Dear Editor,Longitudinal melanonychia (LM) is a longitudinal pigmentation of the nail plate. It occurs due to the increased production of melanin in the nail matrix, either by activation or proliferation of melanocytes. It is more prevalent after the fifth decade of life and uncommon in childhood.While approximately 5% of LM in adults correspond to melanoma, it is typically benign in childhood, with MN being one of the major causes, but it shares clinical, dermoscopic, and histopathological features with subungual melanoma.Hutchinson's sign corresponds to periungual pigmentation , and micro-Hutchinson's sign is periungual pigmentation seen only at dermoscopy, both of which are commonly found in childhood LM. The pseudo-Hutchinson sign corresponds to the pigmentation of the nail matrix visible through the cuticle, thus not being a true warning sign.5A series of four cases of LM in children are described, highlighting the peculiarities of this entity in childhood.A two-year-old male patient, presented with a single LM on the left hallux that started at six months of age, with progressive growth. A light and dark brown band occupied 40% of the nail plate width, showing a triangular shape. Dermoscopy disclosed irregular lines regarding color, thickness and spacing, with blurred lateral edges. Intraoperative dermoscopy showed an irregular pattern. An excisional biopsy was performed, and histopathology was compatible with a junctional lentiginous ungual MN. The patient developed nail dystrophy after the biopsy and the melanonychia recurred two years later, with the presence of Hutchinson's sign in the hyponychium. Patient follow-up was chosen, with stability throughout the four-year follow-up .Figure 1A 13-year-old female patient with a single LM present at birth and showing progressive growth. There was a light and dark brown band on the second left toe, measuring 3 mm, which occupied 20% of the nail width, with the presence of Hutchinson's sign in the proximal and lateral nail folds. Dermoscopy showed irregular lines in thickness and color, with loss of parallelism and blurred edges. A tangential biopsy was performed, which was compatible with a junctional MN. After the biopsy, the LM persisted on the lateral nail border without dystrophy and remained stable throughout five years of follow-up .Figure 2A three-year-old female patient with LM on the fifth finger of the left hand for two years, with recurrence after a previous biopsy performed one year had shown a lesion compatible with a junctional MN on histopathology, and which had grown since then. A black to dark brown band occupied 50% of the nail width, with pseudo-Hutchinson's sign. Dermoscopy showed irregular lines regarding color and thickness, loss of parallelism, and blurred edges. A second evaluation of the histopathological examination did not detect any signs of malignancy. The LM remained stable throughout two years of follow-up .Figure 3in situ. A second evaluation of the histopathology favored the hypothesis of lentiginous MN, but it was not possible to rule out melanoma in situ. The margins were widened by 5 mm, and the ungual complex was removed up to the periosteal level, with healing by second intention. She was maintained under strict clinical follow-up, with no signs of recurrence or metastasis during eight years of follow-up., with pseudo-Hutchinson's sign. Dermoscopy showed homogeneous lines, preserving parallelism. Follow-up was chosen, but there was a loss of follow-up, and the patient returned four years later, with a biopsy performed in another service compatible with acral lentiginous melanoma ollow-up.Figure 4, Hutchinson's sign, and associated nail dystrophy. Warning dermoscopic findings include heterogeneous brown to black color, irregular lines , blurring of edges, and micro-Hutchinson's sign.6in situ. Interestingly, Case 4, reported as subungual melanoma in situ, had less clinical and dermoscopic suspicion during the initial evaluation. The biopsy showed lentiginous melanocytic proliferation with rare nests, focal cytologic atypia, and preserved symmetry. Acral MN may present with cytoarchitectural atypia without indicating malignancy, while subungual melanoma may have few atypia in the initial phase, which makes the differential diagnosis between these two entities a difficult one. Considering the preservation of histological symmetry and the long period of 10 years of evolution with no evidence of progression to invasive melanoma, Case 4 is more likely to represent an MN than an in situ melanoma.However, such findings are common in childhood LM, without translating into an increased risk of malignancy. The MN, a major cause of LM in children, often presents with rapid growth, wide bands, heterogeneous pigmentation, irregular lines, triangular shape, and Hutchinson's sign, as demonstrated in other studies.The cases described herein illustrate the challenge in managing children with LM. Although the appearance and behavior of the lesion can be challenging, simulating melanoma, some authors disagree with the systematic indication of biopsy.None declared.Isabela Boechat Morato: Design and planning of the study, data collection, drafting and editing of the manuscript, critical review of intellectual content, approval of the final version of the manuscript.João Renato Vianna Gontijo: Drafting and editing of the manuscript and critical review of the relevant intellectual content, approval of the final version of the manuscript.Glaysson Tassara Tavares: Drafting and editing of the manuscript and critical review of the relevant intellectual content, approval of the final version of the manuscript.Flávia Vasques Bittencourt: Drafting and editing of the manuscript and critical review of the relevant intellectual content, approval of the final version of the manuscript.None declared.


Congenital anosmia can be a presentation of olfactory bulb aplasia; however, little is known about isolated olfactory tract agenesis and its treatment options. The patient was counselled on the diagnosis and safety advice provided.A 14-year-old adolescent was referred to a regional paediatric outpatient clinic with anosmia by her family doctor in Western Australia. The patient has no recollection of her previous ability to smell, suggesting the possibility of congenital anosmia. She was assessed in the paediatric outpatient clinic. A “noncontrast high-resolution MRI-brain scan with Anosmia-Protocol” was requested as the first-line investigation of choice by the treating paediatrician. The MRI was reported  Olfactory dysfunction is not uncommon in the general population and its prevalence increases with age . Around ICA is an extremely rare condition . It is oWe discuss a relatively straightforward clinical assessment and diagnostic approach in establishing the cause of ICA in a regional paediatric outpatient setting in Western Australia.An adolescent was referred by her general practitioner to the paediatric outpatient specialist clinic for “inability to smell” since a “young age.” The patient has no recollection of any previous sense of smell. She has no previous medical illnesses. No other family members were reported to have anosmia or hyposmia.Physical examination revealed a postpubertal and a nondysmorphic child. Her upper nasal passage was noted to be patent without any hypertrophied nasal turbinate or obstruction. The neurological and cardiorespiratory examinations were unremarkable. In this regional hospital, subspecialty support like ear nose throat (ENT) and neurology consultation was not readily available. A quick informal bedside “wafting smell test” was carried out using some readily available bedside substances like coffee beans and alcohol hand gel by the duty paediatrician. Based on the history and physical examination, an impression of “isolated anosmia with a likely congenital etiology” was made. MRI of the brain with anosmia protocol was ordered as the first-line investigation of choice, which revealed a rare case of olfactory tract agenesis with an intact olfactory bulb (as discussed below).Following an initial clinical assessment of the index patient, there was a strong indication to suggest that the patient's anosmia was congenital in nature. An “MRI Brain with Anosmia Protocol” was ordered as the investigation of choice which revealed the diagnosis as discussed below.Due to the lack of clinical suspicion for other associated genetic or endocrine disorders in this index patient, there was no indication for other imaging and blood investigations. Further genetic testing was deemed unnecessary as there was no reported family history of anosmia Figures –5The MRI technique adopted was a “Noncontrast Anosmia Protocol” study performed with high-resolution T2 sequence through the anterior cranial fossa.The formal reported findings from the MRI brain with anosmia protocol are as follows.This is the report by the radiologist- to maintain originality, “I will not be altering the wording of the report of the MRI images.” There are normal appearances of the midline structures including the pituitary. The white matter returns a normal signal with no evidence of demyelination. The olfactory bulbs are present and of normal volume. However, these appear to end abruptly with the absence of the olfactory tracts. There are otherwise normal appearances of the anterior cranial fossa. The olfactory sulci are normally formed.The olfactory bulbs are present and of normal volume. However, there appears to be absence of the olfactory tracts, with the bulbs terminating abruptly. This is most likely congenital rather than related to prior trauma (of which there is no other evidence). No other abnormality is identified of the anterior cranial fossa and the midline structures are normal in appearance.No intracranial abnormality is identified with no mass, infarction, or evidence of demyelination.There is minimal mucosal thickening within the bilateral maxillary and left sphenoid sinuses. The paranasal sinuses are otherwise clear.The olfactory system is one of the five main sensory systems in the human body. A functioning olfactory system requires normal anatomy of the nasal cavity  coupled with a normal sensory neural pathway (olfactory bulbs and tracts).The olfactory system is one of the most precocious sensory systems to develop in human embryology . Its embOlfactory dysfunction is an uncommon presenting complaint in this regional paediatric outpatient setting. Most paediatric patients with olfactory dysfunction present with hyposmia rather than complete anosmia due to other acquired causes like craniofacial trauma, infection, adenoid hypertrophy, and malignancy . BecauseThere are very limited case reports on isolated congenital anosmia . One casThe causes of congenital anosmia in the paediatric population can be generally divided into those with underlying congenital anatomical defects or those associated with genetic or endocrine disorders (as discussed below), for example, congenital choanal atresia, olfactory bulb/nerve agenesis, CHARGE syndrome (OMIM #214800), Bardet- Biedl syndrome (OMIM #209900), Refsum disease (OMIM #266500), and Kallman syndrome (OMIM #308700).Intriguingly, there is a recently published research revealing a series of people with normal olfactory function despite having a complete absence of the olfactory bulbs . In thisWe further discuss the clinical approach to a child presenting with congenital anosmia in a regional paediatric outpatient setting  as illustrated below .Congenital isolated anosmia (ICA) caused by aplastic olfactory bulb/tract has limited treatment options known to date. Counselling and safety advice form the pillar of the management plan for such patients. No further active medical or surgical intervention was thought to be available for this index patient following a discussion with the paediatric neurologist and ENT team. General safety advice was provided to ensure the patient would be able to avoid potential life-threatening conditions like having a functioning smoke and gas detector at home, avoid using a gas cooker, and to be more cautious on reading food expiry date labels prior to consumption.


