The lipomas of oropharynx, hypopharynx, and larynx are so rare that up to now approximately there have been 100 cases reported. The lipomas are slow-growing lesions that are capable of reaching considerable dimensions and are often detected at a late stage. The symptoms can vary both in dimension and in location, semiobstructing the aerodigestive tract or exerting compression on adjacent structure. In this case, the lesion, which originated from the piriform sinus, was removed endoscopically urgently due to obvious signs of tissue suffering caused by stretching of the pedicle as a result of displacement of the mass. The two aims of this case report are to expose an interesting and rare case study mainly for an Emergency Room Specialist and an ENT  Specialist involved in solving the problem and to demonstrate that the choice of an endoscopic approach is useful in order to have an optimal visualization of the lesion and to perform a total eradication. The use of endoscopic devices also allows a rapid postoperative recovery, compared to external access and optimum locoregional control in the follow-up procedures to prevent possible relapses. Lipomas are tumors that represent 4-5% of all benign tumors and they are predominantly found in the hypodermic layer .These tumors are rare in the head and neck region and specifically for the upper aerodigestive tract represent 0.6% of all neoplasias , 3.We present a rare case of a 63-year-old woman who arrived at the emergency room of our hospital with a pedunculated mass protruding from the buccal rhyme, emitted by coughing.In August of 2011 a 63-year-old woman suffering from multiple sclerosis and diabetes mellitus type I, in treatment with insulin since the age of 18, arrived at the emergency room with severe dyspneic syndrome. She presented a voluminous mass, partially protruding from the mouth and completely occupying the oral cavity, looking diverticular with a solid consistency and brownish-yellow color, cylindrical, and smooth, with a diameter of about 25 mm. The protruding portion from the mouth measured in length about 65 mm .The relatives, who accompanied the patient, reported a sudden onset of dyspnea and the appearance from the mouth of the abovementioned lesion protruding after regurgitation and coughing. After the first examination it was clear that the tumor extended in the hypopharynx with slightly smaller dimensions. The patient was immediately submitted to an endotracheal intubation, and an urgent CT scan of the neck was carried out to identify the relationship and the cause of the neoformation.The CT scan showed the presence of solid polypoid-like tissue that occupied the space from the hypopharynx to the oral cavity with a large extraoral hypodense component having thin branches of vascularity to the left of the center section; the first hypothesis could be defined as a fibrovascular polyp with the implantation on the left side of the hypopharynx .The microlaryngoscopy exploration, performed immediately due to obvious signs of the insufficient blood supply of the neoformation with the risk of ulceration and consequent bleeding, showed instead that the base of implant, also cylindrical, but with a diameter of about 10 mm, was located in area of the medial wall of the piriform sinus on the right .During the procedure, we used a Polysorb n.1 lace as a landmark and as point of traction at the base of implantation of the neoformation which was subsequently sutured with 2 stitches of Monocryl 2-0 and 2 stitches of Polysorb 2-0. With the aid of mechanical stapler Endo Gia Universal 12 mm used to dissect the neoformation at the base, it was consequently removed and the material was sent for a definitive histological examination ; then a The final histological examination described an oval shape lesion with a size of 15 × 2,5 × 2 cm, smooth in texture, soft in consistency, and yellowish in color. Fifteen blocks in paraffin, one centimeter in diameter, were obtained and were available for microscopic examination. Microscopic examination demonstrated a subepithelial neoplasm not encapsulated, composed of mature adipocytes with no cellular atypia. The diagnosis of lipoma was thus proposed .The postoperative recovery period was quick and without complications, with resumption of oral feeding after 72 hours. Upon the patient's discharge from the hospital the examination with fibrolaryngoscope showed the absence of residual disease and the advanced state of reepithelialization of the implant site.Lipomas are benign tumors of mesenchymal originating from mature fat cells (adipocytes) in adipose component tissue. The adipose tissue in the larynx is represented in epiglottis, in the ventricular and aryepiglottic fold.In this case the origin of the adipose tissue was located in the lateral submucosa to the arytenoid cartilage.Lipomas generally are slow-growing sessile or pedunculated lesions having a rough surface, yellowish color, and soft consistency.Histologically these lesions can be classified into several subtype groups based on their stroma: angiomyolipoma, spindle cell lipomas, myolipoma, chondrolipoma, and myxolipoma .However among the possible malignant histotypes we find liposarcoma having well-differentiated cells .The microscopic histological characteristics that allow differentiating benign from malignant neoformation are the following: presence of pleomorphism, atypical cells, and infiltration of surrounding tissues and lipoblasts.The suspicion of malignancy growth can be defined in the case of the presence of one or more relapses after surgical removal ; howeverThe etiology of lipomas is unknown; however some authors have suggested that they derive from lipoblasts or by a metaplasia of muscle cells, while others have suggested a possible etiopathological role of familiar and endocrine factors or conditions such as trauma, infection, or chronic diseases. Nowadays some risk factors such as abuse of alcohol, tobacco, and environmental and work conditions, which involve toxic chemicals, have not been recognized as a possible cause , 6.Clinically the lipomas remain asymptomatic for a long time, but once they reach large dimensions, symptoms may arise in relation to the size and lead to the compression of adjacent structures .Lipomas of the upper aerodigestive tract occur with continuous or intermittent symptoms over the course of a few months or years, which include dysphagia, hoarseness, feeling of discomfort in the throat like the feeling of a mass in the pharynx, and, in case of airway obstruction, stridor and dyspnea . In seveThe diagnosis of these lesions starts with a local physical examination  ; and conImaging techniques such as CT and MRI are helpful for the diagnosis and allow an acceptable preoperative evaluation of the lesion. On CT images lipoma appears as a homogeneous lesion with low attenuation values of ionizing radiation with a density lower than water , 11. TheMRI is preferable to CT because it allows a better study of the soft tissues, the patient is not exposed to ionizing radiation, and it does not require iodinated radiocontrast agents. Furthermore MRI also allows a more accurate and specific diagnosis of the lesion with a better indication of position of the peduncle or of the extension of the lesion and its relationship with the surrounding structures .In this case CT scan, performed in urgency, helped to identify the caudal limit of the lesion and therefore identifying its place of origin, but not showing its position. The choice of using an endoscopic access , despiteThe lipomas are benign tumors, but because of their rare location found in the upper aerodigestive tract, they must be taken seriously by the Emergency Room Specialist, the ENT Specialists, and Maxillofacial Surgeons. In fact often these lesions are very voluminous and their rapid displacement from the area, in which they have been growing for a long time, may endanger the life of the patient due to obstruction of upper airways. After the stabilization of the patient, ensuring good and safe ventilation, it is necessary to proceed with a quick imaging study and then to perform an endoscopy exam in order to plan a correct treatment. When the endoscopic approach is technically possible, with ablation of the neoformation at the base of the root, it is possible to apply an effective treatment and to obtain a rapid postoperative recovery period.


