Unusual Radiographic Appearance Research Articles

Magnesium implants in orthopaedic surgery create a diagnostic conundrum: A radiology case series and literature review.

During a routine post-operative orthopaedic radiograph reading session, repeated unusual radiographic soft tissue and bone appearances became evident. It was discovered that these patients had received biodegradable magnesium implants which have recently been introduced into orthopaedic clinical practice. To the untrained eye, the combination of peri-metallic bone resorption with associated soft tissue gas, could easily be mistaken for post-operative infection. The aim of this study is to properly characterise the radiographic post-operative appearances of biodegradable magnesium orthopaedic hardware. We retrospectively evaluated radiographs of all patients who underwent magnesium screw implantation for fractures over a 6 month period. Four patients, mean age of 9.75 (range: 6-15) years who underwent magnesium screw fixation following fracture were included in the study. Follow up duration was 100 days (range: 75-122) with a mean of 2.5 postoperative radiographs being performed per patient during this period. All cases demonstrated post-operative peri-metallic radiolucency which developed around the magnesium screws on x-ray, which subsequently resorbed over time. Peri-metallic soft tissue gas was observed in all patients. In two cases, magnesium implants fractured. As the use of biodegradable metal implants becomes more common, it is important for radiologists to be aware of their imaging characteristics. Prior to reporting a case, it would be prudent to know if biodegradable screws have been utilised and whether there exists a clinical concern for post-operative infection in patients with these particular implants, in which case it would be critical not to dismiss peri-prosthetic radiolucencies and soft tissue gas as merely a sequela of the natural metal degradation process.

Granular cell ameloblastoma in maxilla: update of unusual clinical, radiographic and histological appearance

Objective: to describe the successful treatment of a 5mm-sized granular cell ameloblastoma in the posterior region of the maxilla, discovered in a routine examination during the evaluation of an oroantral communication. Patients and methods: the case repot is presented based on a simple literature review of the last 10 years with the descriptors (Ameloblastoma; Maxilla; Surgery; Oral Diagnosis; Neoplasms) in Pubmed. Treatment consisting of fistulectomy and closure of the oroantral communication with the buccal fat pad and vestibular flap was associated with enucleation and curettage of the adjacent lesion under local anesthesia. Results: a satisfactory evolution was observed in the 1 year postoperative, with a good healing aspect and no signs of oroantral complications or recurrence of the lesion. Conclusion: for minor lesions, more conservative treatment proposals such as enucleation represent a viable alternative and, in addition, the use of adjuvant techniques such as curettage can offer benefits when the differential diagnosis includes more aggressive lesions or with a higher rate of recurrence.

Multi-Level forestier syndrome in the cervical vertebra with an unusual radiographic appearance: Case report

We present a rare case of Forestier disease with multi-level vertebra involvement from the upper cervical to the thoracic area which has not been reported in the literature before. A 65- year old male patient was admitted to our outpatient clinic with neck pain, dysphagia and sleep apnea for over 5 months. On his cervical CT scan revealed broad ossification of the anterior longitudinal ligament from C2 to T1 with anteriorly beaking osteophytes surrounding the vertebral bodies causing compression of the trachea and esophagus on C2 and C3. With the diagnosis of Diffuse Idiopathic Skeletal Hyperostosis (DISH), the patient underwent surgery. With an anterolateral approach the ossified pathological segment was removed with a high-speed drill and the patient’s symptoms revealed immediately after the surgery.

Fractographic Analysis of a Split Tooth Presenting Radiographically as a Horizontal Root Fracture in an Unrestored Mandibular Second Molar

IntroductionSpontaneously catastrophic fracture of intact unrestored molar teeth is not common. Nevertheless, cracks do occur that progress apically, resulting in the complete splitting of the tooth and root. This report describes a catastrophic fracture that occurred in an unrestored mandibular second molar resulting in a previously unreported combination of a longitudinal and horizontal root fracture, appearing radiographically as a single horizontal root fracture. MethodsTooth fragments were examined clinically, stereoscopically, and by scanning electron microscopy. Fractographic analysis was used to investigate the dynamics involved in fracture initiation, structural resistances encountered during progression of the fracture, and reasons for direction changes culminating in the unusual radiographic appearance. ResultThe uniqueness of this report is that it describes fractographic evidence of factors contributing to the initiation and progression of an in vivo crack. It shows fracture markings that are evidence of the energy dissipation mechanisms. The topographic location of these markings confirmed that cracks occur in vivo in stages with different rates of progression. ConclusionThis analysis helps to explain why split teeth are uncommon and highlights some of the multitude of factors that have to coincide for a tooth to catastrophically fracture. The report describes the mechanism of fracture and should stimulate clinicians and researchers to investigate cracking of teeth by undertaking fractographic analysis of extracted cracked teeth.