Schwannomas are benign tumors composed of neoplastic Schwann cells and rarely occur in the central nervous system. Schwannomas account for approximately 8% of intracranial tumors and most commonly originate from cranial nerve VIII at the cerebellopontine angle in the posterior fossa. Herein, we report two cases of vestibular schwannomas extending in the middle fossa. The first case shows a 51-year-old male who presented with a history of mild headaches for one year associated with acute nausea, vomiting, and word-finding difficulties. Imaging revealed a large multicystic contrast-enhancing lesion in the left middle cranial fossa. The middle fossa lesion was resected with pathology indicating a schwannoma. The second case shows a 63-year-old woman who presented with seizures, right-sided hearing loss, and right-sided facial weakness. On MRI, she is found to have a large right middle fossa lesion originating from the right internal auditory canal and consistent with vestibular schwannoma with a 9 mm leftward midline shift. The histopathologic examination of the excised tumor indicated a schwannoma. Schwannomas most commonly occur in the posterior fossa when they present intracranially. However, in rare occurrences, they may present as middle fossa masses with significant intracranial compression. Schwannomas (SCs) are benign tumors composed of neoplastic Schwann cells, which do not commonly occur intracranially. SCs account for approximately 8% of intracranial tumors and usually originate from cranial nerve VIII, commonly known as vestibular SC or acoustic neuroma . SCs areCase 1A 51-year-old Caucasian male presented to the neurosurgery service with nausea, emesis, and severe headache. This was preceded by a two-week history of worsening headaches, fatigue, gait instability, and word-finding difficulties. He also had a one-year history of intermittent headaches that were mild and relieved with nonsteroidal anti-inflammatory drugs. He had no other major medical problems, and he had no prior workup for these complaints. On examination, the patient had a mild right-sided weakness with right-sided pronator drift associated with mild difficulty in naming objects. The medical evaluation revealed the presence of multiple bilateral subsegmental pulmonary emboli although no other major medical issues were encountered.A computed tomography (CT) of the head without contrast was obtained, which demonstrated a left-sided supratentorial cystic mass lesion. Further evaluation with contrasted magnetic resonance imaging demonstrated a T1 hypointense lesion measuring 5.0 cm x 6.9 cm x 6.2 cm, which had multiple intralesional cysts. T2-weighted imaging revealed a hypointense lesion with a small amount of perilesional edema. Contrast administration revealed avid enhancement of the peripheral portion of the tumor without enhancement of the cystic middle portion  with focal loose reticular areas (Antoni B). Foamy Schwann cells and structures vaguely resembling Verocay bodies were occasionally seen. The blood vessels show marked mural thickening, hyalinization, and hemosiderin pigment deposition Figure . An immuSCs are benign tumors originating from Schwann cells, which account for approximately 8% of all intracranial masses ,3. BilatIn most cases, vestibular SCs grow initially inside the internal auditory canal and then extend into the cerebellopontine angle. In MRI, it is characterized by the absence of a cerebrospinal fluid (CSF) signal in the internal auditory canal . The masAs SCs tend to be slow growing, this mass reached a large size before causing symptoms severe enough that the patient sought care. The location of the mass determines the symptoms . In the Although the tumors are typically well-circumscribed, imaging characteristics are largely nonspecific for SCs, and larger tumors may exhibit cystic degeneration as seen in our two cases ,18. On MHistologic analysis is necessary to diagnose such a lesion as meningioma, or other extra-axial masses could present in a similar manner . MeningiIntracranial SCs of the middle cranial fossa can grow to be rather large and may present with symptoms that are not commonly seen in association with these masses. The imaging characteristics tend to be nonspecific although clues to a possible diagnosis can be obtained based on the proximity of the lesion to adjacent structures, such as the petrous bone and internal auditory canal, and the symptoms resulting from the vestibular and facial nerve involvement, such as hearing loss and facial paralysis. Gross total resection should be obtained when feasible and could be curative.


Giant esophageal hemangiomas are rare. The extent is usually in the mediastinum but may spread down to the upper abdomen. Such vascular pathology is hard to treat and typically to be resected along with the organs it is attached to. Here we report a novel way of treatment of giant distal esophageal hemangioma that was considered difficult for resection due to its anatomical spread. With endoscopic ultrasound (EUS) guidance, a few coils were placed in the hemangioma, which lead to stasis of blood and a significant reduction in the size of the lesion in over three months.  We are reporting a unique and rare case of a 54-year-old female who presented with symptomatic giant distal esophageal hemangioma and was treated with a novel endoscopic ultrasound (EUS)-guided coil placement technique. To the best of our knowledge, this is the first case reported for EUS coil embolization as a treatment for giant distal esophageal hemangioma.A 54-year-old female, with no past medical history, was admitted to an outside hospital with fever, atypical chest pain, and severe epigastric pain. Clinically she was not in heart failure, and no pericardial rub was found. She had elevated troponin of 310 ng/dl, and her ECG showed normal sinus rhythm with Q waves in the leads V1-V3. A transthoracic echocardiogram showed a thin rim of epicardial effusion, with a normal left ejection fraction of > 60%. A CT abdomen showed a large lobulated soft tissue density mass in the epigastrium measuring 8.3x10.1 cm. The bulk of the mass was at the gastroesophageal region encasing the aorta, celiac trunk, and superior mesenteric artery (SMA). She was diagnosed with myopericarditis and started on colchicine, aspirin, and atorvastatin.She was transferred to the Sultan Qaboos University Hospital, Muscat, Oman, in order to evaluate the epigastric soft tissue mass, which was seen on the CT scan. She underwent esophagogastroduodenoscopy (EGD) and oral EUS. The EGD detected a 3 cm, protruding, round esophageal sub-epithelial lesion at 30 cm from the incisors Figure . On the To better characterize the lesion, an MRI was done to classify the vascular pathology based on the speed of flow. The MRI showed an area of abnormal signal intensity in the retroperitoneum displacing the stomach slightly anteriorly and reaching up to the GE junction. Posteriorly, it was closely abutting the aorta. It extends into the retro-crural space. There was encasement of the celiac and superior mesenteric arteries origin. Multiple low attenuation areas were identified in this lesion, which is in keeping with numerous calcific foci . There was subtle delayed enhancement identified within it suggesting slow-flow vascular malformation. It appears intensely hyperintense on T2 weighted images Figure . The diaThe patient was hospitalized due to ongoing pulsating chest pain. A coronary CT scan did exclude any coronary artery disease. In order to decide the best therapy and due to the rarity of such a condition, we conducted a multidisciplinary team meeting that included vascular surgeons, upper gastrointestinal surgeons, interventional gastroenterologists, and interventional radiologists. The team concluded that the surgery is to be the last resort due to anatomical location and vascular encasement. A coil embolization to solidify the content of the hemangioma was felt to be the best option. EUS-guided route to place these coils were felt to be easier compared to the endovascular route due to the lack of identifiable feeder vessel.The patient and her family agreed to the proposed plan. The patient underwent a EUS-guided coil embolization with the placement of five coils  using a 19G fine needle aspiration (FNA) needle through a transesophageal approach with fluoroscopic support. The doppler activity ceased after the coil's placement (Figure On day one post-procedure, the chest pain disappeared and the patient was discharged a few days later after a period of in-hospital observation and adequate rehabilitation. A follow-up CT scan of the chest was done three months after discharge and showed a significant reduction in the overall size of the hemangioma to 5.7x 6.2 cm. The patient remained asymptomatic since the placement of the coils (Figures Giant esophageal cavernous hemangioma was described in 1976 by Feist, Talley, and Hunt. It was preoperatively 4 × 7 cm and pathologically 12.0×5.0×2.5 cm in size [Our patient had a unique presentation of myopericarditis possibly due to mechanical rubbing between the giant hemangioma and the pericardium. Her symptoms evolved to pulsating chest pain and one episode of self-resolved minor upper gastrointestinal bleeding.Endoscopic management for esophageal hemangiomas may include endoscopic or surgical approaches. Endoscopically, there have been reports of endoscopic mucosal resection, ablative argon therapy, or sclerotherapy, while surgical techniques usually involve distal esophagectomy with pull-up of the stomach . A case We applied a unique and novel therapy, which was used for the first time to treat a giant distal esophageal hemangioma. It was EUS-guided coil embolization without sclerotherapy. The technique aimed to solidify the blood and induce stasis to hinder the growth and possibly regress the size of the hemangioma. The intervention was successful in resolving all the symptoms of the patient immediately. As expected, the intervention led to a significant reduction of the hemangioma size as observed at the three-month follow-up based on CT measurement.A giant distal esophageal hemangioma is a truly challenging pathology to treat, especially if it is engulfing the surrounding vascular bed as in this case. EUS-guided coil embolization was used as a novel and minimally invasive technique. This was the first time, according to our knowledge that EUS-guided coil embolization was used to treat a giant distal esophageal hemangioma. The intervention was successful in immediately treating the symptoms. There was a significant size reduction of the hemangioma over the 90-day follow-up with CT scan.