A 69-year-old man presented with right hypochondriac pain accompanied by postprandial nausea and vomiting for 2 months. Additional symptoms included fever and fatigue for 4 days. There was associated history of weight loss of approximately 6 kg over the past few months. Vital signs were normal, and he was febrile (38.3°C). His skin and sclerae were mildly icteric. He had no signs of liver failure. His abdomen was soft, with tenderness noted in the right hypochondriac region (Murphy sign positive); no tenderness was noted elsewhere, and there was no evidence of ascites. The tip of the gallbladder was palpable in the right 9th costal margin. Laboratory evaluation revealed mild conjugated hyperbilirubinemia , with normal levels of transaminases and alkaline phosphatase. Mild hypoalbuminemia was present. Other investigations were unremarkable. On the basis of the clinical and laboratory findings, the patient was evaluated for obstructive jaundice, and ultrasonography (US) was performed.US revealed an abnormally thick gallbladder wall measuring 3 cm in thickness. The wall thickening gave the appearance of an endophytic mass causing near-total obliteration of the lumen. Multiple intraluminal and intramural calculi were seen . Few echInterval cholecystectomy was performed 4 weeks after initial presentation. At laparotomy, diffusely enlarged gallbladder was seen, which was firm and showed multiple adhesions.A gross cholecystectomy specimen showed diffusely enlarged gallbladder weighing 63 g and measuring 7.5 × 5.5 × 2.5 cm. On cut sections, the gallbladder was firm, with grayish thickened wall measuring up to 2.5 cm and velvety granular mucosa containing numerous multifaceted intraluminal calculi. The gallbladder wall showed areas of hemorrhages and contained multiple pockets, many of which also contained calculi. Microsections showed ulcerations and edematous gallbladder mucosa and myoepithelial hyperplasia with abundant granulation tissue composed of myofibroblasts. Inflammatory cells, such as neutrophils, plasma cells, and macrophages, were also present, with congested vessels . The fin13 Varied names have been applied to this lesion in the literature, including adenomyomatosis, adenomyoma, diverticular disease, intramural diverticulosis, cholecystitis cystica, and cholecystitis glandularis proliferans. It is more commonly seen in women than in men, the majority presenting with complaints of chronic right upper quadrant pain.2 Frequent coexistence with cholelithiasis is seen; however, no causative relationship has been proved.4 Adenomyomatosis occasionally produces abdominal pain, and in some cases, cholecystectomy may be indicated for relief of symptoms.4Adenomyomatosis is not an uncommon mimic of the gallbladder carcinoma, identified in 1% to 8.5% of cholecystectomy specimens.4Dysplasia, carcinoma in situ, and invasive carcinomas may arise from the epithelium of adenomyomatous hyperplasia. However, most authors believe that the cause for development of carcinoma in adenomyomatous hyperplasia is the presence of stones, chronic inflammation, and metaplastic changes rather than adenomyomatous hyperplasia itself. Thus, adenomyomatous hyperplasia is not considered a premalignant lesion.5 Evaluation of gallbladder wall thickness plays an important role in the sonographic study of the biliary system. The gallbladder wall is no more than 2 mm thick in 97% of healthy subjects, if the short axis of the gallbladder is at least 2 cm in diameter.5 Diffuse gallbladder wall thickening has a differential diagnosis that includes the more common inflammatory and noninflammatory causes of wall thickening. The various causes include hepatitis, artifacts induced by the presence of pericholecystic fluid, hypoalbuminemia, portal hypertension, right-sided heart failure, incomplete gallbladder distention, cirrhosis, hepatitis, and cholecystitis. In addition, focal thickening occurs in gallbladder carcinoma and adenomyomatosis.6 However, gallbladder malignancy should be suspected when there are features of a focal mass with locoregional lymphadenopathy, metastases, and features of biliary obstruction at the level of the porta hepatis.5US is considered as the baseline imaging modality to investigate the hepatobiliary system, and adenomyomatosis of the gallbladder is a not-infrequent pathology, seen in approximately 2% of patients.7 Longstanding Rokitansky-Aschoff sinuses of adenomyomatous hyperplasia result in calcification of the intramural sludge, cholesterol, or stones. Rarely, abdominal radiograph may show them as nondependent calcific opacities in the right upper quadrant.7The pathognomonic pathologic features of the adenomyomatosis are thickened gallbladder wall and intramural diverticula containing bile, with cholesterol crystals, sludge, or calculi that show a distinct correlation with the modality imaging findings.7 Luminal narrowing may be seen in the diffuse and segmental variants that may produce a characteristic hourglass configuration.On ultrasonography, gallbladder involvement by adenomyomatous hyperplasia is variable in location and extent, which varies from focal to diffuse gallbladder wall thickening.7 Comet-tail/V-shaped reverberation artifact is due to echogenic sound reverberation emanating from the small echogenic foci in the gallbladder wall into the central anechoic lumen. Similar appearance may be caused by intraluminal or intramural air, as seen in emphysematous cholecystitis; however, the mobile nature of the air with dirty echogenic shadowing on ultrasonography helps in differentiating them. In equivocal cases, computed tomography (CT) plays an important role.The diagnostic sonographic hallmark on ultrasonography is the presence of the anechoic or echogenic intramural diverticula. Anechoic diverticula contain bile, whereas those that contain sludge, cholesterol, or intramural calculi are seen as echogenic foci.8 Intramural cystic spaces and calculi demonstration on CT scan is not possible, but they are easily picked up sonographically because of reverberation artifact. This makes ultrasonography a primary diagnostic imaging modality for the diagnosis of adenomyomatous hyperplasia. The Rokitansky-Aschoff sinuses that are large enough may be seen on CT scan, giving a characteristic appearance, the rosary sign, which is due to the enhancing epithelium within intramural diverticula surrounded by the relatively unenhanced hypertrophied gallbladder muscularis.9CT findings of adenomyomatous hyperplasia usually correlate to the sonographic findings. All three pathologic forms  are apparent on CT scans.10 When arranged in a curvilinear pattern, they give an appearance of pearl necklace sign.11 The intramural calculi are seen as signal void because of the mineral content. The pearl necklace sign is specific for adenomyomatosis of the gallbladder and is not seen in gallbladder carcinoma.11 Differentiation of echogenic intramural foci from abnormal enhancement requires a multiphasic MRI protocol with intravenous contrast material. Diffusion weighted imaging has been found useful in differentiating gallbladder adenomyomatosis from gallbladder carcinoma and significantly improves the diagnostic accuracy.11aMagnetic resonance imaging (MRI) plays an important role in distinguishing adenomyomatous hyperplasia from malignant lesions; hyperintense intraluminal cavities visualized on T2-weighted MRI are suggestive of Rokitansky-Aschoff sinuses and have been reported to be useful.12In our case, US revealed an abnormally thick gallbladder wall measuring 3 cm in thickness. The wall thickening gave an appearance of endophytic mass causing near-total luminal obliteration. Multiple intramural and intraluminal calculi were seen with few echogenic intramural foci, which did not show the classic comet-tail reverberation artifacts. The cause for the diagnostic dilemma was the absence of the comet-tail/V-shaped reverberation artifact, which is the diagnostic sonographic hallmark of adenomyomatosis. Its absence can be explained on the basis of the absence of central anechoic gallbladder lumen because of gross dense fibrous wall thickening causing near-total luminal obliteration.Although the imaging features of adenomyomatosis can be distinctive enough to allow confident diagnosis, findings such as gallbladder wall thickening and enhancement are somewhat nonspecific. The differential diagnosis includes adenomatous, hyperplastic, and cholesterol polyposis, papillomatosis, adenoma, portal hypertension, total parenteral nutrition, hypoalbuminemia, congestive heart failure, and cystadenoma, as well as malignancies such as gallbladder adenocarcinoma, carcinoid tumor, and metastatic melanoma of the gallbladder .18F]fluorodeoxyglucose (FDG) positron emission tomography may be a useful adjunct in problematic cases.13 Adenomyomatosis does not show any FDG uptake on positron emission tomography study, which makes it a problem-solving tool in differentiating it from malignant gallbladder wall thickening, which shows focal or diffuse FDG uptake.13 Though the FDG uptake within these lesions represents the metabolic activity of the underlying pathological tissue (cancerous cells), false positive results may also be seen in cases with associated active inflammatory process such as cholecystitis.14Metabolic characterization with [In conclusion, great difficulty arises in differentiating the diffuse variant of adenomyomatous hyperplasia that simulates a gallbladder malignancy, especially in the absence of the diagnostic hallmark comet-tail/V-shaped reverberation artifact, which may be absent in cases of total luminal obliteration by the pathology. Surgical resection may be indicated in symptomatic cases and when nonspecific findings present a diagnostic dilemma.


Epithelioid schwannoma as a rare variant poses a challenge to all pathologists, as this uncommon entity is extremely difficult to conclusively diagnose by morphological analyses on a resected sample alone owing to its unique histopathological features. However, few papers have described the detailed clinicopathological characteristics of epithelioid schwannoma.A 65-year-old female presented with a history of a flat and slightly elevated firm and tan plaque accompanied by occasional tenderness, measuring 10 × 8 mm, in the right joint of her hand 1 year before resection. A gross examination of a locally resected specimen revealed an encapsulated nodular lesion, yellow-whitish in color, partly filled with blood. A microscopic examination showed that the tumor predominantly consisted of a solid proliferation of epithelioid cells having mildly enlarged and round to partially spindled nuclei and abundant vacuolated or clear cytoplasm with very few mitotic figures and modest nuclear size variation, associated with focal hyalinized, cystic and hemorrhagic degeneration. This well-demarcated tumor was surrounded by dense, hyalinized and layered fibrocollagenous stroma. Immunohistochemically, these tumor cells were diffusely positive for S-100 protein and had a very low MIB-1 labeling index, and type IV collagen was strongly reactive with reduplicated basal lamina of them. We ultimately made a diagnosis of cutaneous epithelioid schwannoma.We should be aware that, since pathologists might misinterpret epithelioid schwannoma as other soft tissue tumors, including its malignant counterpart, a wide panel of immunohistochemical antibodies can be powerful supplementary tools for identifying a very rare entity of conventional schwannoma. Among cutaneous soft tissue neoplasms, benign nerve sheath tumor, i.e. schwannoma, is a very common and well-known entity; however, epithelioid schwannoma is a very rare and relatively new morphologic variant of benign schwannoma, composed predominantly of histopathologically characteristic epithelioid schwann cells –4. EpithClinically, epithelioid schwannoma of the skin may simulate various benign to malignant neoplasms of the skin, including pyogenic granuloma and basal cell carcinoma or squamous cell carcinoma, because all of these lesions can look tan and reddish on the surface –4. In thWe herein report an extremely rare case of benign epithelioid schwannoma displaying unique histopathological features originating from the superficial subcutaneous soft tissue of the joint of the right hand, together with presentation of a review of the literature. The microscopic examination via H&E staining did not allow for a conclusive diagnosis, and the diagnosis was ultimately made based on a wide panel of immunohistochemical analyses, including one of its hallmark antibodies, S-100 protein.A 65-year-old female presented with a history of a very slow-growing, flat and slightly elevated firm and tan plaque covered by mostly a smooth epidermis and accompanied by occasional tenderness measuring approximately 10 × 8 mm in the ulnar joint of the right hand, 1 year before resection  and S-100 protein (Dako) Fig. , and typBased on these features, we ultimately made a diagnosis of epithelioid schwannoma arising from the superficial subcutaneous soft tissue of the ulnar joint of the right hand. To date, after approximately 9 months of post-operative follow-up, the patient remains well with neither recurrence nor metastases.As presented in Tables Therefore, we agree with previous studies indicating the importance of applying a wide panel of immunohistochemical antibodies in the conclusive diagnosis of round to spindle cell neoplasms of the skin , 5. AmonIt is very likely that the present case report of epithelioid schwannoma arising in the superficial subcutaneous tissue in the right forearm is histopathologically remarkable for one reason at least: the present tumor was surrounded by dense, hyalinized and layered fibrocollagenous stroma, reminiscent of vascular-like structures. Although conventional schwannoma usually exhibits hyalinized and thick-walled small- to medium-sized vessels in its stroma , 2, thisWe herein reported a very rare case of epithelioid schwannoma arising from the superficial subcutaneous soft tissue of the ulnar joint of the right hand that proved very difficult to tentatively diagnose based solely on a morphological examination of a resected specimen. However, we were subsequently able to accurately diagnose the lesion after thorough analyses of the immunohistochemistry. All pathologists should be aware that the characteristic features of this lesion might result in a diagnostic pitfall. An appropriate and wide panel of immunohistochemical antibodies, including various schwann cell, myoepithelial, endothelial, perineurial, and smooth muscle cell markers, p53 and MIB-1 labeling index, can therefore be powerful supplementary tools for identifying benign lesions and reaching the correct, final diagnosis of cutaneous epithelioid schwannoma.


