Suprasternal Region Research Articles

Comparative study of the gular gland of three species of Molossidae bats (Mammalia: Chiroptera) from South America.

The gular gland is a skin gland located in the suprasternal region of adult males of some bat families. Knowledge of the morphology and functional aspects of these gland types is often limited. This study aimed to describe the structure and composition of the gular glands of three molossid species (Eumops patagonicus, Molossus fluminensis and Molossus molossus) with respect to their reproductive activity and to define the mechanism involved in secretion release. Different histological, histochemical and immunohistochemical techniques were used to achieve these goals. The results revealed that the size and composition of this gland are variable and are mostly related to the lipid content during the reproductive season. The results also documented, for the first time, the occurrence of mechanoreceptors associated with the surface of the glandular duct by detecting an S100 protein, indicating that an external stimulus activates secretion. Previous studies on other species have classified the gland using obsolete criteria; hence, we adopted a new classification of adenomeres in this study. Moreover, we investigated the gland secretion mechanism previously proposed. This study defines the implications of this gland in the reproduction of this species. Our preliminary interpretation of the function of the gular gland is that it is a cutaneous exocrine gland activated by mechanoreceptors involved in the reproductive behaviour of the Molossidae family.

Thyroglossal Duct Cyst in the Suprasternal Region.

A thyroglossal duct cyst (TGDC) is the most common congenital anterior neck mass. It can develop from residual tissue not degenerated during development and is mainly diagnosed in pediatric patients. However, a TGDC is sometimes diagnosed for the first time in adult patients. A TGDC is mainly caused by repeated infections of the duct and there might be no specific symptoms. A TGDC can occur anywhere from the floor of the mouth to the thyroid but is most often found at the infrahyoid level. Over the past 10years, there has been no report of a TGDC in the suprasternal region among TGDCs in unusual locations. This paper describes one case of a suprasternal TGDC with a review of the literature on this topic.

PHACE syndrome: a frequently overlooked entity

<p>Infantile hemangiomas are the commonest vascular tumors of infancy. About 10% are associated with PHACE syndrome, a rare condition presenting with multiple systemic anomalies along with large cervicofacial hemangiomas<strong>.</strong> We present two case reports of this rare entity. First, a six year old female, with cutaneous hemangiomas involving the face and oral cavity, and extracutaneous hemangiomas involving the parotid glands, choroid and peripapillary region of the eye. MRI brain revealed presence of vascular malformations in the circle of Willis along with impingement of optic nerve. MRI head and neck region confirmed the presence of hemangiomas in bilateral parotid gland, right upper eyelid near medial canthus and in the suprasternal region. Second, a three-month-old female presenting with stridor along with hemangiomas involving segment 3 of face, oral cavity and parotid glands. CECT neck and Chest showed hemangiomas involving bilateral parotid and submandibular glands. Mediastinal involvement with extraluminal compression of airway was noted. Microlaryngobronchoscopy did not reveal presence of any airway hemangiomas. Ophthalmological examination showed signs of optic nerve hypoplasia. In both the cases, all the clinico-radiological findings were put together to establish the diagnosis. Both of them also showed significant response to the oral propranolol therapy. Due to the rarity and overlapping features of this syndrome, there is a high chance to overlook this diagnosis. A high index of suspicion and awareness about the features is needed to identify this condition and provide specific treatment.</p>

Non-functioning parathyroid cyst

Abstract Rationale: Parathyroid cysts are rare lesions which are classified as functioning and non-functioning, based on the hormone activity. We report an incidental finding of a non-functioning parathyroid cyst in a patient who showed good prognosis after surgery. Patient concerns: A 63-year-old female patient had a medical history of stage III chronic kidney disease, asthma, and idiopathic hypothyroidism. She underwent low-dose lung computed tomography and a suspected enlarged lymph node in the suprasternal region was identified. Diagnoses: The nodular site was considered relatively safe, thus, we did not arrange for further examinations and decided to perform a surgical biopsy intervention first. Consequently, immunohistological examination findings led to the diagnosis of parathyroid cyst. The patient's serum calcium level was normal. Thus, she was diagnosed with a non-functioning parathyroid cyst. Interventions: Surgery was performed with a 3-cm long incision on the midline of the upper chest wall for biopsy. A 19 mm × 15 mm × 7 mm cystic lesion was excised. Outcomes: No complications were observed after the surgical biopsy. The patient remains asymptomatic with no recurrence or serum biochemical abnormalities during the 1-year follow-up. Lessons: In cases of non-functioning parathyroid cysts, it is difficult to precisely diagnose it before surgery. We report a case of an incidental finding of a parathyroid cyst and the patient had a good prognosis after excision of the parathyroid cyst.