Rabbits have become popular pets in recent years and thus are increasingly presenting as patients to veterinary clinics. The medical examination and diagnosis of this type of patient are difficult due to the high degree of sensitivity and weakness of evident symptoms. However, in pet rabbits, several tumors and pathologic conditions have been already reported. In the present case, a female 8-year-old pet rabbit showed a severe respiratory disorder and a lack of improvement after antibiotic therapy. A computer tomography scan was performed which revealed the presence of air in the pericardial sac, a pneumopericardium. The rabbit died from circulatory and respiratory failure soon after the examination, and the necropsy revealed the presence of a tumor histologically consistent with hemangioma within the lumen of the trachea. This tumor, reducing the lumen of trachea, caused the pet rabbit to have dyspnea, and most likely predisposed the rabbit to a pneumopericardium. Tracheal hemangioma and a pneumopericardium have never been described in a pet rabbit. Moreover, this is the first report on the association of the two pathologic conditions in an animal or human.A pet rabbit  with symptoms of dyspnea, apathy, and weight loss was treated for an acute respiratory infection. Due to the lack of improvement, it was referred to the Imaging Diagnostics Laboratory of the Department and Clinic of Surgery for a computer tomography scan of the thoracic cavity. The examination revealed the presence of air in the pericardial sac, a pneumopericardium, along with pulmonary emphysema. A few minutes after the examination, the rabbit developed circulatory and respiratory failure and died. Necropsy confirmed the presence of a pneumopericardium and pulmonary emphysema, and revealed, in the tracheal lumen, the presence of a tumor histologically consistent with hemangioma. A spontaneous pneumopericardium occurs when air from the respiratory system moves into the pericardial sac. This is the first case of the simultaneous occurrence of tracheal hemangioma and a pneumopericardium in a rabbit. A pneumopericardium is a rare condition defined as a collection of air, or other gases, within the pericardial cavity . A pneumRespiratory hemangiomas are also rare in animals. So far, two cases of respiratory hemangioma have been reported in animals; one was located in the nasal cavity of a sheep and the other in the nasopharynx of a dog ,5. IndepThe present report describes the first case of the simultaneous occurrence of tracheal hemangioma, which probably caused lung emphysema and pneumopericardium, in a rabbit.A domestic pet rabbit in middle age  was referred to the Imaging Diagnostics Laboratory of the Department and Clinic of Surgery exhibiting dyspnea, apathy, anorexia, and slight weight loss. According to the information obtained from the owners, the rabbit was kept at home and fed a ready-made feed, well-balanced with nutrients. The owners claimed that the rabbit had never had disorders connected with the respiratory system. No data on a possible injury were available, and according to the information obtained, the animal was suspected of an acute respiratory infection. Therefore, the rabbit was subjected to seven-day antibiotic therapy with azithromycin at a dose of 20 mg/kg b.w . Additionally, 0.5 mg/kg b.w meloxicam  and nebulization with budesonide  were given. Due to the lack of improvement, the patient was examined again, and since during auscultation increased respiratory noises were found, the animal was submitted to a respiratory system computed tomography (CT) scan to identify the cause of the current state. Before the CT, a complete blood count and biochemical exams were performed revealing mild monocytosis and leukopenia in the absence of other abnormalities.For the CT, the animal was sedated with 0.1 mg/kg b.w medetomidine  and 5 mg/kg b.w ketamine  and intubated. During the contrast test (slice thickness time point: 0.6 mm/90 s), iomeprol  was used at a concentration of 350 mg iodine/mL administered at a dose of 700 mg/kg b.w, intravenously. During the CT (nativ scan) of the nasal cavities, no abnormalities were observed, while the chest CT scan revealed features of emphysema, multifocal atelectasis, and mild diffuse thickening of the bronchial walls. No pulmonary lesions were detected. Of note, there was a small amount of gas in the pericardial sac , consistThe external examination revealed only bloody discharge from both nostrils. In the thoracic cavity, the lungs were slightly congested, mosaic-like, and edematous, with scattered multifocal gross lesions consistent with emphysema and atelectasis. The internal examination of the trachea revealed, at the cranial level, the presence within the mucosa of a flat, elongated red/brownish lesion slightly extending to the caudal part of the larynx. In the pericardial sac, which was thin and stretched, no air was found at necropsy, probably due to the freezing and defrosting of the corpse. No cardiac-relevant lesions were detectable except for a dilation of the right ventricle. Within the abdominal cavity, a general congestion of the organs, consistent with circulatory acute failure, was the only pathological finding detected.For histopathologic examination, sections of the trachea, lungs, and heart were collected, fixed in 7% buffered formalin, passed through graded alcohols, clarified in xylene, and paraffin-embedded. From the paraffin blocks, 4 μm-thick sections were obtained and stained with hematoxylin and eosin (HE) and Masson′s trichrome staining.Histologically, the tracheal lesion revealed to be a well-demarcated tumor, composed of cystic spaces and lacunae, frequently filled by erythrocytes, separated by variably thick fibrovascular septa, and lined with a single layer of flattened cells, characterized by a moderate amount of faintly eosinophilic cytoplasm and elongated, thin, and hyperchromatic nuclei a. CellulPrimary neoplastic tumors within the trachea are rare in humans and animals as well ,8. The pA pneumopericardium is a rare lesion, and its etiopathogenesis may be related to four different pathologic conditions: the existence of a fistula between the respiratory system and the pericardial sac, the action of a mechanical or pressure-altering trauma, the presence of an inflammation caused by gas-forming bacteria, or due to iatrogenic causes .In case of development of a fistula connecting the respiratory system with the pericardial sac, the air comes out from the alveoli and accumulates in the pericardial sac with no possibility to return to the respiratory system. Such a fistula may arise because of the development of, inter alia, bronchial cancer or trauma within the chest . In addiClostridium perfringens type A or Klebsiella [Another path for pneumopericardium formation is represented by the transfer to the pericardial sac, through the blood or lymph, of gas-producing bacteria, such as ebsiella .A pneumopericardium can also develop on an iatrogenic basis; most often it is a complication of the endoscopic examination of the esophagus , and a cSpontaneous pneumopericardium occurs, even more rarely, with the withdrawal of air from the alveoli into the pericardial sac ,16,17. IIn the current case, the presence of the hemangioma reduced the tracheal lumen resulting in dyspnea, and most likely, in emphysema, which in any case cannot be excluded as pre-existing. The severe respiratory impairment led to the development of respiratory failure, and as a result, to the dilation of the right ventricle. Emphysema is defined as an excessive accumulation of air in the alveoli and interstitial tissue due to damage of the alveolar walls . ProbablSpontaneous pneumopericardium has been reported several times in human patients ,16. In t


Bifurcation of the femur is a rare congenital orthopedic anomaly that is usually accompanied by tibial agenesis. Femoral bifurcation has been a part of the Gollop-Wolfgang complex criteria, which also include the tibia and fibula deformities with or without other variant abnormalities. Approximately 200 cases have been reported worldwide. This article presents a case of isolated bilateral distal femur bifurcation in a three-and-a-half-year-old girl who presented with abnormal gait and bilateral knee contractures. Extensive studies were performed to aid an appropriate diagnosis and treatment plan, including clinical history, physical examination, laboratory, and other investigations. After multiple consultations from different specialties, a gradual deformity correction was suggested as a treatment of choice. To our knowledge, there is a paucity of reported cases in the medical literature. Further research and case reporting are essential to better define the pathogenesis, prognosis, and treatment of such conditions. Within the last few decades, hundreds of cases with congenital anomalies of the femur have been reported. Distal femur bifurcation is a rare congenital anomaly and is always accompanied by deformity or aplasia of one of the lower leg bones . In 1885In late August 2021, a three-and-a-half-year-old female presented to the outpatient clinic with an abnormal gait since she took her first steps. The mother noticed it early and described it as a “flexed knee walk.” There was a growing concern from the parents when the patient complained of pain at the knee site in addition to a lump sensation laterally. The patient was born of non-consanguineous parents and premature labor (32 weeks) due to preeclampsia with a history of admission in the neonatal intensive care unit because of sepsis and grade one intraventricular hemorrhage. During her lifetime, there were no observed abnormalities or mental, developmental, or other musculoskeletal concerns. The family sought medical advice multiple times before this visit. At the age of 19 months, a hamstring tenotomy was performed bilaterally, followed by a specialized physiotherapy program. Upon clinical examination, the girl was standing and walking with bilateral flexion contracture of the knees with no functional limitation. A general lower limb examination showed normal neuro-vascularity with a normal range of motion except for the knees. They appeared relatively larger compared to her overall body, with contracture at approximately 45 degrees, and grossly intact skin. On palpation, there was no joint line tenderness but an irregular bony swelling was noted laterally on both sides. Moreover, there were no positive specific tests and no signs of inflammation or systemic involvement. Further, extensive investigations performed for the past year included complete blood count, white cell differential, and inflammatory markers, which were appropriate to the serum levels of her age group. In addition, minerals such as calcium, phosphate, potassium iron, and vitamin D were within acceptable ranges.In addition, hormonal and organ profiles for thyroid, parathyroid liver, and kidney functions were appropriate for her age. Genetic analysis including the chromosomal microarray analysis showed no positive results. For skeletal screening, a complete bone screening with an X-ray was performed, which showed an abnormality at only the knee sites. Other regions were biologically and anatomically accepted for her age. X-ray of the lower limbs Figures , 2 illusIn March 2022, the study was repeated and compared to the previous findings; however, no differences were found. Likewise, in December 2021, magnetic resonance imaging (MRI) of the lower limbs showed few abnormalities. First, the distal metaphysis of both femurs was cone-shaped with corresponding deformed epiphysis. Moreover, both growth plates were narrowed yet symmetric. Similarly, both proximal tibial metaphysis and epiphysis were minimally cone-shaped Figures , 4.The established diagnosis was bilateral congenital deformity  with abnormal gait. After multidisciplinary discussion with pediatrics, genetics, pediatric neurology, and other orthopedic pediatric consultants, a treatment plan was established, which included the application of a Taylor spatial frame in the femur to gradually correct the deformity one side at a time. First by operating on the right limb to lengthen the femur by 3 cm, followed by the left side at a later age. However, the parents preferred to seek another expert opinion in this regard. Despite that, the patient will benefit from gradual deformity correction using a Taylor spatial frame in the femur.Femoral bifurcation was first described by Ehrlich in 1885 in a case associated with tibial hypoplasia . It is aOn reviewing the literature, there was no single best approach for the treatment of such cases. In 1987, a case of a boy who presented with knee contracture and distal femur bifurcation was reported, similar to this case. First, for the progressive flexion contracture, a posterior release of his right knee was performed at the age of nine months to improve the 60-degree flexion contracture. Then, a trial of distal femur osteotomy was attempted to fuse the condyles together, yet the femur regressed to its original state after three years . In anotOur patient is a three-and-a-half-year-old girl who presented with abnormal gait and bilateral knee contractures for which further diagnostic studies have been performed. The X-ray scan showed femoral bifurcation and leg length discrepancy and MRI demonstrated similar findings and growth plate narrowing. After discussion with multidisciplinary teams of different specialties, gradual deformity correction using a Taylor spatial frame in the femur has been suggested; however, the patient did not complete her care with us. Outcomes in this rare condition can be hardly decided upon. As a result, reported cases with various presentations had different management plans. Further research and case reporting are essential to better define the pathogenesis, prognosis, and treatment of this condition to improve the morbidity of such cases.


