Skull Films Research Articles

Adenoid measurement accuracy: A comparison of lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy (gold standard)

ObjectiveTo compare the accuracy of lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy in assessment of adenoid size. MethodsA cross-sectional study was conducted in 43 pediatric patients undergoing ENT surgery from July 2017 to December 2018. All patients underwent preoperative lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy. ResultsThe average adenoidal-nasopharyngeal (A/N) ratio obtained from lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy was 72.9, 79.5, and 81.6, respectively. There was a moderate correlation between A/N ratio from lateral skull film and intraoperative rigid endoscopy (Pearson's correlation: 0.567, p˂0.001). Whereas, the A/N ratio from flexible endoscopy compared to intraoperative rigid endoscopy showed a stronger correlation (Pearson's correlation: 0.791, p˂0.001). From linear regression analysis, the intraoperative adenoid measurement was estimated from the results of flexible endoscopy (intraoperative rigid endoscopy: 0.72 [flexible endoscopy] +24.47) and lateral skull film (intraoperative rigid endoscopy = 0.65 [lateral skull film] + 34) ConclusionFlexible endoscopy yields the most accuracy in the assessment of adenoid size and nasopharynx visualization, without radiation exposure or anesthesia. Despite less accuracy, lateral skull film is more availability in every hospital. The correlation of adenoid size measurement in this study can also be applied for the actual size of adenoid.

SIMULATION OF SLAG SKULL FORMATION ON THE WALL OF CCM MOLD

The processes of formation of the skull and liquid film between the mold and surface of the billet effect on quality indicators and stability of the continuous casting of steel. A number of theoretical studies devoted to the forecast of skull thickness and the film of liquid slag are known. However, these studies do not take into account the mutual influence of formation processes of skull and film, as well as formation of shell thickness of the billet. In this connection, the paper presents a mathematical model of interrelated thermal processes developed by the authors in the system of layers “copper wall of crystallizer – skull – film of liquid slag – crust of ingot”. The model makes it possible to predict the dynamics of formation of the thickness of the ingot crust, slag skull and the layer of liquid slag along the height of the mold and the length of liquid friction portion in it, depending on casting speed, temperature of casting steel and melting of the slag, thickness of the slab and working layer of the copper wall. The adequacy of the model to the object is determined by such parameters, as surface temperature of the billet, thickness of the crust, specific heat flux in the mold and temperature of the working wall. An example of application of the developed model is shown, in which the effect of casting speed on length of the liquid friction portion in the mold is investigated. It was found that at speeds of 0.8; 1.0 and 1.2 m/min the slag layer is retained for 0.331; 0.415 and 0.498 m from the meniscus of the metal, respectively. At the same time, the thickness of the skull reaches a maximum value of 0.77 mm. Further formation of the preform occurs in the absence of lubrication in the mold. The possibility of using the developed model by technologists for selecting the chemical composition of casting powder, which provides the required length of the liquid slag section, is indicated by the designers when choosing the mold profile, taking into account the thickness of the skull, and, also for educational purposes.

Breast cancer with extensive bone metastasis mimicking myeloma.

Key Clinical MessagePunched‐out lesions in skull film usually elicit consideration of myeloma. However, some other diseases cause similar clinical presentations. We describe an uncommon presentation of breast cancer, which mimics multiple myeloma. Therefore, in a broad spectrum of clinical settings, physicians should always consider differential diagnosis and await for definitive pathological diagnosis.

Identification and management of neonatal skull fractures.

Suspected skull fractures in the neonate are uncommon and present a management dilemma. We hypothesized that skull fractures are more common than reported in the literature and that few infants require any intervention. We retrospectively reviewed the charts of 21 infants referred to our level IV Neonatal Intensive Care Unit for possible skull fracture over a 3-year period after birth trauma, suspicious findings on clinical exam, or accidental falls in the birth hospital. Skull films at the birth hospital were unreliable for fracture in 23% of cases. Seven of nine infants with accidental falls had fracture on computed tomography scan. Only three infants required neurosurgical intervention, all after severe birth trauma associated with instrumentation. Skull fractures are more common than previously reported in neonates after accidental falls, but few infants with skull fractures require neurosurgical intervention.

