This paper reports a case of gemination in a maxillary lateral incisor with two root canals and crown-root dilaceration. A 16-year-old male patient was referred for endodontic treatment of the maxillary left lateral incisor and evaluation of esthetic and functional complaints in the anterior region. The patient reported trauma to the anterior primary teeth. There was no spontaneous pain, but the tooth responded positively to the vertical percussion test and negatively to the pulp vitality test. Clinical examination showed esthetic and functional alterations and normal periodontal tissues. CBCT imaging confirmed the suspicion of gemination and crown-root dilaceration and also revealed the presence of two root canals and periapical bone rarefaction. The root canals were instrumented with Reciproc R40 and 1% NaOCl irrigation and were filled by lateral condensation of gutta-percha and AH Plus sealer. The tooth was definitely restored with composite resin to recover esthetics. Continued follow-up over 6 months has shown absence of pain or clinical alterations as well as radiographic image suggestive of apical repair. Deep knowledge of the root canal system anatomy is critical to the success of endodontic therapy . AnatomiGemination is considered a rare developmental dental anomaly affecting the morphology of teeth. It is defined as a failed attempt at division of a single tooth germ by invagination, resulting in a tooth with a larger, incompletely separated crown having a single root and a single root canal . There iAlthough gemination can also occur in premolars and molars, it is more common in anterior teeth . In mostIn certain cases, two-dimensional imaging modalities, such as conventional and digital radiography, do not provide sufficient information for an accurate detection of anatomical variations and the use of more advanced auxiliary imagining resources is necessary. Imaging modalities that provide an undistorted three-dimensional vision of the tooth and surrounding structures should be used to improve the diagnostic potential. Cone-beam computed tomography (CBCT) provides three-dimensional images with high precision and sensitivity, offering a more detailed analysis of the case, a more adequate planning of root canal treatment, and guidance throughout the operative phase , 20.This paper reports a case of gemination in a maxillary lateral incisor with two root canals and crown-root dilaceration.A 16-year-old male patient was referred to the clinic of our Department of Restorative Dentistry for evaluation and endodontic treatment of the maxillary left lateral incisor with main complaint of aesthetic and functional impairment.Review of the patient's dental history revealed trauma to the anterior region of the maxilla around the age of 5 due to a fall. The traumatic injury caused intrusion of the primary maxillary left lateral incisor, which exfoliated after approximately 30 days. Orthodontic traction of the impacted permanent maxillary left lateral incisor was necessary at that time.Clinical examination showed an amorphous, small, darkened crown and normal adjacent gingival tissues. There was no spontaneous pain, but the tooth responded positively to the vertical percussion test and negatively to the pulp vitality test.Panoramic  and periUnder local anesthesia and rubber dam isolation, access to the pulp chamber was achieved with round bur number 2  and Endo-Z bur . Because of the difficulty in locating the canal openings, an ultrasonic insert  was used to remove dentin tissue until finding the entrances of the mesiobuccal and distopalatal canals. The pulp chamber was flooded with 1% NaOCl solution and the canals were explored with a size 10 K file. In both canals, the working length was determined at 18 mm using an electronic apex locator . The canals were instrumented with R40 file of the Reciproc system  under irrigation with 1% NaOCl. Root canal treatment was carried out in two sessions. At the end of the first session, a calcium hydroxide paste was used as an intracanal medication and restorative glass-ionomer cement was used as temporary restoration. In the second session, after 15 days, the intracanal medication was removed and the canals were filled with 17% EDTA for 3 minutes for smear layer removal, irrigated again with 1% NaOCl, dried with absorbent paper points, and filled by lateral condensation of gutta-percha and AH Plus sealer  . The patContinued follow-up over 6 months has shown a successful outcome with absence of pain, no clinical alterations, and radiographic image suggestive of apical repair .An accurate diagnosis and the precise determination of the number of root canals are mandatory for the success of endodontic treatment. Overlooking dental anomalies and anatomical variations can have a negative impact on treatment outcome, with persistence or exacerbation of preexisting apical periodontitis .Radiographic examination is an important part in diagnosis and treatment planning . PeriapiThe maxillary lateral incisor usually has a single root and a single canal , 26. HowGemination is less prevalent in the permanent dentition than in the primary dentition, affecting mainly maxillary incisors and canines . The incThe etiology of gemination is not clear, but it is known to be associated with trauma to the primary dentition during the development of the permanent tooth germ. Some authors have also claimed that gemination could be the result of the interaction of hereditary genetic variations and environmental factors , 34. In Gemination can often be confused with fusion, which is a developmental dental anomaly characterized by the union of two adjacent tooth germs, resulting in a reduction in the number of teeth in affected arch. The differential diagnosis is usually made by counting the number of teeth in the arch, which is not altered in the cases of gemination , 35.Developmental dental anomalies like gemination can cause functional, orthodontic, endodontic, and esthetic impairments and represent a challenge for dentists because, in most cases, a multidisciplinary approach is required to obtain the best treatment and a successful outcome .Although it is considered a rare developmental dental anomaly with low prevalence, the occurrence of gemination deserves attention in clinical practice. Knowledge of the literature-based definition of this anomaly, review of dental history, and the use of accurate imaging resources, such as CBCT, are essential for a correct diagnosis and establishment of an adequate treatment plan in geminated teeth.


CTNNB1 mutations accompanied with aberrant nuclear beta-catenin expression. RCC show neither nuclear beta-catenin expression nor BRAF mutation. The latter is a hallmark of papillary craniopharyngiomas (papCP) that exhibit remarkable histological similarity with metaplasia of RCC. Diagnosis of the patient was elucidated by CTNNB1 and BRAF mutation screening, utilizing different approaches, as well as histological examination of markers, e.g., beta-catenin, claudin-1, EpCAM and the mutated BRAFV600E protein, which are known to be differentially expressed in sellar lesions. The case presented reveals extraordinary aspects for two reasons. Firstly, the lesion appeared clinically, on MRI, intraoperatively and histologically as RCC with prominent squamous metaplasia, but showing an expression pattern of markers also found in papCP, whilst exhibiting a hitherto undescribed BRAFV600E mutation. This important result documents a supposable transition of RCC metaplasia into a papillary craniopharyngioma (papCP). Secondly, this intriguing case shows unexpectedly that although papCP usually occurs almost exclusively in adults, it can also arise in childhood.A 6-year old patient presented with an intra and suprasellar cystic lesion accompanied with impairment of the hypothalamic-pituitary axis and partial hypopituitarism. The most likely cause of sellar lesions in this age group are adamantinomatous craniopharyngioma (adaCP) or Rathke´s cleft cysts (RCCs). AdaCP are characterized by  A 6 year old child progressively developed polydipsia and polyuria with a fluid intake of more than 4 l per day since April 2016. Interestingly, the child was hospitalized for several days only 1 month prior in another hospital with abacterial meningitis without any laboratory abnormalities. Laboratory tests revealed a central diabetes insipidus and the MRI displayed an intra and suprasellar, cystic, slightly contrast enhancing mass , accounting for nearly 50% of sellar lesions in childhood, and Rathke´s cleft cysts (RCC)  was inconclusive, although the labeling of ciliated cells must be interpreted as a false positive staining (Jones et al., n Figure  suggesten Figure  of the sn Figure  (Holskenn Figure , Pyroseqn Figure  and SNapn Figure  (Figuresn Figure . Furthern Figure , which wn Figure .CTNNB1gene using SSCP (Figure For the sake of completeness, adaCP diagnosis, which is common in the pediatric age group, was excluded by the histomorphological appearance of the lesion and by beta-catenin analysis. Neither an immunohistochemically nuclear accumulation of beta-catenin Figure  nor mutaP Figure  and SangBRAFV600E mutation in 38–58% of cases (Louis et al., Furthermore, there was no histological evidence for Langerhans cell histiocytosis. This histiocytic tumor was excluded because it occurs mostly in childhood, could also be seen in the hypothalymic-pituitary region, and carries a BRAFV600E mutation representing a hallmark of papCP. Therefore, this supports the assumption that papCP could originate from RCC. Additionally, this intriguing case unexpectedly shows that papCP can occur in childhood.This is the first report describing a pediatric patient with a sellar mass lesion that appears clinically and histologically as an RCC with pronounced metaplastic squamous epithelium but harbors a The patients' parents/legal guardians provided written informed consent for research participation as well as for the publication of the child's indirectly identifiable information. All methods used were carried out in accordance with the approved guidelines of the Ethical Committee of the University of Erlangen-Nürnberg and in accordance with the Declaration of Helsinki.Conception and design: S-MS and AH. Providing clinical data: S-MS and MB. Histological and genetic analyses: AH, RS, and RB. Drafting the article: AH and S-MS. Critically revising the article: RB, MB, RS, and RB.