Leiomyosarcomas are rare aggressive smooth muscle tumors that represent 0.1% of all colorectal malignancies. The lack of literature available concerning leiomyosarcomas presents a challenge when diagnosing and treating these tumors, thus it is crucial that we differentiate them from gastrointestinal stromal tumors (GIST), the most common type of mesenchymal neoplasms of the gastrointestinal (GI) tract, especially when considering leiomyosarcoma's high prevalence of recurrence and malignancy. In this article, we present a case of a 74-year-old male with a diagnosis of colonic leiomyosarcoma. We analyze the tumor's CT imaging findings as well as correlation with the patient's pathological findings including immunostains, size, and mitotic activity, as well as the patient's risk for recurrence. Gastrointestinal stromal tumors (GIST) are the most prevalent type of mesenchymal neoplasms in the gastrointestinal (GI) tract 2, and less than 50% tumor necrosis was observed.A 74-year-old male presented to his local hospital with complaints of persistent diarrhea over the previous 2 months, as well as intermittent rectal bleeding. An obstructing mass that could not be traversed was identified via colonoscopy. A follow-up computed tomography (CT) scan displayed a mass-like dilatation involving the short segment of the sigmoid colon, composed of heterogeneous soft tissue density, measuring 10 × 6 × 9 cm A follow-up positron emission tomography (PET) scan indicated some residual tumor at the site of the colectomy, as well as a borderline enlarged left upper paratracheal lymph node. Given a review of the available literature, gemcitabine/taxotere chemotherapy was selected as the main course of treatment. Additionally, due to the patient's concerning PET scan images and the tumor's high rate of recurrence, we advised close follow-up and regular imaging.2 are labeled as leiomyomas, and tumors larger than 10 cm with mitotic rates of 3 or greater per 5 mm2 as leiomyosarcomas This article reviews a case of colonic leiomyosarcoma, an extremely rare smooth muscle tumor commonly found in the stomach, followed by the small intestines, colon, and rectum 2), the patient's risk of progressive disease was 86%; additionally, the high rate of tumor necrosis was consistent with aggressive leiomyosarcomas We report a 74-year-old male who presented to his local hospital with frequent diarrhea and occasional rectal bleeding. Leiomyosarcomas present various non-specific symptoms including rectal and intra-abdominal bleeding, abdominal pain, weight loss, diarrhea, tenesmus, constipation, bowel obstruction, and fever CT appearance of leiomyosarcomas in this case was noteworthy because despite its nonspecific features, it was helpful in outlining the mass and determining the viability of tumor resection.The patient reported in the manuscript signed the informed consent/authorization for participation in research, which includes the permission to use data collected in future research projects such as presented case details and images used in this manuscript.


Spontaneous rupture of the Iliac Vein is very rare in practice. In over 90% of cases, the venous lesion is located on the left side. The exact etiology of this condition is unknown. Spontaneous injury of the iliac vein is thought to be favored by intense exercise, constipation, cough, labor, May-Thurner syndrome or pre-existing inflammatory changes in the venous wall are also implicated. We present the case of an 83-year-old woman who is brought to the Emergency Department for abdominal pain located in the left flank and in the left iliac fossa, which appeared after a medium physical exertion. After an emergency contrast-enhanced abdominal CT scan, the diagnosis of spontaneous rupture of the left external iliac vein is established. Surgery is performed with extreme urgency by retroperitoneal approach and due to the very precarious condition of the patient, venous ligation is done, wishing to perform a Palma-Dale venous bypass at a later time. Although a rare cause of spontaneous retroperitoneal hematoma, a non-traumatic rupture of the common or external iliac vein should be considered in patients in shock with massive retroperitoneal bleeding, accompanied by a high mortality rate.


Testicular adrenal rest tumours (TART) are found in patients with congenital adrenal hyperplasia (CAH) with the severity of testicular infiltration linearly related to the degree of enzymatic defect and subsequent compliance with treatment. We report a highly unusual case of TART in an adult patient with CAH caused by 21-hydroxylase deficiency who had not engaged with health services over a 3-year period. Typical imaging features of TART include bilateral well-defined lesions adjacent to the rete testes. However, in this rare case, the follow-up imaging found that the entirety of the testicular parenchyma had been replaced with TART and the patient had gone on to develop an adrenal nodule. As these testicular tumours are commonly misdiagnosed as primary germ tumours and tend respond well to treatment with circadian or reverse glucocorticoids, it is essential for the radiologist to be aware of both the common and more unusual imaging features appearances of TART in patients with CAH in order to facilitate early diagnosis and thus timely initiation of treatment. A 23-year-old male with a history of congenital adrenal hyperplasia (CAH) presented to the genitourinary medical clinic with right-sided testicular pain and an associated large right-sided testicular lump. He claimed to be taking prednisolone and fludrocortisone, as recommended. On clinical examination, the testes appeared diffusely swollen and were enlarged and nodular on palpation. He did not show any clinical signs of hyperandrogenism or iatrogenic Cushings syndrome. Blood profile demonstrated elevated ACTH and 17-hydroxyprogesterone levels which can be seen in untreated cases of CAH. Urea and electrolytes and 9-am testosterone were normal. These findings suggest at least partially adequate glucocorticoid treatment. The patient was sent for an ultrasound to further characterise the clinical findings.A scrotal ultrasound was performed which found that the normal testicular parenchyma had been entirely replaced with ill-defined hypoechoic hypervascular masses and were grossly enlarged bilaterally . A diffeT1 and T2 weighted imaging. Furthermore, the testicles demonstrated homogenous intense enhancement on dynamic post-contrast imaging and generalised restriction of diffusion bilaterally. The paratesticular structures and penis appeared normal and there was no evidence of significant lymphadenopathy within the imaged pelvis. This appearance was thought to be most in keeping with an unusual presentation TART, however, a primary testicular germ cell tumour could not be definitively excluded on imaging and a biopsy was performed for confirmation.A subsequent CT CAP was completed in order to rule out distant malignancy and although no discrete evidence of distant metastasis was found, the partially imaged testicles were hyper attenuating and avidly enhanced when compared to skeletal muscle . With fuFollowing biopsy , the haeFollowing formal histological diagnosis and up titration of steroid treatment by the endocrinology team, the patient had a repeat testicular ultrasound 1 year later which did not demonstrate any interval change. Subsequent to this, the patient was lost to follow-up for a 3-year duration after which he presented to the accident and emergency with acute scrotal pain and oedema. At this time, the testicular imaging appearances remained relatively unchanged, however, a new 3 cm adrenal nodule arising from the body of the right adrenal gland and a hyperplastic left adrenal gland was found on CT abdomen and pelvis .Unfortunately, following the CT diagnosis of new adrenal nodules, the patient failed to attend follow-up appointments and relocated. Most frequently, CAH is caused by a deficiency of the enzyme 21-hydroxylase which is essential for cortisol and aldosterone production within the adrenal cortex..CAH is a rare group of autosomal recessive disorders caused by a deficiency of the enzymes required for adrenal steroidogenesis and is seen in approximately 1 in 18,000 children born in the UK. In severe case of CAH, virilisation of female foetuses can be seen with male foetuses remaining anatomically normal.In both male and female cases, the clinical severity of CAH is linearly correlated with the degree of enzymatic defect. Severe disease results in reduced aldosterone and cortisol production, alongside elevated androgens. Androgen excess can cause advanced bone age and short stature while aldosterone deficiency can result in salt wasting which can be fatal in some cases. Furthermore, the excessive systemic ACTH levels result in hyperstimulation of the adrenal rest cells which have descended with the testes during embryological development leading to the formation of testicular adrenal rest cell tumour (TART) in 95% of males with CAH. Further research has also suggested that TART may also arise from testicular pluripotent cells.Lack of cortisol synthesis—and thus low systemic levels of cortisol—results in excessive ACTH release from the anterior pituitary which in turn results in hyperstimulation of the adrenal glands. In untreated, long-term cases of excessive ACTH, the adrenal glands become hyperplastic and nodular and are at an increased risk of tumour formation such as pheochromocytomas and myelolipomas. Typical MRI features of TART include discrete lesions which are hypointense relative to normal background testicular parenchyma on T2 weighted imaging and enhance avidly with gadolinium. However, in our highly unusual case—which has not been demonstrated in any previous literature—the entirety of the normal testicular parenchyma has been replaced by TART. This is thought to be a consequence of the patients poor compliance with recommended treatment which has resulted in long-term excessive systemic ACTH levels and subsequent insidious replacement of the normal testicular parenchyma by responsive testicular adrenal rest cells. Furthermore, as seen in this case, the long-term elevated ACTH levels has resulted in bilateral adrenal hyperplasia with associated adrenal nodule formation.Imaging plays a pivotal role in the diagnosis of TART. Ultrasound is used during the initial workup and typically reveals bilateral well-defined hypoechoic testicular masses which lie adjacent to the rete testes and usually do not demonstrate any internal vascularity on doppler ultrasound. Contrast-enhanced ultrasound evaluation of these lesions usually demonstrate hypervasularity. Another important differential to consider in cases of TART is that of leydig cell tumours; however, these tumours tend to present unilaterally as opposed to the bilateral nodules typically seen in TART. Leydig cell tumours can present as small, well-defined hypoechoiec intratesticular masses on B mode ultrasound. Larger lesions can show internal and peripheral colour flow whilst smaller tumours can often not demonstrate colour flow. On dynamic contrast-enhanced ultrasound, these lesions will typically demonstrate arterial phase hyperenhancement with delayed phase washout. It must be noted, however, that testicular malignancy vs a TART diagnosis may not be distinguishable on imaging alone. In our case with its unusual imaging appearances, it was essential that a clinical history, endocrine profile and histological diagnosis was sought in order to determine the final diagnosis.In such cases of extensive infiltration of the testes, one of the main differential diagnoses that must be considered is that of lymphoma or leukaemia. However, it is more usual for lymphoma of the testes to present in older adults with the majority of cases of TART presenting in childhood and early adulthood. Sonographic features of haemotological malignancy are variable and may show discrete intratesticular hypoecheoic lesions, diffusely enlarged hypoechocic testes or parallel striated hyperechoeic and hypoechoic bands radiaging from the mediastinum on greyscale B mode imaging.When considering patient morbidity, the testicular parenchymal replacement seen in cases of TART can impair both spermatogenesis and testicular endocrine function with subsequent testicular atrophy and infertility in those affected. Therefore, early recognition of TART on imaging is essential in order to facilitate prompt diagnosis and initiation of treatment. TARTs have been shown to have excellent regression with steroid treatment which in selective cases can alleviate the need for surgical intervention such as orchidectomy.TART are found in 94% of patients with CAH and should always be considered in the differential diagnosis when imaging the testes in such patients.Although TART typically appear as discrete well-defined foci adjacent to the rete testes on imaging, one must be aware of the more unusual patterns of TART especially in cases with a history of poor compliance with treatment. In this rare case, we have demonstrated that TART can insidiously replace the testicular parenchyma in its entiretyTART can have a negative impact on patient’s quality of life and is the leading cause of infertility in males with CAH. Early recognition on imaging is therefore essential for timely initiation of treatment.It is not always possible to differentiate TART from malignancy on imaging alone and clinical history, endocrine profiling and histological evaluation all play essential roles in the diagnosis.


