal opening was 96.83% after a single treatment without complications. Following reoperation, a successful outcome was achieved in the remaining 4 patients. Length of stay ranged from 10 to 14 days. No recurrences occurred within 12 to 120 months followed-up. Endoscopic suture combined with chemocauterization is a safe and effective treatment of PSF. Surgery can be performed during the acute cervical inflammatory period without increased risk of complication or recurrence, however, patients found to have acute changes affecting the pyriform sinus should be treated with a staged surgery strategy.

ШЕЙНАЯ ЭКТОПИЯ ТИМУСА У ДЕТЕЙ

Thymus ectopia is a rare solid neck lesion in children. The location of the formation along the path of thymus migration (thymopharyngeal duct), the echo pattern and the intensity of the MR signal, which is identical to the normally developed thymus, help in making a confident diagnosis. Materials and methods of the research: 14 pediatric patients were treated against the cervical thymus ectopia in 2018-2022 in the Russian Children's Clinical Hospital with the Pirogov Russian National Research Medical University of the Ministry of Healthcare of Russia and the National Scientific and Practical Center for Pediatric Hematology, Oncology and Immunology named after Dmitry Rogachev (both located in Moscow, Russia). The diagnosis was set only after the histological examination results in all cases. A differential diagnosis was made with other cystic and solid formations, taking into account its location and distribution according to ultrasound, computed tomography, and magnetic resonance imaging in each case. Results: stable, relapse-free treatment result was achieved after more than a year of follow-up in all cases. The correct diagnosis wasn’t set in every case until the biopsy results due to the rarity and diverse clinical and radiological picture of the disease. Conclusion: cervical thymus ectopia is a benign and relatively rare condition in children that is rarely diagnosed preoperatively by the visualization only. The conservative management may be appropriate in some cases when the thymus is in the chest cavity only, but surgical correction is more often needed in cases with the neck deforming formations.

Photodynamic Therapy in Oral Cancer: A Narrative Review.

Methods: A comprehensive search in PubMed, Scopus, and Google Scholar was performed using relevant keywords to structure this narrative review. Only English articles were included and assessed according to titles, abstracts, and full texts. Background: Photodynamic therapy (PDT) is applied for targeting pre-malignancy and malignancies in the head and neck, skin, lungs, and gastrointestinal tract and has been greatly promising in reducing disfigurement and morbidity. This method includes a light-sensitive medicine known as a photosensitizer and a light source used through a minimally invasive surgical tool. Objective: This study aimed to review the application of PDT in managing head and neck cancers (HNCs) and provide an overview of the most recent advances in PDT and its efficiency in increasing the long-term life quality of patients with HNC. Results: The light source irradiates light at an appropriate wavelength that can be absorbed by the sensitizer and produce cytotoxic free radicals that can kill tumor cells, impair microvasculature in the tumor microenvironment, and stimulate further inflammatory responses of the immune system. Patients with either early lesions or advanced disease conveniently accept to receive PDT in outpatient clinics. Therefore, this simple technique is considered a novel and promising approach that can be used either individually or in association with other methods. However, its application as a management method in oral malignancies has yet to be studied. PDT is also suggested as a promising adjuvant treatment with better functional results. Then, it is possible to conclude that PDT's effectiveness in treating various tumors has been shown to depend on the depth of the lesion location. Its safety is acceptable, but its limited irradiation depth confines its application in the advanced stages of cancer. Conclusions: PDT is critically applicable in the early diagnosed cancers and superficial tumors where many heads and neck lesions settle as an ideal candidate for PDT because of the possibility of accurate evaluation of lesions and providing appropriate irradiation at these sites.

P231 CORONARY VASOSPASM REFRACTORY TO MEDICAL THERAPY AND COMPLICATED BY ASYSTOLE, HOW TO MANAGE IT?