Three-Dimensional Computed Tomography Skull Reconstructions as an Aid to Child Abuse Evaluations

Skull fractures can be difficult to recognize on radiographs and axial computed tomography (CT) bone windows. Missed findings may delay abuse diagnosis. The role of three-dimensional (3-D) reconstructions in child abuse evaluations was retrospectively evaluated. Twelve exemplary cases between August 2006 and July 2009 are described. All, except 2 medical-legal cases, were clinical abuse consultations. With the use of a 1-to-3 scale, ease and accuracy of interpretation of findings between plain films, bone windows, and 3-D CT images were independently assessed by 2 radiologists. In 7 cases, skull fractures were missed on initial review of skull films and/or bone windows. Three children sustained additional abusive injury before 3-D CT reconstructions demonstrated subtle skull fractures, though imaged, were missed on initial readings. Three children with initially unrecognized fractures had timely 3-D reconstructions confirming fractures, allowing protective intervention before additional injury. An unrecognized ping-pong fracture was discovered on 3-D reconstructions with an inflicted subdural hemorrhage, defining the injury as an impact. Two 3-Ds demonstrated communication of biparietal fractures along the sagittal suture. This changed interpretation to single, rather than 2 separate, concerning impacts. Three potential skull fractures were found to represent large sutural bones. In all cases, ease and accuracy of interpretation scores were highest for 3-D CT. Without increasing patient radiation exposure, 3-D CT reconstructions may reveal previously unrecognized skull fractures, potentially allowing abuse diagnosis before additional injury. They may clarify normal skull variants and affirm accidental injury causes. We now routinely include 3-D reconstructions on cranial CTs for children younger than 3 years.

Life-threatening neonatal epidural hematoma caused by precipitous vaginal delivery.

Patient: Male, 0Final Diagnosis: Epidural hematomaSymptoms: ApneaMedication: —Clinical Procedure: CraniotomySpecialty: Pediatrics and NeonatologyObjective:Unusual clinical courseBackground:Neonatal in-hospital falls occur relatively frequently, although they are likely underreported. Significant intracranial head trauma from a fall or birth injury is not common in the immediate newborn period. Furthermore, intracranial bleeding requiring surgical intervention is exceedingly rare. We present an unusual case of an inhospital fall in the delivery room requiring neurosurgical intervention.Case Report:A term infant, appropriate for gestational age, delivered precipitously from a maternal standing position. The vertex neonate struck the linoleum floor after an approximate 80-cm fall, landing headfirst. The physical and neurological exams were initially normal, and skull films did not demonstrate an obvious fracture. The baby was closely observed, undergoing continuous cardiorespiratory monitoring. After the patient had an episode of apnea, a scalp hematoma was noted. A computed tomography (CT) scan revealed a left parietal fracture with an acute epidural hematoma, which required emergent craniotomy. The infant had an unremarkable post-operative course and had a normal neurodevelopmental assessment at 15 months of age.Conclusions:Close, continuous observation is recommended for infants following an in-hospital fall or after significant birth trauma. A high degree of suspicion for intracranial hemorrhage must be maintained. Fall prevention strategies should focus on careful baby handling by the convalescing mother.

Incidental Finding of an Elongated Styloid Process during Tonsillectomy Procedure

Patients with recurrent throat pain, dysphagia, or facial pain symptoms might have Eagle’s syndrome due to abnormal length of the styloid process or calcification of stylohyoid ligament complex. In adults, the styloid process is approximately 2.5 cm long. The etiology of this disease is not well understood, and usually asymptomatic. In some cases, the styloid tip, which is located between the external and internal carotid arteries, compresses the perivascular sympathetic fibers, resulting in a persistent pain. The disease can be diagnosed by physical examination through digital palpation of the styloid process in the tonsillar fossa or by radiographic workup that includes anterior-posterior and lateral skull films. We report a 33-year-old woman with an incidental finding of an elongated styloid process during a routine tonsillectomy procedure.

Infectious complication of Blunt head injury

A middle-aged man presented to a rural hospital in South Africa with a history of head trauma. He reported being attacked and stoned 2 weeks prior, and subsequently noticed drainage...

New section—Rediscovering the Physical Exam

Beginning with this issue, The Journal will publish “typical” physical examination features—both normal findings as well as classic features of diseases. This new section, “Rediscovering the Physical Exam,” will utilize descriptive text and well-illustrated examples. The Editors hope that you, our readers, will find this new section to be of value, as a tool to help sharpen diagnostic skills and as a reminder of important physical findings. If you are interested in submitting a manuscript to this section of The Journal, please review The Journal's Guide for Authors (http://jpeds.com/authorinfo#redis). Although at least one publishable figure is required for the print issue, we strongly encourage you to also submit online-only figures, illustrations, video and audio clips, etc. After the manuscript has been properly formatted, please upload it through The Journal's online submission and editorial system (http://ees.elsevier.com/jpeds). Please feel free to contact The Journal ( [email protected] ) with any questions or comments. Article page 691 ▸ Differentiating a Mendosal Suture from a Skull FractureThe Journal of PediatricsVol. 157Issue 4PreviewA 6-day-old infant was brought to her pediatrician with a right clavicle fracture. This injury could have happened at birth; however, the history provided by her mother was concerning enough that a skeletal survey and additional tests were performed and child protective services was notified. The lateral skull film seemed to show an occipital skull fracture (Figure 1), and the results of computed tomography of the head showed a single defect in the bone window that seemed to correlate with the finding on plain film. Full-Text PDF