Coexistent growing teratoma syndrome (GTS) and gliomatosis peritonei (GP) arising during chemotherapy of ovarian immature teratoma (IMT) is extremely rare and can be misdiagnosed as recurrent or progressive disease. We present a 33-year-old woman diagnosed with GTS with synchronous GP during chemotherapy of IMT. She underwent ovarian cystectomy due to ovarian immature teratoma and chemotherapy were administered. The α-fetoprotein (AFP) concentration decreased from 28.7 ng/mL to normal after the second cycle. Four days after the third cycle of chemotherapy, ultrasound and CT revealed an 8-cm mass with negative tumor markers in the pouch of Douglas. An exploratory laparotomy was conducted, and a smooth round cystic-solid 8-cm mass was noted in the pouch of Douglas. Extensive peritoneal seeding glial nodules were also observed on the surface of the uterus, peritoneum, and omentum. The patient underwent a partial omentectomy, intact resection of the tumor, and resection of most of the glial nodules. Postoperative pathology demonstrated a pure mature cystic teratoma component in the mass, as well as diffuse GP involving the uterine serosa, peritoneum, and omentum; this diagnosis of GTS with synchorous GP should be considered in IMT patients with mass newly identified during chemotherapy while tumor markers are normal after treatment. Ovarian immature teratoma (IMT) is one of the most common histologic subtypes of malignant ovarian germ cell tumors that contain tissue from all three germ layers as well as immature neural components, representing approximately one-third of cases ,2. When GTS and GP often occur after initial surgery or chemotherapy but can sometimes develop during chemotherapy , which mA 33-year-old woman at 34 weeks gestation presented to the Xuanwu hospital emergency department with severe abdominal pain on the end of November 2021. 5-cm bilateral ovarian teratomas had been noted in May 2021, but she had no further interventions as she was in her first trimester at the time. A diagnosis of ruptured ovarian teratoma was established, and she had a cesarean section with bilateral ovarian cystectomy. The cesarean section was conducted to avoid second surgery within nearly 6 weeks and potential postoperative treatment may affect the fetus. She delivered a healthy female baby of 2360 g. Intraoperative exploration showed a 25 × 25 × 20 cm multilocular tumor with a dominant solid component in the right ovary, along with a 7-cm cystic mass arising from the left ovary; moreover, the tumor in the right ovary was ruptured and actively bleeding. Fast frozen pathology of the right ovarian tumor revealed no malignant components, and the left ovarian cyst also ruptured during resection. The estimated blood loss was 1000 mL, and she was transfused 2 U of red blood cells. Paraffin pathology confirmed that most of the right ovarian tumor was composed of mature teratoma with focal primitive neuroepithelial elements , consistA right ovarian immature teratoma, grade 2, stage IC2 was diagnosed based on the FIGO stage classification for ovarian tumors. A chemotherapy regimen including bleomycin, etoposide, and cisplatin (BEP) was given for three cycles based on the NCCN clinical guidelines for ovarian germ cell tumors. AFP levels quickly decreased from 27.8 ng/mL to normal after two cycles of chemotherapy, and the last cycle was completed in mid-March 2022. The serum CA19-9 was less than 2 U/mL before surgery. Repeat ultrasonography conducted one month after the surgery did not show any abnormalities, but an ultrasound examination on five days after the last cycle of chemotherapy showed an approximately 8-cm solid cystic mass located in the left posterior uterus. The patient was then referred to our hospital. A repeat blood draw showed that serum AFP, CA125, NSE, and CA19-9 were all within normal ranges. Recurrence of immature teratoma and progressive disease could not be excluded. Further ultrasonography conducted by an expert demonstrated an 8.0 × 7.3 cm mixed-echo, lobulated mass with clear boundaries in the left adnexal area. The presence of lipid and hair-like echo, as well as a CDFI that revealed only scattered, short strips of blood flow signals in a small portion of the mass, were suggestive of GTS . EnhanceA suspected diagnosis of GTS was established, and an exploratory laparotomy was performed on April 2022. An 8-cm solid cystic mass with a smooth appearance and multiple nodular protuberances originating from the pouch of Douglas was found during the operation. There were no abnormalities in either adnexa, except for a 1-cm endometrioma on the right ovary, and there was no connection between the bilateral ovaries and the pelvic mass. There was extensive seeding of glial-like nodules in the uterine serosa, vesical peritoneal reflection, right pelvic wall peritoneum, and partial omentum majus . Intact The patient recovered uneventfully and was discharged three days after her operation. Comprehensive explanations about her disease condition and a further follow-up plan were made at subsequent consultations. No further adjuvant therapy was administrated, and an ultrasound was shown to be negative four months after the operation. We recommended repeating imaging evaluations, including ultrasonography and tumor maker monitoring, every three to six months.GTS and GP are two distinct entities that can occur following ovarian IMT. Current research suggests that they are both benign diseases even though they have metastatic growth potential, but the mechanism underlying their development remains unclear.Researchers have proposed two theories about the formation of GTS. The first is that chemotherapy induces a change of immature teratoma cells into mature teratoma cells. The other hypothesis suggests that mature teratoma cells survive while immature cells die following the administration of chemotherapy drugs . PublishPrevious studies have rarely presented detailed clinical characteristics of patients with synchronous GTS and GP . MałgorzThe incidence of GTS has ranged from 13% to 40% in previous reports ,16; thisGTS and GP may present simultaneously or on their own, but either way, they usually have different clinical manifestations and are subject to different treatment principles ,6. GTS cLong-term close monitoring even after GTS diagnoses should be emphasized due to the potential possibility of malignant transformation in unresected GTS. Although rare, sarcoma, carcinoid, adenocarcinoma, and primitive neuroectodermal tumor (PNET) have previously been described as malignant transformation patterns in GTS ,22,23. OGTS with synchronous GP in ovarian IMT is an extremely rare entity that may be misdiagnosed as disease recurrence or a treatment insensitivity when it arises during postoperative chemotherapy. A suspected diagnosis should be considered when IMT patients with normalized tumor markers after treatment but reveals a newly identified mass.


To date, along with the progress of new technology and computer program development, the high-resolution computed tomography (HRCT) had been applied in different clinical application, such as HRCT for coronary angiography. In the current neuroimaging reports, we present HRCT images of the head/neck of two cases, in which one had a diagnosis of benign paroxysmal positional vertigo (BPPV) and the other did not, to represent the Tyndall effect, which describes the scattering of light by particles  in the path of light and enables clinicians to see a specific signal on the HRCT images. On the HRCT image of the patient with canalolithiasis with BPPV, we could obviously see the scattering effect  in the horizontal/posterior semicircular canal; however, on the HRCT image of the other without canalolithiasis, we could not see such findings. Therefore, through the assistance of technological progress, HRCT might be beneficial in the diagnosis of semicircular canalolithiasis, which has the advantage of being noninvasive and having a low risk of complications. However, because of the disadvantages of expense and risk of radiation exposure, HRCT should be reserved for patients who are difficult to diagnose. The Tyndall effect, which is also known as Willis–Tyndall scattering, describes the scattering of light by particles in the path of light, which enables humans to see a beam of light . The TynMs. A was a 37 y/o patient with generalized anxiety disorder with long-term insomnia. In the last 1–2 weeks, she encountered psychosocial stress, and her insomnia worsened. Along with the worsening insomnia, vertigo developed and disturbed her life, leading her to visit our clinic. The physical examination showed normal findings. The neurologic examination (NE) revealed ambiguous positive findings in the fistula test, and the right supine head to lateral test induced more prominent geotrophic nystagmus than the left test. Therefore, she was referred to the general hospital to receive a general survey. As a result, none of the surveys revealed abnormalities except for head/neck HRCT images. In the HRCT image, some snowy dots were seen among the horizontal and posterior semicircular canal, which represented the scattering effect A,B. The Mrs. B was a 73 y/o patient with a history of tinnitus and insomnia. Since her husband’s death 1–2 years ago, her insomnia and tinnitus worsened. Transient dizziness was noticed when she could not fall asleep. There were ambiguous positive findings in the right-ear fistula test. She was referred to receive temporal bone HRCT to rule out the risk of inner ear endolymphatic fistula. In the HRCT images, there was neither a scattering effect among the horizontal/posterior semicircular canal nor other abnormalities detected C,D.To our knowledge, this is the first neuroimaging report providing the potential application of Tyndall effect in the clinical practice of otorhinolaryngology. The potential differential diagnosis for the neuroimage finding in Ms. A’s HRCT included fibrosis, partial volume effect, or artefact of the bony part of nearby structure. Since there is no any other evidence to approve the existence of inflammation within Ms. A’s inner ear, the possibility of fibrosis might be lower. On the other hand, the partial volume effect or artefact of the bony part of nearby structure might be a reasonable differential diagnosis in the traditional low-resolution CT, which had lower resolution. However, the initial rationale of development of HRCT was to resolve the resolution-related misdiagnosis. Therefore, although it could not be completely ruled out, the possibility partial volume effect or artefact of the bony part of nearby structure might be lower. Because of the progress of technology, the application of Tyndall effect had been used in the laboratory study to detect the suspended small particles   or nanopThere were several potential limitations in the current study to be addressed. First, this neuroimage finding should be repeatedly confirmed in a large scale case-control trial. However, because our medical institute is a clinics, we shall not collect such a huge number of cases. Second, there was one potential concern when conducted a large number study. That is the potential radiation risk by the exposure of HRCT. Therefore, this kind of case-control study should be reserved to patients who are difficult to diagnose. Third, in the current study, we did not arrange a rechecked HRCT to confirm the repositioned otoliths because of patient’s fear of radiation overdose. In addition, the selection of controls shall be a difficult issue. Because of the concerns of radiation, it was ethically dilemma to invite patients without definite indication of HRCT to receive such a examination with high radiation.The head/neck HRCT had relatively low cost and lower radiant exposure than the 3DCT of head. Through the assistance of technological progress, HRCT might be helpful in the diagnosis of semicircular canalolithiasis, which has the advantage of being noninvasive and having a low risk of complications. Based on its advantage of noninvasive, there had been studies addressing its application, although inconclusive, to detect accurate blood flow estimation . Further