Thyroglossal cyst at unusual site: a rare case presentation

<p>Thyroglossal duct cyst is a congenital lesion in the anterior side of neck which results from embryonic remnant of the descending thyroglossal duct. It may get enlarge by infection, inflammation or mucous retention but can be found anywhere in the midline from the base of the tongue to thyroid gland. Most commonly it is present infrahyoid only. In this case, it is present at an unusual site at suprasternal region. A young male presented in the OPD with a single, non-tender swelling in the midline at suprasternal region, almost reaching upto superior mediastinum. After radiological examination and histopathological excision biopsy, it came out to be thyroglossal cyst. No recurrence had occurred.</p>

A case of ectopic hamartomatous thymoma: controversy over the designation

BackgroundEctopic hamartomatous thymoma, which usually occurs in the lower neck, is a rare benign tumor containing spindle cells, epithelial nests, and adipose tissue. Although the origin of this tumor is still unknown, recent reports suggest that the designation of this tumor is inappropriate.Case presentationA 38-year-old with an anterior cervical mass in the suprasternal region of her neck was referred to our hospital. An ultrasound examination showed that the well-defined oval mass was 31 × 23 × 17 mm in size. A non-enhanced computed tomography scan of the neck revealed that the distinct neck mass in the subcutaneous tissue had a mixture of soft tissue and fatty components. The cervical tumor was clinically diagnosed to be an unusual lipoma with degeneration. The patient underwent the neck mass extirpation. During the surgery, the cervical mass was well demarcated and did not adhere to the surrounding tissues. The postoperative course was uneventful. The gross pathology report showed that the neck mass measured 3.0 × 2.5 × 2.0 cm. Microscopically, the tumor was composed of spindle cells, epithelial nests, and mature adipose tissue. Immunohistochemical examination revealed that both spindle cells and epithelial nests were positive for cytokeratin AE1/AE3. These histopathological findings were consistent with the features of ectopic hamartomatous thymoma. Over a follow-up period of 30 months, this patient exhibited no evidence of recurrence.ConclusionsEctopic hamartomatous thymoma should be considered in the differential diagnosis of subcutaneous tumors in the lower neck, when the CT shows the tumor has the mixed components of fat and soft tissues.

Thyroglossal duct cyst coexisting with a fistulous tract: A rare case report and literature review

Abstract An 11-year-old boy was admitted to the hospital complaining of odorous discharge from an opening in the anterior region of the left side of his neck. During physical examinations, we understood that his cyst moved with deglutition and protrusion of the tongue. In order to get a correct diagnosis of the patient problem, fistulography with contrast agent meglumine was done from the patient neck in two projections, anterior-posterior and anterior-posterior-oblique. By information obtained of physical examinations and his neck radiographs, thyroglossal duct cyst coexisting with a fistulous tract was diagnosed. In adolescents and adults, thyroglossal duct cyst is one the most common causes of midline congenital cyst formation in the neck that may appear anywhere between the base of the tongue and the suprasternal region. Thyroglossal duct cyst develops from a persistence of any portion of the thyroglossal tract in the embryonic period. After birthday, infection of cyst can sometimes lead to fistula formation in the neck. Both of them, thyroglossal duct cyst and thyroglossal fistula, are usually diagnosed by imaging techniques.