Abstract Vasospastic angina is a form of angina caused by coronary artery spasm. This usually determines rest chest pain and electrocardiogram changes. In some patients severe ventricular tachyarrhythmias or bradyarrhythmias may develop during myocardial ischemia. Vasospastic angina attacks can be prevented by calcium antagonists and nitrates but artery spasm may be refractory to optimal medical therapy. A 66–year–old woman, affected by Hailey–Hailey disease was brought to the emergency department for hemorrhagic shock after anti–conservative purposes. She underwent emergency surgery for haemostasis of the neck lesion, reinsertion of the subhyoid muscles and right parotidectomy. After surgery an electrocardiogram (ECG) showed inferior and posterior ST–segment elevation, total atrioventricular block (AVB) and torsades de pointes (FIG 1), then evolved in asystole and cardiac arrest . ROSC occurred in 4 minutes. Temporary pacemaker (PM) was placed. Coronary angiography showed right coronary artery and left anteriori descending artery vasospasm, slightly reduced after nitroglycein infusion (FIG 2). Transdermal nitrates and calcium channel blocker were started. Hospitalization has been prolonged due to infectious/psychiatric problems, with necessity of percutaneous endoscopic gastrostomy and tracheostomy, A new episode of vasospastic angina developed during hospitalization with recurrence of total AVB and torsades de pointes. Temporary PM was placed but after 24 hours perforated the right ventricle free wall. Echocardiogram showed small circumferential pericardial effusion. The patient underwent transvenous removal of the right ventricular catheter and two lead DDD PM was implanted. She was discharged with nitrate and calcium channel blocker therapy. No recurrence of angina was documented at 6–months follow–up. The management of this clinical case was complex because it was a form of vasospastic angina complicated by 2 cardiac arrests, unresponsive to medical therapy and with temporary PM that perforated the right ventricle. We therefore opted for a definitive PM implant for protection. Few case report describes definitive PM implantation in fatal bradyarrhythmias during vasospastic angina. To date, the best treatment of coronary vasospasm refractory to medical therapy is debated, pecutaneous revascularization and sympathectomy are considered, treatment methods that we will consider at follow–up in case of (probable) anginal recurrences.

Comparison of Percutaneous Interventional Ablation-Osteoplasty-Reinforcement-Internal Fixation (AORIF), Long Intramedullary Nailing, and Hemiarthroplasty for the Treatment of Focal Metastatic Osteolytic Lesions in the Femoral Head and Neck

Osteolytic metastatic lesions in the femoral head and neck are traditionally treated with intramedullary long nailing (IM) or hemiarthroplasty (HA). Recovery, surgical complications, and medical co-morbidities delay oncologic care. This study sought to elucidate the comparative efficacy of percutaneous ablation-osteoplasty-reinforcement-internal fixation (AORIF), IM, and HA in stabilizing osteolytic lesions in the femoral head and neck. A retrospective study of 67 patients who underwent IM, AORIF, or HA for osteolytic femoral head and neck lesions was performed. Primary outcome was assessed using a combined pain and ambulatory score (Range 1-10: 1=bedbound, 10=normal ambulation) at firstfollow-up (~2weeks). Surgical complications associated with each treatment were compared. Sixty-seven patients (mean age, 65±13, 36 men and 31 women) underwent IM (40), AORIF (19), and HA (8) with a mean follow-up of 9±11months. Two patients in the IM group (5%), three in the AORIF group (16%), and none in the HA (0%) group required revision procedures. AORIF demonstrated superior early improvement in combined pain and ambulatory function scores by 3.0points [IQR=2.0] (IM p=0.0008, HA p=0.0190). Odds of post-operative complications was 10.3times higher in HA than IM (95% confidence interval 1.8 to 60.3). Future revision procedures were not found to be statistically significant between AORIF and IM (p=0.234). A minimally invasive interventional skeletal procedure for focal femoral head and neck osteolytic lesions may serve as an effective alternative treatment to traditional surgical approaches, conferring a shorter recovery time and fewer medical complications.

Top Ten Oncocytic Head and Neck Lesions to Contemplate.

Oncocytes are a component of many metaplastic and neoplastic lesions throughout the head and neck area, primarily originating in salivary/seromucinous glands and the thyroid gland. In addition, other lesions can contain cells that mimic oncocytes (pseudo-oncocytes); these can be of epithelial or non-epithelial origin. Review article. Oncocytic metaplasia is common in seromucinous glands throughout the upper aerodigestive tract, most notable in the oral cavity, nasopharynx and larynx. The main oncocytic salivary gland neoplasms are Warthin tumor and oncocytoma. Infarction of Warthin tumor may lead to recognition difficulties. Oncocytic subtypes of mucoepidermoid carcinoma and intraductal carcinoma have morphologic and immunohistochemical features that allow distinction from major oncocytic entities. Oncocytic thyroid tumors include adenoma, carcinoma (follicular, papillary and medullary), along with poorly differentiated tumors. Oncocytic papillary sinonasal and middle ear tumors must be distinguished from low grade adenocarcinomas. Pseudo-oncocytic entities include paraganglioma, Langerhans cell histiocytosis, giant cell tumor, rhabdomyoma, and metastatic tumors. Correct diagnosis of oncocytic head and neck lesions requires a knowledge of the spectrum of possible entities, their characteristic sites of occurrence, architecture, histomorphology, and immunohistochemistry. Oncocytic subtypes of several newly described entities are now recognized. Both epithelial and non-epithelial mimics of oncocytes exist. The molecular features of oncocytic tumors can be helpful in their diagnosis and understanding their pathogenesis.