Laryngoceles are abnormal dilatations of the laryngeal saccule, which rises between the ventricular folds, the base of the epiglottis and the inner surface of the thyroid cartilage. Clinical symptoms are rare, and the find of asymptomatic laryngoceles in pathology studies are frequent. Sometimes it is presented as cervical swelling causing airway obstruction in need of emergency intervention. In this study, we report a case of upper airway obstruction due to laryngocele treated by emergency tracheotomy and we review of the literature. Laryngocele complications include infection (pyocele formation), pathogens aspirations with subsequent bronchitis and pneumonia and upper airway obstruction, as in the case reported. Despite being benign tumors, laryngoceles cause relevant airway obstruction. Correct diagnosis and proper treatment can preclude emergencies as it happened to our patient hereby reported. The saccule or laryngeal ventricle appendage is usually present in most human larynxes. It exits through the anterior border of the ventricle and extends superiorly through the Paralaryngeal space, having the ventricular fold medially and the thyroid cartilage laterally. Laryngoceles are dilations of the Morgagni's ventricle sacculus, filled with air that communicate with the laryngeal lumen and may be temporarily distended by mucus.Clinical relevance is rare and it is common to find laryngoceles in postmortem exams of asymptomatic people. In other cases it may present itself as a large cervical mass that blocks the airways and needs urgent care. In this study, the authors report a case of laryngocele causing airway obstruction, requiring urgent tracheostomy, and they review the literature on this topic.Our patient was a 45 year old female, housewife, seen in May of 2002, complaining of dysphonia for 40 days, associated with snoring. She did not smoke or had any pulmonary disorder, nor had she had prior laryngeal problems. During physical exam, she had a mass in her right cervical region  and duriVirchow, in 1867, was the first to call this abnormal dilation of the laryngeal ventricle a laryngocele, however the first report of such disorder came in 1829, from a French military surgeon - Dominique Larrey.Laryngoceles may expand medially, causing a reduction in the supraglottic space called internal laryngocele. Other times it may expand laterally, reducing the supraglottic space, thus being called internal laryngocele. Other times it may expand laterally, exiting through the thyroid membrane near the internal branch of the upper laryngeal nerve, causing neck bulging, thus being called external laryngocele. About half of the laryngoceles are of the mixed type, having both the internal and the external components. It is usually unilateral, being bilateral in only 15%.Laryngoceles are more commonly found in men in a 5:1 ratio, in their fifth or sixth decades of life. Its cause is unknown, however it is associated with chronic cough, blowing in musical instruments, glass blowing and laryngeal carcinoma. Histologically we find a ciliated pseudostratified cylindrical epithelium with a varied number of goblet cells on a thin basal membraneThere is much controversy regarding the etiology of laryngoceles4. Its origins involve congenital factors, such as laryngoceles in neonates; and also acquired factors. In adults, a congenital defect or an anatomical variation of the sacculus may be the cause, as are acquired factors such are the cases of pharyngeal or laryngeal carcinomas, and people whom occupation or leisure involve raising intralaryngeal pressure, such as blowing musical instruments. However, some factors do not corroborate this statement, such as the fact that many patients do not have any predisposing factor and most of these alterations are unilateral. Laryngeal carcinoma is very likely associated with an increase in intraluminal pressure, both by obstruction of upper airways, speech effort, excessive cough and local mechanical conditions. Thus, it is important to carry out an investigation in patients with laryngocele aiming at ruling out any associated malignancy. In 1995, Thomé et al., described nine cases of laryngoceles and saccular cysts in the following patients: an army horn player, two smokers with chronic cough and two patients who used their ventricular folds to speak.Symptoms may be divided according to the type of laryngocele. In the internal laryngoceles they may interfere in speech production and cause snoring or hoarseness, and even upper airway obstruction as the case hereby presented. Other symptoms are: a foreign body sensation, sore throat and cough. In cases of external laryngoceles of the mixed type, there will be a neck mass with or without laryngeal symptoms associated.A CT scan can help distinguish between cysts filled with air from those filled with liquid and may detect a mixed laryngocele in which only one of the components, internal or external, was clinically suspected.,,Differential diagnosis include: saccular cyst, branchial cyst, neck abscess and lympho-adenopathy. Saccular cysts do not communicate with the laryngeal lumen, and it is usually filled with fluidLaryngocele complications include infection (pyocele), pathogens aspiration and subsequent bronchitis and pneumonia, infection in the lateral larynx (after rupture) and upper airway obstruction, as is the case hereby presented. In 1997, Pinto et al., described a similar case that also caused upper airway obstruction, however the patient also had chronic obstructive pulmonary disease, and this made things even worse as far as respiratory failure is concerned,Laryngocele treatment will depend on disease size and repercussion. Small internal laryngoceles and saccular cysts may be removed endoscopically or transendoscopically excised with laser, causing less edema and less post-operative adherence when compared with the conventional method. Small and recurrent internal laryngoceles, which may be associated with malignancy and large internal or external laryngoceles are removed by an external approach. Small, asymptomatic laryngoceles are followed up and only removed in case they become symptomatic or cause some cosmetic alterationDespite representing benign disorders, laryngoceles are a potential cause for respiratory obstruction that may threaten the patient's life. Proper diagnosis and handling may avoid an emergency situation, as was the case hereby presented.