Ganglion cysts are masses that we encounter frequently in our daily practice, usually in the upper extremity, less frequently in the lower extremities, and rarely cause compression symptoms. We present a case of a massive ganglion cyst of the lower limb causing peroneal nerve compression, managed with excision and proximal tibiofibular joint arthrodesis to prevent recurrence.Examination and radiological imaging of a 45-year-old female patient who was admitted to our clinic showed new-onset weakness in right foot movements and numbness on the dorsum of the foot and lateral cruris, a mass consistent with a ganglion cyst expanding the muscle was detected in the peroneus longus muscle. In the first surgery, the cyst was carefully resected. After three months, the patient came with a repeated mass on the lateral side of the knee. After confirmation of the ganglion cyst with clinical examination and MRI, a second surgery was planned for the patient. In this stage, we performed a proximal tibiofibular arthrodesis for the patient. Her symptoms recovered during the early follow-up period and no recurrence occurred during the two years of the follow-up period.Although the treatment of ganglion cysts seems easy, it can sometimes be challenging. We think that arthrodesis may be a good treatment option in recurrent cases. Synovial cysts may arise from any synovial joint, synovial-lined tendon sheath, or bursa. It is more common in the upper extremity and rarely causes peripheral nerve compression ,2. ArounAlthough drop foot secondary to peroneal nerve damage is mostly seen after acute injuries such as trauma, it may also develop on a chronic basis. Peroneal nerve palsy (PNP) may result from tumors (sarcoma), hematoma, and cysts ,4. As faA 45-year-old female was admitted to the outpatient clinic with progressive pain followed by swelling on the proximal lateral side of her right leg, which progressively increased during the past one month. For 10 years, the patient was complaining an episodic pain around this area. Additionally, for the past 15 days, she had numbness on the lateral side of her leg and drop foot developed in this duration. There was no history of trauma. Previously, a cyst was detected at the lateral side of the proximal tibia in an ultrasound (USG) examination performed in another center. Since she was suffering from intermittent moderate pain, analgesics were used regularly by the patient during this period. She applied to our hospital due to the numbness and drop foot developing in recent days.On physical examination, swelling was seen along the peroneal muscles starting from the right fibular head up to the middle one-third of the tibia, and tenderness was palpated around the fibular head. There were sensory disturbances along the territory of the superficial peroneal nerve and palsy of muscles, dependent on the deep peroneal nerve. She was unable to evert or dorsiflex her foot and peripheral pulses were palpable.USG, MRI, and electromyogram (EMG) were performed on the patient. In USG examination, an anechoic cystic lesion was observed in the posterolateral area of the right cruris. Further investigation with MRI revealed a lobulated, multilocular, well-demarcated cystic lesion in the peroneus longus muscle, diffuse edema, and inflammation around this region. Its size was approximately 36*35*120 mm  therapy was started by the physiotherapist. In the sixth week, ankle dorsiflexion and toe extension recovered. But the patient was not able to dorsiflex her first toe.At the third month, a 3*3 cm, well-demarcated, mobile mass was palpable on the lateral side of the knee. No worsening was noticed in motor and sensory function. In the imaging performed with suspicion of recurrence, an appearance compatible with a ganglion cyst originating from the proximal tibiofibular joint (PTFJ) was observed. PTFJ arthrodesis was planned when the MRI revealed the ganglion cyst originating from the PTFJ  again. After eight months from the first operation, the patient could fully dorsiflex and evert her ankle, and extend her toes. EMG revealed significant improvement in motor strength. On her second-year control examination, no recurrence, and no motor and sensorial loss was noted Figure .Synovial cysts are common soft tissue tumors. They usually appear in the upper extremity and may lead to ulnar and median nerve compression . AlthougSynovial cysts appear in areas that are constantly exposed to mechanical stress. Most often they arise from periarticular soft tissue and also synovium and contain a clear, colorless, gelatinous fluid as it seems in our case. A synovial cyst may be intraneural and extra-neural. Most of the cysts that cause peroneal nerve compression are intraneural . Extra-nSome imaging methods and EMG is required in establishing the diagnosis. EMG can be useful in determining the level of lesions and the severity of motor. Ganglia appear on MRI as lobulated, rounded, well-limited fluid collections. However, it is not always easy on MRI to distinguish a ganglion cyst from a giant cell tumor of synovial sheath or sarcoma ,11. USG To avoid misdiagnosis, it needs to be kept in mind that patients visiting the clinic with pain radiating along the anterolateral surface of the leg, hypoesthesia, and motor deficiency may have other reasons such as nerve compression at the lumbar level. Nikolopoulos et al. presented a patient who was initially evaluated as having spinal stenosis and was finally diagnosed with ganglion cyst at the lateral side of the proximal fibula as a result of further examinations after his complaints were not overcome with medical treatment . PreoperDuring excision, complications such as vascular and nerve injuries may occur during surgical dissection. Another complication is recurrence. Recurrence after cyst excision from the lower extremity has been reported in the literature as occurring in 13% of cases . Also, iIt should be kept in mind that synovial cysts developing on a chronic basis may cause progressive symptoms. The masses around the vessels, nerves, and tendons should be well evaluated and it should not be forgotten that these structures may cause symptoms and signs secondary to compression. In case of recurrence, complex options such as arthrodesis may be required. In addition, proximal tibiofibular joint arthrodesis is a valuable option in patients with recurrence.


Osteosarcomas are primary malignant bone tumors that are driven from bone-forming mesenchymal cells and account for nearly 20 % of primary bone tumors.A 16-year-old female presented with chief complaint of pain and swelling on her right knee for 6 months with history of trauma. Her knee mobility and ROM was limited due to pain and the mass. Physical examination revealed a 15 × 22 cm mass on distal part of right femur with visible dilated veins. There was normal distal motor, sensory functions. Imaging revealed distal femur mass with mixed lytic and blastic features, wide transitional zone with hair and periosteal reaction; features suggestive of osteosarcoma that was confirmed by histopathological examinations as intramedullary osteosarcoma. She undergone surgical treatment consisting of surgical excision of the mass with safety margins and knee reconstruction by knee arthrodesis using femoral-nail and bone cement technique with excellent outcome.Osteosarcoma is best investigated through plain imaging, MRI and possible CT with histology being confirmatory. It is best approached with meticulous dissection to ensure clear margins or if necessary, amputation. Following resection, reconstruction can be done. In this specific case, the tumor was on the distal femur and the underlying knee was arthrodesed using cemented nail technique in which a cemented intramedullary nail was inserted with excellent clinical outcome.Surgical approach to osteosarcoma can be performed through limb salvage or amputation. Arthrodesis with cemented nail technique using an intramedullary nail can be performed in some patients with excellent clinical outcome. •Osteosarcomas are malignant bone tumors driven from bone-forming mesenchymal cells.•Preoperative imaging usually performed: plain radiographs, MRI and possible CT scans.•Best approached through meticulous dissection or if necessary, through amputation.•Arthrodesis can be used for limb salvage which is well-known for centuries. Patients usually present with symptoms of bone pain especially with activity. Given the specific age group it is more common in , parents usually attribute that pain to growing pains, arthritis or even simple sprains in case of associated traumatic events. Pathological fractures are not common with osteosarcomas 2A 16 years old female who is a high school student presented with a chief complaint of pain and swelling on her right knee for 6 months. She has history of a fall while playing. She had difficulty with mobilization due to large mass and pain. She performed daily activities and ambulation with the assistance of her family. She has been taken to a traditional bone setter several times. There was no history of allergies or history of the malignancy in her family.3The physical examination revealed a mass on the distal part of the right femur, visible dilated veins over swelling, no distal oedema with the knee in a flexed position. The size of the mass was 15 × 22 cm. The mass was immobile with an ill-defined border. It was hot compared to the surrounding and contralateral parts with normal distal motor, sensory and distal capillary refill time. There were intact popliteal, dorsalis pedis and posterior tibial arteries pulsations. The knee range of motion was limited to 100°. There was no inguinal lymphadenopathy.4The patient started complaining of the above-mentioned symptoms 6 months prior to presentation after her trauma, a period during which she visited a traditional bone setter with no relief. Instead, the tumor has even increased in size within the last 3 months. Once admitted, immediate investigations followed by treatment were commenced.5Laboratory examination revealed normal inflammatory markers. The hemoglobin level was 9.1 g/dL, leucocytes count was 8.7/μL, alkaline phosphatase was 500 U/L; lactate dehydrogenase was 157 U/L. Radiographs showed a distal femur with mixed lytic and blastic lesion, wide transitional zone with hair and end periosteal reaction. The MRI revealed a heterogenous mass at the distal femur (Low T1 and high T2) with no skip lesion and minimal soft tissues extension. The lesion did not affect the proximal part of the tibia. There was no neurovascular bundle involvement based on the MRI. A bone scan and CT chest revealed no distal metastasis. The lesion was staged as grade IIB according to Enniking classification She was then planned for core needle biopsy and the histopathology revealed malignant cells producing osteoid and stromal cells that are highly malignant with increased nuclear cytoplasmic ratio, hyperchromasia and cellular pleomorphism features pointing towards the diagnosis of conventional intramedullary osteosarcoma.6The surgery performed consisted of wide excision of the mass with reconstruction by knee arthrodesis using femoral-nail and bone cement technique , Fig. 2.The skin was incised and the mass was dissected until the tumor was exposed. Fortunately, the neurovascular bundle in the popliteal area has not been not affected by the tumor. Nonetheless, the tumor was already affecting the joint; therefore, the distal 24 cm of the femur was cut to ensure safety margins, and the tumor was removed by intraarticular resection.After the tumor was excised, the defect was 32 cm from the distal resected femur to the proximal tibia. The cement arthrodesis was then performed. First, the femoral-nail was inserted from the distal femur into the proximal tibia and the length of the nail that is not inserted into the long bone is 32 cm to ensure the same length as the contralateral leg.We modified the nail direction to ensure a 3° degrees valgus in arthrodesed knee and to allow the anterior to posterior direction of screws to facilitate proximal interlocking screws insertion without repositioning the patient. The nail was then fixed with 2 proximal and 2 distal interlocking screws. The bone cement was augmented to fill the defect between the bone ends . The lenThis surgery was done by a consultant orthopedic oncologist assisted by an orthopedic oncology trainee.7The resected part of tumor was sent to histopathology which revealed clear surgical margins. The patient underwent an uneventful postoperative recovery period with starting of walking using cane from day one. There were no complications related to the wound.8Osteosarcoma is a malignant primary bone tumor of mesenchymal origin. It commonly affects and has a peak incidence in young adult patients and adolescents To diagnose any suspicious bone mass, a pre-operative imaging is usually performed consisting of plain radiographs, MRI and possible CT scan. A two views X-ray will usually show a mass with non-specific findings of an ill-defined lesion with osteoblastic or mixed osteoblastic/osteoclastic features and a periosteal reaction Osteosarcoma is generally treated with combining surgery and chemotherapy whether it is neoadjuvant or adjuvant or both One and not commonly practiced procedure for limb salvage is knee arthrodesis which is a procedure that is well-known and practiced for centuries and has some traces of radiological evidence been found in an Egyptian mummy. It can now be used among other modalities in some conditions including failed total knee arthroplasty as a modality for limb salvage, reconstruction of the knee after removal of a tumor as well as any condition in which there is an inability to reconstruct the knee as in severe trauma or in traumatic osteoarthritis in young patients Many approaches have been described with the shared goal of maintaining the knee stability including external fixation with Ilizarov apparatus, internal fixation using a plate as well as intramedullary nailing When comparing this specific case to previous cases, there are some similarities to a previous most recent case of Achmad Fauzi Kamal et al. 9The learning objective is that osteosarcoma is malignant bone tumor of mesenchymal origin that usually affects patients in their second decade of life and is best approached through meticulous dissection to ensure clear and safe margins or if necessary, amputation can be performed. Following the resection, reconstruction can be done. In this specific case, the tumor was on the distal femur and the underlying knee was arthrodesed using cemented nail technique in which a cemented intramedullary nail was inserted with excellent clinical outcome for a 16-year-old female patient. This technique, although it has been known before, is not commonly used due to advances in care provided to patients. Here, however, we have done such procedure due to limited facilities and the economic status of the patient and we think this could be a bridge till eventual and final treatment can be provided.This case has been reported in line with the SCARE criteria Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.No ethical approval was required for this case report and only informed consent was taken from the patient.Authors received no funding from any source and this work is completely a voluntary work.Not commissioned, externally peer-reviewed.Hassan Mohammed Hassan Elbahri: Involved in study design, data acquisition, drafting the article and revising it critically and finally approved the manuscript.Hozifa Mohammed Ali Abd-Elmaged: Involved in study design, data acquisition, drafting the article and revising it critically and finally approved the manuscript.3: Involved in study design, data acquisition, drafting the article and revising it critically and finally approved the manuscript.Mohamed AbdulkarimMohammed Mubarak Mohammed Ahmed: Involved in study design, data acquisition, drafting the article and revising it critically and finally approved the manuscript.: Involved in study design, data acquisition, drafting the article and revising it critically and finally approved the manuscript.Mohamed Medani Elhag MedaniNot applicable.Hozifa Mohammed Ali Abd-Elmaged.Authors report no conflict of interest of any sort.