Full moon shaped unusual appearance of a globulomaxillary cyst: A case report

Globulomaxillary cyst is a rare, spurious cyst. It was considered to be an inclusion or developmental cyst that arises from entrapped nonodontogenic epithelium in the globulomaxillary suture. Later, it was included as a fissural cyst secondary to proliferation of entrapped epithelium between the globular portion of the medial nasal and maxillary processes. Because of lack of evidence to support the theory of embryogenic epithelial entrapment in the site, most authors dispute the presence of the lesion. Herein, we are presenting a case of globulomaxillary cyst in a 20 year old female patient with an unusual radiographic appearance as a full moon.

Maxillary Parosteal Osteosarcoma: Report of a Case with Unusual Radiographic Appearance and Long-Term Follow-Up

Maxillary Parosteal Osteosarcoma: Report of a Case with Unusual Radiographic Appearance and Long-Term Follow-Up

THE "SILVER-NITRATE-OMA"

This case report demonstrates and emphasises the unusual radiographic appearance of silver nitrate treatment in a 30-year-old patient, who subsequently underwent excision biopsy of a presumed potentially malignant lesion.

Atypical Radiologic Appearance of a Second Cervical Vertebral Fracture in a Horse

This report presents the case of a 21-year-old Warmblood mare referred to the clinic with neurological dysfunctions and considerable signs of discomfort. A fracture of the caudal vertebral body of C2 with a very unusual radiographic appearance was diagnosed, and the mare was euthanized due to deterioration in neurological status. Histology revealed no evidence of neoplasia or pathological fracture.

Langerhans cell histiocytosis in a 5-month-old presenting with biparietal masses

Langerhans cell histiocytosis (LCH) is a rare proliferative disorder that occurs most commonly in the pediatric population as a result of pathological clonal proliferation of Langerhans cells with subsequent damage and destruction to surrounding tissue. Clinically, LCH presents in a variety of ways, which often results in prolonged time to diagnosis and subsequently poorer outcomes. In this case report, the authors describe an unusually early presentation of multisystem LCH in a patient at birth, which resulted in a 5-month delay to diagnosis and treatment. This patient presented both atypically young and with an uncommon initial manifestation of multisystem disease with multiple soft-tissue swellings rather than early skin involvement. Additionally, this patient had an unusual radiographic appearance with biparietal skull destruction on initial skull radiographs and biparietal soft-tissue lesions on CT resembling cephalohematoma at 3 months of age. The clinical and radiological evaluation, pathology, and treatment strategies are discussed, with particular attention paid to the importance of further workup of atypical nonresolving cephalohematomas to prevent disease progression and poorer outcomes.

Unusual radiographic appearance of ossifying fibroma in the left mandibular angle

Ossifying fibroma is usually a unilocular lesion with a well-defined, thinly corticated margin radiographically, although various patterns have been noted. The patient was a 27-year-old woman with a painless radiolucent lesion demonstrated on panoramic radiography to involve the root-apex area of the left lower second and third molars. Radiographically, the lesion had some features of a benign tumour, such as an odontogenic myxoma. However, the deep invaginations towards the interalveolar septa suggested a simple bone cyst, whereas the irregular margin and lack of expansion or mandibular canal displacement were consistent with a malignant lesion. A hard tissue component was confirmed only by soft-tissue mode CT. Although this lesion was histopathologically diagnosed as ossifying fibroma, the conflicting imaging findings were challenging and very intriguing.