No consensus exists regarding follow-up recommendations for suspected pituitary microadenoma in children. To address this knowledge gap, we investigated the growth potential of pituitary solid and cystic lesions <10 mm in children and evaluated the accuracy of magnetic resonance imaging (MRI) measurements.The children included were <18 years at first pituitary MRI and radiologically diagnosed with a non-functioning microadenoma or cyst <10 mm. Lesion size at first and latest MRI as well as all individual MRI examinations were re-evaluated.In total, 74 children, median age 12 years (range 3–17), had a non-functioning microadenoma, probable microadenoma, or cyst. Of these, 55 underwent repeated MRI  with a median follow-up of 37 months (range 4–189). None of the pituitary lesions without hormonal disturbances increased significantly during follow-up. Two radiologists agreed that no lesion could be identified in 38/269 (14%) MRI examinations, and in 51/231 (22%) they disagreed about lesion location. In 34/460 (7%) MRI measurements size differed >2 mm, which had been considered significant progression.Non-functioning pituitary microadenoma in children has small size variations, often below the spatial resolution of the scanners. We suggest lesions <4 mm only for clinical follow-up, lesions 4–6 mm for MRI after 2 years and ≥7 mm MRI after 1 and 3 years, with clinical follow-up in between. If no progression, further MRI should only be performed after new clinical symptoms or hormonal disturbances. Pituitary adenomas are usually benign lesions with a lower incidence in children and adolescents than in adults , 2. In tIn studies performed on volunteers and in unselected patients, the estimated prevalence of pituitary incidentalomas  is as high as 20–22.5% , 5. In aBoth microadenomas (diameter < 10 mm) and macroadenomas (≥10 mm) are found in children, but microadenomas are much more frequent and often found incidentally . PituitaWhen pituitary adenoma needs treatment, the choice of treatment depends mainly on the size of the lesion and hormone status. Intervention may consist of medical treatment, surgery, and/or radiation , 2. For Increased use of MRI and improved technique provides the opportunity to detect small pituitary lesions and during recent years, it has become a more common finding. Focal findings in the pituitary gland are usually adenomas and cystic lesions. Cysts are divided into Rathke’s cyst, usually situated in the midline, and off-midline cysts, which might represent a cystic microadenoma. As these lesions are often close to the resolution of MR scanners, considerable diagnostic overlap is likely.MRI protocol requires both sagittal and coronal planes in thin sections (2 or 3 mm) and small field of view focused on the pituitary gland. T1-weighted sequences before and after intravenous gadolinium contrast are crucial for evaluation of a solid microadenoma, visualized as an area with delayed contrast enhancement. A cystic lesion is depicted as a liquid-filled tumour on T2-weighted sequences or a lesion with lack of contrast enhancement on T1-weighted gadolinium sequences. Sometimes dynamic post-contrast MRI sequences highlight a small microadenoma as an area with delayed contrast enhancement, only visible during the first arterial phase of the contrast injection. Most often a pituitary adenoma is adequately demonstrated on standard acquisition after contrast administration .We have limited knowledge about the natural history of a microadenoma, including whether it presents as a microadenoma and later develops into a macroadenoma and, if so, whether its size increases over a shorter or longer period. A few studies, performed mainly in adults, found that 3–13% of incidentalomas increased in size between 18 months and 8 years –13. The The first aim of this study was to investigate the growth potential of pituitary microadenomas and cystic pituitary lesions less than 10 mm in children examined with repeated MRI scans and to evaluate presenting symptoms, hormonal status, and clinical status at the time of the first MRI. The second aim was to evaluate how accurate and reproducible detection and measurements of the pituitary microadenomas and cysts were between two different reviewers on individual MRI scans.This retrospective study included children younger than 18 years old referred for a dedicated MRI scan of the pituitary gland between 2007 and 2017 at Skåne University Hospital, Sweden. The initial patient cohort consisted of 696 patients identified through a search in Picture Archiving and Communication System (PACS). MRI statements and actual age at first examination were checked, and 614 patients were excluded for the following reasons: ≥18 years old, craniopharyngioma diagnosis, lack of pituitary pathology, macroadenoma, microadenoma-producing ACTH, GH or TSH, or incomplete examination. Children with a prolactinoma were included, as we also wanted to explore the methodical accuracy of visualizing the size of lesions, and all of these had repeated MRI scans. As a result of this registry search 82 patients met the inclusion criteria – i.e., <18 years old at first MRI, radiological diagnosis of a non-functioning pituitary microadenoma or cyst <10 mm, or prolactinoma. An additional 11 patients were included from a search in the medical diagnosis registry – ICD D352 (benign pituitary tumour) and D443 (tumour with unknown/uncertain nature in the pituitary gland) – in BORISS (Paediatric Oncology Register in the South Region of Sweden) and in medical records. Seven of the initial 93 patients were excluded after review due to pituitary lesion being ≥10 mm, a diagnosis other than the included ones, or no medical records available. In the end, 86 patients were included in the study, which included 12 patients with a prolactinoma , and prolactinoma (pituitary lesion and elevated prolactin). We used the term probable microadenoma when the original report revealed some uncertainty in the finding, but a follow-up was planned. The suggested diagnosis of the lesion at the initial and final scan was noted.For each patient, the following clinical data were collected from the medical records: presenting symptoms, first MRI scan, and probable diagnosis, treatment, and planned follow-up, results of ophthalmological examination, surgery, and histopathological examination, and data regarding sex, age, weight, and height. Serum hormone levels were also noted  at the initial MRI.The size of the lesion at the first and most recent MRI was reviewed by an experienced neuroradiologist since the lesion’s size was not always well described in the original MRI report. When patients had multiple MRI examinations, a change in size of >2 mm was considered a progression or reduction of lesion size.All individual MRI examinations were independently re-evaluated by two neuroradiologists – a senior neuroradiology resident with more than 7 years of radiological experience and a neuroradiologist with more than 20 years of experience. The MRI scans were randomly assigned with a unique number and all examinations were evaluated in a random order. Both reviewers were blinded to all clinical information, including the time of examination and whether other examinations existed for the same patient. The pituitary gland was divided into quarters in the coronal and in the sagittal plane. Each reviewer was asked to report if they could identify the lesion within the pituitary gland, and, if a lesion was seen, to note what quarter in the pituitary gland the lesion was located. In patients where both reviewers indicated the same location it was considered likely that the same lesion was observed. At last, for evaluation of inter-observer agreement the reviewers’ measurements  were compared. An estimated difference in size of >2 mm was noted – i.e., a difference in size in two consecutive scans was considered a progression. The same calculation was performed for a difference of >3 mm. The differences were compared for the subgroups microadenoma, probable microadenoma, cystic lesion, and prolactinoma. Technical data from the MRI such as field strength, sequence type, and slice thickness were noted together with the size and appearance of the tumour . MRI examinations performed at 1.5 T and 3.0 T were included.MRI parameters were somewhat heterogeneous but generally included a small field of view, T1- and T2-weighted sequences of the pituitary gland, with gadolinium-enhanced coronal and sagittal T1-weighted sequences, and slice thicknesses of 2 to 3 mm with little or no interslice gap. After these assessments were completed, the individual scans were again assigned to the individual patient in chronological order for statistical analysis of the diagnosis suggested in the primary report.The study was approved by the Regional Ethics Committee, Medical Faculty, Lund University, Sweden / (Dnr 2017/849).Descriptive data were expressed as count, percentage, and median (minimum–maximum). For all MRI examinations, the largest dimension of the pituitary lesion was used for statistical analysis. For inter-observer agreement of the lesion size, kappa (95% CI) were calculated separately for microadenoma, probable microadenoma, cystic lesion, and prolactinoma . All analyses were performed in Stata SE 16.0. Confidence intervals (CI) were set to 95%.n = 48, 65%) were pubertal  and growth disturbances . Of these 74 children, 32 had received hormonal treatment , with a median follow-up time of 37 months 4–189 months)  were females and their median age at the initial MRI was 16 years  in Fig. In eight cases, the lesion was assessed primarily as a microadenoma Fig. , median In 35 patients, the lesion was initially assessed as probable microadenoma Fig. . The medIn 12 patients, the lesion had mainly cystic characteristics Fig. . At the Of the 12 patients with a prolactinoma, the median size at initial MRI was 6.0 mm (range 4.8–8.8 mm), and the median size at the latest MRI was 3.9 mm (range 0–6.4 mm) Fig. . Three . Of the remaining 231 examinations, the reviewers reported 180 (78%) lesions in the same quarter; that is, for 51 (22%) of the MRIs, the reviewers could not agree on lesion location. At validation of the accuracy of the MRI lesion size measurement, the median of all measurements in all three dimensions and the differences in measurements between the reviewers were calculated. All examinations where both reviewers reached an agreement concerning lesion location were identified and presented as a proportion of all reviewed examinations. The median height, width, and depth of the lesion measured by both reviewers is shown in Table In 46 of 86 patients, both reviewers and the primary report noticed the lesion within the same location in the pituitary in all examinations in the same patient. Thus, in 40 patients (46.5%) there was disagreement between the reviewers themselves and/or the primary report. In the two cases with lesion enlargement, both reviewers agreed with the primary report.In this retrospective study, we observed the growth potential of distinct or probable pituitary non-functioning microadenoma and cystic lesions. We also tested the measurement accuracy of the pituitary lesions, which has not been performed in previous studies, and therefore a few children with a prolactinoma were included. Among 55 children with at least one follow-up MRI, we found that non-functioning microadenoma and cysts showed small size variations, often below the spatial resolution of the scanners. In one case, there was a small increase in size over five years. In no case did the MRI surveillance finding change clinical management.Data revealing the natural history of pituitary microadenoma/incidentaloma are still scarce, but the risk of pituitary apoplexy, visual field deficits, and endocrine dysfunction seems low in small lesions . In adulThere are only four published reports that include follow-up MRI of small non-functioning pituitary lesions in children , 14–16, To our knowledge validation of the MRI accuracy, regardless of field strength (1.5 or 3 T), in detection of microadenoma has not been studied previously. In the assessment of randomized, individual MRI scans in our study, there was disagreement both between the two reviewers and between the two reviewers and the original report regarding lesion size and location. In many MRI exams (22%), the radiologists could not even agree on the location of the lesion. We found that both reviewers agreed on size in most cases, but in 7% of the measurements, they disagreed to an extent that would have been considered tumour progression. The MRI technique has obvious limitations in measurement accuracy for small pituitary lesions. Three out of the four previous studies assumed that the original radiological assessment was accurate, although the size and changes in size of many lesions are close to the spatial resolution of MRI scans. One can question the accuracy of such measurements, especially when comparing consecutive measurements where we have the bias of knowing a lesion’s location and size from a previous report. Indeed, in the second part of our study we have shown that the randomized assessment of a single scan by two neuroradiologists may vary considerably. The inter-observer agreement was less accurate with the high field strength (3 T), possibly because 3 T scanners, even though they have better spatial resolution, are more prone to artefacts caused by motion, vascular flow, and susceptibility .Unnecessary MRI examinations may not add any decisive clinical information. MRI with contrast enhancement carries a risk for gadolinium brain depositions with a potential, albeit unknown, of neurotoxicity . AnotherTo our knowledge, there are no available consensus guidelines for children. The Endocrine Society 2011 formed guidelines for clinical and radiological follow-up for pituitary incidentaloma in adults .A limitation of our study is its retrospective design, limited follow-up time, and sample size. On the other hand, strengths are the re-evaluation of lesion size and the assessment of detection and measurement accuracy of MRI as a method in this patient cohort.In conclusion, the probability of progression for a small non-functioning pituitary microadenoma or cystic lesion in the short term is very small. The measurements that these assessments are based on are fraught with methodological limitations, as described above. Current knowledge suggests that the risk of progression of size that causes endocrine dysfunction is low in small lesions. Until there are more studies about the natural cause and risk of long-term growth of a microadenoma, we suggest the following protocols: lesions <4 mm only clinical follow-up, lesions 4–6 mm for MRI after 2 years and ≥7 mm MRI after 1 and 3 years, with clinical follow-up in between. The follow-up MRI can be performed without gadolinium as significant change in size and shape can be visualized without contrast enhancement, and cystic lesions are also well visualized this way. If no progression is observed, further MRI examinations should only be performed if there is clinical evidence of new symptoms or hormonal disturbances.Supplementary Table 1Supplementary Table 2


Lipomas are the commonest benign tumour, made up exclusively of adipose tissue, and can arise anywhere in the body. However, giant lipomas of the hand, defined as >5 cm in diameter, are rare. They have the potential to invade into surrounding areas and cause a multitude of symptoms due to the compression and proximity of underlying structures. We describe a case of a 64-year-old woman who presents with a swelling of the left thenar eminence, associated with numbness and tingling in all fingers. Magnetic resonance imaging and nerve conduction studies confirmed the diagnosis of a lipoma causing median nerve compression. The patient underwent elective surgical excision with good postoperative recovery. The excised lesion, measuring 12 × 7 × 2.4 cm, is one of the largest giant lipomas of the hand reported in literature, and the first to demonstrate invasion from the mid palmar space into both the dorsal sub-aponeurotic space and carpal tunnel. Lipomas are the commonest benign tumour, made up exclusively of adipose tissue, and can arise anywhere in the body . They moGiant lipomas of the hand, defined as >5 cm in diameter, are extremely rare, and tend to develop in the thenar/hypothenar spaces. They can progressively enlarge and cause symptoms of pain and nerve compression and require surgical excision due to the risk of malignant transformation , 3.We describe a case of a giant, multicompartmental lipoma occurring in the left palm of a 64-year-old woman. This case is one of the largest giant lipomas of the hand reported in literature, and the first to demonstrate invasion from the mid palmar space into both the dorsum and carpal tunnel, thus representing a significant surgical challenge.A right hand dominant, 64-year-old woman, with a background of hypertension, was referred to our tertiary care unit with a 9-month history of progressive swelling of the left thenar eminence. She complained of reduced sensation and paraesthesia predominantly in the radial three digits, as well as a reduced range of movements of the thumb.Physical examination revealed a non-tender, soft, palpable mass, measuring 3 × 3 cm, over the volar aspect of the left thenar eminence, with limited flexion of the interphalangeal joint of the thumb. Neurological examination demonstrated reduced sensation in the radial three and half digits of the left hand, with reduced grip strength on the ipsilateral side.The patient underwent nerve conduction studies, which suggested a carpal tunnel lesion on the left. Magnetic resonance imaging (MRI) of the left hand confirmed the presence of a large, lobulated and well-defined fatty lesion in the palm centred between the flexor tendons and metacarpals, with dorsal and volar extensions , and a pThe patient underwent an elective marginal excision under brachial plexus block and tourniquet haemostasis. A volar approach with an extended carpal tunnel release was utilized to access the lesion . Given tHistopathological analysis of the soft-tissue lesion revealed sections showing lobules of mature adipocytes, consistent with a diagnosis of lipoma. There were no features of malignant change. The patient was seen in our hand dressing clinic 3 days postoperatively, whereupon the drain was removed, and wound was noted to be healing well. At the 1-month postoperative review, the patient reported complete resolution of paraesthesia with partial functional recovery including improvement in mobility of all digits and grip strength.Although lipomas represent the most common soft-tissue benign mass in the body, their incidence in the hand is nonetheless rare, accounting for between 1 and 3.8% of all lipomas . The difOnly a handful of case reports and case series have been published demonstrating nerve compression of the upper extremity due to a giant lipoma . Our casThe risk of malignant transformation of giant lipomas is extremely rare; hence, surgical treatment using en bloc marginal excision can provide excellent postoperative recovery, especially in cases of functional impairment including the presence of neurological symptoms . TypicalThe authors declare no conflict of interest and no funding.