Advanced-stage pancreatic cancer can present as secondary gastric outlet obstruction (GOO), which is an extremely rare entity. Given the initial vague presentation of gastrointestinal symptoms, the diagnosis is often delayed, leading to high morbidity and mortality. We report the case of a 68-year-old male patient who presented with vomiting, epigastric pain, and weight loss. CT abdomen and pelvis showed a distended stomach with a transition point in the duodenum. Immediate stomach decompression through the nasogastric tube was performed. Upper endoscopy (EGD) revealed ischemic gastritis with gastric body necrosis. Biopsy of the duodenum revealed moderately differentiated invasive adenocarcinoma. Magnetic resonance cholangiopancreatography (MRCP) showed a 7-cm mass centered in the body and the tail of the pancreas, invading the duodenojejunal junction. No surgical or oncological management was indicated due to the advanced stage of the malignancy at the time of the diagnosis. Malignant GOO, even though rare, should be a part of the differential diagnosis in elderly patients with vague gastrointestinal symptoms. Gastric outlet obstruction (GOO) in elderly patients is concerning for malignancy. GOO, especially in advanced stages, can be life-threatening as it might cause malnutrition, electrolyte imbalance, and dehydration ,2. AlthoA 68-year-old male presented with epigastric pain and non-bloody, non-bilious vomiting for three days. He endorsed loss of appetite, 20 pounds of unintentional weight loss, constipation, and weakness in the last two months. On presentation, the patient was noted to be in atrial fibrillation complicated by hypotension. On exam, the patient was lethargic with cold and clammy extremities; no abdominal tenderness or palpable masses were appreciated. His labs were significant for elevated lactate  and a new cholestatic pattern of liver injury . CT abdomen and pelvis showed a distended stomach with a transition point in the duodenum. Immediate stomach decompression through the nasogastric tube was started, and the patient was transferred to the ICU for septic shock secondary to suspected bowel obstruction. He was started on cefepime and vancomycin. Upper endoscopy (EGD) revealed ischemic gastritis with gastric body necrosis , but laparoscopic GJ has been shown to have fewer complications . EndoscoGOO may prove to be life-threatening as it causes severe disruption in vasculature, solid organs, and viscera, making patients prone to hypotension, multifactorial shock, and numerous metabolic derangements. Although malignant GOO is rare, it should be part of the differential diagnosis in elderly patients with vague gastrointestinal symptoms, and a lower threshold for abdominal imaging may be beneficial in such patients.


Cervical teratomas are one of the rare tumors. Relating to the size of the tumor, they present as a huge neck mass with solid and cystic components. Furthermore, they are able to induce a hyperextension of the neck, neonatal respiratory distress, and possible malignancy. The computed tomography scan examination of this case revealed that there was a mass. It was a component of a teratoma and pathological anatomy which supported the finding. Thus, this study provided a case of a fully excised and cured cervical mature teratoma occurred in an infant. Surgical management must be undergone as thorough as feasible in order to prevent recurrences and the development of the cancer. The term “teratoma” is coined from a Greek word which means a “monster.” Commonly, it is originated from the tissues of the ectoderm, mesoderm, and endoderm. These three germ cell layers serve as the basis A 7-month-old male infant presented to the surgical outpatient department with the prior complaints of the left-sided neck mass. This condition was presented since he was born. The swelling measured approximately in 5.6 × 7 × 7.6 cm. The infant was properly fed as in his normal sensory and motor milestones were well-indicated. There were no symptoms of respiratory distress. Moreover, the infant underwent a computed tomographic scan which resulted in; a complex heterogeneous solid cystic and calcification enhancing mass lesion in the left cervical region with extensions into the left parotid space, left buccal space, left submandibular space, left carotid space, left parapharyngeal space and left retropharyngeal space . FurtherApparently, the tumor was found in a gray-white to brown with globular measuring as 6 × 5 × 4.5 cm. The cut section portrayed a variegated appearance with focal areas of cystic degeneration as in The most prevalent extragonadal germ cell tumors found in children are teratomas. There is no gender prevalence in these tumors. The typical one has an incidence of 4000 live births Children's cervical teratomas are typically benign; however, they are occasionally aggressive. They may exhibit respiratory distress which the case of rapid excision is indicated. Relating to the radiological perspective, multiple calcified foci on computed tomography are very suggestive kind of teratomas There are some differential diagnoses for teratomas, e.g., lymphangioma, venous malformations with phleboliths, dermoid, neurenteric cysts, Thornwald's cyst, and basal meningocele. All cervical teratomas should have preoperative thyroid function testing to be performed, because they contain thyroid tissue and postoperative hypothyroidism.Cervical teratomas can typically and promptly be removed with surgery. Surgery is efficient and has a positive long-term effect. In addition, close monitoring is required in preventing the emergence of any post-operative respiratory distress. Infantile cervical teratomas are rare and mostly benign tumors. On the other hand, certain thyroid teratomas are considered as a malignant and risk for recurrence. The authors highlighted that pediatric cervical teratomas should be acknowledged in determining a differential diagnosis for cystic lesions in the head and neck region. For the excellent outcomes, complete resection is highly recommended. A constant and proper long-term follow-up is essential to monitor potential complications from the malignancy or the possibility of recurrence disease in the future.Written informed consent was obtained from the patient for the publication of this case report.


Tailgut cysts, or retrorectal cystic hamartomas, are rare congenital abnormalities that develop when the embryologic tailgut fails to involute. They are found in the presacral space, which is an area with quite a complex anatomy. Tailgut cysts can be symptomatic due to their mass effect and can even result in complications, including malignancy. Because of their rarity and varied presentations, tailgut cysts are frequently misdiagnosed. CT scans and MRI are useful in the diagnosis of these retrorectal masses, and surgical resection is the definitive treatment. Multiple surgical approaches can be used, with the treatment tailored to suit each individual patient’s anatomy and suspected lesion diagnosis. The retrorectal or presacral space is bounded anteriorly by the rectum, posteriorly by the sacrum, superiorly by the peritoneal reflection, inferiorly by the pelvic diaphragm muscles (levator ani and coccygeus), and laterally by the ureters and iliac arteries and veins . TailgutTailgut cysts are quite rare, but the true incidence has been difficult to quantify as the majority are asymptomatic and can easily be missed on the digital rectal exam ,4. Most In this report, we present the case of a woman with a tailgut cyst that caused lower back pain, whose symptoms were successfully relieved with surgical resection.A 46-year-old woman with an uneventful past medical and surgical history was evaluated for lower back pain. Her diagnostic workup included an MRI of the lumbar spine and sacrum. This imaging study demonstrated an extremely low-lying , multi-loculated retrorectal lesion 3.7 cm in its greatest dimension, most likely representing a tailgut cyst (cystic hamartoma) Figure . After bDigital rectal examination immediately demonstrated the presence of a caudal, tender, soft, non-mobile retrorectal mass. The examining finger was able to pass superiorly to the mass and palpate a normal mid-S5 sacral vertebra. Perianal examination revealed a normal resting tone, normal squeeze, and no perineal descent or prolapse with Valsalva; furthermore, there was no gross perianal pathology. Aside from these findings, the remainder of the physical exam was unremarkable. Laboratory studies were within normal limits, and there was no radiographic evidence of extra-pelvic disease.The patient underwent complete resection of the mass through a posterior (Kraske) approach. An incision was made extending 6 cm from the coccyx superiorly. Sharp dissection was used to carry the incision down directly in the midline until the presacral fascia was encountered. The medial gluteal fibers were then divided bilaterally to expose the distal sacrum and attached mass. The mass had multiple tense and cystic loculations, one of which was inadvertently entered, releasing a thick, non-malodorous, purulent fluid consistent with sterile pus. The lesion was resected en bloc with its fibrous attachments to the distal coccyx and inferior S5 sacral vertebra by dividing across the mid S5 sacral vertebra. After the removal of the mass, orthopedic files and a rongeur were used to dull the sharp edge of the sacral transection, and bone wax was placed to prevent additional bleeding or soft tissue injury. The gluteal muscles were returned to the midline, and a Jackson-Pratt drain was cut to size and passed into the presacral space through a separate, lateral skin site. The remaining layers of the incision were re-approximated and closed. The patient tolerated the operation without any complications, and her postoperative course was uneventful. The patient returned to the clinic two weeks later for the removal of the drain and skin sutures and achieved a complete functional recovery soon thereafter.Pathological findingsGross pathological examination revealed an irregular, rubbery, firm, tan-red mass of tissue measuring 5.5 x 3.7 x 2.6 cm with attached coccyx and inferior S5 sacral vertebra  and symptomatic tailgut cysts ,5,7. AppDespite the rarity of tailgut cysts, it is important for clinicians to be alert to recognize these lesions’ clinical features. Because symptoms can range widely, physicians must keep tailgut cysts on their differential diagnosis; additionally, physicians must have a high degree of suspicion because of the cyst's potential for malignant transformation. Being aware of and recognizing these lesions can help in applying rapid surgical intervention for definitive treatment, as well as decreased patient morbidity and mortality.