AVF) is an extremely rare disease in children. When a child presents with sudden onset of hemiparesis and headache, it is very important to perform spinal magnetic resonance imaging (MRI) scanning for early diagnosis and treatment.Pial arteriovenous fistula ( Pial arteriovenous fistulas (AVFs) are rare vascular lesions comprising single or multiple arterial feeders draining directly into the venous channel without an intervening tangle of blood vessels The present case was a 2‐year‐old boy who was admitted to the emergency room at our hospital with a sudden onset of left hemiplegia and right headache on 13 October 2016. He had been healthy and fully vaccinated according to the Japan child vaccination program, including polio vaccine. His family history revealed no unhealthy parents or siblings. Neurological examination revealed left hemiplegia and a decrease in the left patellar tendon reflex. No nuchal rigidity was detected. Informed consent was obtained from the parents of our patient for publication of this case report.Complete blood count (CBC), serum electrolytes, blood urea nitrogen, creatinine, urinalysis, and glucose levels were all normal. The lumbar puncture revealed normal cerebrospinal fluid. He underwent brain MRI and computed tomography (CT). No hemorrhage was detected on head CT or MRI. The MRI revealed a varix on the posterior inferior cerebellar artery (PICA), which was not considered to be related to the presenting symptoms Fig. . TherefoOn the next day, he developed quadriparesis, disturbance of consciousness, and dyspnea. A sagittal T2‐weighted MRI of the cervical spine showed mixed signal intensity within the spinal cord, consistent with an intramedullary lesion of focal hemorrhage and edema extending to the C2‐C3 level  are rare vascular malformations associated with significant risks of hemorrhage and neurological deficits. It is also known to be a complication of hereditary hemorrhagic telangiectasia In this case, we performed laboratory studies and lumbar puncture, and results were normal. Before conducting a spinal puncture, the space occupied by the lesion in the brain, including brain tumors has to be checked to avoid puncturing the encephalocele. Thus, we performed the spinal puncture after the brain CT and MRI in this case.No brain hemorrhage or abnormalities were detected on brain MRI or CT, except for the presence of a varix on PICA, which was not considered as the cause of the symptoms. We did not perform a spinal MRI upon his arrival at the hospital because we did not consider spinal bleeding as the cause of the hemiplegia as it is extremely rare especially in children. Based on this experience, we recommend that a spinal imaging should be performed immediately in children who present with acute hemiplegia. Moreover, we administered intravenous immunoglobulin for AFM or GBS. In 2015, a series of AFM cases were reported, which prompted us to suspect AFM in this case When the patient developed quadriplegia, disturbance of consciousness, and dyspnea, the hypercapnic state caused by the dyspnea was considered the reason for the disturbance of consciousness at that time. We consulted neurosurgeons, and a cervical MRI was performed, which revealed the spinal AVM and bleeding; thus, we performed an angiography. Angiography is currently the gold standard for determination of the location and flow characteristics of vascular lesions The motor function of the upper limbs recovered well in our patient. On the other hand, the motor function of the lower limbs is not as good as that of the upper limbs. He can only walk for one or two steps using a support gear on his legs. The absorption of hematoma in the spine parenchyma, as seen on the subsequent MRI, may be the reason for the motor function recovery of the upper limbs.Young‐Jun Lee et al. reported that the long‐term clinical outcomes of AVF are stable On the other hand, Saliou et al. reported that more than 40% of children experienced recurrence, and the main factor associated with recurrence was perimedullary venous drainage. They showed that an occlusion rate >50% was associated with a decreasing risk of recurrence and concluded that the elimination of perimedullary venous drainage should be the primary goal of treatment to avoid recurrence The potential harms of radiation exposure by a CT scan and endovascular therapy for such little children must be considered. Brenner et al. Acute hemiparesis in children is a clinical syndrome with diverse causes In conclusion, the sudden onset of hemiparesis and headache should be considered during the differential diagnosis of spinal malformation in children. Spinal MRI is important for the early diagnosis and treatment of this condition. To prevent recurrence, vascular treatment should be performed at an early stage.None declared.KH, SG, NA, and MI: drafted the manuscript and contributed to treatment of the patient. All authors have read and approved the final manuscript.


A 24-day old female Nigerian neonate presented with protracted vomiting, fever and dehydration but without palpable abdominal tumour or visible gastric peristalsis. There was no derangement of serum electrolytes. The initial working diagnosis was Late-Onset Sepsis but abdominal ultrasonography showed features consistent with the diagnosis of IHPS. This case report highlights the atypical presentation of this surgical condition and the need to investigate cases of protracted vomiting in the newborn with at least, ultrasonography to minimize complications and reduce the risk of mortality in a resource-poor setting. Vomiting, in the newborn, frequently connotes physiologic events such as feed regurgitation or poor positioning after over-feeding and less commonly, follows serious illnesses such as asphyxia, sepsis, necrotizing enterocolitis, in-born errors of metabolism or upper gastrointestinal obstructive lesions . TherefoInfantile hypertrophic pyloric stenosis (IHPS) is one of the surgical causes of protracted vomiting in early infancy. This condition is characterized by abnormal thickening of the muscular wall of the pylorus hence it is the commonest cause of gastric outlet obstruction in infancy. The exact aetiology of IHPS is unclear but the roles of genetic predispositions and prenatal or postnatal exposure to drugs such as the macrolides and nalidixic acid are known. The condition is not a common finding in clinical practice as earlier reported in The Gambia  where noThe classical presentation of IHPS includes persistent copious non-bilous vomiting (which may become projectile), visible intestinal peristalsis, palpable epigastric tumour, constipation, failure to thrive despite sucking hungrily, dehydration and electrolytes derangements such as hypokalaemia and metabolic alkalosis. However, inconsistencies in the pattern of the aforementioned clinical features in IHPS have been reported  and thatA 24-day old female neonate presented at the Children's Emergency Room of the Olabisi Onabanjo University Teaching Hospital, Sagamu, southwest Nigeria on referral from a General Hospital on account of persistent vomiting and high grade continuous fever of five days duration. The vomiting was described as projectile, post-prandial, non-bilous and of large volume. The frequency of vomiting was 4 to 5 times daily. Although the infant had not opened the bowel for two days prior to the onset of the illness, there was no abdominal distension at any point. Apart from scanty urinary output, the baby presented with no other symptoms.This infant was the first child of her mother - a 30-year old second wife, known epileptic. The pregnancy was booked for antenatal care in a secondary health facility at about 22 weeks of gestation. The prenatal and perinatal periods were uneventful and the mother could only recall taking routinely prescribed haematinics and anti-convulsants in pregnancy. From birth, the infant had been exclusively breastfed and adequately immunized.At presentation, the infant weighed 2kg, was febrile (axillary temperature - 400C), but was not pale or icteric. However, she was conscious and severely dehydrated but had no other systemic abnormalities. The initial diagnosis was Late-Onset Neonatal Sepsis with severe dehydration to exclude upper intestinal obstruction. The baby was admitted into the Neonatal Ward and the haematocrit, random blood glucose and serum electrolytes, urea and creatinine were within normal. Dehydration was appropriately corrected using intravenous fluids Normal Saline. Subsequently, the baby received maintenance intravenous 8%Dextrose in 5th Saline, intravenous antibiotics (ceftriaxone and gentamicin) and was placed on nil per os.The vomiting persisted despite management, but without fever. At this point, the possibility of IHPS was entertained and test-feeding was done but no epigastric mass was palpable. However, abdominal ultrasound scan revealed distended stomach with food and fluid residual, active peristaltic waves without emptying, thickened muscular pyloric canal measuring 7.5cm in length and 0.74cm in thickness. The typical “doughnut-shaped” appearance of the gastric shadow in transverse abdominal scan was seen. These findings are consistent with the diagnosis of Infantile Hypertrophic Pyloric Stenosis. Plain abdominal X-Ray in the erect position showed gross gastric dilatation .Gastric decompression with an open-ended nasogastric tube was commenced, maintenance intravenous fluid was continued with strict monitoring of fluid input and output with subsequent paediatric surgical intervention. Pyloromyotomy  was doneThis case report aims at highlighting the diagnostic challenges which may be encountered in IHPS. The admission diagnosis was Late-Onset Neonatal Sepsis based on the history of protracted vomiting, fever and dehydration. These are known features of septicaemia in the newborn. The persistence of vomiting despite intravenous antibiotic therapy prompted the managing team to consider an obstructive upper gastrointestinal condition. This implies the need to consider both medical and surgical causes when young infants present early in life with protracted vomiting.The infantile hypertrophic pyloric stenosis, previously known as congenital pyloric stenosis, is characterized by postnatal hypertrophy of the circular and longitudinal muscles of the pylorus resulting in a pyloric swelling which blends into the gastric antrum at the proximal end but ends abruptly at the duodenum distally. The pyloric canal is elongated, thickened and narrow with eventual gastric outlet obstruction and secondary hypertrophy of the stomach. In a review of cases of IHPS, increased pyloric canal length, diameter and thickness were reported in 98%, 87% and 60% of cases .Despite the varying incidence across different regions, the condition is less common in blacks and female children, same groups to which the index case belongs . Howeveret al in Lagos, Nigeria [The age of the index baby at presentation agreed with the frequently reported four to six weeks . The acu Nigeria . In the  Nigeria . This is Nigeria .The typical serum electrolyte derangements in IHPS include hypokalaemia, hyponatraemia and hypochloraemic metabolic alkalosis . This paAbdominal ultrasound was useful in making a clinical diagnosis in the index baby. Indeed, this imaging method has been reported to make accurate diagnosis in 98% of cases . This obIn IHPS, clinical diagnosis may be difficult when it is strictly based on the clinical and laboratory features. In addition, normal values of serum electrolytes do not preclude the diagnosis in IHPS. Therefore, being the commonest surgical cause of non-billous vomiting in infancy, a high index of suspicion is important for early diagnosis, prompt intervention and avoidance of mortality.