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cases of diverticula of the buccal mucosa are extremely rare. Literature searches of databases such as PubMed/MEDLINE for this condition have revealed only 10 case reports. In this case report, we describe our experience in the management of this rare condition and review the previous 10 previously reported cases.A 66-year-old man presented with a pouch containing inspissated food debris located posterior to the papilla of the parotid duct in his left buccal mucosa. The diagnosis of a diverticulum arising from the buccal mucosa was confirmed based on clinical and radiographic findings. Gross examination of the locally resected tissue specimen revealed a pouch measuring 14 mm in diameter and 8 mm in depth, that was whitish in color and had an elastic, soft, and smooth surface. Microscopic examination revealed a cyst-like lesion lined by stratified squamous epithelium and granulation tissue, with a chronic inflammatory infiltration in the peripheral stromal tissue of the epithelial layer. After surgical excision of the lesion, there was no recurrence during the follow-up period of 5 years and 10 months.We have presented a rare case of a diverticulum of the buccal mucosa. This is the first report of a case confirmed not only by the clinicopathological findings, but also by computed tomography and magnetic resonance imaging findings. From the magnetic resonance imaging and intraoperative findings, we inferred that the diverticulum was caused by an idiopathic developmental anomaly due to a partial defect of the buccinator muscle. A diverticulum is a protrusion of the inner lining of the digestive tract through a defect in the outer muscular coat to form a small pouch with a narrow neck. The commonest site for development of diverticula is in the lower left portion of the colon. The presence of diverticula is often referred to as diverticulitis, presumably in reference to the irritation caused by retained fecal material .Diverticula of the buccal mucosa are very uncommon. The first report of a diverticulum in the buccal mucosa was described by Bailey  as a casWe herein report a case of a diverticulum of the buccal mucosa, confirmed by clinical examination, computed tomography (CT), and magnetic resonance imaging (MRI), and discuss the etiology of this rare condition.. A CT examination revealed a discontinuity of his buccal mucosa and a cavity containing fluid and air . An additional CT image with radiopaque, contrast medium-soaked gauze placed in the cavity outlined the extent of the pouch . The MR examinations provided T2-weighted images that showed a pouch with an opening and a slightly thickened wall, with a partial defect in the buccinator muscle on the left side . Gadolinium-enhanced T1-weighted MR images revealed enhancement of the wall extending over the surrounding tissues antero-posteriorly in the buccal lesion and superiorly in the maxilla on the left side, which was considered to indicate an inflammatory reaction . The lesion was diagnosed as a diverticulum of the buccal mucosa and was surgically resected with the patient under general anesthesia. A partial defect in the buccinator muscle was found underneath the pouch during the operation.A 66-year-old Japanese man was referred to our university hospital in April 2011 with a complaint of food impaction in his left buccal region. The patient had no history of injury, tumor, or cyst in the oral and maxillofacial region. He had a medical history of hypertension, gastric ulcer, gout, nephrolith, and alcohol dependence, but no family history of congenital anomalies. He had been smoking 10–15 cigarettes per day for 45 years. He denied having any allergies. On general physical examination, his physical and nutritional statuses were good. Upon intraoral examination, an orifice containing inspissated food debris was observed posterior to the papilla of the parotid duct in the left buccal mucosa. Neither a mucinous discharge nor a communication with the parotid duct could be observed. A pouch measuring 14 mm in diameter and 8 mm in depth was noted after removing the food debris air Fig. . An addiuch Fig. . The MR ide Fig. . Gadolinion Fig. . The les. Microscopic examination revealed a cyst-like lesion lined by stratified squamous epithelium and granulation tissue, with chronic inflammatory cell infiltration in the stroma. The affected mucosa was focally depressed and the muscular tissue below the lesion could not be clearly visualized, though the muscle tissue was partially observed in the surrounding tissue .Macroscopically, the excised tissue specimen showed a pouch measuring 14 mm in diameter and 8 mm in depth, that was whitish in color and had an elastic, soft, and smooth surface. Fig. . Microscsue Fig. .Fig. 5MaThese findings led to the final diagnosis of a diverticulum of the buccal mucosa. There has been no subsequent food impaction and no evidence of disease recurrence in the 5 years and 10 months since the lesion was resected.A diverticulum refers to the presence of an outpouching in the wall of the digestive tract mucosa, such as the colon or small intestine. The most common type of diverticulum affecting the colon is the pseudodiverticulum, in which the saclike mucosa herniates or projects through the muscularis propria . There hThe patient characteristics from the 11 reported cases of buccal diverticula, including our case, are presented in Table The etiology of the buccal diverticulum is unclear, though some theories have been reported. First, the cheek is anatomically composed principally of the buccinator muscle, which consists of three groups of muscle fibers . It has With respect to clinical manifestation, the diverticula appeared as asymptomatic lesions in five of the reported cases, while the other cases presented with halitosis, food impaction, or swelling. Surgical treatment should be recommended in symptomatic cases involving food impaction or voluminous diverticulum. Of the 11 reported cases, six cases underwent surgical excision and the remaining five cases received conservative treatment, including periodic irrigation and cleansing of the oral cavity. Since our patient complained of food impaction, local excision was the most appropriate treatment option. After the surgery, the patient’s symptom of food impaction resolved and there has been no recurrence to date.In conclusion, this report has described a rare occurrence of a diverticulum of the buccal mucosa. While a small number of other reports of this condition do exist, this is the first proven case, and we have provided substantial evidence in the form of clinical, pathological, and radiographic findings. In addition, we were able to elucidate that an idiopathic developmental anomaly caused by a buccinator muscle defect was responsible for the development of the diverticulum in this case.


Internal herniation following laparoscopic surgery is rare. We present a case of small bowel obstruction secondary to internal herniation in a 76-year-old male patient. Presentation was on postoperative day 28 following transperitoneal laparoscopic radical left nephrectomy for suspected renal carcinoma. The herniation was through a defect in the large bowel mesentery identified at exploratory laparotomy. To date, 10 cases of internal herniation following laparoscopic nephrectomy have been described in the literature. Two cases were managed laparoscopically and the remainder by laparotomy. One case required resection of an ischaemic portion small bowel and the remainder were managed by reduction of the hernia and closure of the defect. Internal herniation is rare but carries significant morbidity. It must be considered in cases presenting with obstructive symptoms after laparoscopic nephrectomy. Early CT scanning and prompt surgical management are hallmarks of best management. A 76-year-old Chinese gentleman presented to our surgical department with acute central and lower abdominal pain. He was at postoperative day 28 following laparoscopic radical left nephrectomy performed via a transperitoneal approach. A diagnosis of small bowel obstruction was made based on computed tomography (CT). Findings included dilated small bowel loops and transition points at both the distal ileum and duodenojejunal flexure. An exploratory laparotomy was performed after a failed trial of conservative management. Intraoperative findings were small bowel obstruction secondary to internal herniation of the small bowel through a defect in the large bowel mesentery. Small bowel resection and primary anastomosis were performed followed by repair of the mesenteric defect. The patient was discharged from hospital on postoperative day 13 following resolution of postoperative small bowel ileus.A 76-year-old Chinese male presented to the emergency department with a 12-hour history of acute central and lower abdominal pain which was constant and colicky in nature. He denied any nausea or vomiting; he had opened his bowels normally that morning and was still passing flatus. He was noted to be at postoperative day 28 following laparoscopic radical left nephrectomy. This was performed for a mass found in the upper pole of the left kidney and was completed via a transperitoneal approach.He is a lifetime nonsmoker and denies regular alcohol consumption. He is fully independent and still works as a taxi driver. His past medical history includes a D1 duodenal ulcer with a recent admission for upper gastrointestinal bleeding. He also takes regular medication for hypertension, hyperlipidaemia, benign prostatic hypertrophy, and gout.On presentation to the emergency department he was afebrile and had a blood pressure of 156/69 and a heart rate of 87 beats per minute. On examination he had a soft abdomen with central tenderness and no guarding. Hernial orifices were normal and on digital rectal examination the rectum was empty and no masses were palpable.Initial abdominal X-ray showed no dilated bowel loops and the working diagnosis was adhesion colic in view of his recent operation. Within 24 hours of admission a contrast enhanced CT scan was performed in view of clinical deterioration, rising lactate, and worsening metabolic acidosis and acute kidney injury. At CT the findings were small bowel obstruction, suggestion of 2 transition points in the left hemiabdomen , and no evidence of ischaemia .An emergency exploratory laparotomy was performed after review of the CT findings. Findings at laparotomy included almost complete small bowel herniation up to distal ileum through a descending colon mesenteric window. There were 2 transition points. The first was at the distal ileum at the point of herniation; the second was 40 cm from the duodenojejunal flexure where the jejunum was adherent to the retroperitoneum at the site of the left nephrectomy pedicle. There were omental adhesions noted to mesh in the right inguinal region consistent with previous laparoscopic transabdominal preperitoneal inguinal hernia repair. The small bowel was distended but healthy and the colon was healthy.The operative procedure consisted of reduction of the small bowel through the mesenteric window and division of jejunal-retroperitoneal adhesions. An inadvertent enterotomy was made at the adhesion site causing some peritoneal soiling. The small bowel was decompressed through the enterotomy site and after resection of a short segment of jejunum a functional end-to-end stapled anastomosis was made.Postoperatively the patient was treated with intravenous antibiotics for a presumed aspiration pneumonia thought to have been caused by vomiting during induction of anaesthesia. He was managed for postoperative ileus which resolved on postoperative day 4 and was discharged from hospital on postoperative day 12. The patient was readmitted on postoperative day 25 and managed conservatively for ileus. CT of the abdomen and pelvis on admission showed a 2.3 × 3.6 × 6.6 cm abscess in the left retroperitoneal region abutting the psoas muscle . The absLaparoscopic radical nephrectomy has been adopted as the preferred surgical approach in cases of renal cell carcinoma. It has been shown to provide equivalent cancer control and lower complication rates when compared with an open approach , 2.A retrospective analysis of over 7000 patients undergoing open or laparoscopic radical nephrectomy by Tan et al. showed that the laparoscopic approach offered the benefit of lower complication rates when compared with an open approach. Mortality and failure-to-rescue rates in patient with complications after having laparoscopic surgery were significantly higher however when compared to patients undergoing open surgery . This stBowel complications are rare in laparoscopic nephrectomy, accounting for 1% of total complications , being mA literature search identified 8 publications reporting a total of 10 cases of internal herniation following laparoscopic nephrectomy. Five were carried out for suspected or confirmed cancer and the remaining 5 donor nephrectomies. All 8 cases presented with small bowel obstruction and required operative management. One case progressed to small bowel gangrene and required small bowel resection. The remaining cases were managed by reduction of the hernia and closure of the defect. All 10 cases survived their hospital admission and were discharged from hospital.All 10 cases described the internal herniation resulting from a tear in the colonic mesentery. In all cases the mesenteric defect was made inadvertently and not as an intended step in the operation. The defect is made when an incision is made in the lateral colonic mesentery in order to mobilise the colon medially and access the kidney . CreatioSix cases identified from our literature search used CT to diagnose internal herniation. A CT scan in 2 of these cases identified a mesenteric defect and evidence of internal herniation. In the remaining 4 cases small bowel obstruction was reported but the diagnosis of internal herniation was not made until laparotomy. CT findings in these cases include dilated small bowel, evidence of small bowel venous