Thyroglossal Duct Cyst Recurence. A case report

Thyroglossal duct cyst is a congenital malformation that occurs due to incomplete closure of the thyroglossal duct. The cyst typically appears along the midline of the neck on the ventral surface. Apart from being a quiescent embryological remnant, it presents itself clinically at any age and often requires surgical excision. It is the most common congenital tumor neck mass and occurs in 7% of the population. The thyreoglossal cyst may be located in the intralingual, suprahyoid, thyrohyoid or suprasternal region. Its position in the hyoid bone is extremely rare. There are a few differences between thyroglossal duct cysts (TGDCs) expression in children and adults. The lesion mostly found in children but adult population also possesses this anomaly. Position is almost similar in both age groups with midline and infrahyoid location while laterality is seen mostly in adults. Size of Cyst is found to be larger in adults. The recurrence and post-operative complication rates between children and adults usually are not significantly different. Malignant transformation is rare and can be diagnosed only after histologic examination of a biopsy specimen. We present a clinical case of a 25 year old female patient, with previous surgery in childhood (at the age of 7) due to thyroglossal duct cyst. She came to the ENT clinic complaining of painful tumor mass at the middle of her neck 3 centimeters large. Thyroglossal duct cyst recurrence with inflammation was discovered. The patient underwent antibiotic treatment for 10 days as a start and after a week a surgery was performed as a method of definitive treatment.

Bariatric Endocrinology, Adiposopathy, and Disorders of Regional Fat Distribution

Bariatric Endocrinology, Adiposopathy, and Disorders of Regional Fat Distribution

A Vallecular Thyroglossal Duct Cyst Presenting with Persistent Unexplained Cough in a Toddler

Laryngeal cysts involving the valleculae are rare but well known cause of upper respiratory obstruction. Vallecular cysts are uncommon lesions seen in the pediatric population and mostly present within the first few weeks of life. They may present with diversity of clinical signs and symptoms including failure to thrive, stridor and respiratory distress. Thyroglossal duct cyst, on the other hand, is the most common pediatric congenital anomaly that usually presents as a midline anterior neck mass but may occur anywhere from the foramen cecum to the suprasternal region. We hereby report a case of thyroglossal duct cyst occurring in the vallecular region mimicking a vallecular cyst in a pediatric patient with unexplained cough.

胸骨部分切除術を施行し，気管圧排を回避した頸髄腫瘍の1症例

頸髄腫瘍摘出術患者の術前診察において，強度の胸椎前弯による気管および腕頭動脈圧排を認めた．腹臥位手術では気管狭窄悪化による換気困難および腕頭動脈圧迫による脳血流低下の危険性が伴うと考えて，まず全身麻酔下で胸骨部分切除術を計画し，二期的に頸髄腫瘍摘出術を行うこととした．術前に3D-CT画像を作成し，解剖学的位置関係を評価した．麻酔法は自発呼吸下に導入，換気確認後挿管を行い，狭窄部を越えてチューブを留置した．術中は無侵襲脳局所酸素飽和度（rSO2）を用いて脳血流を監視し，合併症なく手術を終えた．159日後に施行した頸髄腫瘍摘出術では気管狭窄や動脈圧排の危険性は除去されており，安全に麻酔管理を行うことが可能であった．

EReply. Re: Unusual presentation of acute aortic dissection

We would like to thank Hajj-Chahine et al. for their ecomment [1], which requires some explanations as follows: First of all, we recognized the intimal tear in the aortic arch in perioperative observation, but it was not the single source, there were multiple tears as it always occur. Nevertheless, all tissues were so inflammatory and fragile (subacute dissection) that finding a certain starting point for the dissection was not possible. We noted the perioperative findings and retrospectively speculated the possible mechanisms in the discussion after consulting every medical record with interventional cardiologists to figure this unusual problem out. These records suggested that the reason for the dissection could be related to right coronary engagement after re-checking the angiographic images. This is because the medical history only included angiography, which could have been a trigger for subacute aortic dissection. As I explained above, these aetiologic explanations remain speculative for this patient. We also consulted with a forensic medical specialist for the possible mechanism of this pathology. It was not possible to examine the structure of the thoracic arteries but we know that when an injury to arterial supply occurs, it is termed ecchymosis. We did not have the chance to apply meticulous forensic examinations, which are the best methods to discover the main source. The precise mechanism accounting for the bilateral chest bruising remains controversial for our case. Furthermore, neither the resolution nor quality of the magnetic resonance images (from another hospital) enabled us to figure out the exact mechanism. Thanks for your contribution on issues that we have somehow overlooked. An additional article on unusual presentation of aortic dissection by Al-Hity et al was noted. However, these two references are both unrelated to type I dissection [2, 3]. Taken together, these studies make it reasonable to speculate that chest wall ecchymosis might have been related to another mechanism if neck ecchymosis located in the suprasternal region is a consequence of periaortic haematoma secondary to aortic dissection. Conversely, our patient had no signs of neck-related pathologies, such as swelling or ecchymosis, as shown figure 1a [5]. In conclusion, acute aortic dissection may have variable presentations, making the diagnosis clinically challenging [4]. Chest pain is the key symptom as in our case, this symptom was apparent with concomitant unusual chest wall ecchymosis that we could not address the aetiology promptly. Our recent report describes a somewhat unusual presentation that we thought deserved to be shared with other clinicians. All speculations about such a different presentation are surely expectable or acceptable. However, the precise trigger for this clinical scenario is still unclear and so far, we have not been aware of chest wall ecchymosis as a sign of acute type A dissection. Conflict of Interest: None declared