This report describes the usefulness of dermoscopy as a supportive diagnostictool in a pseudomonas folliculitis case. However, obvioussources of contamination are not always detectable.Pseudomonas aeruginosa sources. Physicalexamination revealed numerous erythemato-edematous papules and a few pustules  was prescribed and lesions cleared after fivedays.A 41-year-old Caucasian woman presented with a 5-day history of an itchy rash, localizedmainly on her armpits, inguinal areas and thighs. Before coming to the clinic, she hadbeen diagnosed with insect bites but topical steroid application had not entailed anyimprovement. The patient was otherwise healthy and was not taking any medication. Herpast medical history was unremarkable and she could not recall any obvious recentexposures to potential pustules  and 1B. pustules . Swab cu2 The distinction from such conditions is typically clinical,evidenced by the folliculocentric nature of the lesions and positive lesionalswabs.2 However, detecting the former feature may betroublesome, particularly in subjects with fair skin/hair and when lesions are locatedon sites with few terminal hairs.The main, challenging differential diagnoses for PF include insect bites and nodularscabies. 10 In recentyears, its use has been extended to numerous "general" dermatoses to assist clinicaldiagnosis. 10 In this PF case, dermoscopy proved helpful in identifying thevellus hairs at the centre of each lesion, otherwise not clinically visible, thusdisplaying the folliculocentric nature of the rash and therefore ruling out insect bitesand nodular scabies. In fact, the lesions of these conditions are typically not centeredaround follicles and usually reveal other dermoscopic findings. In particular, insectbites may display a central punctum and some haemorrhagic spots ,while nodular scabies is generally characterized by mites ("hang glider sign") and/orburrows ("jet with condensation trails").3 Furthermore, in the authors' opinion, dermoscopy may be useful evento distinguish PF from staphylococcal folliculitis since, unlike the former, its lesionstypically do not exhibit a central pale aspect (corresponding to the remarkable oedemapresent in PF) but display central pustules on a reddish background with or withoutnonspecific vessels.6Dermoscopy is a low-cost, noninvasive technique that allows the clinician to notesignificant findings, which are not visible to the naked eye.In conclusion, dermoscopy may be a useful tool for assisting the noninvasive diagnosis ofsome challenging PF cases. Further studies on larger groups of patients are needed tosupport the observations.


Non-occlusive mesenteric ischemia (NOMI) is ischemia of the mesentery that is caused by hypoperfusion or vasospasm without any thrombosis. NOMI is difficult to diagnose by physical examination alone. Although angiographic examination of the superior mesenteric artery (SMA) is the usual diagnostic method used, it is an invasive examination. Usually, a long range of the bowel becomes discontinuously necrotic in NOMI. Here, we report a rare case of NOMI localized in the transverse colon that was diagnosed by computed tomography (CT) angiography which is a minimally invasive examination.A 72-year-old woman was referred to our hospital for further treatment of abdominal pain that developed 1 day before presentation. Contrast-enhanced abdominal CT scan revealed attenuated enhancement of the transverse colon. CT angiography showed SMA irregularities due to vasospasm. The middle colic artery could not be detected by CT angiography. No occlusion due to thrombus or embolism in the SMA and superior mesenteric vein was observed. Based on the findings, NOMI was suspected, and emergency laparotomy was performed, which revealed a segmentally necrotic transverse colon. The necrotic bowel was resected, and stomas were created.The presence of hypotension in the patient necessitated the use of CT angiography, which proved very useful in the early diagnosis of the present case. Thus, if intestinal ischemia is suspected, even in case of a short segment, CT angiography should be performed. Non-occlusive mesenteric ischemia (NOMI) is ischemia of the mesentery without thrombus or embolism in the superior mesenteric artery (SMA) or vein (SMV). It is caused by hypoperfusion or vasospasm and was first reported by Ende et al. in 1958 . Thus, tIn patients with NOMI, a long range of the bowel usually becomes necrotic, and typically, skip lesion is observed, which necessitates the resection of a large amount of the necrotic bowel. Here, we report a rare case of NOMI localized in the transverse colon that was diagnosed by CT angiography.3, 12.7 mmol/L; base excess, −13.8 mmol/L).A 72-year-old woman, who had hypertension and emphysema treated by her personal physician, was referred to our hospital for further treatment of abdominal pain, which developed 1 day before presentation. Oral intake was decreased because of the abdominal pain. The pain was mild, and no peritoneal irritation sign was detected. The vital signs were normal, except for the blood pressure, which was low (88/59 mmHg). Dehydration was suggested owing to the elevated level of blood urea nitrogen and serum creatine. Although her lactate dehydrogenase and creatine kinase levels showed no abnormality, white blood cell count and aspartate aminotransferase level were elevated . Moreover, metabolic acidosis was observed  was used as the contrast agent. The patient was injected with 0.7 g/kg iodine for 30 s, and the scan timing was 90 s after the injection. The tube potential was 120 kVp, and the tube current was adjusted by automatic exposure control with a noise index of 10 and a slice thickness of 0.5 mm. Image processing analysis was performed using a 3D volume rendering technique with the ZIOstation system .Contrast-enhanced abdominal CT scan revealed a dilated and thinned transverse colon. The enhancement of the transverse colon was mainly attenuated, except for a remaining partial enhancement Fig. . CT angiBased on these findings, necrosis of the transverse colon due to NOMI was suspected, and emergency laparotomy was performed. At laparotomy, the transverse colon was segmentally necrotic, as diagnosed preoperatively; however, the pulsation of the peripheral arteries of the transverse colon was not attenuated. Intraoperative findings also suggest NOMI, and the necrotic bowel was resected Fig. . Bowel aHistopathological findings showed massive ischemic changes with various depths of necrosis, ranging from mucosal ischemia to transmural necrosis, which reflect discontinuous necrosis of the transverse colon Fig. . ArteriaAngiography of the SMA is necessary for the diagnosis of NOMI. Angiographic findings suggestive of mesenteric vasospasm are (1) narrowing at the origins of the major branches of SMA, (2) irregularities in the intestinal branches with segmental narrowing, (3) spasm of the intestinal arcades, and (4) impaired filling of intramural vessels . After mCT is often used to diagnose NOMI by detecting the signs of intestinal ischemia such as attenuated enhancement of the intestinal wall, dilated intestine, and intramural gas –10. VasoAlthough there are only a few reports on the pathological features of NOMI, Sarda et al. reported congestion and flattening of the plicae with inflammatory exudates in the substantia propriae in less advanced cases as well as necrosis and ulceration of the mucosa, submucosa, and muscularis. Typical macroscopic findings show well-defined multiple circumferential ulcers of variable depths. In the present case, congestion and flattening of the mucosa and edema of the submucosal layer were observed . AlthougIschemic colitis is also known to sometimes cause bowel necrosis despite the absence of thrombosis or embolism in the mesenteric arteries. In many studies, NOMI was not distinguished from ischemic colitis. Wittenberg et al. reported that NOMI typically occurs in the area of the bowel perfused by the SMA, whereas ischemic colitis usually presents in the area perfused by the inferior mesenteric artery . UsuallyOnly a few cases of NOMI localized in the colon were reported , 12, andNOMI is difficult to diagnose by physical examination alone, such as in the present case. If intestinal ischemia is suspected, even in case of a short segment, CT angiography should be performed as a minimally invasive examination.


Posterior mediastinal schwannomas are benign, slow growing nerve sheath tumors and rarely cause symptoms. We present a case of a 47-year-old man who presents with severe mid-back pain and dyspnea on exertion. Chest radiograph and computed topography revealed a large posterior mediastinum mass. Surgical resection required en bloc resection of a portion of the diaphragm, and wedge resection of the left lower lobe of the lung via left thoracoabdominal approach. Pathology was consistent with ancient schwannoma. This case is unique due to the location and size of the mass and the surgical approach required for complete resection. Schwannomas are nerve sheath tumors which commonly originate from the extremities, head, neck and the posterior mediastinum . Most arA 47-year-old obese man with severe mid-back pain for 6-months was found to have a large intra-thoracic mass on a routine plain film of the chest. A computed topography (CT) scan of the chest/abdomen/pelvis revealed a 20.5 × 15.5 × 16.0 cm heterogeneous mass in the left posterior mediastinum with effacement of the left lower lobe, left inferior pulmonary vein, displacement of hemi-diaphragm inferiorly and mediastinal structures towards to the right chest . A magneA left thoraco-abdominal incision was made, extending along the 8th inter-space along the thorax . ExposurThe final pathology demonstrated a 23 × 14.5 × 13.5 cm, 2590 grams, multiloculated, cystic mass , 5 consiNeurogenic tumors represent about 12-39% of all mediastinal tumors . Other tSchwannomas occur equally between the sexes, and presentation is typically in patients older than 40 . Most paMicroscopically, the tumor contains varying proportions of Antoni A and B histologies . Antoni-Posterolateral thoracotomy has traditionally been the preferred surgical approach for resection of large posterior mediastinal tumors . Video aThe tumor was confirmed to be an ancient schwannoma based on unique histopathologic features of fibrous background with spindle cells, strong positivity for S-100 and negative for neurofilament protein, and epithelial membrane antigen . The speIn conclusion, posterior mediastinal schwannomas are benign and usually asymptomatic but can grow to a large size causing significant compressive symptoms. Such massive size may require modification of the traditional posterolateral thoracotomy for safe resection. A thoraco-abdominal approach is ideal for resection of giant posterior mediastinal schwannomas or other tumors and is safe and may be considered in the management of these tumors.