congestion, pneumatosis coli, and translocation of the small bowel loops to the respective renal fossa. In 2 cases the patient underwent exploratory surgery following laboratory investigations and plain X-rays only. In one case the mesenteric defect had been identified during laparoscopic nephrectomy. In this case prior knowledge of the presence of such a defect may have negated the need for CT. This patient underwent exploration laparoscopy and laparoscopic repair of the defect after reduction of the hernia. In a different case Kumar et al. proceed straight to exploratory laparotomy without performing a CT scan. It is unclear why CT scanning was not used in this case. In the 2 remaining cases reported in the literature preoperative imaging is not discussed.Of the cases described 1 was managed laparoscopically, 1 was laparoscopically assisted, and the remainder was managed by laparotomy. In the case describing laparoscopically assisted exploration the mesenteric defect was recognised during laparoscopic nephrectomy but was not closed . The surIn only one case small bowel resection was performed . In thisIn all reported cases the mesenteric defect was closed after identification and reduction of the internal hernia.When an inadvertent or intentional mesenteric defect is recognised during the primary operation the surgeon can choose to leave the defect behind, repair it, or extend it. Traditionally we teach that hernias with a narrow neck are more likely to be incarcerated and become complicated compared to those with a wide neck. Although wide necked hernias are potentially uncomfortable or unsightly, they are less likely to be incarcerated as contents move freely in and out of the sac. In the case described by Regan et al., the mesenteric defect was recognised at primary operation . The defInternal herniation and small bowel obstruction are a rare complication of laparoscopic nephrectomy but should be considered in cases presenting with bowel obstruction early or late in the postoperative course. It is associated with significant morbidity and the need for operative intervention in all reported cases and has been shown to cause ischaemia necessitating bowel resection in one case.The authors of this report advocate that, during laparoscopic nephrectomy for any purpose, the mesentery must be inspected for defects and any recognised intended or inadvertent defects should be repaired to prevent internal herniation. The hallmarks of best management in cases resulting in obstruction include early CT scanning and surgical intervention with the aim of repairing the mesenteric defect after reduction of the hernia and appropriate management of any bowel ischaemia or perforation. This has been performed laparoscopically in 2 cases; however the decision for open or minimally invasive surgery is dependent on institutional policy and surgeon experience.


Dieulafoy lesions are a rare etiology of gastrointestinal bleeding from a large caliber-persistent tortuous submucosal artery. They account for 1-2% of all causes of acute gastrointestinal hemorrhage with 80%–95% of these lesions located in the stomach along the lesser curvature. One-third of these lesions present at an extragastric location, with the proximal duodenum accounting for 15% of them. We present a 21-year-old male with no significant past medical history or risk factors, who presented with repeated syncopal episodes followed by hematemesis, found to have a Dieulafoy lesion located at the duodenal bulb. This lesion was diagnosed and successfully treated via upper endoscopy with epinephrine injection and the application of 2 endoscopic clips. Dieulafoy lesion represents an uncommon source of gastrointestinal (GI) bleeding but a potentially fatal one. It is defined anatomically as a dilated, aberrant, submucosal artery that erodes overlying gastrointestinal mucosa in the absence of an underlying ulcer or aneurysm . ApproxiA 21-year-old male with no significant past medical history presented to the emergency department after having multiple episodes of syncope upon standing associated with prodromal symptoms but with no loss of bowel function, urinary incontinence, or palpitations. He did not experience any seizures or history of seizures. Patient also reported having 3 weeks of worsening lower vague abdominal pain and constipation with flatus prior to presentation. He denied any prior nausea or emesis but did develop an episode of nausea with coffee-ground emesis in the emergency department. There was no history of alcohol abuse or NSAID use. On admission, his orthostatics were positive and respiratory rate was 17 breaths per minute with a heart rate of 113 beats per minute. There were no significant findings of physical exam apart from conjunctival pallor, tachycardia, and lower abdominal tenderness without guarding, rigidity, or rebound. Hemoglobin and hematocrit were initially 11 g/dL and 34.2%, respectively, with a significant subsequent decline to 6.0 g/dL and 18.2%, respectively, with positive occult stool suggestive of gastrointestinal hemorrhage. Two units of packed red blood cells were given along with 2 L normal saline bolus IV. Coagulation parameters were within normal limits. Patient was transferred to the ICU and subsequently underwent esophagogastroduodenoscopy, which revealed an actively bleeding Dieulafoy lesion located in the duodenal bulb .Homeostasis was successfully achieved with epinephrine injection and the application of 2 endoscopic clips . H. pylori and the rest of his hospital course was uneventful.A repeat esophagogastroduodenoscopy revealed normal esophageal and gastric mucosa and a Dieulafoy lesion in the duodenal bulb with 2 endoclips in place. The patient tested negative forDieulafoy lesion is a rare but potentially fatal etiology of gastrointestinal bleeding due to its ability to cause significant acute life threatening hemorrhage. It consists of a large caliber-persistent tortuous submucosal artery . As the Histologically, there is subintimal fibrosis of the artery without any structural aneurysmal change and without any inflammation at the edge of the mucosal defect, which is in stark contrast to that which is present in peptic ulcer disease . The diap < 0.05) [There is currently no consensus on the treatment of Dieulafoy lesions. The literature suggests that combination endoscopic therapy is superior to monotherapy consisting of injection therapy followed by thermal or mechanical therapy, with permanent hemostasis achieved in 95% of all cases . The ris < 0.05) . The res < 0.05) . In one In conclusion, one must always be mindful to keep Dieulafoy lesion as part of their differential diagnosis when evaluating any individual of any age who presents with acute gastrointestinal hemorrhage, even in the absence of significant comorbidities or risk factors. Early diagnosis is crucial, with endoscopy being the investigative modality of choice. The specific treatment of choice should be individualized to each patients' clinical presentation, site of lesion, and the technical expertise of the operator.


Trigeminal neuralgia is a disorder characterized by unilateral electric shock-like pain, distributed in one or more trigeminal nerve branches and triggered by usually innocuous stimuli. Among the few case reports and literature reviews on familial trigeminal neuralgia (FTN), the results of several suggest the involvement of genes associated with biochemical alterations or atherosclerotic vascular malformations.We present four cases of FTN within two families . All patients were submitted to surgical treatment by the same surgeon.Cases 1 and 2 (family A) exhibited FTN with an uncommon autosomal recessive pattern and clinical features consistent with previous literature reviews and case reports. However, in cases 3 and 4 (family B), we found FTN with a dominant autosomal pattern and an unusual physiopathology characterized by arachnoid adhesions.We conclude, in this case report, that there are several inheritance patterns as well as physiopathology that may be involved in FTN, and that both patterns described in our reported cases were successfully managed with surgery. According to the International Classification of Headache Disorders 3rd edition (ICHD-3) , trigemiThere is a gender predominance for females in TN of 1.7:1.6. The incidence of TN is 4–13 in every 100,000 people, a rate which gradually increases with advanced age .There is a subclassification for TN in the ICHD-3, which divides the disorder into three categories. The first category, classical TN, is likely caused by neurovascular compression, seen in 80–90% of cases . In the Familial trigeminal neuralgia (FTN) is not officially coded in the ICHD-3 and does not fit into any subclassification. In fact, FTN has only been described in case reports since it is a very rare condition representing only 1–2% of all cases .Unlike TN, FTN has a gender predominance of males at 53:47. In terms of laterality, symptoms of FTN present unilaterally in 18%, while 19% exhibit symptoms bilaterally, even though there is a higher frequency of bilateral symptom presentation in some studies. The FTN onset is usually around 43 years of age . All patients were submitted to surgical treatment by the same surgeon. Written informed consent was obtained from all patients for the publication of this case report.Case 1 consisted of a male patient, 71 years of age, who had developed, over 5 years, electric shock-like pain in the left mandibular that was triggered while eating or swallowing in access for 1–4 min. This patient had a family history of TN and reported having a brother with the condition. The patient’s personal pathological history consisted of hypertension for the past 30 years managed with Telmisartan (80 mg every 12 h), umbilical hernia surgery 45 years ago, and an allergy to acetylsalicylic acid. This patient was also a smoker (20 cigarettes/day) for 30 years. Clinical exam demonstrated hyperesthesia of the left maxillary and mandibular nerves . An MRI exam showed vascular compression of the cisternal portion of the left trigeminal nerve. The patient partially responded to carbamazepine (200 mg every 8 h); however, he still displayed outbursts of pain, and so a trigeminal nerve microvascular decompression was performed. Surgical findings: two veins that drain toward the petrous sinus. The superior cerebellar artery (SUCA) was in contact with the trigeminal nerve. Three Teflon sponges were placed between the trigeminal nerve and SUCA, and trigeminal nerve neuropraxia was performed. Following the surgery, the patient reported no further pain , of a high intensity that lasted 5–10 min, and was triggered by chewing and brushing her teeth. The patient had a family history of TN; both her father and sister reported having the condition of the clinical exam hyperesthesia in the left V2 and V3 was demonstrated. An MRI exam showed vascular compression of the cisternal portion of the left trigeminal nerve. Oral medication had no effect on the patient’s symptoms. Trigeminal nerve microvascular decompression was performed. Surgical findings: arachnoid adhesions were found at the cerebellopontine angle. We observed compression of the trigeminal nerve by the SUCA. We placed Teflon sponges in the areas of contact. Five months after the procedure, the patient presents with the same symptoms as well as left hemifacial hyperesthesia. A re-intervention was performed. Surgical findings: We found multiple arachnoid adhesions, and a misplaced Teflon sponge. The Teflon sponge is replaced. Following the surgery, the patient reports no further pain.Case 4 consisted of a female patient of 48 years with a 15-year history of maxillary and right mandibular lancinating pain in periodic episodes. These episodes were triggered by touch, and associated with same-side epiphora and sialorrhea, and total mandibular occlusion is enabled. The patient had a family history of TN, with her father and sister having both been diagnosed with the condition. An MRI exam showed no vascular compression of the trigeminal nerves. The patient experienced partial relief of pain with medication (gabapentin and carbamazepine). We performed trigeminal nerve microvascular decompression. Surgical findings: we found multiple