EComment. Unusual presentation of acute aortic dissection

We read with great interest the report by Yazici et al [1]. The authors presented a case of a 66-year-old patient with bilateral anterior chest wall ecchymosis suffering from a subacute type A aortic dissection. The patient was successfully managed, and the postoperative course was uneventful. However, we believe that there are some issues that need to be addressed. Firstly, the authors stated that the intimal tear was located in the aortic arch. On the other hand in the discussion, they assumed that during coronary angiography the inappropriate engagement of the right coronary ostium with the guiding catheter was responsible for the aortic dissection. Iatrogenic aortic dissection in this setting would have been presented with an intimal tear in the vicinity of the coronary ostium. Secondly, they speculated that the extensive anterior chest wall ecchymosis in this patient was due to the extension of the dissection to both internal thoracic arteries. The precise mechanism accounting for the bilateral chest bruising remains to be demonstrated. Thirdly, ecchymosis in the suprasternal region in the context of acute aortic syndrome was previously depicted in two patients. Hashimi et al. [2] described a 72-year old female patient with progressive periaortic haematoma of the arch and descending aorta. Al-Hity et al. [3] presented a case of a 66-year old female patient with acute aortic dissection (DeBakey type III). These two patients presented with ecchymosis in the suprasternal region secondary to the leakage of blood from the pathologic aortic arch to the neck area. Although acute onset of severe chest or back pain is the most common presenting symptom, some patients may present with nonconforming symptoms and signs. There is a plethora of clinical presentation of this dreadful entity with varied symptomatology, including but not limited to syncope, headache, hemiparesis, atrial fibrillation, and superior vena cava syndrome [4]. Establishing a prompt diagnosis of aortic dissection can be difficult in the presence of atypical symptoms, especially in the absence of pain. Conflict of Interest: None declared

A reminder on superior herniation of normal mediastinal thymus

Dear Editor,We read with interest the article “Inspiratory stridor anddysphagia in two newborn infants caused by ectopicthymus tissue” in the September 2009 issue of theEuropean Journal of Pediatrics [1]. This has caused us toremind that “superior herniation of normal mediastinalthymus” or “thymic herniation” is an entity defined asintermittent migration of the normal thymus out of thethorax into the suprasternal region during increasedintrathoracic pressure caused by coughing, sneezing,crying, and Valsalva maneuver [2]. As the authorsmentioned, surgical removal and histological examinationis often the only way to prove the diagnosis of ectopicthymic masses, so to avoid unnecessary biopsy or surgery,it is very important to identify and differentiate thymicherniation from other neck masses especially from ectopicthymic masses because it is only normal thymic tissue andnecessary for the maintenence of normal immune function inchildren. Pediatricians, radiologists, and especially surgeonsshould be aware of this entity so as not to give harm to thechildren.References

Mediane Halsspalte

The CMCC (congenital midline cervical cleft) lesion is localized between the chin and suprasternal region, usually immediately below the thyroid region. A nipple-like protuberance at the upper end is typical, followed by a reddish skin depression and a sinus tract. A firm fibrous cord is found beneath these superficial skin lesions. For cosmetic reasons, as well as the increased risk of progressive contracture with age and better wound healing in infancy, prompt surgical correction is recommended. By means of ellipsoid excision of the lesion and subsequent closure with Z-plasty, a good cosmetic and functional result can be achieved.