Ganglioneuromas are a very rare benign neural tumor, commonly derived from the ganglia of the sympathetic system, and are composed of mature Schwann cells, ganglion cells, and nerve fibres. They may arise anywhere from the base of the skull to the pelvis along the paravertebral sympathetic plexus. We report a rare case of synchronous ganglioneuroma and schwannoma, mistaken for carotid body tumor. The coexistence of these two entities in head and neck region is very rare. Ganglioneuroma (GN) is a very rare entity, one per million population . It is dWe present a case of synchronous ganglioneuroma and schwannoma mistaken for carotid body tumor.A 17-year-old female was referred to Oral and Maxillofacial Department of G. Papanikolaou General Hospital of Thessaloniki, Greece, complaining about a slow-growing neck mass on her left side. She did not complain of any other symptoms. The clinical examination did not reveal any symptoms of cranial nerves. A magnetic resonance imaging (MRI) scan and angiography (MRA) revealed a well surrounded tumor 4,4 × 2,3 × 2,7 cm between the left internal and external carotid artery. It was taken as a carotid body tumor or a paraganglioma. Under general anesthesia, the mass was excised by oral and maxillofacial and vascular surgeons, without any problems during the operation. The postoperative course of the patient was uneventful.The mass was solid, encapsulated, and measured 4 × 2.5 × 1 cm in size. It was whitish in color and soft to firm in consistency. Immunohistochemical analysis showed S-100 (+), GFAP partly (+), Vimentin (+), CD57 (−), Calretinin (−), and AE1/AE2 (−), and a Ki-67 was expressed rarely, which confirmed a diagnosis of schwannoma. It was connected with a nerve which revealed ganglioneuroma with the presence of numerous collections of abnormal but fully mature ganglion cells, often having more than one nucleus Figures 1.Ganglioneuromas may arise along the paravertebral sympathetic plexus with common sites of origin of the posterior mediastinum 41.5%), retroperitoneum 37.5%), adrenal gland (21%), and neck (8%) [7.5%, adr1.5%, retIn our case, the patient only complained about a slow-growing neck mass on her left side and she did not reveal any other symptoms. Her mass was mistaken for a carotid body tumor and it was treated as it was really a CBT. So after MRI and MRA, it was excised by oral and maxillofacial and vascular surgeons, without any problems during the operation. Pathological examination showed a synchronous ganglioneuroma and schwannoma and not a carotid body tumor. Although the percentage of a neck GN is 8% , 4, the


A 51-year-old caucasian woman, living in Italy since her birth, presented with a 6-month history of a left swollen cheek and intraoral nodule, unresponsive to antibiotics. Her previous medical history was positive for seasonal allergies and left jowl reconstructive surgery with filling for a car accident 5 years before. Blood tests were unremarkable; physical examination showed an asymptomatic left cheek bulge and a 1 × 0.5 cm nontender noninflammatory submucosal firm nodule located in the left maxillary vestibule. An intraoral ultrasound examination was performed . Differe1 Man is a dead-end host rarely infected by bites of vector mosquitoes.1 Endemic areas include tropical and subtropical regions, the United States, Australia, and the Mediterranean area.1 Recently, dirofilariasis spread to previously free countries because of climate changes and emerging vectors.2Dirofilaria are mosquito-borne nematodes infecting canines.3 The most common presentation is a single symptomless subcutaneous/submucosal nodule.3 As in our case, dirofilarias usually affect adult females, and microfilaremia, eosinophilia, and immunoglobulin E elevation are absent.3 Serology is not helpful; polymerase chain reaction has been suggested,2 but it is resource consuming and not widely available. Because of the wide variety of the differential diagnoses, surgical excision is the most used technique to reach the diagnosis.5 However, histopathology has limitations because the nematode morphology may be altered by inflammatory responses or surgical manipulations,4 as in our case.Most of the cases involve the head, neck, or periocular region; oral dirofilariasis is rare.4 Older lesions present calcification and fibrosis,5 whereas younger nodules may show a weakly moving filiform worm .4 In cases of surgical difficulty in reaching sites and controindications to diethylcarbamazine, ultrasonography should be considered for a watch and wait strategy. Physicians should be aware of this possibility to prompt the best diagnostic workup to avoid patient anxiety and invasive or unnecessary investigations.To date, scarce data are available about ultrasonography of dirofilarial nodules; doppler imaging may also be helpful in the differential diagnosis.Supplemental Video.


Osteosarcoma, the most common primary bone malignancy, has an extremely poor prognosis and a high rate of local recurrence and distal metastases. Because osteosarcomas of the head and neck region are rare, accounting for less than 10% of all osteosarcoma cases, limited information is available about their treatment and prognosis. Because of the high rate of distal metastases associated with extragnathic osteosarcoma, surgery combined with chemotherapy is currently considered essential in its treatment. However, the role of chemotherapy has not been well elucidated in the treatment of head and neck osteosarcoma because of the rarity of this condition.In this report, we present the case of a 58-year-old Japanese woman with osteosarcoma of the mandible that was treated with radical surgery combined with neoadjuvant and adjuvant chemotherapy. Because the tumor showed rapid growth during neoadjuvant chemotherapy, neoadjuvant chemotherapy was suspended and surgical resection was performed, followed by adjuvant chemotherapy. No evidence of local recurrence and distal metastasis was found 14 months after initial treatment. Local control is considered a principal prognostic factor for head and neck osteosarcoma.Wide surgical excision should be considered a primary goal even during neoadjuvant chemotherapy, especially in cases that respond poorly to neoadjuvant chemotherapy. Osteosarcoma is a high-grade primary bone malignancy with a high rate of metastasis and local recurrence , 2. The In the present case report, we describe a case of high-grade conventional osteosarcoma of the mandible that was successfully treated with a combination of surgery, and neoadjuvant and adjuvant chemotherapy.A 58-year-old Japanese woman complaining of pain and numbness in her left mandible was referred to our hospital in 2014. For a couple of months prior to her visit, she had been aware of an abnormal sensation in her left mandible, which gradually progressed to mild pain and numbness. She visited a general dental practitioner, who diagnosed her condition as osteomyelitis and referred her to our department. Her medical and family histories were unremarkable. On initial assessment, no obvious systemic symptoms were evident. A panoramic radiograph showed a widening of the periodontal ligament space, periapical bone loss in tooth #37, and a diffuse radiolucent lesion involving the left body of her mandible, with an indistinct cortical margin and ill-defined cortical borders of the inferior alveolar nerve canal Fig. . ComputeAlthough no consensus exists regarding the efficacy of chemotherapy in head and neck osteosarcoma, a few studies have shown that chemotherapy in neoadjuvant and adjuvant setting improves survival in patients with head and neck osteosarcoma , 20. HowAlthough the width of surgical margins remains controversial, and clear bony margins of 2 cm have been reported after effective preoperative chemotherapy , the safIn the present case, because the tumor was unresponsive and showed rapid growth during neoadjuvant chemotherapy, this therapy was suspended and radical surgery took precedence. Local control is currently the most important prognostic factor for survival in head and neck osteosarcoma. Therefore, to avoid missing the optimal time window for performing complete surgical excision with clear margins, clinicians should meticulously assess the response to neoadjuvant chemotherapy and not hesitate to suspend this treatment if the response is inadequate.The most critical issue in the future development of novel treatment strategies for osteosarcoma in the head and neck is the circumvention of therapy-resistant osteosarcoma. To accomplish this, biomarkers predicting the response to chemotherapy urgently need to be identified, especially for the treatment of patients who respond poorly to chemotherapy. Nevertheless, limited data are available about the mechanism by which chemoresistance develops in head and neck osteosarcoma. Various processes have been implicated in the mechanism underlying the development of chemoresistance in extragnathic osteosarcoma, including altered cell cycle , reducedBecause of the high rate of distal metastases, surgery combined with chemotherapy is currently recommended as an essential treatment for extragnathic osteosarcoma. Local control has been suggested to be the principal prognostic factor for head and neck osteosarcoma; therefore, the achievement of wide surgical excision should be the primary goal, even during neoadjuvant chemotherapy, especially in patients who respond poorly to neoadjuvant chemotherapy.Further studies are necessary to clarify the clinical impact of chemotherapy on tumor control or better prognosis for survival which will contribute to the establishment of the role of chemotherapy in the management of head and neck osteosarcoma.