A cholesteatoma is an abnormal, noncancerous skin growth that can appear beneath the eardrum in the center of your ear. Although it might be a congenital condition, frequent middle ear infections are the main culprit. A cholesteatoma frequently appears as a cyst or sac that exfoliates the skin's outer layers. As these dead skin cells build up, the growth can enlarge and penetrate intratemporal tissues, leading to various intracranial and extracranial difficulties that can compromise facial muscles, hearing, and balance. Cholesteatomas were recognized more than three centuries ago. A cholesteatoma can develop into a serious condition if it is not treated right away. Because of its fast development and invasive nature, it can cause several consequences, some of which can be fatal for people without access to advanced medical treatment. There are no effective nonsurgical treatments available right now. It will be necessary to have a thorough awareness of both previous developments and more current ones to develop an appropriate management approach for this condition. The background information on acquired middle ear cholesteatomas is briefly reviewed in this paper. We also take into account categorization-, epidemiology-, histology-, and pathogenesis-related difficulties, and we carefully review current management and diagnosis approaches. A cholesteatoma consists of two parts, a matrix and a central white mass. The matrix comprises keratinizing squamous epithelium resting on a tin stroma of fibrous tissue and a central white mass consisting of keratin debris produced by the matrix. Because of this, it is also known as epidermolysis or keratoma. This aberrant growth is invasive locally and has the potential to obliterate middle ear cleft structures. Additionally, squamous epithelium may become destructive in persistent infection, amplifying the osteolytic consequences of cholesteatomas [A cholesteatoma is a well-defined noncancerous cystic lesion that results from the aberrant development of the keratinizing squamous epithelium in the temporal bone. It is commonly characterized as ng place . The terteatomas .cholesteatoma for the first time. The word's origins translate to cholesterol, fat, and tumor, denoting a tumor that contains both fatty tissue and cholesterol crystals. Nomenclature is inaccurate and is regarded as the second incorrect term in otology . In addition to the fact that the tumor's nature is entirely debatable, the usage of this term is improper as cholesteatomas are derived from the keratinized squamous epithelium of the tympanic membrane and the external auditory canal, which contains no cholesterol crystals or fat [In 1838, German anatomist Johannes Mueller used the term s or fat . A cholePatients may develop symptoms such as hearing loss; ear drainage, often with a bad smell; recurrent ear infections; a sensation of ear fullness; dizziness; facial muscle weakness on the side of the infected ear; and earache. A cholesteatoma is diagnosed through otoscopic examination, CT, MRI, and tympanometric and audiometric tests. Any medical treatment cannot cure it. Surgical treatment is necessary to treat this condition. Coexistent infections are treated with local and systemic antibiotics to keep the ear dry, as the surgical procedure cannot be performed when there is ear discharge. The primary goal of surgery is to remove the skin and clear the infection. Surgical methods include canal wall up (CWU) and canal wall down (CWD) mastoidectomies. This may involve reconstructing the eardrum, removing bone behind the ear, or reconstructing the hearing loss. In some cases, a second surgery may be required to ensure all cholesteatomas are terminated before the hearing bones can be rebuilt. If necessary, the second surgery will typically be performed 6 to 12 months after your first surgery.ClassificationCongenitalCholesteatomaIt develops from an embryonic epidermal cell resting in the temporal bone or the middle ear cleft. A congenital cholesteatoma can develop in the middle ear, the petrous apex, or the cerebellopontine angle, and depending on where it develops, it can cause different symptoms. Congenital cholesteatoma of the middle ear causes conductive hearing loss and manifests as a whitish mass behind an intact tympanic membrane. It can occasionally be found during a child's normal checkup or when having a myringotomy . AdditioAcquiredCholesteatomaPrimary acquired cholesteatoma: It is known as primary cholesteatoma because there is no prior history of otitis media or a perforation that is already present. Figure · Invagination of pars flaccida: In the attic, persistent negative pressure creates a retraction pocket where keratin debris gathers. The keratin mass enlarges toward the middle ear when infected. Thus, the proximal end of an expanding invaginated sac is an attic perforation.· Basal cell hyperplasia: Subclinical pediatric illnesses cause the pars flaccida basal layer to proliferate. An attic perforation is then created when an expanding cholesteatoma penetrates the pars flaccida.· Squamous metaplasia: Due to subclinical infections, the attic's normal pavement epithelium goes through metaplasia and keratinizes squamous epithelium. It has also been shown that such a shift occurs in situations of otitis media with effusion.Secondary acquired cholesteatoma: In some instances, the pars tensa already has a hole. This frequently coexists with extensive central or posterosuperior marginal perforations. Theories on its genesis include the following:· Migration of squamous epithelium: The external auditory canal or the tympanic membrane’s outer surface keratinizing squamous epithelium migrates through the opening into the middle ear. Tympanic annulus perforations, such as those that occur in acute necrotizing otitis media, are more prone to allow the squamous epithelium to proliferate.· Metaplasia: Due to recurrent infections of the middle ear through the preexisting hole, the middle ear mucosa goes through metaplasia .EpidemiologyThe annual incidence of cholesteatomas is reported as 3 per 100,000 in children and 9.2 per 100,000 in adults with a male predominance of 1.4:1 . Middle HistopathologyAt the macroscopic level, a cholesteatoma presents as a whitish ovoid or round friable mass with a thin wall that contains pultaceous or a macerated substance. The lesion is divided into three layers at the microscopic level: the cystic content, the matrix, and the perimatrix . The cysPathogenesisExplanations for the pathogenesis of a cholesteatoma can be categorized into the following four groups: (1) the invagination theory (the retraction pocket theory), (2) the theory of epithelial invasion or migration (the immigration theory), (3) the theory of squamous metaplasia, and (4) the theory of basal cell hyperplasia (the papillary ingrowth theory) . AccordiDiagnosisThe following tests are carried out to check for hearing loss: An audiogram is carried out to assess the eardrum, middle ear, and hearing. CT scan of the ear helps to see if there is damage to the ear bones. MRI is done if there is a concern that the cholesteatoma is spreading through the skull base.OtoscopicExaminationOtoscopy, which includes video-otoscopy, otomicroscopy, and video-telescopy, is the most direct and effective technique for inspecting the eardrum. Making certain there is sufficient brightness and light during an otoscopic examination is essential . The earRadiological ExaminationCT: The main imaging technique used in this field to assess the severity of the condition and aid in the development of a surgical strategy is CT. Repeated HRCT scans should be performed before surgery to determine the severity of the illness, any potential osseous damage, any malformations of the body  , and othMRI: Due to the various pulse sequences used in MRI, complementing information is provided, improving tissue distinction . CholestAncillaryDiagnosticToolssilent cholesteatoma, conductive cholesteatoma, or cholesteatoma hearer [Tympanometric and audiometric tests are ancillary diagnostic methods that can be used to assess cholesteatomas. Conducted hearing deficiencies are discovered via audiometric testing. Labyrinthitis may be linked to the symptom of mixed hearing loss with a sensorineural component . Sensoria hearer . To assea hearer .TreatmentCWU Procedure The posterior bone meatal wall is left intact while the illness is removed using a combined approach through the meatus and mastoid, preventing an exposed mastoid cavity . It causCWD ProcedureSo that the affected region is completely exteriorized, they leave the external auditory canal and the mastoid cavity uncovered. Atticotomy, modified radical mastoidectomy (MRM), and radical mastoidectomy are the procedures most frequently used to treat atticoantral illness . One shoReconstructive Surgery and Conservative TreatmentMyringoplasty and tympanoplasty can help restore hearing. It may be carried out as part of the initial surgery or as a subsequent operation . It can To facilitate treatment and management, careful and early evaluation is the key to an early diagnosis. Both classic and current evaluation methods such as audiometric tests, tympanometric tests, X-rays, CT scans, and MRIs can be used. For cholesteatoma to be discovered early, greater awareness is required. Symptoms such as a persistent or recurring watery, often smelly, discharge from the ear, which may be irregular, and gradual loss of hearing in the affected ear may be seen. A thorough understanding of the crucial anatomical structures, their relationships with the middle ear function and management, the histology involved, and the specific surgical procedure is required. CWU and CWD procedures that may need to be customized for each patient, depending on the severity of the disease involved, are all necessary for this process to go smoothly and preserve hearing.