The Incidence, Volume, Absorption, and Timing of Supratentorial Pneumocephalus During Posterior Fossa Neurosurgery Conducted in the Sitting Position

Supratentorial pneumocephalus (STP) is a known complication of neurosurgical procedures of the posterior fossa when conducted in the sitting position. Few studies have examined STP as differentiated from pneumocephalus in the operative field. Ninety-five of 106 consecutive patients had postoperative radiographic studies and median nerve somatosensory evoked potential (SSEP) recording during surgery. STP was identified on postoperative skull films or computerized tomography (CT). STP volume was measured on CT scans. SSEP changes were identified in the monitoring records. STP was identified in 40 patients (42.1%). STP volume on CT scans within 4 hours of surgery ranged from 6 to 280 cm3 (cubic centimeters). An extraventricular drain or ventriculo-peritoneal shunt did not increase the incidence of STP (P=0.85). The absorption of STP in 5 patients with multiple CT scans showed an immediate reduction of 24% followed by exponential decay with an half life of 1.5 days. Four patients with an extraventricular drain or ventriculo-peritoneal shunt had excessive volume of STP when measured at 1 day or later. Six patients with significant SSEP amplitude reductions attributed to STP had volumes exceeding 90 cm3 on a CT scan within 4 hours of surgery. The onset of these changes occurred at various times from dural opening to closing. STP is common after posterior fossa neurosurgical procedures conducted in the sitting position. Further studies are needed to fully characterize the absorption of air and the timing of the entry.

Paget's Disease

A 74-year-old man, who had been aware of a gradual increase in hat size over the past 3 years, complained of a mild headache and backache. His serum phosphatase level was 1,475 U/L (upper normal limit, 120 U/L). Skull films showed calvarial enlargement caused by thickening of the cortical tables, radiolucency in the frontal and occipital regions, and patchy osteosclerosis that produced a cotton-wool appearance.

Excimer Laser as Adjuvant Therapy for Adult Cutaneous Langerhans Cell Histiocytosis

An 86-year-old man with a history of chronic lymphocytic lymphoma presented for evaluation of a persistent erythematous, eroded eruption of the bilateral inguinal folds and gluteal cleft of 6 years’ duration. The lesions were characterized by burning, stinging, and weeping. Previous treatments included systemic and topical antifungal agents, topical glucocorticoid preparations, topical immunomodulators, topical antibacterial agents, barrier creams, and various emollients, with minimal benefit. Previous biopsy findings were consistent with nonspecific spongiotic dermatitis. The results of TRUE Test (Thin-layer Rapid Use Epicutaneous Test; Allerderm Laboratories Inc, Phoenix, Arizona) allergen testing were negative. The patient denied bone pain, dyspnea, cough, abdominal pain, polydipsia, polyuria, urinary retention, fevers, chills, or weight loss. Physical examination revealed circumscribed erythematous plaques with superficial maceration and erosions involving the bilateral inguinal creases and lateral scrotum, with extension to the perineum and gluteal cleft. Erythematous papules measuring 2 to 3 mm in diameter were found at the periphery (Figure 1). There was no evidence of lymphadenopathy or hepatosplenomegaly. The differential diagnosis included Langerhans cell histiocytosis (LCH), intertrigo, contact dermatitis, nutritional deficiency, Paget disease, psoriasis, erosive lichen planus, cutaneous T-cell lymphoma, and sarcoidosis. A punch biopsy specimen revealed dense aggregates of large epithelioid cells with abundant cytoplasm and reniform nuclei filling the papillary dermis (Figure 2). Similarappearing cells were also scattered throughout the epidermis and reticular dermis. Immunohistochemical staining of these mononuclear cells demonstrated CD1a and S-100 protein (Figure 3). A diagnosis of LCH was made. The patient underwent a complete evaluation, including determination of serum zinc levels, complete blood cell count, complete metabolic panel, skull films, chest roentgenogram, skeletal survey, and bone scan. There was no evidence of extracutaneous disease, and the results of all laboratory tests were within normal limits except for an elevated lymphocyte count, which was consistent with the patient’s history of chronic lymphocytic lymphoma. THERAPEUTIC CHALLENGE