arachnoid adhesions at the cerebellopontine angle. The trigeminal nerve was almost completely surrounded by arachnoid adhesions. Adhesions were liberated and neuropraxia was performed; Teflon sponge fragments were placed in probable contact sites even though there was no evidence of compression. Follow surgery, the patient presented contralateral facial pain (left V1). Left microvascular decompression was performed. Surgical findings: we found multiple arachnoid adhesions at the cerebellopontine angle. The trigeminal nerve was almost completely surrounded by arachnoid adhesions. Adhesions were liberated and neuropraxia was performed; Teflon sponge fragments were placed in probable contact sites even though there was no evidence of compression Figure .There are few case reports about FTN in the literature, and very few case reviews. However, in this study, we describe two genetic FTN inheritance patterns in four separate cases of FTN with autosomal dominant form of inheritance being the predominant form. In family A (cases 1 and 2), both siblings are male and have a delayed onset of the disease (around their early 70s). Case 1 had a history of hypertension and atherosclerosis, and case 2 had a history of smoking. In both cases, the surgeries revealed vascular compression by the SUCA. Symptoms were completely eliminated after microvascular decompression. The results of the surgery support previous literature, which report an influence of atherosclerotic changes and associated biochemical changes on TN, which could have particular bearing on case 1. On the other hand, the inheritance pattern reported in cases 1 and 2 was a recessive autosomal inheritance pattern, which is not the pattern that has been suggested in the few FTN case reports.In family B (cases 3 and 4), we report a different presentation of FTN than in family A. First, both patients were female with an earlier onset of the disease (late 40s and early 50s). In case 3, MRI results revealed a compression of the SUCA, and through surgery we also found multiple adhesions. There was a recurrence of symptoms 5 months after the surgical decompression, and so we performed a re-intervention. The re-intervention revealed arachnoid adhesions and a Teflon sponge displacement. Adhesions were liberated and three Teflon sponges were placed in three different contact sites. Following re-intervention surgeries, the patient reported no further symptoms.Case 4 presented no findings of vascular compression, but several arachnoid adhesions were observed. Adhesions were successfully liberated with no further symptoms reported immediately after surgery; however, the patient developed contralateral V1 pain. In response, we performed a second contralateral microvascular decompression. Again, we found arachnoid adhesions, which were successfully liberated, and the patient reported no further symptoms. This case is classified as secondary TN, according to the ICHD-3, since there was no evidence of vascular compression.Family B presented with a dominant autosomal pattern of inheritance with arachnoid adhesions as the apparent cause of pain. An anticipation phenomenon was also identified in this family. Based on the findings in previous literature, all characteristics of FTN in family B were uncommon, except for the inheritance pattern, which is the most commonly reported pattern in cases of FTN. The fact that there was a bilateral TN in case 4 is notable given that it has been described with only 19% frequency in FTN.Familial trigeminal neuralgia is an uncommon pathology with very few reported cases. All four cases in this report were successfully submitted to surgical treatment by the same surgeon after initial unsuccessful pharmaceutical treatment. There was one surgical re-intervention required. We found two different inheritance patterns and two different physiopathologies in these four cases of FTN, and both surgical findings were successfully treated. However, it is of vital importance to continue investigating and analyzing FTN to better understand the uncommon presentation of neuralgia, and to obtain more knowledge to generate a more accurate and improved evaluation and treatment of the disease.RR-G is the tutor of this project. CC-M was in charge of the project analysis. JM-M was in charge of data recollection.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cystic echinococcosis (CE) is a parasitic zoonosis caused by echinococcus larvae. Manifestations of the disease include a severe damage to the liver and lung. Damages to the mesentery, omentum, spleen, brain, heart, bone, thyroid, kidney, and uterus are rarely observed. Moreover, primary ovarian and retroperitoneal hydatid disease is extremely rare, and is easily ignored or misdiagnosed.Echinococcus granulosus.We present a case of CE in a 34-year-old female who presented with an adnexal mass detected by B-ultrasound. Adnexal and retroperitoneal masses were removed by laparoscopic surgery. Postoperative pathological report  Primary ovarian and retroperitoneal hydatid disease.The patient received intravenous injection of dexamethasone (10 mg) before cyst resection to prevent allergic reactions and oral albendazole (600 mg BID) for 14 days to prevent relapse postsurgery.The patient revealed no recurrence of disease and no reportable significant changes in 3 months.We present here a case report of CE. This case described herein inhabited a nonendemic region. Gentle and careful operation, and avoiding cyst rupture is the key to insuring success of the surgery. For safety, dexamethasone may be used before cyst resection to prevent anaphylaxis, and mebendazole can be used postoperatively to prevent relapse. Oncospheres that develop into hydatid cysts, provoke severe liver and lung damage, with possible involvement of the intestinal mesentery, spleen, brain, heart, and kidney.Cystic echinococcosis (CE) is an endemic parasitosis caused by infection of –6 and is seen in epidemic farming areas where it migrates from endemic to nonendemic regions. Echinococcosis is usually asymptomatic and often associated with occasional dull pain or acute diffuse peritonitis. However, anaphylactic shock, due to cyst rupture, and fluid draining to the abdominal cavity following surgery, are the most severe complications of hydatid disease, which carries a risk of high mortality.Primary ovarian and retroperitoneal hydatid disease is very rare with few reported cases,We presented a case without a history of close contact with dogs and lacking clinical symptoms from a nonendemic region. However, on physical examination, a pelvic mass was discovered.2A 34-year-old female was admitted following the diagnosis of adnexal mass detection over a 1 year period by B-ultrasound. The patient was born and raised in Lijiang, Yunnan province, which belongs to a nonendemic area. However, during frequent business travels, this patient visited Echinococcosis endemic regions like Sichuan and Guangxi provinces for prolonged periods. Menstrual obstetric history revealed regular menstruation and occasional dysmenorrhea not requiring pain-relieving drugs, good health, G2P1 , and a single occasion of induced-abortion 3 years ago. with a clear border, medium density, poor motion, and mild tenderness. Gynecological vaginal ultrasound detected adenomyosis with the uterus having dimensions of 10.8 × 5.3 × 6.6 cm, and hypoechoic masses of 3.5 × 2.9 cm, 3.4 × 3.0 cm, and 5.5 × 4.5 cm at the left adnexa with internal compartments  was administered in advance to prevent allergic reactions.E granulosus, which is also known as hydatid disease  ase Fig. C and D. ase Fig. B–D. The 3We presented a 34-year-old female patient who was admitted on diagnosis of an adnexal mass by B-ultrasound. Adnexal and retroperitoneal masses were removed by laparoscopic surgery and the patient was diagnosed as primary ovarian and retroperitoneal hydatid disease by postoperative pathology.The lessons learned from presurgical indefinite diagnosis of this case include: knowledge that the patient was born and lived for a prolonged period of time in Yunnan—a nonepidemic area for hydatid disease. Additionally, the patient provided no prior history of close contact with dogs or sheep, and frequently travelled on business between epidemic areas of Sichuan and Guangxi provinces that surround Yunnan. Thus, awareness of hydatid disease could be improved. No other symptoms showed out on admission of the patient with a diagnosis with “adnexal masses of more than 1 year via B-ultrasound.” A pelvic mass was also discovered by physical examination. Genital system hydatid disease is rarely seen in gynecology clinics. Thus, expertise in the differential diagnosis of ovarian cyst and pelvic echinococcosis by B-ultrasound might be insufficient. All patients should be treated postoperatively with albendazole or its liposomal oral emulsion to prevent recurrence.The key to successful therapy of hydatid cyst lies in protecting the surgical field from error, and preventing dissemination of the vesicular cyst or scolex following leaking of hydatid cyst fluid.The most common complication of hydatid disease is anaphylactic shock from a strong allergic reaction to cystic fluid release in the abdominal cavity caused by surgically induced cyst rupture during surgery or by implementing insufficient protective measures. The current case was not preoperatively diagnosed, and the possibility of hydatid disease was considered only following exploratory surgery. Dexamethasone administration presurgery coupled with abdominal rinsing and irrigation procedures with surgical/sterile saline mitigated para- and postsurgical allergic responsiveness.,8–13 Gurdal et al described a 48-year old woman presenting with a 3-month history of right flank pain, but otherwise without remarkable symptoms. However, by abdominal-pelvic ultrasonography (USG), a solid mass of 60 mm with regular borders and evidence of calcification was discovered in the right suprarenal region. By abdominal contrast CT, a 60 × 40 mm solid mass was seen with egg shell calcification of the soft tissue mass. Exploratory surgery revealed a solid immobile mass, which was suprarenally positioned and resected with a segment of the apical pole of the right kidney. Over a 12-month follow-up, the patient was disease free. Similarly a 76-year-old postmenopausal woman was admitted to an emergency unit with a 10-day history of urinary retention. Authors described an unusual presentation of a solid mass with cystic components located anterolaterally to the bladder and pelvis. Pathology confirmed diagnosis of hydatid cyst, and the patient was discharged following uneventful recovery and prescribed oral albendazole (800 mg QD) as adjuvant therapy for 6 months. Similar cases have been reported, wherein differential diagnosis confirmed primary adnexial hydatid cyst that mimicked a multicystic ovarian tumor. Following resection, the patient was discharged and administered mebendazole (100 mg b.i.d.) for 4 months. Similarly, a diagnosis of hydatid cyst of the ovary was discovered incidentally in a 30-year-old female patient following surgery for suspected ovarian cyst. Exploratory laparotomy revealed a marked cystic mass close to the pelvis. Postsurgical antibiotic and steroidal therapy and recovery was uneventful.The current case is supported by other reports.,8–10 there is also evidence of this condition in male subjects.,9–13 Differential surgical diagnosis was key, and resection of the cyst avoided potential adverse outcomes of cyst rupture and anaphylaxis.Whilst the above cases reported presentation of hydatid cyst in female patients,Patients travelling and carrying slow grow mass in ovarian should consider possibility of hydatid disease. Laparoscopic resection was feasible in primary ovarian and retroperitoneal hydatid disease patient. Gentle and careful operation, and avoiding cyst rupture are the key to insuring success of the surgery. For safety, dexamethasone may be used before cyst resection to prevent anaphylaxis, and mebendazole can be used postoperatively to prevent relapse.4Conceptualization: Qinghua Zhao and Jin Luo.Data curation: Qin Zhang and Tianyan Leng.Formal analysis of the data: Qinghua Zhao, Jin Luo, Qin Zhang, Tianyan Leng, and Lihua Yang.