Point-of-Care ultrasound (POCUS) is based on target ultrasound that is performed wherever a patient is being treated, and by a non-radiologist directly involved in the patient’s care. It is used either for quick diagnosis or procedural guidance. Abdominal pain is one of the most common complaints in emergency departments, and POCUS can help in the differentiation of patients who need additional diagnostic tests or hospital treatment, which eventually reduces the overall costs of health care. POCUS has high sensitivity and specificity in abdominal pathology, it can be helpful in the evaluation of biliary, intestinal, and urinary tract, and it is especially used in trauma. Additionally, the gold standard for abdominal aortic aneurysm detection, follow up and screening is precisely this diagnostic procedure. Unfortunately, the quality of ultrasound examination can be affected by the experience of the physician performing it and the patient’s body weight. There is no doubt that POCUS is being increasingly recognized, but all motivated physicians should be provided with dedicated tutors and enough time for learning. This would certainly help to implement this diagnostic method as a routine in emergency and critical care departments, and significantly shorten the time until definitive diagnosis. Ultrasonography is very important in clinical practice as it is a low-cost, non-invasive, radiation-free diagnostic procedure that can be repeated multiple times with little risk to patients . In partIn emergency departments, abdominal pain is the third most common indication of POCUS ,6,7,8,9.Additionally, POCUS is clinically important in shock status assessment as it provides the examination of different organs systematically at the same time . Shock iIntraperitoneal free fluid (IPF) is a pathological accumulation of fluid in the peritoneal cavity, which occurs as a symptom of various diseases . The mosBased on the amount of IPF present, the classification is made into three grades: a small amount (grade 1), which can only be detected by ultrasound, a moderate amount (grade 2), which manifests as moderately symmetrical abdominal distension, and a large volume (grade 3) with pronounced abdominal distension . On US eBedside ultrasound can also be used during paracentesis , which cBesides the physical examination, in trauma Focused Assessment with Sonography in Trauma (FAST) is also clinically very important to assess for hemoperitoneum, while it provides an additional noninvasive examination of the abdomen with minimal disruption of resuscitation efforts . In addiThere is another type of Focused Assessment with Sonography in Trauma called the extended FAST (E-FAST) which includes pneumothorax and hemothorax assessment . This diThe presence of air in the peritoneal cavity, pneumoperitoneum, is often caused by perforation of a hollow abdominal organ as a result of cholecystitis, diverticulitis, appendicitis, trauma, bowel malignancy or ischemia . When diAn ectopic pregnancy is a potentially life-threatening condition that is frequently seen in gynecology emergency departments. It is the presence of a fertilized embryo that implants outside of the uterus, most commonly in the fallopian tube . FallopiCholelithiasis is the presence of gallstones in the gallbladder , which oThe most common manifestation of acute cholecystitis is biliary colic, defined as the sudden onset of pain in the epigastric region or the right upper quadrant of the stomach. Biliary colic peaks within one hour of the onset  and thenThe gold standard for the diagnosis of cholelithiasis  is an USA gallstone less than 5 mm in diameter presents as a hyperechoic focus without a posterior acoustic shadow , whereasThe results of the study which comprised 1690 patients with abdominal pain showed that POCUS had 88% sensitivity, 87% specificity, 91% positive predictive value, and 83% negative predictive value in the diagnosis of gallstones . MoreoveRenal colic most often occurs as a result of urolithiasis, i.e., the presence of calculus in the urinary tract . It maniUrolithiasis often can lead to hydronephrosis, which is a frequent but reversible cause of acute kidney injury . HydronePOCUS is also used for evaluation of the bladder, allowing the differentiation of a distended bladder (a large fluid-filled structure) from ascites, assessment of bladder volume, and visualization of a Foley balloon within the bladder (confirmation of an adequately placed urinary catheter) .An abdominal aortic aneurysm (AAA) is a permanent and irreversible, localized, enlargement of the lumen of the abdominal aorta . DilatatRecently, there has been an increasing trend in the incidence of AAA, due to the aging of the population, the increase in the number of smokers, but also the introduction of screening programs, and the improvement of diagnostic tools . Among tThe gold standard for AAA detection, follow up and screening is US examination, as it is characterized by a sensitivity of 94% to 99% and a specificity of 98% to 100% ,88,89,90Bowel obstruction is a frequent gastrointestinal emergency, that requires prompt and effective treatment . ObstrucDiagnosis involves imaging methods, as neither the presence nor absence of clinical features or isolated laboratory findings are sufficient criteria to exclude or confirm strangulation or intestinal necrosis . In suchPOCUS can detect the location and potential cause of obstruction in the small intestine, by analyzing the zone where the transition from dilated to collapsed bowel occurs, based on the visibility of valvulae conniventes, which become prominent in jejunal obstruction and are absent or rare in obstruction of the ileum ,109. It Diverticula are the most common changes in the colon . These aThe most common clinical manifestation of acute diverticulitis is the triad consisting of severe abdominal pain, fever and elevated inflammatory markers ,128. RecAs already known in clinical practice, the accuracy of physical examination for diverticulitis is low . In thisUltrasonography signs of diverticulitis include hypoechoic mural thickening of the colon wall (>4 mm), non-compressible target sign, and absence of peristalsis ,129,130.Appendicitis, as the most common surgical emergency, occurs at a rate of 96.5 to 100 patients per 100,000 adults per year , with a The diagnosis of appendicitis is challenging and requires a synthesis of clinical, laboratory and radiological findings . If the The main disadvantage of POCUS is that the quality of the examination is affected by the patient’s body weight, but other disadvantages include the experience of the physician, pain during the procedure and intestinal gases . DespiteThe evidence shows that POCUS is certainly the best additional examination method, which leads to a faster and more accurate diagnosis. It can be performed wherever a patient is being treated and by a non-radiologist, which are the most important advantages of this diagnostic procedure. We are lucky nowadays to have US machines available in almost every medical institution, and it was shown that non-radiologist physicians can be trained quickly. Despite possible rapid learning, the quality of the examination can be affected by the experience of the physician. Usually, the patient’s body weight also influences the quality, which is another common disadvantage of this procedure. The mission is to provide dedicated tutors and enough time for learning to all motivated physicians. In summary, POCUS should be implemented as a routine procedure in clinical practice, especially in emergency and critical care departments, as it can provide less time consumption and establish new standards of care.


Tumors of the nasal cavity and paranasal sinuses are unusual pathologies found in clinical practice. Approximately 0.8% of all human cancers are located in this area. Despite being rare, nasosinusal neoplasms usually manifest through nonspecific symptoms that are common to numerous inflammatory pathologies. The aim of this study is to describe a series of rare nasosinusal tumors, including esthesioneuroblastomas, central giant cell granulomas, extramedullary plasmocytomas, nasosinusal hemangiopericytomas, neurofibromas and cemento-ossifying fibromas, diagnosed at the Fortaleza General Hospital. We, hereby, briefly review each of the aforementioned pathologies, stressing the need for a precise histological diagnosis for proper treatment in each case. Nasosinusal malignant tumors are rare, representing less than 3% of head and neck cancers and 0.8% of all human cancersTumors in this region usually cause unspecific and common symptoms, including inflammatory diseases. Nasal obstruction (61.2%), epistaxis (40.8%), facial pain (39.2%) and local infection (23.9%) are the most commonly reported initial symptomsATS, female, 16 years, coming from Acarape/CE, came to us complaining of epistaxis followed by right side nasal obstruction for 3 years. Anterior rhinoscopy showed a hyperemic tumoral lesion, brittle, involving the upper portion of the right nasal cavity (RNC), extending all the way to the middle meatus.Nasal cavity and paranasal sinuses CT scan showed a dense polypoid mass, well defined, in the right nasal cavity, fully obliterating the middle meatus and the sphenoethmoidal recess, with middle turbinate and poorly defined ipsilateral posterior ethmoidal air cells. We could also see a thickening of the right maxillary and sphenoidal sinuses mucosa .Figure 1Incision biopsy followed by nasal packing was carried out in the outpatient ward. Pathology exams showed clusters of small cells of round hyperchromatic nuclei amidst fibril stroma, matching signs of stesioneuroblastoma. Having a diagnosis of Kadish B , we proposed a mid-facial degloving resection, followed by radiotherapy (RxT). Still during the preoperative, the patient had intensive epistaxis, requiring arteriography and selective right maxillary artery catheterization for tumor embolization.In the eighth post-embolization day, we carried out a cranio-facial tumor resection. The lesion occupied the upper portion of the right nasal cavity, measuring approximately 4cmx3cmx1.5cm. Anterior maxillary sinusectomy showed no tumoral mass in the right maxillary sinus . The medBRN, Female, 26 years, came from Fortaleza/CE, came to us complaining of a bulging on the hemiface and right nasal obstruction, with 8 months of development. She reported she had a tooth removed (1st right pre-molar) one year before. Her CT scan showed an expansive solid large heterogeneous mass occupying her right maxillary sinus, with expansion and small areas of cortical invasion. The lesion extended to the hard palate and ipsilateral tooth alveolar process, to the RNC and partially obstructed the inferior orbital fissure .Figure 3When we biopsied her through a sublabial antrostomy, we could see no anterior bone wall on the right maxillary sinus and a brittle encapsulated bulky and vascularized tumor. An AP study showed tumor sections reproducing giant multinucleated cells inserted in the fibrous stroma of variable density, with ovoid and fusiform cells proliferation, in a clinical picture matching that of giant cells central granuloma (GCCG). Treatment proposed was direct maxillectomy through mid-facial degloving. The patient is in her 24th month of follow up, with no evidences of tumor recurrence .Figure 4CAS, female, 52 years, coming from Fortaleza/CE, complained of epistaxis for 3 years, followed by right side nasal obstruction. Her otorhinolaryngological physical exam was normal. Through nasal-endoscopy we could see a tumor on the RNC floor, extending to the nasopharynx . ParanasLDS, 15 years, female, coming from Fortaleza/CE, came to us complaining of tooth ache and bolus lesion on her palate to the left, followed by epistaxis, hemifacial bulging and ipsilateral exophthalmus, of about one year of evolution. Paranasal sinuses CT scan showed an expansive mass in the left nasal cavity, extending anteriorly to the orbit apexes and supra-sellar region, destroying the pterygoid lamina. The lesion expanded to the ipsilateral sphenoidal and maxillary sinuses and