Lymphangioma, a rare benign tumor of the lymphatic system, is called lymphangiomatosis when it involves >1 organ, which is more rarely complicated with thoracic obstruction, the relationship between them remains unclear. With the development of enteroscopy, clinicians know more about small intestinal lymphangioma and attempt to treat it through enteroscopic injection sclerotherapy(EIS).A 59-year-old male firstly manifested with gastrointestinal bleeding after a gastric perforation, who was diagnosed with lymphangiomatosis by balloon-assisted enteroscopy and abdomen CT showing >1 organ with multiple cysts besides the small intestine. The patient received an EIS, then the melena disappeared. Surprisingly he came back because of refractory ascites confirmed to be chylous by chemical tests 7 months later.Lymphangiography could not determine the location of lymphatic leakage, Ultrasonography showed stenosis of the left cervical part of the thoracic duct.On the condition that medical treatment is ineffective, thoracic duct exploration and lysis of fibrous adhesion were performed.Ascites significantly reduced at last.Lymphangiomatosis is the malformation of the lymphatic system involving multiple organs, it has a possibility to be associated with thoracic obstruction. Capsule endoscopy and enteroscopy are effective methods to diagnose small intestinal lymphangioma, and EIS is an effective therapy. Lymphangioma is a benign tumor, it is composed of dilated, endothelial-proliferated lymphatic vessels and connective tissue. Small intestinal lymphangioma could lead to various symptoms including gastrointestinal bleeding. At present the disease was commonly treated by surgical excision, enteroscopic injection sclerotherapy is seldom used to treat it. We report a rare case of lymphangiomatosis. The patient originally presented with obscure gastrointestinal bleeding, who was treated by enteroscopic injection sclerotherapy (EIS) after being diagnosed by capsule endoscopy and balloon-assisted enteroscopy (BAE). The patient developed ascites recently, diagnosed as thoracic duct obstruction, and his symptoms were quickly relieved after surgical treatment.12/L and hemoglobin value of 69g/L. Subsequently the patient was arranged to undergo a BAE. Dozens of cyst-like raised lesions with dilated lymphatics on mucosal surfaces were located from descending part of the duodenum to the jejunum . It is usually asymptomatic, but with the progression of the disease, a variety of clinical manifestations can occur, such as gastrointestinal hemorrhage, abdominal pain, ileus, intussusception and protein-losing enteropathy. Abdomen CT scan can locate and diagnose lesions, judging the number and range of lesions and the relationship between lesions and surrounding tissues. With the advent of capsule endoscopy (CE) and BAE, small intestinal lymphangiomas have been diagnosed more easily and accurately. We searched related articles on Chinese and Foreign databases, only 13 casesof small intestinal lymphangioma were reported in recent 5 years (Table According to the histology, the classifications of lymphangioma are simple lymphangiomas, cavernous lymphangiomas, and cystic lymphangiomas. One view is that thoracic duct obstruction and other lymphatic diseases are parts of a systemic disease featured with systemic lymphatic hyperplasia, narrowed lumen and lymphatic leakage. Another view is that thoracic duct obstruction is the primary pathological change causing lymphatic malformations in other organs.In this case, although the pathological specimens only included small intestinal lesions, we diagnosed him with lymphangiomatosis based on his clinical characteristics and abdominal CT. Unlike the majority of reported cases, this patient is complicated with thoracic duct obstruction and developed chylous ascites. It is currently believed the diseases of cervical thoracic duct reflux disorder are associated with generalized lymphatic anomaly. In a retrospective analysis of 9 patients with lymphangiomatosis including spleen, bones, axillas, peritoneum, retroperitoneum and etc, Sun Ying et al found 5 of these patients complicated with concurrent thoracic duct obstruction.Generalized lymphangiomas leading the blood supply deficiency of intestinal musoca caused a persistent state of chronic hypoxia and inflammation. Under stress caused by surgery, due to the excitation of sympathetic nervous system, intestinal mucosal blood vessels are strongly contracted and blood perfusion is reduced, which can aggravate the damage to intestinal mucosa. We believed it is the reason why gastrointestinal bleeding occurred after the gastric perforation repair. When lymphatic malformations are generalized and persistent, the high pressure of the lymphatic system inevitably builds up. We hypothesized that the cause of ascites was a sharp aggravation in the high pressure of the lymphatic system caused by EIS.The common treatment of lymphangioma still is surgery, which can completely remove the lesions especially if they are large or diffuse. Presently physicians prefer a less invasive treatment because lymphangioma is a benign disease. EIS is mostly used in the therapy of vascular malformation. In this case, although the range of lesions was about 70cm long, gastrointestinal bleeding and anemia were cured through EIS. It supports that EIS is a feasible and effective method to treat small intestinal lymphangioma.In summary, we report a case of lymphangiomatosis diagnosed by enhanced abdomen CT scan, CE and BAE, which suffered from gastrointestinal bleeding treated by EIS and successively chylous ascites treated by thoracic duct lysis of fibrous adhesion. Lymphangiomatosis is a disease of generalized lymphatic anomaly, and as yet little is known of the causes of the disease. So more further studies about its etiology, clinical features, diagnosis and treatment are significant. When it affects the small intestine, it can cause 1or more gastrointestinal symptoms. It is necessary that this disease should be under consideration in this situation. CE can be the preferred inspection method for screening, and BAE combined with pathological biopsy can be performed for precise diagnosis. EIS is an available treatment of small intestinal lymphangioma. If CT scan reveal cystic lesions in mutiple organs and the lesions are thought to be caused by malformation of the lymphatic system, it is necessary to perform a lymphangiography to know about the specific situation of lymphatic malformation. It is not necessary to treat the asymptomatic patients, but essential to monitor for potential complications through physical examination, imaging, or laboratory test in follow-up period.Conceptualization:Rui Nie, Qian Ren.Funding acquisition:Wei Yang,Qian Ren.Supervision:Qian Ren.Writing – original draft:Rui Nie,Jie Gao.Writing – review & editing:Wei Yang,Hong Lu.


Sarcoptes scabiei. We report disseminated scabies in a 2‐month‐old girl as well as eczematoid lesions in her mother. The diagnosis was made by skin scraping and microscopic examination of the crusts. The patients were successfully treated with permethrin cream (5%).Scabies is a skin disease caused by the mite  Sarcoptes scabiei. The diagnosis was made by skin scraping and microscopic examination of the crusts. The patients were successfully treated with permethrin cream (5%).We report a case of disseminated scabies in a 2‐month‐old infant. Scabies is a skin disease caused by the mite  The infestation is transmitted by person‐to‐person contact. Sarcoptes mite is burrowed into the stratum corneum of the epidermis. The male mites die after mating and the females begin to lay eggs in the skin burrows.Scabies is caused by the mite 2A 38‐year‐old Afghan woman and her 2‐month‐old girl referred to the Shaheed Beheshti Hospital in Kashan  presented with a 2‐month history of severe night itching and cutaneous lesions. The mother had eczematoid lesions on her hands. Further examination of her mother revealed eczematous eruptions and excoriations due to scratching on her forearm. The infant had multiple excoriated papules and erythematous lesions on her abdomen, back, legs, and arms, palms and between fingers Figure . Clinica3Tinea corporis infection, infantile acropustulosis, and nutritional deficiency.Staphylococcus aureus and Group A Streptococcus pyogenes (GAS) is another complication of the infestation that can lead to acute and superficial bacterial infections, invasive bacteremia, acute post‐streptococcal glomerulonephritis (APSGN) and acute rheumatic fever (ARF).The common clinical features of scabies in infants and young children are vesicles, pustules, and nodules. Eczematization and impetigo are also common. However, lesions may be atypical may confused with acropustulosis or atopic dermatitis. In infants with poor nourishment, pruritus may be so severe and infants can be irritable.Skin scraping and microscopic examination is the usual diagnostic method of scabies. Repeated scrapings are needed because the sensitivity is rather low.Taken together, differential diagnosis of scabies should be made from other dermatitis, especially in infant and children.All authors are involved in the care of the patient. SR examined laboratory assessments. RT performed clinical evaluation and treatment procedures. AA selected the patient images and wrote the manuscript. All authors have approved the final version of the manuscript.None declared.Written informed consent was obtained from the patient's parents for publication of this report and any accompanying images.