O tumor de corpo carotídeo é uma neoplasia rara, geralmente benigna, que acomete, sobretudo, indivíduos entre a quarta e a quinta décadas de vida. Manifesta-se pela presença de massa cervical consistente localizada abaixo do ângulo da mandíbula, pulsátil e comumente indolor. Pode evoluir para dor local, disfagia, soluços, rouquidão e síndrome do corpo carotídeo hipersensível. Este artigo relata os casos de duas pacientes diagnosticadas com essa neoplasia e submetidas ao tratamento cirúrgico. A primeira foi submetida a uma ressecção em bloco do tumor, enquanto a segunda, com estadiamento mais precoce, foi tratada com uma ressecção subadventicial da lesão. Negava antecedentes de disfagia, disfonia, ataques isquêmicos e emagrecimento. Ao exame físico, foi observada uma cicatriz de aproximadamente 3 cm no bordo anterior do músculo esternocleidomastoideo, à esquerda. Através da palpação, ficaram evidentes duas massas ovoides, uma medindo 3 × 4 cm, à esquerda, e outra medindo 2 × 2 cm, à direita . Ambas sA paciente foi hospitalizada e submetida a exames de eco-Doppler colorido e tomografia computadorizada , que sugshunt temporário de Pruitt-Inahara para proteção cerebral, interposição de safena interna com anastomose proximal lateroterminal e distal terminoterminal , queixava-se da presença de tumoração na região cervical esquerda. Relatava histórico de hipertensão arterial sistêmica e hipercolesterolemia, ambas sob controle. A paciente também relatou possuir meningioma aderido ao seio sagital superior, que não apresentava atividade de crescimento desde 2009. Ao exame físico, verificou-se, na palpação, a presença de massa ovoide pulsátil e indolor em trígono carotídeo esquerdo. Havia consistência elástica sem aderência aos planos profundos e com mobilidade lateral, porém imobilidade em sentido longitudinal. Sem frêmito e sopros. Assim como no caso anterior, os exames da cavidade oral e neurológico não mostraram alterações. A paciente foi submetida a exames de imagem no período pré-operatório. O eco-Doppler colorido evidenciou massa tumoral extremamente vascularizada com dimensões de 3,9 × 3,2 cm ao nível na bifurcação carotídea com afastamento das carótidas internas e externa .O tratamento cirúrgico foi instituído. Sob anestesia geral, fez-se uma incisão cervical semelhante à descrita no caso anterior, à esquerda. Foi encontrada uma massa sólida aderida à bifurcação carotídea. As estruturas nobres adjacentes foram isoladas facilmente e a dissecção do tumor foi realizada pela técnica subadventicial sem intercorrências 9. Retir,,Segundo Shamblin et al.,,,,,,Em relação aos exames complementares, o eco-Doppler colorido é a primeira opção, pois fornece informações sugestivas do diagnóstico, que são importantes para triagem e diagnóstico diferencial. A tomografia computadorizada cervical ou, melhor ainda, a ressonância nuclear magnética são os exames de escolha para obter dados de localização, extensão, correlação com estruturas adjacentes e natureza vascular do tumor,,,A cirurgia é o tratamento de escolha, tendo em vista a possibilidade de malignização, invasão peritumoral e metastação. A técnica mais utilizada é a dissecção subadventicial do tumor (Gordon-Taylor),shuntNo intraoperatório, é muito importante, antes da dissecção, a identificação e a exposição ampla de todos os nervos, evitando sua manipulação em excesso,,,As taxas de complicações gerais variam entre 32 e 44%, e as taxas de mortalidade variam entre 8 e 20%,,A embolização pode ser utilizada no caso de tumores grandes, em que ela reduz a perda sanguínea e o tamanho do tumor e melhora os resultados cirúrgicos, porém não se pode descartar o risco de embolia cerebral -,-The carotid body is a structure of elliptical shape, 3 to 4 mm in size, that is located at the bifurcation of the common carotid, at the level of its adventitial layer.-,-Carotid body tumors are neoplasms that arise from paraganglion cells and although they are well-delimited, they are unencapsulated tumors and are highly vascularized by branches of the external carotid artery and their “vasa vasorum”.,,,,,,While rare, they are the most common paragangliomas that occur in the head and neck area 60-70%).0-70%.,,The first patient was a 28-year-old white female from Loanda, PR, Brazil, who was seen at a clinic in the Hospital Universitário Evangélico de Curitiba with a history of bilateral tumors in the cervical region, with onset 5 years previously. She had had a surgical biopsy of the left cervical region 4 months previously and referred with a diagnosis of carotid aneurysm. She stated that she had no history of dysphagia, dysphonia, ischemic attacks or weight loss. During the physical examination, a scar approximately 3 cm long was observed at the anterior margin of the sternocleidomastoid muscle, on the left. Palpation revealed two ovoid masses, one measuring 3 x 4 cm, on the left, and the other measuring 2 x 2 cm, on the right . They weThe patient was admitted to hospital and underwent examinations with color Doppler ultrasonography and computed tomography , which wThe patient underwent surgery under general anesthesia. An incision was made at the anterior margin of the left sternocleidomastoid muscle, revealing a solid tumor adhering to the carotid bifurcation, without involving the vagus or hypoglossal nerves. A ligature of the external carotid at the origin was observed. Since dissection was difficult, en bloc resection of the tumor and carotid bifurcation was performed . A tempoThe second patient was a 65-year-old female from Curitiba, PR, Brazil, who complained of a tumor in the left cervical region. She reported a history of systemic arterial hypertension and hypercholesterolemia, both under control. She also reported having a meningioma adhering to the superior sagittal sinus, which had not exhibited growth since 2009. During physical examination, palpation identified an ovoid, pulsatile, and painless mass in the left carotid trigone. It was of elastic consistency, with no adherence to the deeper planes and was mobile laterally, but immobile in the longitudinal direction. There was no thrill or murmur. In common with the first case, examination of the oral cavity and a neurological examination did not detect abnormalities. The patient underwent imaging exams during the preoperative period. Color Doppler ultrasonography showed an extremely vascularized tumor with dimensions of 3.9 × 3.2 cm at the level of the carotid bifurcation, with separation of the internal and external carotids (the “lyre sign”).Surgical treatment was chosen. Under general anesthesia, a cervical incision similar to that described in the previous case description was made on the left. A solid mass was found adhering to the carotid bifurcation. Essential adjacent structures were isolated easily and the tumor dissected using the subadventitial technique with no intercurrent events  and 9. M,,According to Shamblin et al.,,,,,,With regard to work-up tests and examinations, color Doppler ultrasonography is the first choice, because it provides information that is suggestive of the diagnosis and important for screening and differential diagnosis. Cervical computed tomography or, better still, magnetic resonance imaging, are the examinations of choice for obtaining data on location, extension, correlation with adjacent structures and vascular nature of the tumor.,,,Surgery is the treatment of choice, bearing in mind the possibility of malignant transformation, peritumoral invasion and metastasis. The most widely-used technique is subadventitial dissection of the tumor (Gordon-Taylor).,During the procedure, before dissection, it is very important to identify and fully expose all nerves, avoiding excessive handling.,,,Overall complication rates vary from 32 to 44% and mortality rates vary from 8 to 20%.,,Embolization can be employed in cases of large tumors, which will reduce blood loss and the size of the tumor and improve the results of surgery, but the risk of cerebral embolism cannot be ruled out.