Hourglass Ganglion Cyst of the Foot: A Case Report

Ganglion cyst, a common benign soft tissue lesion, is not uncommon in the foot, with the most common location being the dorsal aspect. We describe a case where the ganglion had an unusual radiographic appearance in the form of an hourglass, extending from dorsum into the planter compartments of the foot. A 74-year-old woman presented with longstanding pain in her midfoot. Clinical examination revealed a soft tissue swelling with minimal tenderness in the first webspace of the right foot. The initial radiograph was normal. Ultrasound examination revealed a cystic swelling filled with hemorrhagic fluid with an hourglass appearance. Magnetic resonance imaging examination confirmed the cystic nature of the swelling and depicted the hourglass-shaped ganglion extending from the dorsal to plantar aspect of foot. Complete excision was possible with a combined dorsal and plantar approach. Ganglion cyst can present in the foot in locations other than the dorsum and could have extensions into the plantar aspect. This variation needs to be considered when planning surgical excision, which could be aided by preoperative magnetic resonance imaging.

Unusual Radiographic Appearance of Adamantinoma

Adamantinoma is a rare tumor with an indolent course that occurs most commonly in the tibia. It is locally aggressive, and local recurrences are described after resection. Pain is the most common symptom. Since the lesion is typically slow growing, the pain can be present for many years before the patient seeks medical attention. Microscopically, adamantinoma consists of islands of epithelial cells in a fibrous stroma. Nuclear atypia is minimal, and mitotic figures are rare. The most common radiographic appearance is that of multiple sharply demarcated radiolucent lesions surrounded by areas of dense, sclerotic bone. This tumor most often affects the tibial diaphysis and produces lytic lesions that can cause fractures. A 31-year-old man presented with a rapidly growing lytic lesion of the distal tibia. On histological examination, many areas of epithelial cells in a fibrous stroma were identified. Diagnosis of adamantinoma was performed. The lesion was treated with en bloc resection and reconstruction with distal tibia allograft and ankle arthrodesis with retrograde nail. At 2-year follow-up, there were no clinical or radiological signs of recurrence of disease.

Diagnostic value of ex-vivo three-dimensional micro-computed tomography imaging of primary nonhematopoietic human bone tumors: osteosarcoma versus chondrosarcoma

Osteosarcoma and chondrosarcoma are the most common nonhematopoietic primary malignancies of bone. However, unusual radiographic appearances can lead to delay in diagnosis and confusion with benign diseases. To evaluate the feasibility of micro-computed tomography (CT) for the analysis of primary, nonhematopoietic human bone tumors ex vivo. Samples from 12 human bone specimens (osteosarcoma, n=6; chondrosarcoma, n=6) obtained for diagnostic purposes were scanned using industrial X-ray film without amplifier foil and scanned with micro-CT (7- and 12-microm-cubic voxels). Trabecular bone CT "density" and tumor matrix CT "density" were determined, and results were compared with those obtained from a detailed conventional histopathologic analysis of corresponding cross-sections. The significance of differences in grayscale measurements was tested with analysis of variance. Micro-CT provided quantitative information on bone morphology equivalent to histopathological analysis. We established grayscale measurements by which tumor matrices of chondrosarcoma and osteosarcoma could be radiographically categorized following histological classifications (P<0.001). Micro-CT is feasible for the analysis and differentiation of human osteosarcoma and chondrosarcoma.

Unusual Radiographic Appearance of Drug-Induced Pharyngeal Angioedema and Differential Considerations

A 59-year-old woman treated chronically with enalapril, an angiotensin-converting enzyme inhibitor (ACE-I) presented with difficult swallowing and speaking. Although her symptoms were clinically consistent with an adverse angioedema reaction to the ACE-I, initial imaging was not entirely consistent with our conceptual understanding of angioedema. This case report will discuss the myriad possible imaging presentations of this disease, as well as the differential diagnosis for this atypical manifestation of ACE-I-induced angioedema.

Radiographic Evaluation of Arthritis: Degenerative Joint Disease and Variations

In the presence of joint space narrowing, it is important to differentiate inflammatory from degenerative conditions. The presence of osteophytes, bone sclerosis, and subchondral cysts and the absence of inflammatory features such as erosions suggest osteoarthritis. Typical osteoarthritis involves specific joints at a particular patient age. When osteoarthritis involves an atypical joint, occurs at an early age, or has an unusual radiographic appearance, then other causes for cartilage destruction should be considered, such as trauma, crystal deposition, neuropathic joint, and hemophilia. There are several types of arthritis, such as juvenile chronic arthritis and gouty arthritis, that may have a variable appearance compared with that of other common inflammatory arthritides.