Cervical necrotising fasciitis and descending mediastinitis secondary to unilateral tonsillitis: a case report

IntroductionCervical necrotizing fasciitis is an aggressive infection with high morbidity and mortality. We present a case of cervical necrotizing fasciitis and descending mediastinitis in a healthy young man, caused by unilateral tonsillitis with a successful outcome without aggressive debridement.Case presentationA 41-year-old man was admitted to our unit with a diagnosis of severe acute unilateral tonsillitis. On admission, he had painful neck movements and the skin over his neck was red, hot and tender. Computed tomography scan of his neck and chest showed evidence of cervical necrotizing fasciitis and descending mediastinitis secondary to underlying pharyngeal disease. He was treated with broad-spectrum intravenous antibiotics. His condition improved over the next 3 days but a tender and fluctuant swelling appeared in the suprasternal region. A repeat scan showed the appearance of an abscess extending from the pretracheal region to the upper mediastinum which was drained through a small transverse anterior neck incision. After surgery, the patient's condition quickly improved and he was discharged on the 18th day of admission.ConclusionLess invasive surgical techniques may replace conventional aggressive debridement as the treatment of choice for cervical necrotizing fasciitis and descending necrotizing mediastinitis.

Superior Herniation of the Thymus Into the Neck—A Familial Pattern

Superior herniation of normal mediastinal thymus into the anterior neck is a rare cause of neck masses in children. It is defined as intermittent migration of the broadest part of the normal thymus out of the thorax into the suprasternal region during Valsalva maneuver with an increase in the intrathoracic pressure. The fact that the mass apparent only during Valsalva maneuver and typical ultrasound characteristics usually allow the diagnosis but computerized tomography scan or magnetic resonance imaging is necessary to assess the extent of the mass. We report the first and the only siblings with the most dramatic degree of superior herniation of normal mediastinal thymus. We discuss the findings of imaging and the differential diagnosis. We try to remind this entity to avoid unnecessary biopsy or surgery and their potential risk of altering immune function.

Laryngoaltimeter: A New Ambulatory Device for Laryngeal Height Control, Preliminary Results

The vertical larynx position has significant effects on vocal tract resonances and on the biomechanical properties of the vocal folds. It is generally agreed that the larynx should be kept in a comfortably low position during singing, and voice problems are often associated with a habitually raised larynx. A new method, and a battery operated portable device called Laryngoaltimeter, was developed to control laryngeal height continuously for therapeutic or educational purposes. Two similar condenser microphones attached on the suprasternal notch and supraglottic region were used to capture corresponding vibrations during phonation. The microphone signals were then filtered through a band pass filter (90-240 Hz), digitized, and compared to each other by detection algorithms of the Laryngoaltimeter. When the supraglottic microphone received subglottic resonance related vibrations due to laryngeal elevation, auditory and visual signals were produced as a biofeedback by the device. Waterfall amplitude spectrograms of the microphone signals verified that the frequencies captured by each microphone were dissimilar before and similar after laryngeal elevation. The accuracy of the device was found to be 87% on 13 subjects having different voice classifications as a demonstration of its use. Laryngoaltimeter is a prototype device and needs to be developed. Further research may also be established to investigate the habitual effects of keeping vertical position low by using Laryngoaltimeter as a biofeedback device during therapy exercises or voice lessons.

Thyroglossal duct cyst in hyoid bone: Unusual location

A 10-year-old female presenting with a discharging sinus in the midline of the neck of one month duration was diagnosed to have a thyroglossal sinus. She underwent sistrunk's operation, intra-operatively a thyroglossal duct cyst was atypically sited in the intrahyoid region. The cyst may be located in the intralingual, suprahyoid, thyrohyoid or suprasternal region. A literature search revealed that this intrahyoid location of a thyroglossal duct cyst is extremely rare and so far only three cases have been reported. A case and review of literature regarding this unusual entity are presented.

A Case in which Partial Removal of the Suprasternal Region was Effective in Relieving Tracheal Stenosis Caused by Abnormal Thoracic Shape

A Case in which Partial Removal of the Suprasternal Region was Effective in Relieving Tracheal Stenosis Caused by Abnormal Thoracic Shape