A 38-year-old black male patient was admitted with diarrhea and nausea over two days and aggravating pain in the meso- and epigastium that resolved after urination. He had no surgical history and only an episode of pulmonary tuberculosis five years earlier, for which he was properly treated. Physical examination revealed a tender and distended abdomen with clangorous sounds. His temperature was 36.1°C. Routine laboratory blood analyses were normal. An abdominal ultrasound revealed diffuse distention of the small intestine. A computed tomography (CT) scan showed a conglomerate of dilated small bowel loops in the meso- and hypogastrium, suggestive for a supravesical mechanical small bowel obstruction. Peritoneal thickening was seen in the right epigastrium Figure . ExtensiAbdominal cocoon, or sclerosing encapsulating peritonitis, is a rare cause of intestinal obstruction which usually remains undiagnosed pre-operatively. The condition is divided in a primary or idiopathic form and a secondary form which is mostly seen after chronic ambulatory peritoneal dialysis, infection, or auto-immune disease that provoked a peritoneal inflammation. The condition is clinically characterized by an acute or sub-acute intestinal obstruction. Despite the fact that CT is mostly performed pre-operatively, the condition is often overlooked. Retrospective analysis of the images reveals the typical finding of abdominal cocoon as a concentration of the whole small bowel to the center of the abdomen encased by a soft tissue-density mantle, mimicking a cocoon. This coiling of the small bowel in a concertina-like fashion has been described as a “cauliflower-sign”. Other CT features include signs of obstruction, agglutination and fixation of intestinal loops, mural thickening, fluid collections, peritoneal thickening and enhancement .In most of the cases, adhesiolysis is indicated. Perioperatively, a well-formed membrane is found covering or encasing the small intestine. Although the disease primarily involves the small bowel, it can involve other organs, such as the large intestine, liver, and stomach. Adhesiolysis and stripping the membrane of the intestine is usually easy and effective, hereby resolving the kinking and mechanical obstruction.In the case described herein, we hypothesized that the abdominal cocoon-related obstruction was a late symptom of an earlier episode of tuberculosis with intra-abdominal manifestations. This was confirmed histologically since the primary or idiopathic form is mostly found to consist of a thin mesothelial layer, whereas the secondary form is described to be a thick fibrous structure that includes inflammatory cells – as found in our case – due to a previous episode of inflammation.The authors declare that they have no competing interests.


Sinonasal inverted papilloma is a relatively rare disease; however, it is prevalent enough for every ENT practitioner to encounter it several times throughout medical routines. Despite the developments in experimental and clinical medicine as well as surgical techniques, our knowledge of this disease is still inadequate. With improved imaging and better diagnostic techniques, proper diagnosis and qualification for surgical approaches leave no doubt. Although the endoscopic approach seems to be the gold standard for such condition, some cases may additionally require an external approach. Regardless of the type of surgery, postoperative management is crucial for both healing and long-term follow-up. Unfortunately, the procedures are still lacking in explicit and standardized postoperative management guidelines. Moreover, an important issue is still the need for a biomarker indicative of inverted papilloma and its malignant transformation. Several particles, within the spotlight of the researchers, have been SCCA, Ki-67, Bcl-2, Wnt proteins, and many more. Nevertheless, the topic requires further investigations. Sinonasal inverted papilloma (IP) was first described in 1854 by Ward and belongs to a rare group of Schneiderian papillomas—benign tumors deriving from the Schneiderian membrane—the embryonal ectodermal remnant forming the boundary between the nasal and sinus mucosa . It may Obviously, the diagnosis of IP needs histopathological verification. It is usually possible to take the material with the use of nasal and/or sinus endoscopy. The procedure allows clear imaging of IP as a pink/grey/brown polypous, soft tumor with nontransparent and uneven surface , 8 Figu. DependiCT scanning does not allow, however, for explicit differentiation between soft tissues and secretions retained within the sinuses, which may result in overinterpretation of the extent of the lesion. In order to ensure an appropriate surgical method, it is suggested to perform complementary, preoperative nasal endoscopy or, if the tumor extends beyond the endoscopic range , to complement the investigations with contrast-enhanced MR  and desi  T1: tumor restricted to the nasal cavity only  T2: tumor restricted to ethmoid cells and/or medial wall of the maxillary sinus  T3: tumor extending to the lateral, inferior, superior, anterior, or posterior wall of the maxillary sinus or penetrating the sphenoid or frontal sinus  T4: tumor extending beyond the sinonasal boundaries and any malignant tumorThe most frequent method used currently to evaluate the clinical preoperative grade is the four-stage Krouse classification, taking into account the tumor location and malignancy :  T1: tuIn 2007, Cannady et al. published the newest staging method showing correlation between anatomical extension and recurrence rate for IP managed by advanced endoscopic techniques  Table 1Table 1.The elective procedure for IP is total resection of the tumor . The surThe key issue is qualification of the patient for a proper method of the surgery which is supposed to remove a lesion radically, with special regard to the ossified foci . ESS hasThe major cause for recurrence of the disease, or rather failure to cure it, is in case of IP the incomplete resection of the tumor or insufficient cleanliness of the surgical margin . The ris angulus anteromedialis may appear impossible, if only via endoscopic access [The most frequent recurrence is then in tumors located in sites with difficult access, such as the frontal sinus or even the maxillary sinus, the inferior wall of which may be found far below the level of the nasal cavity floor, where radical resection of a lesion in the region ofc access , 40, 46.A condition for appropriate  surgery is to resect the tumor along with the periosteum, with special regard to the ossified focus observed upon CT scanning, that is, a potential “origin site” of the tumor , 38. MorBased on our own experience as well as the congress contributions , our center adopted a postoperative procedure, assuming follow-up every three months during the first two years after the surgery, every six months during the subsequent two years, and then once a year for at least five years, as approx. 90% recur during that very period . MoreoveIt is thought that about 9% of inverted papillomas transform into malignant tumors. The most frequent malignant tumor deriving from IP is squamous cell carcinoma . A maligLately, it was reported that MRI examination can be helpful in recognizing malignant transformation of IP. We already know that IPs in the conventional MRI should be indicated by a convoluted cerebriform pattern (CCP), a band-like region of hyperintense and hypointense signals on T2-weighted images or/and postcontrast-enhanced T1-weighted images. Recently, authors suggested that the focal loss of a CCP might be indicatory for IPs concomitant with malignancy , 50. AccThe literature available contains scarce information on the recurrence risk factors in IP  while thAlthough infection with the human papilloma virus (HPV) seems to show a documented relation with the onset of IP, the actual dependencies between HPV and pathophysiology of IP remain unclear, while the reports published are controversial , 18. HPVRestricted access, preventing accurate evaluation of the nasal sinuses, and difficulties in distinguishing an inflammatory condition from the papilloma mass upon imaging (both in the primary disease and during the follow-up of recurrence) indicate the need for an independent marker to establish explicitly the presence of IP itself as well as possible transformation into a malignant tumor.Among the first IP associated markers evaluated and best described is the squamous cell carcinoma antigen (SCCA). This protein belongs to the group of serine protease inhibitors, serpins. SCCA is known as a free circulatory antigen, passively released into circulation by the squamous cells . SCCA prα, and CK10 proteins, E-cadherins, and β-catenin, as well as p16, p53, EGFR proteins, cyclin D1, and PLUNC   . follow-up must be based upon frequent visits with accurate endoscopic examination and, if necessary, additional imaging and microscopic procedures.Sinonasal inverted papilloma is a statistically rare condition; however, it is prevalent enough for each ENT practitioner to encounter this disease multiple times throughout his professional routines. Although progress in experimental and clinical medicine and development of endoscopic surgical techniques extended our knowledge of IP, the treatment, diagnostics, and postoperative management demand further improvement along with better recognition of IP pathophysiology. Regardless of the surgical method selected, the


Cytology and histopathology examinations corroborated the US in 86.4% (n = 64/74) of primary and 66.2% of secondary (n = 49/79) lesions. Using US as the “criterion standard”, the sensitivity of abdominal palpation for identification of ascites and masses was 32.4% and 43.7%, respectively, while the specificity was 93.7% and 94.4%, respectively. Abdominal US is a useful preoperative modality for diagnosing acute abdominal diseases in dogs and cats. Care should be taken with interpretation of gastrointestinal perforation, omental tumors, and common bile duct rupture, as these lesions are frequently misinterpreted with US.Acute abdomen syndrome is an emergency in small animal practice that requires rapid diagnosis to determine the appropriate treatment. No studies have correlated the preoperative abdominal ultrasonography (US) findings with the clinical, surgical, cytopathologic, and histopathologic findings. This retrospective study was designed to evaluate abdominal US in the diagnosis of acute abdomen syndrome using surgery as a “criterion standard”. The most frequently misinterpreted lesions with US were also identified. The study included 50 dogs and cats with physical examination, an US diagnosis, US guided fine-needle aspiration cytology, intraoperative findings, and histopathology. Intraoperatively, 49 primary and 43 secondary lesions were identified. The sensitivity, specificity, and positive and negative predictive values for US were calculated. There was a good agreement between the US diagnosis and intraoperative findings of 86.9% (80/92), for both primary and secondary lesions ( Acute abdomen syndrome is a clinical syndrome characterized by the sudden onset of severe abdominal pain accompanied by signs and symptoms of abdominal involvement ,2,3,4. AAbdominal ultrasonography (US) is a valuable procedure for the diagnosis of a wide range of acute abdomen diseases ,3,4,6,8.The purpose