Internal hernias through a defect in the broad ligament is an uncommon cause of intestinal obstruction and most often the finding is intra-operative. What makes it rare is when the hernia occurs through a congenital defect in the broad ligament. We present the case of a 48-year-old female patient operated on an emergency basis for intestinal obstruction and intra-operatively the cause was identified to be a herniated ileal loop through a defect in the broad ligament. There was no history of any prior abdominal surgery or any interventions and all of her children were born by normal vaginal delivery, making it a case of congenital broad ligament defect. The postoperative period was uneventful and she was discharged in good health. Protrusion of abdominal viscera through an opening within the boundaries of the peritoneum could be termed Internal Hernia , accountA 48-year-old female presented in emergency with chief complaints of colicky pain abdomen associated with on and off nonprojectile vomiting for 15 days along with absolute constipation for the last two days. There was no history of any comorbid illnesses or prior abdominal surgeries. All of her children were born by normal vaginal delivery.On examination, she was having tachycardia and showing signs of moderate dehydration and rest was normal. The abdomen was soft but distended with no guarding or rigidity. There were visible and palpable bowel loops in the lower abdomen. On auscultation, hyperperistaltic bowel sounds were heard. An initial x-ray was done showing features of small bowel obstruction. All baseline blood investigations were normal except for hyponatremia. CECT's whole abdomen was planned. But, she continued to deteriorate and was taken up for emergency laparotomy. Initially, she was resuscitated with IV fluids, IV antibiotics, continuous nasogastric tube aspiration, and other supportive measures. Once hyponatremia was corrected, she underwent exploratory laparotomy.During laparotomy, the proximal small gut was grossly distended. On, further exploration, distal ileal loops were herniating through a defect in the left Broad ligament Figure . OpinionPostoperative period was uneventful and she recovered well.EmbryologyThe joining of the Mullerian ducts is followed by the formation of broad ligaments during the embryological developmental phase and this fusion leads to the formation of the female pelvic organs. A broad ligament is, actually, a fusion of the two layers of peritoneum .AnatomyDifferent parts of the broad ligament are named based on the structures contained between the two layers of peritoneum forming the broad ligament. The largest portion is the mesometrium extending laterally from the entire surface of the uterus. The mesosalpinx drapes over both the uterine tubes and the mesovarium attach the anterior portion of each ovary to the posterior part of the broad ligament .Congenital internal abdominal hernias can either be retroperitoneal or formed through congenital anomalous openings or defects. Retroperitoneal hernias include paraduodenal 30%-53%), Winslow's foramen (8%), paracecal (6%), and intersigmoid hernias (5%), while those occurring through congenital openings can be, further, classified as transmesenteric (5%-10%), broad ligament (4%-7%) or transomental hernias (1%-4%) [3%, WinslThough congenital internal hernias are rare, this pathology needs to be considered while working up a patient with acute symptoms of bowel obstruction, with no external hernias . While iThe first reported case of such type of hernia, similar to our report, was by Quain in 1861 . LelardiBeing a phenomenon of rare occurrence, citations and articles regarding small bowel herniation through congenital broad ligament defect are rare. Management of such condition is always surgical which might include an exploratory laparotomy or a surgeon might proceed with a laparoscopic intervention. The basis of surgery is reduction of content and primary closure of the defect. If needed resection of the strangulated or gangrenous bowel might be performed and in cases of peritonitis, the need for creating a diversion might arise. In some cases, the adnexa need to be excised out.Internal herniation of the small bowel through congenital broad ligament defect is the rarest finding and a diagnostic dilemma. A keen and quick clinical assessment aided by emergency radiological facilities helps in establishing an early and timed diagnosis. Such diagnosis needs quick surgical intervention and a delay might cause any permanent damage to the herniating structure. Hence, the management is always an emergency surgical exploration.


We report a case of malignant transformation of a phalangeal enchondroma into a grade II chondrosarcoma requiring two successive transcarpal amputations owing to recurrence. Soft tissue defects were repaired using single-stage reconstruction with a posterior interosseous artery flap. The 2-year follow-up assessment was satisfactory and no recurrence was observed. Chondrosarcomas are the most common primary malignant bone tumor except for osteosarcomas . They reSites where they commonly occur are the pelvis, proximal femur, and proximal humerus in patients aged between 50 and 70 years . Hand chThese tumors are composed of cartilage-producing cells and usually present as slow-growing and painful masses. They are histologically classified into three grades: grade I or low, grade II or intermediate, and grade III or high , with thAlthough they may be primary tumors, chondrosarcomas can also result from the malignant transformation of a pre-existing lesion, such as enchondromas, multiple enchondromatosis, or osteochondromas ,7,10. BeIt is particularly challenging to manage soft tissue defects of the hand following wide-margin resection because numerous underlying structures such as bones, tendons, vascular pedicles, and nerves are exposed. Various types of hand reconstruction techniques and skin flaps have been described, to preserve limb function as well as the integrity of underlying structures; however, the posterior interosseous artery (PIA) flap is the option that was selected by us. These flaps are known to be reliable for wrist and hand reconstruction in the background of traumatic soft tissue defects  and follIn this case report, we describe a rare case of a patient initially treated with curettage and bone filling for a symptomatic enchondroma of the fourth proximal phalanx that presented with malignant transformation to secondary chondrosarcoma (Grade II) at the first follow-up at one year following initial treatment. We performed a wide resection of the 4th ray, and a recurrence of the lesion was discovered again at the 8-month follow-up, which resulted in ulnar transcarpal amputation. The hand defect was repaired using a posterior interosseous artery flap, and at the follow-up 2 years after transcarpal amputation, the clinical evaluation was satisfactory.A 66-year-old Caucasian man with no significant medical history was referred to our department of hand surgery and treated for an enchondroma of the proximal phalanx of the fourth ray of the left hand with curettage and bone filling using a cancellous allograft. Anatomopathological analysis revealed an enchondroma without malignancy.A year later, the patient presented with a mass appearing next to the metacarpophalangeal joint on the fourth ray, along with persistent pain. Standard radiographs revealed bone lysis and periosteal reaction suggestive of malignant evolution of the previous lesion’s remnants into chondrosarcoma . MagnetiUnfortunately, recurrence was observed 8 months following the resection. Local revision surgery was performed, prior to which the patient was informed of the intraoperative risk of amputation being required in the forearm. Transcarpal amputation was performed, and only the first two rays of the hand were preserved . The motThe evolution of the flap was favorable. Two years later, the patient showed satisfactory functional outcomes, without any signs of local or distant recurrence. No complications occurred at the donor sites. The patient reported no hand or wrist pain at the last follow-up. The thumb-index force was 5.5 kg and the wrist was capable of generating a force of 10 kg . The patAsymptomatic enchondromas are usually incidental findings that do not require immediate treatment. On radiographs, they are intramedullary lucent lesions with lobulated contour, endosteal scalloping, and chondroid calcification . EnchondMoreover, pain in the absence of a pathological fracture can be an important feature to differentiate LGCS from enchondromas, which are usually painless because of their slow growth, minimal peritumoral reaction, and avascularity . This diRecurrence of enchondromas is uncommon, and malignant transformation of a benign enchondroma or multiple enchondromatosis to secondary chondrosarcomas in the hand is extremely rare . Some coOur case report highlights the difficulty in differentiating between enchondromas and low-grade chondrosarcomas at the time of initial diagnosis. When in doubt, apart from standard clinical as well as radiological evaluations, MRI and histopathological evaluations should be performed. In our patient, the biopsy revealed a benign enchondroma without histological features suggestive of malignancy. Welkerling et al. reported that the same biopsy can be graded differently by different labs . This caChondrosarcomas vary from low-grade, which are relatively benign to high-grade, or dedifferentiated tumors which are associated with very poor survival rates . On the In large soft tissue defects, the primary focus is to minimize donor site morbidity and at the same time, to obtain sufficient flap coverage to preserve limb function. In our case, we chose a PIA flap as a therapeutic option for reconstruction. It was first described as a reverse-flow pedicle flap in 1986  and provIn this report, we present a rare case of a phalangeal enchondroma that demonstrated malignant transformation into chondrosarcoma. Following resection of the fourth ray, recurrence was observed despite wide-margin resection being performed, leading to partial amputation of the ulnar ray of the hand. Although chondrosarcomas rarely metastasize, local aggressiveness has the potential to result in recurrence; therefore, clinical and radiological follow-up must be performed. There is no consensus regarding the management of chondrosarcomas of the hand, and large soft-tissue defects at this site remain challenging to tackle. Based on our experience, we suggest that the posterior interosseous artery flap remains an effective option to cover ulnar soft tissue defects following transcarpal amputation in cases of chondrosarcoma. Finally, it is recommended that such cases are approached by multidisciplinary teams comprising of orthopedicians, pathologists, and oncology specialists.Written informed consent was obtained from the patient to participate in this study for the publication of this case report and accompanying images. A copy of the written consent form is available for review on request.