Pediatric meningeal tumors are rare, but those in the region of the sylvian fissure without dural attachment are extremely rare, with only 24 previously reported cases in the world literature. In this series, we report two additional cases of sylvian fissure meningioma without dural attachment and one case of perisylvian meningioangiomatosis in the medial temporal lobe. All three patients presented with complex partial seizures, but the diagnosis was delayed in each case because the symptoms were misinterpreted to be behavioral rather than epileptic. The seizures were eventually confirmed with electroencephalogram, and subsequent imaging showed enhancing masses within the sylvian fissure region that were at least partially calcified in all three cases. Each patient underwent craniotomy. In the first case, gross total resection was achieved, and in the second case, a small residual portion of tumor was densely calcified and adherent to the middle cerebral artery branches. Both of these were World Health Organization (WHO) grade I meningiomas. The third patient underwent biopsy and limited resection of meningioangiomatosis. No dural attachments were noted in any of the tumors, but one of the meningiomas was intraparenchymal in location, surrounding the sylvian fissure in both the frontal and temporal lobes, which has been described in only a small number of these cases previously. The patients underwent pre- and postsurgical neuropsychiatric testing and did not experience any significant cognitive deficits. At 10-year follow-up, the patient who had gross total resection of the tumor has had no recurrence and is seizure-free without anticonvulsant medications. The incompletely resected intraparenchymal meningioma in the second patient recurred after 5 years, however, and at repeat surgery was found to have transformed to a WHO grade II tumor. Radiation therapy was delivered and the tumor has been stable for 2 years, but the patient continues to have occasional seizures despite medication. The patient with meningioangiomatosis has had no further growth and has excellent control of seizures but remains on medication. We review the clinical presentation of these rare tumors and discuss the treatment, outcomes, and possible relationship of meningiomas to meningioangiomatosis. Meningiomas are very common intracranial tumors in adults but are relatively rare in pediatric patients, comprising only 0.4 to 4.6% of all pediatric brain tumors in several large series.All three case histories and this manuscript were reviewed by our Institutional Review Board, which deemed the text acceptable for publication without a formal review. The case histories, images, operative reports, and follow-up notes were reviewed retrospectively.An 11-year-old boy was referred for new-onset partial complex seizures occurring with increasing frequency over the previous 9 months. His mother described mild nausea, staring spells, and vague olfactory sensations during these episodes, which typically lasted 1 to 2 minutes and then resolved spontaneously. He was initially misdiagnosed with attention deficit disorder, because they occurred during school classes and caused him to lose concentration, but when treatment with methylphenidate was unsuccessful, he was also noted to have automatisms of his hands and lip-smacking, which eventually led to electroencephalogram (EEG) examination that revealed epileptiform activity in the left temporal lobe. Magnetic resonance imaging (MRI) then showed a 5 × 5 × 4-cm enhancing mass within the left sylvian fissure region and1B,He underwent a left frontotemporal craniotomy, and a grayish, relatively soft mass was found within the sylvian fissure, without any attachment to the dura. There was an easily discernible arachnoid plane surrounding the tumor, which was only mildly adherent in some areas to the middle cerebral artery (MCA) branches, where it was removed with careful microdissection. Postoperative imaging showed no residual tumor and1D.A 7-year-old boy presented with a 9-month history of partial complex seizures. He was noted by his schoolteachers to have staring spells for a few seconds at a time, during which he was verbally unresponsive. He was thought to have attention deficit disorder or a behavioral abnormality, but EEG was performed after he described the sensation of olfactory auras at onset of these spells, and it confirmed seizures. An MRI showed a 4 × 5 × 4-cm mass in the left sylvian fissure region, very similar in appearance to the first patient . It wasRepeat craniotomy was performed, but the tumor was so densely calcified that it could only be removed by drilling it with a diamond-coated burr, a slow and tedious process, and only about half of the tumor could be safely removed without undue risk of injury to the MCA vessels. Postoperatively, he had a significant expressive aphasia that lasted almost 3 weeks before it resolved completely. Pathology from this recurrent tumor showed microscopic invasion of the pial surface, consistent with transformation to WHO grade II meningioma, but no increase in mitotic rate or nuclear atypia was seen. Further surgery was deemed very high risk for permanent speech and language deficits, and he underwent fractionated external beam radiation therapy instead. His tumor remains stable in size 2 years later, but he continues to have occasional seizures, despite medication.A 16-year-old girl was referred for evaluation because of a history of complex partial seizures preceded by olfactory auras, which had initially occurred infrequently but then increased to daily episodes. After more than 6 months of symptoms, these were finally recognized as seizures and confirmed with EEG. MRI showed a small enhancing right temporal lobe intraparenchymal mass , with sIn this article, we describe two additional cases of meningiomas in children in the sylvian fissure region without dural attachment and one case of MA in the perisylvian region. All three presented with partial complex seizures that were misdiagnosed initially as behavioral disorders, which is not uncommon in children with such seizure types and can delay diagnosis and treatment. The rarity of meningiomas in this location and the lack of dural attachment can mislead surgeons to exclude this diagnosis prior to surgery, which may lead to incomplete surgical planning. In particular, the intraparenchymal location of the tumor in our second case caused great concern initially when the sylvian fissure was opened and no tumor was seen. In our review of the literature, this intraparenchymal location has been described in detail previously for five cases,Microsurgical resection of these tumors has been reasonably successful in reducing seizures, especially when complete resection is achieved.Some authors postulate that these tumors arise from arachnoid cap cells within the Virchow-Robin space,MA can also occur in the medial temporal lobe/perisylvian location, as we describe in our third case. Most are sporadic, but some have been observed in patients with neurofibromatosis.Meningeal tumors in the sylvian fissure region without dural attachments are extremely rare, but should be considered preoperatively in patients with an enhancing mass in this region, especially in a pediatric patient with complex partial seizures. The diagnosis may be delayed as the patients may be misdiagnosed with behavioral or cognitive disorders before the seizures are discovered, as in the patients in our series. EEG studies may confirm the seizure disorder, and MRI provides the diagnosis and important details regarding location, size, presence of edema, and so on. Preoperative diagnosis of meningioma remains difficult based on imaging alone, however. Craniotomy and resection remain the treatment of choice for these meningiomas and can be performed with minimal cognitive deficits and improvement of seizures in many cases. They may pose great surgical risk, though, when adherent to the MCA vessels or when heavily calcified, which increases the incidence of subtotal resection. Subtotal resection poses a higher risk of recurrence, and these patients should be followed with long-term serial imaging. MA appears to have a more benign clinical course and does not necessarily require complete resection but may be associated with a higher risk of meningioma formation.


Congenital bronchopulmonary malformations are usually asymptomatic. Precise multimodality imaging plays an essential role in the identification of rare cardiothoracic entities, offering excellent imaging quality and the decisive diagnosis. A 68‐year‐old male patient presented to our department complaining of eight‐month‐lasting dry cough. Physical examination showed nothing of significance. Chest X‐ray demonstrated lobar atelectasis of the left lung. Chest CT scan confirmed the initial diagnosis, and per os antimicrobial medication was prescribed.After 8 months, and due to persistent symptoms, a new CT scan was performed, which showed no changes of the lesion in the left paravertebral space. The patient underwent bronchoscopy which identified an ectopic port of the left main bronchus Fig. A. MaximuEleftherios Spartalis: involved in conception and design of the research and writing of the manuscript. Eleftherios Spartalis and Michael Spartalis: involved in acquisition of data. Eleftherios Spartalis, Michael Spartalis, Demetrios Moris and Antonios Athanasiou: analyzed and interpreted the data. Theodore Troupis and Periklis Tomos: performed critical revision of the manuscript for intellectual content.The authors report no financial relationships or conflict of interests regarding the content herein.


Penile malignant tumors constitute less than 1% of all malignancies in men but penile lymphoma is even rarer in this population ,4,5,6,7.A 51-year-old man was admitted with the appearance of swelling and ulcerations of the penis that had started 2 weeks earlier. His history revealed that he was diagnosed with stage IIIB diffuse large B-cell lymphoma (DLBCL) 7 years ago, received 6 courses of R-CHOP, and was assumed to be cured after 5 uneventful years of follow-up. Swelling at the penis increased within 2 weeks with the addition of continuous pain, superficial ulcerations, and frequent and painful urination. Physical examination revealed a diffuse and indurated swelling at the shaft of the penis with an ulcer. An enlarged left inguinal lymph node was also palpable. Magnetic resonance imaging revealed a solid lesion of 55x37 mm in size, almost completely filling the penile corpus and significantly narrowing the penile urethra, extending to the glans penis. Tru-Cut biopsy of the penile lesion was consistent with DLBCL. He was staged as Ann Arbor IIIE with positron emission tomography-computed tomography revealing F-18 fluorodeoxyglucose involvement in the deep cervical left inguinal lymph nodes and a solid mass in the corpus penis . TreatmeAlthough most DLBCL patients have nodal presentation at admission, extranodal involvements are also common. The classical extranodal involvements sites are the breast, central nervous system, and testes. Penile involvement is a rare entity reported in case reports ,7,8,9,10Surgery remains the best approach for penile cancers, whereas no standard treatment modality has been established for penile lymphomas. Systemic chemotherapy according to the subtype is a good treatment option because it preserves penile functions . In our In conclusion, the possibility of lymphoma involvement should be kept in mind in patients admitting with penile mass lesions, especially in patients who have a history of aggressive lymphomas, in order to avoid aggressive surgical interventions. It is important to initiate systemic chemotherapy immediately in order to prevent complications related to urethra obstruction and to preserve erectile functions.


Intraosseous vascular lesions are rare conditions. They are most commonly seen in the vertebral column and skull; nevertheless, the mandible is a quite rare location. In this report, we present a case of intraosseous cavernous hemangioma in the mandible and discuss the clinical and radiological features. A 28-year-old male patient attended to our clinic with a complaint of painless swelling of mandible. Clinical evaluation revealed a bone-hard, smooth-surfaced, immobile mass in the left mandibular lingual area. The patient was evaluated with panoramic and occlusal radiography and computed tomography. The lesion surgically excised and pathological examination revealed an intraosseous cavernous hemangioma. Follow-up imaging 1 year later with cone beam computed tomography revealed recurrence of the lesion. The conclusion of this paper; when a bone hard, well-shaped mass was seen in the mandible, the possibility of intraosseous hemangioma must be remembered and before surgical procedure detailed radiographic evaluation should be performed. Key words:Hemangioma, intraosseous, mandible, cavernous, cbct. Primary intraosseous hemangioma is a benign, slow growing neoplasm that comprises 1% of all benign tumors arising from the bones. Hemangiomas mostly arise from the soft tissues, and intraosseous hemangiomas are uncommon . The sitA 28-year-old male patient attended to our clinic with a complaint of painless swelling of mandible. The patient first noticed the swelling about two years ago when brushing his teeth. This swelling which has more than doubled in size since the difference has led to difficulty in speaking since 3 months. Intraoral examination revealed bone-hard, smooth-surfaced, immobile mass in the left mandibular lingual crest. Computed tomography (CT) that had taken at her previous visit at another hospital examined,maxillofacial computed tomography demonstrated a 21x13 mm bone mass originated from lingual cortex of mandible. Panoramic and occlusal radiography imaging performed. Panoramic radiograph of the patient did not reveal any pathology. Occlusal radiography revealed a well defined lesion with radiopaque contours, containing reactive bone spicules  and vascular malformations. Vascular anomalies often affect the soft tissues of the maxillofacial region but are rarely found in visceral organs or bone. The diagnosis and management of vascular lesions continue to present diagnostic and therapeutic challenges to all. This is in part because of lack of agreement regarding the nosology and classifications of the lesions. Many authors use the term hemangioma to describe or qualify vascular malformations and vascular anomalies, whereas others continue to use the term cavernous hemangioma for venous malformation and port-wine stain for capillary malformation, venous malformation, and arteriovenous malformations (AVM) -13.AVMs are a complex network of intercommunicating arterial and venous structures. The presence of nerve in AVM provides an additional diagnostic criterion that can be readily used to differentiate AVMs from hemangiomas .Hemangiomas are benign vascular neoplasms characterized by an abnormal proliferation of blood vessels. They may occur in any vascularized tissue including skin, subcutaneous tissue, muscle, and bone. The microscope appearance has two major classifications; cavernous and capillary types. The cavernous hemangioma is composed of large thin-walled vessels and sinusoids lined with a single layer of endothelium. However, a small fine vascular network filled with blood forms the capillary hemangioma. Capillary hemangiomas are usually present at birth. In contrast, most cavernous hemangiomas occur in adult hood and almost all intraosseous hemangiomas of the facial skeleton are to be cavernous type ,6,10,11.The pathogenesis of intraosseous hemangiomas remains unknown. Nonetheless, local trauma may be a cause, because many patients with intraosseous hemangiomas have had a history of local trauma , but in As intraosseous hemangioma tends to grow very slowly, it remains clinically silent until the tumor becomes large. The radiographic appearance of central hemangioma is not pathognomonic and can simulate many other bone lesions. In this case; the formation of reactive spicula produced by the lesion that was observed in the occlusal radiography is the classic radiographic feature for the tumor ,11. PreoHemangiomas should be considered in the differential diagnosis of multilocular lesions involving the body of the ramus and body of the mandible. The differential diagnoses for intraosseous cavernous hemangioma include AVM, osteoma, langerhans cell histiocytosis, fibrous dysplasia, dermoid tumor and multiple myeloma -11. HistThe most effective treatment to prevent recurrence of intraosseous hemangiomas is to remove the tumor completely without any functional deficit, cosmetic deformity, or significant tissue loss . The bioThe diagnosis of facial bone hemangiomas is somewhat difficult to make, because the lesion is usually asymptomatic, the most affected patients are women in their fourth and fifth decades ,5,9, but