of this retrospective study was to evaluate the performance of US as a pre-surgical diagnostic tool in patients with acute abdomen syndrome, and to identify the most frequently misinterpreted lesions. In addition, the ability of abdominal palpation to identify the presence of ascites or masses was evaluated. We hypothesized that abdominal US is useful pre-surgically for the diagnosis of canine and feline acute abdomen disease.The present study is similar to a previous study that described US features of acute abdomen  and a stThis retrospective study was performed at the Clinic for Small Animals Surgery of the Justus Liebig University in Giessen. Surgical and US records of dogs and cats admitted for acute abdomen syndrome were reviewed. Inclusion criteria were: animals with preoperative physical examination, US, US guided fine-needle aspiration cytology, and laparotomy. Clinical records included a complete history, breed, age (months/years), sex , weight, and duration of clinical signs (hours/days). The patient’s general condition was categorized to one of five clinical stages: undisturbed (1); slightly disturbed (2); moderately impaired (3); severely impaired (4); and anesthetized or comatose animals (5).Abdominal palpation findings were categorized into one of four groups: normal (1); tense abdomen (2); suspicion of ascites (3); and palpable abdominal mass (4).Records of thoracic and abdominal radiographs were reviewed for evidence of abnormalities involving the parenchymal organs, gastrointestinal tract (GIT), and peritoneal cavity. The US examinations were performed by one of three radiologists, each with more than four years of experience . As a routine procedure in our clinic, the linear transducer (7.5 MHz to 14 MHz) is used to image cats and small dogs (<20 kg); while large dogs (>20 kg) are usually examined with a convex transducer providing greater tissue penetration (5 MHz), typically in combination with a high frequency linear probe .Each abdominal organ was examined for size, shape, echotexture, and echogenicity. Scanning was performed in dorsal or lateral recumbency. The examination began at the urinary bladder. A standardized template for US was used for all examinations and included any identified abnormalities. Abdominal structures were considered free of abnormalities if no abnormalities were documented in the written US report. To facilitate statistical analysis, the final intraoperative and US diagnoses were recorded in an excel file with a numeric system . The numeric system included 20 different diagnoses and one to three diagnoses were listed for each patient. The intraoperative findings were classified according to the anatomical location and gross pathology. The intraoperative reports included the surgeon’s remarks and the techniques used. The intraoperative findings were classified as primary or secondary lesions, as designated by the surgeon, and according to the organs involved.A primary lesion is the main intraoperative finding, while secondary lesions include other associated lesions. For instance, in an animal with a gastrointestinal foreign body, intestinal perforation, and septic peritonitis, the foreign body is the primary lesion, and intestinal perforation, and septic peritonitis the secondary lesions.Preoperative US guided fine-needle aspiration cytology was performed in 50 patients and postoperative histopathology in 48. Two patients were humanely euthanized during surgery at the owner’s request and no histopathology was available. Results from cytology were classified into different categories: ascitic fluid, transudate (1); ascitic fluid, modified transudate (2); ascitic fluid, purulent exudates (3); and hemoperitoneum (4). Cytologic and histopathologic findings of mass lesions were classified into six categories: benign epithelial (1a); malignant epithelial (1b); benign mesenchymal (2a); malignant mesenchymal (2b); lymphatic malignancies (3); neuroendocrine malignancies (4); purulent inflammation (5); and inflammatory or hyperplastic (6).p < 0.05 was considered statistically significant.Statistical analysis was done with the statistical program packages BMDP  and BiASn = 28) had clinical signs for less than three days. In most cases, nonspecific clinical signs including vomiting, abdominal pain, lethargy, anorexia, weight loss, and depression were reported. On physical examination, patients were undisturbed (n = 11), slightly disturbed (n = 12), moderately impaired (n = 12), severely impaired (n = 13), and anesthetized (n = 2).Fifty animals met the inclusion criteria. There were 33 dogs (66%) and 17 cats (34%). Thirty-three animals were male (66%) and 17 were female (34%). The mean age of the dogs was 7 ± 4.6 years , and that of the cats was 5.7 ± 4.7 years . The mean weight of dogs was 19.7 ± 13.3 kg  and that of cats was 4.6 ± 1.5 kg . The mean duration of clinical signs prior to presentation was 2.9 ± 1.7 days in dogs , and 4.3 ± 3.7 days (range 2 h to 10 days) in cats. On the day of the first examination, 56% (n = 38) and identified an abdominal mass (n = 14), ascites (n = 11), and tense abdomen (n = 13). The abdomen was palpably normal in 10 animals. Ultrasound was used to confirm abdominal palpation of ascites or masses. Palpation of fluid had a sensitivity of 32.4% (CI: 17.4–50.5%) and specificity of 93.7% (CI: 69.7–99.8%) (p < 0.05), but no significant relationship between palpation and US detection of an abdominal mass (p > 0.05).Abdominal palpation identified acute abdominal disease in 76% of patients (7–99.8%) . Palpatin = 26), the peritoneum and peritoneal cavity , and pancreas . Secondary lesions were most commonly located in the peritoneum and peritoneal cavity , gastrointestinal tract , and spleen .Ninety-two intraoperative lesions (49 primary and 43 secondary) were documented. The preoperative diagnosis in one case was an intestinal foreign body. However, at surgery, the abdomen was normal. Intraoperative findings are summarized by anatomical location in n = 8), splenic tumors (n = 2), kidney tumors (n = 2), nonspecific intra-abdominal mass (n = 2), liver mass (n = 1), and intussusception (n = 1) were suspected by radiography.Thoracic and abdominal radiography did not identify the primary lesion in 71% (35/49) of cases, while secondary lesions were not identified in 41.8% (18/43). Normal radiographic findings were reported in 36% (18/50), while loss of serosal detail was the most common abnormal finding in 32% (16/50). Gastrointestinal obstructions (p < 0.0001). The sensitivity, specificity, and positive and negative predictive values of US with confidence intervals are summarized in n = 64/74) and histopathology in 66.2% of the lesions (n = 49/74)  for both primary and secondary lesions (= 49/74) .n = 2), ruptured common bile duct (n = 2), and intestinal foreign body (n = 1) (n = 2), intestinal neoplasia (n = 2), pancreatic tumor (n = 1), pancreatic abscess (n = 1), and intestinal foreign body (n = 1). There was disagreement in the diagnosis of secondary lesions between the US and surgical findings in 16.2% of the secondary lesions (n = 7/43). This included omental tumors (n = 3), gastrointestinal tract perforation (n = 2), generalized peritonitis (n = 1), and an intestinal ulcer (n = 1). The primary lesions in these cases were correctly diagnosed preoperatively. A false positive diagnosis of the secondary lesions was reported in 9.3% (4/43), and included splenic tumors (n = 2), lymphadenopathy (n = 1), and pancreatic abscess (n = 1).Surgical lesions were not identified not identified by US in 13% (12/92) of lesions. False negative diagnoses were reported in 10.2% (5/49) of primary lesions. This included GIT perforation ( (n = 1) . False pn = 9), intestinal neoplasia (n = 7), foreign body (n = 5), perforation (n = 4), gastrointestinal ulcer (n = 4), and gastric tumor (n = 3). Intussusception was accurately diagnosed by US in all cases (9/9). Secondary lesions including omental masses were diagnosed in one case. Intussusceptions were confirmed histologically, with enteritis and lymphadenitis as the most reported findings. Intestinal neoplasia was suspected by US in nine cases and intestinal masses were identified intraoperatively in seven cases (7/9). Histopathology corroborated the US suspicion in five cases (5/9) of lymphoma (n = 3) and fibrosarcoma (n = 2), while purulent inflammation was documented in four cases. Four of five cases of gastrointestinal foreign body suspected with US were confirmed at surgery. In one case (1/0), a false positive diagnosis was reported by the US. In another case (n = 1), the false negative diagnosis was reported by the US. Gastrointestinal perforation location was not detected with abdominal ultrasound (0/4).Lesions of the gastrointestinal tract were reported in 34.8% (32/92); 53% (26/49) were primary and 14% (6/43) were secondary. The pathological conditions included intussusception (n = 3) and gastric foreign body. Gastric tumors were diagnosed accurately by US in all cases (3/3) and were identified as gastric carcinoma on histopathology. Ulcerative gastritis was reported on histopathology in the case of foreign bodies.Gastrointestinal ulcer was suspected by US and corroborated by histopathology in three cases (3/4). The etiologies were: neoplasia (n = 33/92) of lesions and included primary  and secondary  lesions. Generalized peritonitis (n = 13), peritoneal effusion (n = 9), focal peritonitis (n = 6), and omental masses (n = 5) were identified.Diseases of the peritoneum and peritoneal cavity were detected in 35.9% (n = 1) and a secondary lesion (n = 8). Cytological examination indicated a modified transudate (n = 7) and purulent exudate (n = 2). Focal peritonitis as a secondary lesion was suspected by US and confirmed intraoperatively in six cases. Cytopathology was available in one case and reported chronic necrotizing peritonitis and omentitis.Ultrasound correctly identified generalized peritonitis and peritoneal effusions in 12 of 13 cases. A history of previous abdominal surgery was reported in two animals. Purulent exudate was reported in all cases and purulent inflammation was diagnosed in the omentum, liver, and stomach. Ultrasound accurately diagnosed peritoneal effusion as a primary lesion (n = 3), 3 cm (n = 1), and 15 cm (n = 1). However, only the large (3 cm and 15 cm) omental masses were detected by US and were classified as lymphadenopathy and a splenic tumor . The masses were identified as benign hyperplasia (3/5), omental fibrosarcoma (1/5), and lymphoma (1/5).Five omental masses were diagnosed. The masses measured approximately 1 cm (n = 5) and neoplasia (n = 2) were diagnosed. Ultrasound identified pancreatic abscess in seven cases (7/5), four of which were confirmed by histopathology (4/7). In three cases, the pancreas was normal. Pancreatic neoplasia was suspected by US in three cases (3/2) but was not corroborated by histopathology.Pancreatic disease represented 7.6% (7/92) of all lesions including primary  and secondary  lesions. Pancreatic abscess (n = 5) and ruptured common bile duct (n = 2) were diagnosed. Based on US, nodular hyperplasia (n = 3), neoplastic infiltration (n = 1), and abscessation (n = 1) were suspected. Fine needle aspiration and postoperative pathology diagnosed extra medullary hematopoiesis in three cases, while hepatic neoplasia and hepatic abscess were confirmed with cytology (2/2). The bile duct