TS is a benign condition, whereas other causes of pleural nodules are relatively malignant, hence its diagnosis is essential in ruling out malignancies. Among the multiple invasive and non-invasive diagnostic modalities, the gold standard remains 99mTc denatured red blood cell scan, which is a sensitive test that provides an accurate diagnosis and bars the need of multiple invasive procedures.Thoracic Splenosis (TS) is a rare medical condition, where there is auto-transplantation of the splenic tissue in the thoracic cavity, often leading to pleural based nodules. Our patient is the first ever case of this condition in Pakistan, and underwent extensive diagnostic procedures as well as medical treatments, before receiving the diagnosis of TS. He underwent HRCT for chronic cough that revealed pleural and mediastinal nodules. This coupled with a vague mass in the testes led to the provisional diagnosis of metastasized testicular tumour, and later a diagnosis of pulmonary tuberculosis was made. However, eventually a  Thoracic Splenosis is a rare medical condition, with less than 100 cases reported in the literature thus far. It is defined as auto-transplantation of the splenic tissue in the thoracic cavity. The condition is usually a result of joint traumatic injury to the abdomen and diaphragm,Our case report describes one such patient of thoracic splenosis, and is the first case of this condition to be reported in Pakistan.Our patient has a history of gunshot wound at the age of 15 years. The bullet entered from the right side following a transverse trajectory to the left and then upwards into the thorax. The course of the bullet resulted in liver damage, entry and exit wound in the stomach, splenic rupture, rupture and herniation of diaphragm, and eventually exit of the bullet from the left lung causing hemopneumothorax. As a result, the patient underwent chest intubation and splenectomy. Owing to the splenectomy, the patient experienced recurrent infections in the following years, despite receiving pneumococcal, meningococcal, and H influenza vaccination. Regular blood tests also revealed high platelet count and Howell-Jolly Bodies were seen on the peripheral blood smear. Over next 10 years, however, the infections gradually decreased and the routine CBC showed normal platelet count.At the age of 33 years, the patient then started experiencing chronic cough for which investigations were done. The HRCT revealed mild central bronchiectasis, along with one soft tissue nodule in left mediastinum adjacent to cardiac apex and multiple other pleural based nodules on left side. No attention was paid to the nodules and the symptoms resolved spontaneously.Two years later, the patient again complained of non-resolving cough, along with approximately four kilograms of weight loss. A repeat CT was done and the nodules were observed again with an approximately 10% increase in size; the mediastinal nodule being the largest and measuring 2.1x1.5cm. This time, further investigations were done with regards to these nodules, including an ultrasound of whole body, followed by CT scan of neck, abdomen and pelvis. A faint doubtful hypo-echoic lesion was observed in left testes, and a provisional diagnosis of testicular tumour with lung metastasis was formed. On receiving this diagnosis, the patient started experiencing severe anxiety, and so was prescribed Escitalopram 10 mg OD as well as Propranolol 10 mg TDS.Even though the germ cell tumour markers of AFP and beta-HCG were within normal range, a thoraco-oncology multidisciplinary team discussion reached the consensus for carrying out radical orchidectomy for the testicular mass. Histopathology of the sample later showed normal tissue with no evidence of malignancy. This was then followed by a bronchoscopy that revealed chronic non-specific inflammation, which led to a differential diagnosis of pulmonary tuberculosis, for which the patient was started on anti-tuberculosis treatment. After six months of treatment, a repeat CT was done, which showed no regression in nodule size.99mTc denatured red blood cell scan) was carried out. The study revealed significant red cell accumulation in the nodules consistent with splenunculi, and thus confirmed the diagnosis of thoracic splenosis in light of current findings and history of traumatic injury. Informed consent was taken from the patient to publish these findings.The patient continued to remain asymptomatic, and went to UK where his case was reviewed at The New Queen Elizabeth Hospital Birmingham, and a denatured red cell sequestration study (Thoracic splenosis (TS) was first discovered in an autopsy of a 25-year old male in 1896,TS appears to have an advantageous function in splenectomised individuals who are immunocompromised and at an increased risk of severe infections owing to the absence of a spleen. In such cases, the auto-transplanted splenic tissue serves as an accessory spleen, and can thus decrease the risk of infections.8Confirming the diagnosis of TS is essential as pleural based nodules enlist multiple differential diagnosis, including but not limited to metastatic tumor, lymphoma, post traumatic scarring, malignant mesothelioma, infectious diseases, empyema, hamartoma, schwannoma, rheumatological lesions, atelectasis, invasive thymoma and sclerosing hemangioma.There are multiple different modalities for reaching a diagnosis of TS. Pleural based nodules on the left side of chest picked up on X-ray, CT scan or MRI, in the presence of thoracoabdominal injury especially with splenic rupture and diaphragmatic herniation, should be one of the very first indications of TS. Furthermore, the absence of Howell-Jolly bodies, Heinz bodies and siderocytes on the peripheral film, as well as a normal platelet count in splenectomised individuals should also be an indication of TS, as such individuals commonly present with increased platelet count and the aforementioned findings on smear.99mTechnetium (Tc) sulfur colloid, indium 111-labeled platelet, 99mTc denatured red blood cell, or 99mTc white blood cell. Among these, the most specific is the 99mTc denatured red blood cell scan where the uptake of the denatured RBCs can be seen even in those splenunculi that could not be identified on CT imaging, making this diagnostic method more effective than all others.10One very important non-invasive diagnostic modality for TS is that of nuclear imaging. Nuclear imaging techniques include SPECT or scintigraphy labelled with Once the diagnosis of TS is confirmed, its management is merely symptomatic if needed. Removal of the accessory splenic tissue via surgery is unnecessary as the nodules are unlikely to cause any problem besides mass effect depending upon their location. Leaving the splenic tissue in the body will also serve the benefit of combatting infections in the absence of a spleen.99mTc denatured red blood cell scan, which can diagnose even very small splenic nodules, and thus bar the need for other diagnostic or invasive procedures.In conclusion, thoracic splenosis is an important diagnosis to be considered in cases of asymptomatic pleural based nodules and history of joint traumatic injury to the thorax and abdomen, and should not be mistaken for malignant conditions that may resemble it on imaging. The most effective diagnostic technique for TS remains to be FM: Acquisition of data and reviewed the manuscript.MMM & SA: Conception and manuscript writing.AA: Acquisition of data, review and final approval of manuscript.


To present a case of intraocular schwannoma arising from the ciliary body with description of histological and immunophenotypic characteristics.A 32-year-old woman who was followed for glaucoma of the left eye and chronic renal failure at the stage of hemodialysis presented with buphthalmos and two weeks of blurry vision of the left eye. A magnetic resonance imaging exam was performed suspecting melanoma. Enucleation was rapidly performed. The histological examination after HE (Hematoxylin and Eiosin) and HEA50 (Hematoxylin and polychromatic solution EA 50) staining showed proliferation of mesenchymal monomorphic fusiform cells with eosinophilic cytoplasm and small oval nuclei which showed a tendency toward palisading. Some parts of the tumor were hypercellular with a fascicular arrangement (Antoni A pattern); other parts were weakly cellular with a myxoid arrangement (Antoni B pattern). Several Verocay bodies and a lot of hemorrhagic suffusions were described. Mitotic ﬁgures were very rare. Immunohistochemistry staining showed that tumor cells were positive for PS100 and vimentin.Although ciliary body schwannoma is extremely rare, it should be considered in the differential diagnosis of intraocular tumors. Intraocular schwannomas represent approximately 1% of the globe tumors. In most cases, the diagnosis is histological after enucleation. Here, we report histological, immunohistochemical findings of a benign ciliary body tumor treated by enucleation as malignancy was suspected, but microscopic examination of the specimen revealed a benign ciliary body schwannoma.Schwannoma is an uncommon benign peripheral nerve neoplasm that grows slowly and can occur in any location.A 32-year-old North-African woman presented with two weeks of blurry vision of the left eye. This patient was suffering from chronic renal failure at the stage of hemodialysis and was recently followed for one year for glaucoma of the left eye.At the time of her visit, the patient presented with an enlarged, buphthalmic eye [Figure 1]. There was scleral ectasia inferiorly. The cornea was cloudy with neovascularization of the iris. The anterior chamber was flat and the lens was pushed toward the cornea. The intraocular pressure was 28 mmHg.A magnetic resonance imaging exam was performed. It revealed a mass occupying the lower part of the globe at the back of the vitreous cavity without invasion of the optic nerve or the sclera [Figure 2]. A decision was made to perform enucleation with histological examination of the mass.At macroscopic examination, the eyeball weighed 12 gr and measured in diameter at 2.5 cm horizontally and 2 cm vertically. The optic nerve measured 0.5 cm in length and 0.4 cm in diameter. The anterior and posterior chambers were reduced in size. The lens measured 0.3 cm. There was a triangular-shaped tissue lesion that reached the posterior portion of the lens and appeared to originate from the ciliary body [Figure 3].The histological examination after HE and HEA50 staining showed proliferation of mesenchymal monomorphic fusiform cells with eosinophilic cytoplasm and small oval nuclei with a tendency toward palisading. Some parts of the tumor were hypercellular with a fascicular arrangement (Antoni A pattern); other parts were weakly cellular with a myxoid arrangement (Antoni B pattern). Several Verocay bodies and multiple hemorrhagic suffusions were present. Mitotic ﬁgures were very rare [Figures 4a and 4b].Immunohistochemistry staining showed that tumor cells were positive for PS100 and vimentin [Figure 5]. Intraocular schwannomas are rare and most of them are not associated with neuroﬁbromatosis, malignant transformation of schawannoma may occur more frequently in the setting of type 1 neuroﬁbromatosis. It is hard to make the diagnosis of ciliary body neoplasm based only on clinical findings, even if a magnetic resonance imaging exam is applied.Schwannoma is a benign nerve sheath neoplasm of Schwann cells that occurs sporadically in any location of the body.,5,6The MR imaging appearance of uveal schwannoma has been mentioned in just a few reports in ophthalmic literature, without accurate detailed descriptions. The few published reports describe a well-defined lesion getting enhanced after contrast administration.,8In most cases, enucleation was performed due to suspicion of malignant melanoma, but microscopic examination of the specimen revealed that the tumor was benign. Magnetic resonance imaging and noninvasive quantification of aqueous flare with the laser flare cell meter may also be helpful in the differential diagnosis of malignant and benign lesions. Fine needle biopsy and cytological examination is another alternative of differentiating ciliary body tumors. Rapid tumor growth, invasion of the anterior chamber and shifting of subretinal fluid represent some clinical signs which can suggest malignancy.,10Through clinical findings, there are several differential diagnoses of ciliary body schwannoma such as leiomyoma ciliary body melanoma, adenoma of the non-pigmented ciliary epithelium, and adult medulloepithelioma, but the hardest differential diagnosis is an unpigmented malignant melanoma which may be impossible to exclude with just clinical findings.Schwannomas have histological characteristic features: Antoni A/B area and Verocay bodies. Immunohistochemistry staining in our study showed that the tumor cells were positive for PS100 and vimentin. To our knowledge, just four more cases have been reported after that review, which makes a total of 16 reported cases.,8,11 Enucleation was performed in most of these cases as malignant melanoma was suspected [Table 1].In 1999, Kim and Chang reviewed the literature and identified 12 cases of ciliary body schwannomas.In conclusion, the diagnosis of a benign schwannoma arising from the ciliary body was made based on the histopathology exam. This tumor is very rare. Even if the clinical signs are suspecting malignancy, complementary investigations including magnetic resonance imaging, noninvasive quantification of aqueous flare, and fine needle biopsy or local excision should be performed to first determine whether the tumor is benign or malignant to avoid overtreatment by enucleation.The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for his images and other clinical information to be reported in the journal. The patient understand that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.None.There are no conflicts of interest.