Arachnoid cysts can be associated with neurologic symptoms due to compression of underlying brain structures though indications for surgical intervention are unclear. We present the case of a 70-year-old man who presented with a two-year history of speech changes along with decreased initiation and talkativeness, shorter utterances, and dysnomia. [ Primary progressive apraxia of speech is a recently described neurodegenerative disorder in which patients present with an isolated apraxia of speech and show focal degeneration of superior premotor cortex . LongituA 70-year-old right-handed man was brought to the Emergency Department for an episode of confusion at work characterized by “saying things I didn't mean to say.” His family reported a 2-year nonprogressive history of word finding difficulty and shuffling gait. He had once worked as a computer database developer but in the last decade had shifted to working as a greeter in a department store.On examination, the patient displayed limited facial expression with mild right oral commissure depression and slowed voluntary face, lip, and tongue movements. Perceptual speech analysis revealed a harsh voice with episodes of decreased volume, imprecise speech sounds, occasional repetition of sounds, difficulty sequencing multisyllabic words, slowing, and diminished stress patterns. He did not initiate conversations. The patient generally answered questions with 1 to 4 words but occasionally said up to a 9-word, grammatically correct sentence. Testing revealed impaired word finding and impaired verbal fluency. Handwriting demonstrated decreased smoothness and extra loops. Overall, the patient's speech and language skills appeared more impaired than his global cognitive status. Together, these findings suggested a mixed disorder of both motor speech sequencing (praxis) and language (nonfluent aphasia). There was no evidence of gait apraxia.An EEG showed findings of left temporal slowing. Brain MRI demonstrated mild diffuse cerebral atrophy and mild convex contour deformity of the left frontal skull. FDG PET-CT of the brain  revealedExtra-axial arachnoid cysts may be associated with a variety of neurologic symptoms that sometimes may require surgical intervention . HoweverWe conclude that timely diagnosis and workup of focal cortical syndromes, such as motor speech apraxia, may uncover treatable or relatively benign mimics of neurodegenerative diseases. Understanding the natural history of such mimics, however, is still a work in progress.


The incidence of intrahepatic cholangiocarcinoma (ICC) is reported to be 4.4 % of all primary liver tumors; it is the second most common type after hepatocellular carcinoma, and the 5-year survival rates are 12.2 % for non-surgical cases and 31.3 % for cases that were treated surgically [A 71-year-old male underwent distal gastrectomy for gastric cancer of T3N2M0, stage IIIA according to the AJCC/UICC pathological staging system [In August 2009, the patient visited our hospital due to new onset of epigastralgia. He was referred to our surgical department because of an abnormality found by an abdominal enhanced CT examination.The patient weighed 53.0 kg, with a height of 145.6 cm, and showed no abnormalities in the physical examinations except for a surgical scar on the upper abdomen. His laboratory data on admission showed a slightly low hemoglobin (Hb) level of 12.9 g/dl and slightly elevated alkaline phosphatase (ALP) level of 387 U/ml; however, the other data were nearly within the normal ranges. The levels of tumor markers such as carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, α-fetoprotein (AFP), and protein induced by vitamin K absence or antagonist (PIVKA)II were within the normal limits.Abdominal contrast CT scans taken upon admission showed a tubular mass lesion along the Glisson’s sheath at S5 as a low density area. The border of the mass lesion was unclear and it was enhanced gradually from the early to late phases. The normal part of the liver surrounding the mass lesion was enhanced by the A-P shunt, and slight atrophy of the right lobe of the liver was seen Fig. . AbdominAfter obtaining informed consent from the patient, we performed right hepatic lobectomy under the preoperative diagnosis of suspected ICC. The pathological examination of the excised specimen revealed that the mass lesion was cholangiocellular carcinoma (moderately differentiated adenocarcinoma) at S5/6 of the liver, and the tumor cells had spread along the bile duct of B5 similar to a tumor thrombus Figs.  and 5. TThe patient had an uneventful postoperative course and was discharged on the 17th day after the operation. We advised the patient to undergo adjuvant chemotherapy; however, he refused. The patient has shown no signs of recurrence 24 months after liver surgery.We herein described a case of ICC that was curatively resected after 5 years of observation. To the best of our knowledge, there is no previous report of curatively resected ICC after such a long-term strict observation.According to the World Health Organization (WHO) classification of tumors, ICC is defined as an intrahepatic malignant tumor composed of cells resembling those of the bile duct. ICC arises from any portion of the intrahepatic bile duct epithelium, such as the intrahepatic large bile duct or intrahepatic small bile duct. Cholangiocarcinoma arising from the right and left main hepatic ducts or their junction is referred to as hilar cholangiocarcinoma . AccordiAccording to progressive features, two distinct neoplastic lesions have been identified thus far . One is Although the present case did not have mucin production, the tumor did gradually increase in size. We speculated that the tumor in the B5 region might initially have been an intraductal neoplasm equivalent to BilIN or IPN-B. Subsequently, repeated blockage and healing of the peripheral bile duct might have caused the neoplasm to gain malignant potential gradually, finally contributing to its acquiring the ability to invade and form the mass lesion outside of the bile duct.On the other hand, histological examinations of the present case revealed that the intraductal growth lesion demonstrated significant neutrophil invasion and tumor necrosis. These findings were consistent with the finding that the tumor temporarily decreased in size during the observation period. Although the IG type of ICC has a different biological behavior from the other types of ICC, a further understanding of the pathological and molecular biological features is required. Therefore, this case is particularly interesting because it contributes to understanding the IG type of ICC.In the present case, we considered that surgical resection should have been performed in the earlier period, because the mass lesion increased in size, resulting in progressive atrophy of the right lobe of the liver. In addition, we must continue to pay attention to recurrent or new lesions in this case, because the tumor consisted of the IG component, as well as the MF component.


Schwannomas are benign nerve sheath tumors and are most frequently encountered as soft tissue tumors of peripheral nerves of the head and neck or the extensor extremities. Osseous involvement is very uncommon with fewer than 200 cases described in the world literature, the majority of which arise in the skull (including mandible), vertebrae, and sacrum. Long bone involvement is highly unusual and of the approximately 20 cases described thus far, only five have been documented to arise in the femur. We describe an unusually large schwannoma of the femur which was discovered incidentally and was diagnosed only after biopsy, given the rarity of this tumor at that particular site. Following prophylactic internal fixation and bone grafting, our patient remains well and disease-free, 2.5 years later.A 56-year-old Sri Lankan woman was discovered to have a large lytic lesion in her lower femur on routine X-ray following a fall. A history and physical examination, along with selective imaging and tissue sampling, were necessary to arrive at the diagnosis of schwannoma of the femur. The clinical presentation, radiology, pathology, and surgical management are discussed and contrasted with the other five cases documented in the literature. The tumor was successfully treated with evacuation through a lateral surgical approach and internal fixation. She remains well and disease-free 2.5 years later.We present the case of an unusually large lytic lesion found incidentally in the femur of a 56-year-old woman, which was subsequently diagnosed to be a schwannoma on biopsy. Its exceptional rarity in long bones makes it less likely to be considered in an initial differential diagnosis, and we stress the importance of tissue biopsy for diagnosis. Schwannomas are benign nerve sheath tumors originating from Schwann cells and are most frequently encountered as soft tissue tumors of peripheral nerves of the head and neck or the extensor extremities . OsseousA 56-year-old Sri Lankan woman presented with pain in her left knee and difficulty in weight bearing following a fall 6 weeks prior. Clinical examination of her knee and lower end of her thigh did not reveal any abnormality. She had no family history or symptoms of neurofibromatosis.Anteroposterior Fig.  and lateAt surgery, a large tumor expanding the lower anterior end of her femur was found. The tumor was partly cellular and partly gelatinous. A regular punched out area where the tumor appeared to have extended out of the femur anteriorly was found. Abnormal-looking tissue extending outside her femur was excised. The defect in her femur was expanded and the whole tumor evacuated. The lower end of her femur (supracondylar area) was severely weakened after resection of the tumor. Prophylactic internal fixation was done with a locking distal femoral plate Fig. . A bone Hematoxylin and eosin-stained sections revealed a benign spindle cell tumor showing cellular, hyalinized, and hypocellular microcystic areas with areas showing a focally whorled appearance. The spindle cells contained elongated nuclei, characteristic Verocay body-like structures with nuclear palisading Fig. , and incMicroscopy of the tissue removed from outside her femur showed fat necrosis and fibrosis, with no evidence of tumor.Schwannomas are benign nerve sheath tumors which originate from Schwann cells. They usually occur in soft tissue and are often found in the peripheral nerves of the head and neck or on the extensor extremities. They may be seen at all ages, but occur predominantly in the 20- to 50-year age group. No gender predilection is noted.They are usually solitary and sporadic, but a few occur in the setting of neurofibromatosis type 2. They are slow growing tumors, which displace nerve fascicles as they expand and are often present for several years before diagnosis. When occurring in bone, they are often asymptomatic, with pain or other neurological manifestation a rare presenting feature .Schwannomas in bone are extremely uncommon, accounting for <0.2% of primary bone tumors. Fewer than 200 have been described in the world literature , 9. The The cause for their relatively common occurrence in the mandible and sacrum have also been discussed. Traditionally, this has been attributed to the presence of long nerve segments which traverse these bones, although this theory remains debatable , 12.Schwannomas are thought to involve bone by one of three mechanisms. An extra-osseous tumor arising from nerves in soft tissue may cause secondary erosion of bone. They may also arise either from nerves entering bone through nutrient canals or within the medullary cavity from non-myelinated nerves associated with blood vessels , 10–12.Schwannoma occurring in the long bones are exceptionally rare. When solitary and not associated with neurofibromatosis, they are thought to arise either from nerves that accompany the nutrient vessels of bone in the diametaphysis or from nerves of the periosteum , 10.Only approximately 20 cases of intraosseous schwannoma involving the long bones have been reported in the literature including tibia , 13–15, Our patient had no evidence of disease at her most recent follow-up, 2.5 years after surgery and had returned to normal activities.The purpose of this paper is to call attention to the fact that a common soft tissue tumor like schwannoma can also present as a primary bone tumor. Its nonspecific clinical and radiological findings together with its exceptional rarity of long bone involvement, makes it less likely to be considered in an initial differential diagnosis of lytic lesions of bone. Histological evaluation following biopsy is key to diagnosis.