lesions were not diagnosed by US (0/2), but cholangitis, pericholecystic echogenic reaction, and duct obstruction were identified.Hepatic lesions were identified in 7.6% (7/92) of lesions as primary  and secondary  lesions. Hepatic masses (n = 3), regenerating nodules and nodular hyperplasia (n = 2), and omental fibrosarcoma (n = 1) were diagnosed by histology. Splenic abscessation was diagnosed preoperatively in one case (1/5) and was confirmed with histopathology.Splenic masses represented 5.4% (5/92) of lesions as primary  and secondary  lesions. With US, malignant splenic neoplasia was suspected in six cases and confirmed in four cases (4/6). A large mass in the omentum (1/6) and normal spleen (1/6) were reported in the other two cases. Extra-medullary hematopoiesis (Lymph node disease was reported in 6.5% (6/92) as primary  and secondary  lesions. Ultrasound correctly identified all cases (6/6); in three cases, purulent lymphadenitis was the primary US differential diagnosis, followed by neoplasia; the opposite was reported in the other three cases. Histopathology confirmed the US diagnosis as purulent lymphadenitis (3/6), malignant lymphosarcoma (2/6), and undifferentiated blastoma (1/6). A false positive US diagnosis of lymphadenopathy (1/0) was diagnosed intraoperatively as an omental tumor and corroborated by histology as nodular hyperplasia of the omentum.n = 1) and urinoma (n = 1); all were accurately diagnosed by abdominal ultrasound. With histological examination, a malignant renal epithelial tumor was diagnosed in one case, and a proteinaceous granulomatous inflammatory effusion was aspirated in the case of urinoma.Kidney lesions were detected in 2.1% (2/92) as primary lesions . Ultrasound accurately diagnosed renal neoplasia  than cats , and male animals were more commonly affected  than the female animals . Our results are consistent with a large cohort study which reported that three times more dogs (n = 942) were affected than cats (n = 309), and that male animals were represented 63.1% (n = 790) of the cases [There are few studies that provide details on the species, sex, predisposition, duration of signs before presentation, and general condition of patients presenting with acute abdomen syndrome. Our study had more dogs  were classified as mildly to severely impaired at presentation, and two were comatose.The physical examination was used to triage patients with acute abdomen syndrome . In our Abdominal palpation is a component in the diagnosis of acute abdominal syndrome . DetectiSurvey abdominal radiography did not identify abnormalities in 71% of cases. In patients with peritoneal fluid or peritonitis, loss of intra-abdominal detail makes abdominal radiography less useful for diagnosis of acute abdomen . In a prn = 12/92) of lesions. The false positive diagnosis by US was reported in 11 lesions (seven primary and four secondary). A higher rate of misdiagnosis (25%) has been reported and gastrointestinal tract ulcerations and perforations were the most commonly misdiagnosed (16). The experience of the examiner and the quality of the machine are important in the interpretation of US findings, as ultrasonography is highly operator and equipment-dependent [The present study showed good agreement (86.9%) between US and intraoperative lesions. This is higher than the 64% agreement reported in a study of 100 dogs and cats  where diependent .Omental tumors were the most commonly misinterpreted lesions including two primary  and three secondary  lesions. The poor sensitivity of abdominal ultrasound for small lesions has been previously reported in human medicine. Macroscopic peritoneal lesions of less than 2 cm are difficult to identify with US and US had a low sensitivity and specificity. Ultrasound cannot replace exploratory laparotomy for the detection of small lesions .Perforation of the GIT was not identified  by US in two primary and two secondary lesions. Peritoneal effusion is a principal finding in patients with GIT perforation . UltrasoOne case of GIT foreign body was not detected by US, resulting in a sensitivity of 80%. A prospective study that assessed small intestinal obstruction using specific ultrasonographic criteria correctly diagnosed obstruction in 11 of 13 dogs . Our resBile duct rupture was not identified  as primary lesions in two dogs. Although signs of peritonitis, cholangitis, and pericholecystic echogenic reaction were detected by abdominal ultrasound, duct rupture was not listed in the differential diagnosis, suggesting that identifying pericholecystic reaction, and localized or generalized echogenic peritoneal fluid are suspicious for bile duct rupture .n = 2). However, the false positive diagnosis was reported in one case; lymph node neoplasia with pancreatitis and general peritonitis were the reported diagnoses in this case. A neoplastic pancreas may appear normal with US or may mimic or be associated with abscessation, pancreatic necrosis, or pancreatitis [Pancreatic neoplasia was documented as the primary lesion intraoperatively in two cases. Abdominal ultrasound indicated the neoplasia preoperatively ; abdominal imaging ; and cytopathological analysis.


Localization of calcified canals has always been a challenge in the field of endodontics. The following report of three cases describes a technique for the identification and negotiation of obliterated canals by use of cone beam computed tomography (CBCT) intraoperatively. Canal orifices could not be found clinically in all three cases. Gutta-percha points were placed and compacted at the position where the canal orifices were estimated to be. Intraoperative CBCT was taken, and the distance between the gutta-percha points and the canal orifices was calculated at all planes of space in the first two cases. In the third case, only one canal orifice could be identified due to obliteration of the other canals. Cone beam computed tomography (CBCT) produces three-dimensional scans of the dentition, the maxillofacial skeleton, and the relationship of anatomic structures. Endodontic applications of CBCT include diagnosis of periapical bone defects , assessmThe size of the field of view (FOV) can vary among different CBCT scanners from 3 to 4 cm up to 20 cm . TypicalThe intraoperative use of CBCT for the assessment and management of calcified canals has recently been reported . When caRecently, intraoperative use of limited FOV for intraappointment identification and localization of calcified canals was recommended ; howeverAn 83-year-old female was referred for evaluation and treatment of her right mandibular second premolar. Clinical examination revealed pain on percussion and palpation. Periodontal probings were within normal limits, and there was no mobility. The tooth was an abutment tooth, and there was an attachment on the crown for a removable partial denture. The patient's general practitioner reported previous intraoral swelling on the buccal side of the tooth and administered antibiotics (Augmentin 625 mg three times per day for 1 week). Radiographic examination revealed canal obliteration and a periapical radiolucency of the tooth . The patAfter anesthesia with 4% septocaine with 1 : 100,000 adrenaline  and rubber dam isolation , an access cavity through the crown was prepared. The pulp chamber was presented with calcification, and no canal orifice could be identified under magnification. Ultrasonic preparing was performed at the depth of the preparation in an attempt to locate the canal orifice, but it was not successful. Following that, a 0.5 mm in diameter GP point was placed and compacted at the depth of the preparation where the canal orifice was estimated to be . A cottoA 47-year-old female was referred by her general practitioner for evaluation and retreatment of her right mandibular first molar. Clinical examination revealed no symptoms. Periodontal probings were within normal limits, and there was no mobility. Radiographic examination revealed previous root canal treatment with silver points and a periapical radiolucency of the tooth. Mesial canals were obliterated and not visible . The tooAfter anesthesia with 4% septocaine with 1 : 100,000 adrenaline  and rubber dam isolation , the coronal restoration and all root canal filling materials were removed from the mesiolingual and distal canals, but the orifice of the mesiobuccal canal could not be located clinically under the dental operating microscope. Ultrasonics were used to treph along the isthmus area at a position where the orifice of the mesiobuccal canal was estimated to be. After trephing a 1 mm deep groove at the mesiobuccal canal position, the orifice could not be located. A GP point was placed and compacted at the depth of the groove . FollowiA 55-year-old male was referred for evaluation and treatment of his right maxillary third molar. The referring prosthodontist reported that the tooth had symptoms on biting and made an access cavity and placed a temporary restoration as an emergency treatment. The tooth would be used as an abutment tooth for a fixed partial denture. Clinical examination revealed a temporary restoration on the tooth and no symptoms upon percussion or palpation. Periodontal probings were within normal limits, and there was no mobility. Radiographic examination revealed canal obliteration and no apparent periapical radiolucency of the tooth . The patAfter anesthesia with 4% septocaine with 1 : 100,000 adrenaline  and rubber dam isolation , the coronal restoration was removed, and an access cavity was prepared. The pulp chamber was presented with calcification, and no canal orifices could be identified clinically under the dental operating microscope. Ultrasonic preparing was performed in an attempt to locate the canal orifices, but it was not successful. Following that, two GP points were placed and compacted where the orifices of the mesiobuccal and palatal canals were estimated to be . A cottoCalcific metamorphosis or calcification is a pulpal response to trauma characterized by rapid deposition of hard tissue within the canal space . In mostDifferent ways to locate canal orifices have been reported in the literature. The use of illumination and magnification provided by the dental operating microscope leads to easier and safer identification of canal orifices . KnowledThe intraoperative use of CBCT in complicated endodontic cases can assist the clinician in ensuring a safer procedure and a more predictable treatment outcome. However, the use of ionizing radiation should always comply with the principle of ALARA (As Low As Reasonably Achievable) in order to minimize the patients' exposure to radiation . TherefoIn the cases reported in our study, conventional periapical radiographs and the dental operating microscope could not provide sufficient information on the location of calcified canal orifices. Therefore, the intraoperative use of CBCT was necessary and proved to be vital in successfully locating the calcified canal orifices. However, a maxillary third molar case is also reported where the buccal canals were completely calcified and could not be located even with the intraoperative use of CBCT. A limited FOV was used, thus reducing the effective dose to the patient and producing higher resolution images. Additional research on the intraoperative applications of CBCT in endodontics and their impact on the treatment outcome will be needed.