Abnormal orientation of Amplatzer PDA device on a chest radiogram masking foreign body aspiration

Foreign body aspiration and consequent atelectasis of the lower lobe of the left lung with rotation of the heart resulted in an unusual radiographic appearance in a young girl who had recently undergone transcatheter closure of a patent arterial duct and coil embolization of an aortopulmonary collateral. The patient's chest radiography, who was originally admitted at a center with no echocardiography availability, was interpreted as showing embolization of one or both devices. Only clinical evaluation and echocardiography confirmed appropriate device position. Subsequently, foreign body aspiration was suspected and confirmed at bronchoscopy, and successfully treated. Atelectasis resolved within few days.

DECEMBER 2007 CASE 2: 56‐YEAR‐OLD MALE WITH LEFT‐SIDED WEAKNESS

A 56-year-old male with a 3-year history of multiple myeloma that was treated with tandem autologous stem cell transplantations. He presented in July 2006 with a left partial hemiparesis and ataxia. MRI of the brain revealed an enhancing large right frontoparietal lesion with heterogeneously hyperintense nodular septations on T2WI, with no significant surrounding edema. The differential diagnosis of this lesion placed a high-grade glioma at the top of the list. The patient underwent surgical resection of the lesion. Pathology confirmed the diagnosis of a relapse of his multiple myeloma. The specimen demonstrated a monomorphic neoplasm arranged in sheets and trabeculae floating in a background of a proteinaceous substance. Immunohistochemistry showed the neoplastic cell was a CD138 positive plasma cell. The nature of the background substance is still undetermined and is a very unusual appearance for multiple myeloma. Flow cytometry revealed a monoclonal plasma cell population with an immunophenotype identical to the initial diagnostic bone marrow aspirate. A completely intraparenchymal manifestation of multiple myeloma is rare in itself but the unusual radiographic and histological appearance of this case is extraordinary.

A mature cystic teratoma in pineal region mimicking parietal encephalocele in a newborn

Teratoma is the most frequently encountered intracranial tumor at birth and constitutes 18-20% of all germ cell tumors. They are usually located in pineal and suprasellar regions. The authors aim to report an extremely unusual presentation, location, and appearance of a teratoma in a newborn. A soft tissue swelling in the vertex was detected in a 1-month-old girl. Neurological examination was normal. A big, cystic-solid lesion beginning from pineal region and extending to the scalp was detected in magnetic resonance imaging. It is interesting to note that cerebral venous angiography showed that the superior sagittal sinus (SSS) was divided into three branches at the level of the lesion and they joined together distally. The tumor was excised totally. Histopathological examination revealed the diagnosis of a mature cystic teratoma. A mature cystic teratoma mimicking parietal encephalocele is extremely rare. Germ cell tumors should be kept in mind in the differential diagnosis of all midline lesions with unusual radiographic appearance. Cerebral venous angiography or MR angiography must be performed for the diagnosis and the surgical planning in lesions located near SSS.

Esophageal Coin With an Unusual Radiographic Appearance

Esophageal coins are typically seen as radiopaque disks on anteroposterior chest radiographs. This radiographic finding is generally considered classic for identifying "swallowed" coins as being in the esophagus. We report the case of an 11-year-old girl with an esophageal coin seen end-on on an anteroposterior chest radiograph and as a disk consistent with a coin in the lateral view. These findings are typically associated with coin aspiration. Clinicians should be wary of making the diagnosis of foreign body aspiration of coins by relying on single-view radiographic findings alone. When clinically reasonable, we suggest additional imaging to help further localize swallowed coins.

Sinus lift procedure of the maxilla in patients with inadequate bone for dental implants: radiographic appearance.

Dental implants have gained popularity for treating edentulism, but some patients develop jaw atrophy, which leaves insufficient bone for implants. To treat these patients, the sinus lift procedure, which augments bone, was developed. Altered anatomy from this procedure has an unusual radiographic appearance, confusing those unfamiliar with it. We describe the sinus lift procedure and its radiographic appearance. With knowledge of this surgery and some of its pitfalls, radiographs can be more easily and accurately interpreted.