Tongue is formed of a mass of muscles and salivary gland embedded in anterior highly vascular and posterior lymphoid stroma and covered by specialized surface epithelium. Growths from all of these heterogonous components may occur resulting in a wide variation in clinical features and behavior, ranging from self-limiting to aggressive lesions. Therefore, surgical excision is the treatment of choice. The aim of the current study is to report three different lesions that came to the Oral Surgery Department in the Faculty of Oral and Dental Medicine, Cairo University. Following clinical and histopathological examination, the diagnosis of reactive lymphoproliferative lesion, cystic lymphoepithelial lesion, and developmental lymphatic vessel malformation was reached. Tongue is a unique vital structure that favors great importance to the oral health. It usually appears at the fourth week of fetus intrauterine life. The anterior two-thirds of the tongue is formed by the fusion of both primary pharyngeal arches and tuberculum impar. While the posterior one-third arises from the 2nd, 3rd, and 4th pharyngeal arches .Tongue is a highly vascular and muscular organ that is involved in a mucous sac . This saIts nomenclature as a muscular hydrostat arises from its ability to move and to give skeletal support for this motion. These hydrostatic properties are related to the specialized muscle arrays and muscle fibers. Therefore, tongue controls critical function such as speech, taste sensation, swallowing, and cleansing of the oral cavity. Tongue provides clue and reflection about the systemic condition. If lingual deformation or pathology occurs, these functions become impaired . This deLymphangiomas are congenital malformations that are derived from the lymphatic vessels. They are mainly related to the head and neck. There are various theories that explain their origin. They are mainly formed due to defect occurring during embryogenesis. They can be capillary, cavernous, or cystic . IntraorLymphoepithelial cyst is rare idiopathic intraoral condition. It usually arises in relation to the lateral and ventral surface of the tongue , 9. AlthLymphoid hyperplasia is one of the rare lymphoproliferative lesions. Although it has common clinical and histopathological features with oral carcinoma, it is benign in nature. It usually appears as painless malignant-like ulcer , 14.A fifty-eight-year-old female patient came to the Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Cairo University, complaining of a swelling in the right side of the tongue. The presence of this swelling caused also difficulty in speech and deglutition.Upon clinical examination, a well-circumscribed pinkish white nodule approximately 1 × 1 cm in size and round in shape was noted on the right lateral border of posterior third of the tongue . The surAs a differential diagnosis, fibroma, lymphoid hyperplasia, lymphoepithelial cyst, choristoma, lymphoma, and salivary gland neoplasm were included.The excisional biopsy was performed at the Oral Surgery Department and the surgical specimen was submitted for microscopic examination in the Department of Oral and Maxillofacial Pathology, Faculty of Dental Medicine, Cairo University. In macroscopic examination, the specimen was received as one mass that appeared rounded in shape of about 1.0 × 1.2 cm in size with a narrow stump of about 1.0 × 0.6 cm. The specimen was whitish in color and soft in consistency .Histopathological examination revealed a cystic cavity lined by orthokeratinized stratified squamous epithelium with uneven thickness. Within the lumen, keratin sloughs interspersed with lymphocytes were observed. The connective tissue wall contained well-demarcated aggregates of lymphocytes. Few germinal centers were detected within the lymphoid tissue. The lesion was covered by keratinized stratified squamous epithelium . ImmunohA sixty-year-old female patient came to the Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Cairo University, complaining of bilateral swellings in the tongue. The patient noticed the enlargement of the left side mass.On clinical examination, well-circumscribed red nodules approximately 1 × 1 cm and 1.5 × 1.25 cm in size were noted on the right and left lateral borders of posterior third of the tongue, respectively . The surThe excisional biopsy from the left side was removed in Oral Surgery Department and submitted for microscopic examination in the Department of Oral and Maxillofacial Pathology, Faculty of Dental Medicine, Cairo University. In macroscopic examination, the specimen was received as two small pieces of 0.5 × 1 and 0.8 × 1 cm in size, reddish in color, and soft in consistency.Histopathological examination revealed a hyperplastic lymphatic tissue containing aggregations of lymphocytes that form germinal centers in some areas. The lesion was covered by hyperplastic keratinized stratified squamous epithelium . The finA ten-year-old female patient came to the Department of Oral and Medicine, Faculty of Dental Medicine, Cairo University, complaining of a swelling and multiple red areas on the dorsal surface of the tongue.On clinical examination, well-circumscribed bluish nodule approximately 1.2 × 1.2 cm in size was noted on the right dorsal surface of the tongue . The surHistopathological examination revealed numerous variably sized lymphatic vessels, some of which contain coagulated lymph. The lesion was covered by keratinized stratified squamous epithelium . The finFive days later, the healing of the area of surgery was reexamined and the disappearance of red areas was noticed .Swellings in the posterior part of the tongue present a diagnostic and therapeutic dilemma due to their different histogenesis, nature, and subsequently behavior. Slowly growing, painless nonulcerative growths are usually benign while presence of pain, bleeding, ulcer, and induration are characteristic for malignancy. However, some overlapping clinical features are encountered. Therefore, biopsy is usually required to differentiate benign lesions from premalignant and malignant lesions , 7, 15.Oral lymphoepithelial cysts (OLC) are rare lesions arising commonly in the floor of the mouth followed by lateral border and ventral surface of the tongue. Few cases were also reported in soft and hard palate, retromolar area, palatoglossal arch, and palatine tonsil , 16, 17.Despite early description of this type of cysts, the pathogenesis is still debatable. Sethi and Patankar have suggested that oral lymphoepithelial cyst is a pseudocyst caused by obstruction in the crypt of tonsil orifice , while BThe LC can occur in any age with the majority of cases being usually diagnosed in the second and third decade with a slight male predilection , 12.As noticed in our case, clinically, OLC appears as a solitary small soft swelling usually with the color similar to that of adjacent mucosa. However, in some cases, it may appear as yellow papule due to the presence of keratin in its lumen, which leads to a creamy or cheesy appearance.Histopathologically, the OLC reveals a cystic cavity lined by a stratified squamous epithelium with desquamated keratin in the lumen. The connective tissue wall is usually formed of diffuse lymphoid tissue with frequently observed germinal centers. Our case showed all of these features .Surgical excision is usually done to be examined and exclude the malignant probabilities. Rare recurrence rate was reported with no malignant transformation potentiality , 16.Lymphoid hyperplasia (LH) is an uncommon benign entity related to a rapid proliferation of lymphocytes contained within or outside of lymph nodes. The majority of existing head and neck reports are of hyperplasia in the oral cavity, namely, of the mucosa overlying the hard palate. The exact etiology is not clearly understood, but the reactive nature is strongly suggested .It was called pseudolymphoma due to the great similarity between their clinical and histological pictures .LH affects commonly older female. It may arise as a unilateral, painless, slow-growing, nonulcerated mass. But multifocal lesions were also reported. Histologically, LH is formed of dense lymphoid hyperplasia within the papillary and deep submucosa. Occasionally, germinal centers may also be seen. Absence of cellular monotony and signs of malignancy supports the exclusion of lymphoma , 14.In our case, an old nonsmoker female patient was complaining of slowly growing bilateral swellings in posterior part of lateral borders of the tongue.Histologically, the examined specimen showed dense lymphoid hyperplasia with few germinal centers covered by hyperplastic stratified squamous epithelium. No signs of malignancy were detected. Both clinical and histological pictures were consistent with previously reported data.Lymphangiomas are benign, hamartomatous proliferations of lymphatic vessels. They most likely represent developmental malformations that arise from sequestrations of lymphatic tissue that do not communicate normally with the rest of the lymphatic system [c system , 19.They appear in the first few years of life, grow slowly, and sometime resolve spontaneously. They were classified according to the size of lymphatic vessels into lymphangioma simplex (capillary lymphangioma), which consists of small lymphatic capillaries, cavernous lymphangioma, which contains dilated lymphatic vessels, and cystic lymphangioma (cystic hygroma), which exhibits large, macroscopic cystic spaces .However, all of these variants of vessels may be found within the same lesion. Like our case, oral lymphangioma occurs frequently on anterior two-thirds of the tongue with superficial location and pebbly surface. However, deeply located lesions were also reported that cause diffuse swelling, termed macroglossia , 19.Histopathological features of our case revealed small capillary sized lymphatic vessels containing proteinaceous fluid and occasional lymphocytes. These vessels were superficially located just beneath the epithelial surface. The most probable type is capillary lymphangioma.The other clinical finding noticed in the same patient was the presence of red areas that resolved spontaneously. It met the features of geographic tongue.Geographic tongue is also known as benign migratory glossitis or erythema migrans. It is benign self-limiting condition of unknown etiology that is characterized by depapillated red areas and requires no treatment except reassurance. Mild sensitivity to hot or spicy foods was reported [reported .Histological examination is only safer way to determine the exact nature of the tongue swellings for the selection of appropriate treatment.