to the hard palate, uptaking little contrast. .Figure 7At our first biopsy attempt, there was an important bleeding, then we chose to do an arteriography and tumor embolization, which presented expressive regression. We did an excision biopsy through anterior maxillary antrostomy, and we only saw the tumoral capsule and the necrotic tissue in a large cavity within the maxillary sinus.AP study showed connective tissue with mixed infiltrate of inflammatory cells and vascular clefts with collarette of cells with round nuclei; areas of mucinous material build up and deposits of hemosiderin pigment. We concluded it was an angiomatoid tumor, with no signs of malignancy, with a differential diagnosis between glomangioma and nasosinusal hemangiopericytoma. Tumoral cells laying around vascular spaces that showed only vimentin in the immunohistochemistry exam, negative for actin, smooth muscle actin, CD31 and CD34, is more compatible with nasosinusal hemangiopericytoma.Three months after the surgical procedure, the patient returned complaining of epistaxis. During nasal-endoscopy we noticed a residual tumor in her RNC floor, extending to the soft palate. CT scan showed a lesion measuring about 5cm × 3cm, with bone destruction and rarefaction, involving the orbital floor, lateral wall and maxillary sinus floor. The lesion was destroying the clivus, ethmoid and sphenoid sinuses on the left side, invading the parasellar region and involving the cavernous sinus .Figure 8The patient underwent RxT and chemotherapy (QT), and died about one year after the diagnosis, with clinical signs of intracranial hemorrhage.AAGL, female, 23 years old, coming from Maranguape/Ce, with previous history of epistaxis and left side nasal obstruction for 5 years. She had a hyperemic and non-bleeding tumor in her LNC, and ipsilateral bulging on the nose, maxillary and palate regions. Her CT scan showed an expansive lesion in her left nasal cavity (LNC), occupying the rhinopharynx and ipsilateral maxillary and ethmoidal sinuses, with right side nasal septum deviation and no signs of bone lysis .Figure 9She underwent an incisional biopsy, which showed proliferation of elongated and fusiform cells, some with nuclei arranged in bundles, matching signs of neurofibroma. We carried out a sublabial maxillary antrostomy to resect the lesion, which measured approximately 9cmx9cmx2cm. She is being followed up for 17 months now, and there is no evidence of tumor relapse.MVPM, female, 15 years old, had a bulging in her right infraorbital region, periodontal ulceration of the upper molars and submucosal bulging of her ipsilateral hard palate that had been evolving from one year. She did not have epistaxis or nasal obstruction. CT scan showed an expansive lesion with concentric calcifications in her right-side maxillary sinus, destroying its walls and invading the hard palate .Figure 1We carried out an incisional biopsy through anterior maxillary antrostomy, and we saw a sponge-like tumor. The AP study showed partialy immature bone tissue, and within its trabeculae there was fibrous connective tissue, with no evidence of significant atypia, leading us to consider it a cement-ossifying fibroma. We proposed surgical excision, but the patient refused it.The stesioneuroblastoma is a neurogenic tumor that originates from the olfactory region neuroepithelium,Symptoms are unspecific and common to most tumors and benign diseases of the nasal cavity - unilateral nasal obstruction and epistaxis are the most frequent onesCT scan is the radiologic exam of choice, which shows a homogeneous mass in the nasal cavity, of soft tissue density and uniform and moderate contrast uptake,,The treatment proposed for the case is the one advocated by most authors: cranio-facial resection followed by radiotherapyNeck lymphadenopathy is an important prognostic factor, and the survival rate is 64% in patients without neck metastasis and 29% in patients with metastasisGCCG was only recognized as a clinical entity after 1953, and was first described by Jaffe who called it giant cells central “repair” granuloma,The pathogenesis of GCCGs is still little understood, and there are controversies regarding its neoplastic origin or reactional,According to clinical behavior, the GCCGs are classified in aggressive and non-aggressive forms,Histologically we see CD68+ multinucleated giant cells and mononuclear cells in a fibrous stroma,Treatment is based on en-bloc surgical resection or resection by curettage, depending on the clinical and radiologic aspect of the lesion,The plasmocytoma is a rare neoplasia originated from B cells. It may present as three variants: multiple myeloma (MM), osseous solitary plasmocytoma and extramedullary plasmocytoma (EMP)EMPs represent about 4% of the non-epithelial nasosinusal tumors and about 0.4% of the head and neck tumors,The most common symptoms of nasal cavity EMP, as seen in our case, are progressive nasal obstruction and intermittent epistaxisThe CT scan shows an expansive mass, usually homogeneous, with minimum to no bone erosion. Light microscopy shows groups of plasmocytic cells with different degrees of differentiation, varying from mature and small cells to immature and multinucleated,Laboratorial exams must be ordered in order to rule out MM: CBC, protein electrophoresis, bone marrow aspirate and biopsy, electrolytes, radiological studies of the skeleton, among others. Some patients, between 5% and 32%, will develop systemic manifestations of MM after some years, which require prolongued follow up19. Treatment is based on surgery and complementary radiotherapy. EMPs are radiosensitive and regional control can be achieved in more than 80% of the cases,The NSHP is a rare mesenchymal tumor of the nasosinusal region, characterized by a pattern of prominent perivascular growth,,,Between 15% and 30% of all STHP happen in the neck and head region, they account for less than 1% of vascular neoplasias,,,,Histologically, the NSHP is a submucosal, non-capsulated lesion, with diffuse growth pattern and prominent perivascular hyalinizationIn general, NSHPs are very resistant. They manifest aggressive behavior as in the case hereby presented, they are uncommon and there are reports in the literature of lesions with local destructive potential and metastasis,Treatment is surgical, varying from simple polypectomy to resection with broad free marginsBenign neural tumors, represent about 45% of the head and neck tumorsIt manifests as isolate lesion or multiple tumors, as it happens to the Type 1 neurofibromatosis (NF1) or Von Recklinghausen's disease,Despite being non-capsulated, these are well-outlined lesions. Light microscopy shows a proliferation of all the elements of the peripheral nerve, spread in a loose and disorganized pattern in a myxoid stroma. There is a predominance of Schwann cells with fusiform nuclei,,The COF is a rare, non-odontogenic mesodermic tumorWith still controversial etiopathogenesis, it is believed that these lesions stem from the periodontal membrane, which contains blast cells capable of forming bone, fibrous tissue and cementThe majority occur in the molar and pre-molar regions of the mandibleRadiologically, they manifest as a well outlined mass, with soft tissue density and foci of ossification, there may be bone destruction,,Treatment is surgical, and there are reports of remission after incomplete resectionNon-epithelial tumors of the nasal cavity and paranasal sinuses are rare pathologies, with extremely varied etiopathology, clinical behavior, treatment and prognosis. The lack of symptom specificity usually delays diagnosis. Having all of this in mind, the physician must be attentive to the diverse number of diseases that may affect this region, and histopathology is extremely necessary for properly approaching these cases.


As a rare type of cerebral venous thrombosis, isolated cortical vein thrombosis (ICVT) is easily misdiagnosed as brain tumor, especially in the cases with prominent signs of parenchymal brain lesions. Despite controversy concerning the efficacy and safety, anticoagulant treatment dominates in current therapeutic strategies for ICVT. As yet, surgical thrombectomy in the treatment of ICVT has not been reported. We present hereafter a female with ICVT previously misdiagnosed as brain tumor who had successful surgical thrombectomy.A 54-year-old female with progressive left-sided limb weakness suddenly developed focal tonic-clonic epileptic seizure. Physical examination indicated strength of 0/5 in the left limbs. Magnetic resonance imaging (MRI) showed an irregular juxtacortical lesion surrounded with massive edema in the frontoparietal cortex, which was initially diagnosed as glioma. However, it turned out to be ICVT of the central sulcus vein during craniotomy. Then, venotomy and thrombectomy were performed, with instant recanalization of the vein noticed during surgery. In retrospect, we identified the suspected ICVT of the central sulcus vein in preoperative magnetic resonance venotography (MRV) and contrast MRI images. Laboratory tests also revealed homocysteinemia and hypercoagulable states in the patient. Follow-up MRV obtained 3 months after discharge showed cortical vein recanalization. At the one-year follow-up, she exhibited subtle sequelae of weakness in the left lower limb with a modified Rankin scale score of 1.Physicians should be aware of ICVT in the differential diagnoses in patients with risk factors, classical symptoms, and parenchymal brain lesions in or near cortex. Surgical thrombectomy excels at realizing definite recanalization and avoiding systematic complications of anticoagulation. It might be a therapeutic alternative for ICVT, especially when craniotomy is performed for treating intracranial hypertension or a definite diagnosis is made during craniotomy. As a rare form of cerebral venous thrombosis (CVT) without sinus or deep venous involvement, isolated cortical vein thrombosis (ICVT) has only been reported in single case or small series . DespiteThe therapy for ICVT follows the treatment guideline for sinus vein thromboses . For pat2. Upon arrival, she was afebrile with normal vital signs. Neurological examinations revealed power of 0/5 and hyperactive tendon reflexes in the left limbs. Babinski sign in the left-side was positive. Laboratory studies showed that serum liver and kidney function indexes, lipid profile, glucose, ion levels, tumor markers, and complete blood counts were all within normal limits.A 54-year-old postmenopausal women with a one-week history of progressive left-sided limb weakness suddenly developed involuntary tonic-clonic movements involving left-sided limbs. She did not lose consciousness during the seizure. This episode lasted for 40 min before she received antiepileptic drugs and propofol treatment in a local emergency department. An initial computed tomography (CT) revealed a cortical based right frontoparietal hypodense lesion  imaging findings presented unlike those reported in previous cases of ICVT and (2) a good prognosis after surgical thrombectomy. To the best of our knowledge, there is no published report regarding surgical thrombectomy in ICVT. Although observational studies in a larger cohort are urgently needed to confirm the efficacy, we are optimistic that this therapeutic alternative would lead to better outcomes for patients with ICVT.The original contributions presented in the study are included in the article/Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SF and CY have been involved in the operation and management of the patient. SF and GL designed the report. YB, SF, and GL reviewed the literature and drafted the article. YB and LD prepared the figures. All authors contributed to the article and approved the submitted version. This research was supported by the National Natural Science Foundation of China (grant No. 81971133 to G.L. and 82101318 to Y.B.) and Science & Technology Plan of Liaoning Province (grant No. 2021JH2/10300116 to S.F.).We thank Dr XL in the Department of Pathology for her help in neuropathology analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.