A new tilt on pelvic radiographs: a pilot study

The aim of this study was to evaluate pelvic tilt on commonly performed measurements on radiography in primary protrusio acetabuli and developmental dysplasia of the hip. A dry assembled pelvis and spine skeleton was positioned in an isocentric skull unit and films exposed with increasing degrees of angulation of pelvic tilt. The films were then read by two independent readers for seven different measurements used to evaluate the hips and acetabular: acetabular line to ilioischial line, teardrop appearance, intercristal/intertuberous ratio, co-ordinates of femoral head, centre edge angle, acetabular depth/width ratio and acetabular angle. There was so much variation in the protrusio results that no formal recommendation of any standard radiographic test can be given. Only the inter tuberous distance is not effected by pelvic tilt. The acetabular angles for developmental dysplasia of the hip showed the most potential with pelvic tilt below 15 degrees. As pelvic tilt increases, measurements used in protusio become unreliable, and computed tomography/magnetic resonance imaging are probably going to be more accurate as one can directly visualise pelvic intrusion. We recommend a lateral view to assess the degree of pelvic tilt in patients with protrusion to ensure these measurements are valid.

Video fluoroscopy for evaluating adenoid hypertrophy in children

Adenoid hypertrophy is a common cause of upper airway obstruction in children. Traditionally, adenoid size has been evaluated using a conventional lateral skull film. Flexible endoscopy is now the gold standard for the evaluation of the upper airway. Children need to be cooperative in order to complete a videonasopharyngoscopy examination, which is not always possible. The purpose of this paper is to determine the sensitivity and specificity of lateral video fluoroscopy for assessing adenoid size compared to conventional lateral skull films with videonasopharyngoscopy as the gold standard. Twenty pediatric patients with adenoid hypertrophy demonstrated by videonasopharyngoscopy, and 20 control patients without adenoid hypertrophy were assessed with video fluoroscopy and lateral skull radiograph. Two independent examiners evaluated all studies. Specificity, sensitivity, and predictive values were obtained for findings on video fluoroscopy and lateral skull film. Video fluoroscopy showed 100% sensitivity, and 90% specificity for the diagnosis of adenoid hypertrophy. Lateral skull films showed 70% sensitivity, and 55% specificity. A Spearman correlation coefficient demonstrated a significant correlation (P<0.05) between findings on video fluoroscopy and videonasopharyngoscopy. In contrast, there was a no significant correlation (P>0.05) between lateral skull films and videonasopharyngoscopy. Video fluoroscopy appears to be a safe and reliable procedure for assessing adenoid hypertrophy in children.

Skull metastasis from hepatocellular carcinoma

Metastasis to the skull frequently occurs in patients with lung, breast and prostate cancer. However, skull metastases from hepatocellular carcinoma (HCC) have been rarely reported. We review the literature on skull metastasis from HCC and report a case of a 46-year-old male, who was diagnosed as HCC and was operated on by trans-arterial embolization and lobectomy in Oct. 2004. He complained of a painless mass over the left frontal region for two months. Radiograph of the skull revealed an osteolytic mass about 4-5 cm in size over the left frontal region. A cranial computerized tomography demonstrated a destructive lesion with soft tissue mass over the left frontal region. A left frontal craniectomy was performed and tumor was totally removed. The histological diagnosis was cranial metastasis from HCC. Postoperative recovery was uneventful without any neurological deficits. Because of improved and advancing treatment for HCC, survival time for HCC has been lengthened and distant metastases will thus be found to increase. Early diagnosis is essential to treat the primary disease. Skull metastases from HCC should be considered as a differential diagnosis in patients with scalp subcutaneous mass and osteolytic defect on X-ray skull films.