Ectopic teeth can be supernumerary, deciduous or permanent, and can occur in a wide variety of locations outside of the cavity of the mouth. While supernumerary teeth are rare, supernumerary intranasal teeth are rarer. It is not clear what causes the eruption of teeth intranasally; however, trauma, infection, radiation, and developmental defects may be significant factors in their etiology. We report the case of a 33-year-old woman who presented in the otorhinolaryngology department with complaints of rhinorrhea, nasal obstruction, snoring, pain in the forehead, and bad odor that did not improve with conservative treatment. She had a history of extraction of a supernumerary tooth located in the hard palate. During the endoscopic examination, a second tooth-like body was found in the right nasal cavity, which was later surgically removed with endoscopic guidance. During the follow-up visits at three, six, and 12 months, the patient showed a significant reduction of symptoms with remaining rare reoccurrence of mild sinusitis more prominent on the left side as seen in CT scan, thus presumably unrelated to the ectopic intranasal tooth. Although an intranasal ectopic tooth is a very rare finding, it may cause significant morbidity and its removal improves the quality of life of the patient. The benefits of endoscopic removal are greater visibility, better illumination, and precision in surgical removal. Ectopic teeth can be supernumerary, deciduous or permanent, and can occur in a wide variety of locations outside of the cavity of the mouth. Supernumerary teeth generally affect 0.1-1% of the general population . There iA 33-year-old woman was referred to an otorhinolaryngologist. She complained of rhinorrhea, nasal obstruction, snoring, bad odor, and pain in the forehead that did not improve with conservative treatment. The patient could not distinguish the time when the symptoms began; however, she pointed out that rhinorrhoea and bad odor intensified in the winter. For the relief of the symptoms, the patient tried using a variety of nasal sprays and was prescribed antibiotics, though the treatment did not work. According to the patient, she had undergone extraction of a supernumerary tooth located in the hard palate during adolescence. Upon otorhinolaryngological examination, a hard, immobile, white-colored, tooth-like body was observed on the floor of the right nasal cavity. The tip of the body was surrounded by nasal mucosa, covered in fibrin Figure . An unplA paranasal sinus CT scan in the axial, coronal, and sagittal planes showed a 12 mm in length and 6 mm in width smooth mass of a homogeneous bone density with tooth-like focal radiolucency arising from the right nasal cavity floor Figure . AdditioNo irregularities of the permanent dentition were found upon dental examination; hence, the structure was diagnosed as an intranasal ectopic supernumerary tooth. The patient underwent endoscopic intranasal removal of the tooth from the right nostril, performed by an otorhinolaryngology surgeon. The surgery was performed under general anesthesia. After careful inspection of the nasal cavity, the tooth was extracted using Blakesley forceps Figure . BipolarEctopic teeth can be supernumerary, deciduous or permanent, and can occur in a wide variety of locations outside of the cavity of the mouth, such as the hard palate, maxillary antrum, mandibular condyle, orbit, coronoid process, and nasal cavity. Supernumerary teeth are a rare occurrence that affects only 0.1-1% of the general population, and the incident of such teeth is especially uncommon in the nasal cavity. Supernumerary teeth tend to grow intranasally more often than deciduous or permanent teeth . Male prA variety of clinical manifestations are associated with intranasal teeth, such as pain in the face, nose area, difficulty breathing through the nose, foul smell, headache, mild fever, recurrent epistaxis, crusting of the nasal mucosa, localized ulcerations, external deviation of the nose, nasal septal abscess, and nasal-oral fistula. Our patient presented with clear unilateral right-sided symptoms, whereas in the previously reported cases left side involvement was two times more likely . IntranaClinical and radiographic techniques are used for the diagnosis of ectopic intranasal teeth. An intranasal tooth is usually located on the floor of the nasal cavity and can be visualized through an anterior rhinoscopy or endoscopy of the nose. Erupted intranasal teeth may have an appearance of hard white masses embedded in the nasal mucosa, for which diagnosis is usually uncomplicated. ,5,8. SimSurgery is the main treatment option aimed to alleviate symptoms and prevent complications, such as osteomyelitis, nasal septal abscess or perforation, rhinosinusitis, dacryocystitis, oronasal or intraoral fistula, aspergillosis, and nasal deformity ,7. The sA supernumerary ectopic tooth is a rare phenomenon by itself, yet we report a case where the patient who previously had an ectopic supernumerary tooth in the hard palate presented with a second supernumerary ectopic tooth located intranasally more than a decade later without any clear etiology. Early diagnosis of aberrant teeth can be achieved by clinical and radiological investigations. An endoscopic extraction, which is a favorable way of treatment, is important to prevent potential morbidities and complications associated with foreign objects in the nasal cavity.


Testicular epidermoid cysts (TECs) are rare benign testicular neoplasms. Recently, testicular epidermoid cysts (TECs) are listed as teratoma of prepubertal type, however it is still difficult to differentiate the epidermoid cyst from malign testicular tumor. Therefore, we would like to report testicular epidermoid cyst at our institution.A 67-year-old man from Indonesia, presented with chronical painless mass of testis since one year ago. On physical examination obtained normal penile structure with descended testicles, palpable intrascrotal mass with size of 10 × 7 × 5 cm, firm consistency, immobile, without any tenderness, and no lymphadenophaty in groin. Scrotal USG showed intratesticular mass, homogenous parenchym, showed no vascularization during Doppler examination. Histopathological examination revealed the specimen of right scrotum with size of 12.5 cm × 8.5 cm × 6.1 cm with red-brownish colored, during lamellation, obtained encapsulated mass with size of 12.2 cm × 7.9 cm × 6 cm, hollowed space filled with porridge-like texture with capsule thickness of 0.1–0.3 cm.Epidermoid cysts are benign lesions occurring on the skin usually, however, it rarely occurs in intratesticular area. Most of the cases (60%) presented with the typical onion-ring phenomenon. Histopathological findings commonly revealed typical well-defined cyst lined by a fibrous membrane. No skin appendages are found in the cyst's lumen and no germ cell neoplasm (GCN) is present in the adjacent testicular parenchyma.All testicular masses are considered malignant until proven otherwise. It is necessary to do accurate diagnosis for the prevention of unnecessary radical orchiectomy. •All testicular masses are considered malignant until proven otherwise.•It is necessary to do accurate diagnosis for the prevention of unnecessary radical orchiectomy.•Histopathological findings of testicular epidermoid cyst commonly revealed typical well-defined cyst lined by a fibrous membrane and filled with layers of cornifying squamous epithelium and cell debris. Histologically, epidermoid cysts are true cysts with keratin layers encapsulated with a fibrous capsule and lined with simple squamous epithelium. Calcification may also be seen within the wall or the cyst The variable appearance combined with the rarity of presentation makes it challenging to establish a diagnosis of an epidermoid cyst from clinical examination and sonographic findings alone. It is essential to differentiate these benign cysts from solid intratesticular masses as the latter are invariably malignant. Although benign testicular lesions can be enucleated or managed conservatively, malignant lesions often require orchiectomy This case report has been reported in line with the Surgical Case Report (SCARE) guidelines 2A 67-year-old man from eastern Purwakarta, Jawa Barat, Indonesia, presented with chronical painless mass of testis since one year ago. Currently, the mass was getting larger in size and become firm in consistency. This complaint was accompanied by significant weight loss within two months. Patient also complained for frequent urination with weak stream and dribbling since 3 years ago and the complaint become worst during this 5 months. There was no history of fatigue, malaise, dyspnea, loss of consciousness, trauma, fever, infertility, lymphadenitis, lymphangitis, or previous history of testicular tumor. There was no history of hematuria and stone within the urine. There was no history of allergies. Patient had history of urinary catheter insertion since 5 days before when he was admitted to inpatient care of hospital nearby his hometown. Since the catheter was being removed, patient complained of anuria. Patient had history of controlled Diabetes Mellitus since one year ago. No previous history of hypertension. There was no history of similar disease in family.On physical examination obtained normal penile structure with descended testicles, palpable intrascrotal mass with size of 10 × 7 × 5 cm, firm consistency, immobile, without any tenderness, and no lymphadenophaty in groin . PalpatiThe laboratorium tests revealed anemia with Hb was 10.8 g/dL and Hematocrite was 29.2%, white blood cells of 8600 cells/μL, Platelet was 246,000 cells/μL. Ureum and creatinine were increasing, with ureum was 77 mg/dL and Creatinine was 2.60 mg/dL. Natrium was 137 mEq/L and Kalium was 3.5 mEq/L. Random blood glucose within normal limit (109 mg/dL).Scrotal USG showed intratesticular mass, without peristaltic, homogenous parenchym, showed no intralesion vascularization during Doppler examination. The right and left testis, bilateral epididymis, and bilateral spermatic cords were of normal size, shape, and echotexture .Fig. 2UlAfter assessing the testicular mass, an informed consent was taken. Thereafter left trans-scrotal orchiectomy was performed by urologist resident who experience in this field for around 3 years in operating room and specimen sent to pathology anatomy department. Histopathological examination revealed the specimen of right scrotum with size of 12.5 cm × 8.5 cm × 6.1 cm with red-brownish colored, during lamellation, obtained encapsulated mass with size of 12.2 cm × 7.9 cm × 6 cm, hollowed space filled with porridge-like texture with capsule thickness of 0.1–0.3 cm. Microscopically, right scrotum was covered with keratinized simple squamous epithelium, nuclei within normal limit. Subepithelial revealed fibrocollagenous connective tissue with inflammatory cells, lymphocyte, and histiocyte. Adnexa and hair follicle within normal limit. Cysts were found covered with simple squamous cell . After a3Epidermoid cysts are benign lesions occurring on the skin usually, however, it rarely occurs in intratesticular area The differentiation of a benign epidermoid cyst from a malignant tumor is important to prevent an unnecessary orchiectomy. This differentiation could be made by assessing with B-mode and color Doppler sonography, this assessment become essential, but often not confidently able to establish the correct diagnosis. Further biochemical and imaging investigations have been described to improve diagnostic confidence Tumor marker test results (α-fetoprotein and β-human chorionic gonadotropin) are usually negative for an epidermoid cyst, but a primary germ cell tumor of the testis also may not have elevated tumor marker values. Magnetic resonance imaging characteristics of epidermoid cysts normally mirror the B-mode sonographic appearances Most of the cases (60%) presented with the typical onion-ring phenomenon Local excision (TSS) is the treatment of choice for TEC. Orchiectomy is exceptionally required in cases with a large mass and only little remaining testicular tissue 4All testicular masses are considered malignant until proven otherwise. It is necessary to do accurate diagnosis for the prevention of unnecessary radical orchiectomy.No source of funding.Ethical approval for this study was obtained from Padjadjaran University.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Kiagus Ferry: Analysis and interpretation of data, drafting the article.Ferry Safriardi: Analysis and interpretation of data, drafting the article.Sawkar Vijay Pramod: Analysis and interpretation of data, drafting the article.Bethy S Hermowo: Analysis and interpretation of data, drafting the article,All authors have read and approved the manuscript.Not applicable.Reza Maulana.Not commissioned, externally peer-reviewed.None.