Comparação entre análises de referência incisal em indivíduos jovens melanodermas brasileiros com oclusão normal

A definição da posição do incisivo inferior oferece ao clínico dados para um correto planejamento e tratamento, assim como melhor estabilidade na pós-contenção. Observa-se, porém, que as análises cefalométricas mais utilizadas em Ortodontia para o diagnóstico geralmente são baseadas em indivíduos leucodermas, que diferem em características craniofaciais das outras raças. Desta forma, o presente trabalho teve como objetivo estudar o comportamento do incisivo inferior em relação às referências incisais preconizadas por Andrade (1-Jr), Interlandi (1-linhaI), Vigorito (1-linhaV) e Ricketts (1-linha AP) em jovens brasileiros melanodermas com oclusão normal, verificando também a ocorrência de dimorfismo sexual. Foram selecionadas 36 telerradiografias de cabeça tomadas em norma lateral de indivíduos brasileiros, melanodermas, na faixa etária de 10 a 14 anos, de ambos os gêneros, com oclusão clinicamente normal e que nunca se submeteram a tratamento ortodôntico, do Setor de Documentação Científica do Curso de Pós-Graduação em Ortodontia da FOP/UNICAMP, nas quais foram traçados os pontos, linhas e planos cefalométricos necessários para obtenção das referências incisais e medidas nas análises sugeridas pelos autores selecionados. Os valores médios obtidos para a posição do incisivo inferior diferiram entre si por duas análises estatísticas, havendo diferença significativa (p&lt;0,05) entre os métodos estudados. Também não houve dimorfismo sexual. Concluiu-se que a posição dos incisivos inferiores em indivíduos jovens melanodermas brasileiros apresenta inclinação e vestibularização maior que a preconizada pelos autores consultados, e que a análise de referência incisal de Andrade (1-Jr) parece se comportar mais adequadamente para este grupo étnico.

Interpretation of skull and facial radiographs

There are few indications for the skull X-ray as it has been superseded by head computed tomography (CT) as the initial investigation in head trauma (National Collaborating Centre for Acute Care, 2003). Facial radiographs remain the first-line investigation for facial trauma. This article provides a systematic approach to interpreting skull and facial films and describes the common traumatic conditions requiring these X-rays along with radiological signs.

Hyperostosis cranii in the elderly with various clinical symptoms

We report three elderly patients with hyperostosis cranii. Patient 1 had two episodes of unconsciousness; Patient 2, headache; and Patient 3, dementia. On the basis of Moore's classification using skull films, Patients 1 and 2 showed hyperostosis frontoparietalis and Patient 3 had hyperostosis frontalis interna. Electroencephalography showed transient generalized spike and slow wave complexes over the frontal lobes in Patient 1. Magnetic resonance images showed frontal lobes compressed by the thickness of the frontal bones in all patients and the thickness of the parietal bones in Patients 1 and 2. Since the findings in the present cases and those in the literature suggest that hyperostosis cranii could show unexpected neuropsychiatric symptoms, hyperostosis cranii should be checked in elderly patients whose presenting symptoms include epilepsy, dementia, psychiatric disease, headache and so on. Magnetic resonance images should be helpful in examining the relationship between clinical symptoms and the deformation of the brain by the skull.

Genetic Evaluation in the Newborn

After completing this article, readers should be able to: 1. List important factors in the maternal or family history that may suggest the possibility of a genetic disorder in the newborn. 2. List the prenatal factors that may suggest a genetic disorder in the newborn. 3. Describe the most important steps in the initial evaluation of a baby born with dysmorphic features, anomalies, and birth defects of internal organs. 4. Characterize an appropriate genetic evaluation for the newborn who has hypotonia and poor feeding. 5. Delineate the additional tests to be considered in an infant born with congenital heart disease. Approximately 3% of newborns are born with genetic problems such as birth defects. Some anomalies, such as cleft lip, are isolated defects in an otherwise normal, healthy infant and are associated with an excellent prognosis following surgical repair. Other anomalies, when occurring as part of a constellation of dysmorphic features, and other birth defects, may represent a more serious underlying genetic disorder. This article discusses common findings in the newborn that should prompt more in-depth testing and suggests an initial approach to the genetic evaluation of the newborn. A detailed, comprehensive family history is essential. Important clues to possible genetic factors that can be ascertained include: Detailed …

Bony orbital distances among the Filipino population.

Six hundred and seventy seven radiographs were selected from the logs of films taken in a major hospital in Metro Manila, Philippines over the course of the previous year. Two hundred and eighty-eight female and 389 male, healthy Filipinos between the ages of birth and twenty years were selected based on the availability of a modified Waters' projection and lateral skull film taken at the same time. Measurements for the lateral orbital wall were made at the site of the suture on the medial surface of the zygomatic bone. The medial orbital wall measurement was the distance between the dacrya using a correction factor formula of CF = D-d/D where D is the target film distance and d is the object film distance (1). The actual bony measurements were calculated. The data was gathered and plotted according to sex and in age in years. Graphs were generated using SAS over a graph software. Lines were smooth using cubic spline technique developed by Reinsch with the smoothest value of 75 (2). The mean plus two, four, and six standard deviations were included in each of the curves.