Cochlear implantation (CI) has become an option for the treatment of hearing loss after translabyrinthine resection of vestibular schwannomas. The surgical video presents the case of a 67-year-old male who had translabyrinthine resection of vestibular schwannoma with simultaneous CI and closure with a hydroxyapatite (HA) cement cranioplasty. HA cement cranioplasty can be utilized in place of abdominal fat graft for the closure of translabyrinthine approaches with similar efficacy and complication profile. To the authors’ knowledge, this is the first reported case of a simultaneous CI and translabyrinthine resection of vestibular schwannoma with HA cement cranioplasty.https://stream.cadmore.media/r10.3171/2021.7.FOCVID211The video can be found here:  The purpose of this video is to demonstrate the surgical technique regarding translabyrinthine resection of vestibular schwannoma with simultaneous cochlear implantation utilizing a hydroxyapatite cement cranioplasty for closure.Cochlear Corporation supplied a minor number of cochlear implants for the research study that this patient was a part of. There are no direct conflicts of interest with the presented case.2 Cochlear implantation after vestibular schwannoma removal has been performed previously both as a two-stage and single-stage procedure; however, there is limited data on simultaneous implantation.Cochlear implantation is a viable option for hearing rehabilitation when the cochlear nerve is preserved during translabyrinthine resection of the tumor.The typical closure after translabyrinthine resection with cochlear implantation at our institution varies, with both abdominal fat grafting and hydroxyapetite cement having been utilized. HA cement has the benefit of decreased donor site morbidity as well as improved surgical times. However, given the significant cost, cost-effectiveness evaluation is still needed. HA cement is not utilized in CI without translabyrinthine resection at our institution.The surgery presented here is of a 67-year-old male undergoing right-sided translabyrinthine excision of a 1.3 × 1.4–cm vestibular schwannoma. Gross-total resection was performed, and the cochlear nerve was kept intact throughout the surgery.This patient initially presented to the clinic with sudden hearing loss and tinnitus on the right side. Audiogram of the patient is shown below with a significant right-sided hearing loss with a word recognition score of 40%.Preoperative imaging can be seen here. Depicted is a T1 postcontrast axial and coronal MRI depicting the right-sided vestibular schwannoma.Seen here is the typical surgical positioning with the patient in the supine position and the head turned to the contralateral side. The postauricular incision can be seen here approximately 2 cm from the postauricular crease.After the postauricular incision is completed, a typical canal wall-up mastoidectomy is started. The tegmen and sigmoid sinus are decompressed and the dura is begun to be exposed.The labyrinthectomy is then started. In this case, the posterior semicircular canal is taken down initially.Further drilling of the labyrinth is completed. Seen here is exposure of the superior semicircular canal.The ampullated ends of the semicircular canals can be seen here along with the common crus and bleeding from the subacute artery.The completed labyrinthectomy can be seen here with bone overlying the IAC. Posterior fossa dura is seen exposed.Once the majority of the bony labyrinthectomy work is completed, a facial recess approach is utilized to expose the round window.Attention is then returned to the remaining bony coverage of the internal auditory canal; a superior and inferior trough is drilled in order to isolate and expose the IAC.After complete bony removal over the IAC, the dura is incised. Further dissection of the dura was completed, exposing the cerebellopontine angle.After exposure of the IAC and cerebellopontine angle, the nerve-stimulating spatula instrument is used to ensure that the facial nerve is not on the posterior aspect of the tumor. Once confirmed, tumor debulking is then begun with the intention of finding the facial nerve. Debulking is then continued using an ultrasonic aspirator.After tumor debulking is completed, the eight cranial nerve is identified proximally in the cerebellopontine angle and tumor dissection is continued from proximal to distal along the nerve, being careful to preserve the overlying blood supply.Further dissection is completed in the distal aspect of the CPA. Dissection is performed using a stimulating dissector in order to prevent injury to the facial nerve in this location.As can be seen here, the last segment of tumor is removed and gross-total resection is achieved.The eighth cranial nerve can be seen here still intact along with the labyrinthine segment of the facial nerve, which is obscured with blood.After complete resection of the tumor, the orientation is shifted to view the brainstem root entry zone of the facial nerve for final stimulation.At this point in the surgery, a dural repair substitute was placed into the defect to assist with dural closure and a well and trough was then drilled for the cochlear implant to be placed.A cochleostomy was then performed using a one-diamond burr. In this case, a Cochlear Nucleus Profile Plus with Contour Advance was placed into the cochleostomy site and the electrode is inserted. The stylet is seen being removed here.Fascia was then used to pack the eustachian tube and around the cochlear implant site; this prevents fistula formation as well as prevents the HA cement from leaking into cochleostomy site.After the cochlear implant is confirmed to be activated with neural response telemetry, closure is begun. Cranioplasty was then performed using hydroxyapatite cement.In our experience, it is important to hold and maintain pressure immediately after applying the HA cement as this prevents CSF from creating a pathway through the cement prior to the cement hardening.Of the patients at our institution undergoing concurrent translabyrinthine tumor resection with cochlear implantation, seven have had closure with abdominal fat graft and five had closure with the HA cement. One patient had a CSF leak in the HA cement group; however, this was able to be managed conservatively. A separate patient had a delayed incomplete facial nerve weakness in the HA cement group that is currently being observed.A postoperative T1 postcontrast axial MRI is shown here with gross-total resection being achieved.Postoperatively, the patient’s CNC testing in the affected ear went from 52% to 34%, demonstrating some viable hearing even after translabyrinthine excision.His AzBIO testing in both +10 and +5 signal-to-noise ratio improved from his preoperative state, demonstrating an improved ability to hear in background noise after surgery.3 It has been shown that HA cement is a viable alternative to fat grafting with no donor site morbidity and a similar complication profile.4 It has been shown to have long-term efficacy and safety with use in translabyrinthine repairs.5 A concern with HA cement includes if reexploration of the wound is required.To our knowledge, this is the first report of simultaneous translabyrinthine vestibular schwannoma resection and cochlear implantation with hydroxyapatite cement cranioplasty. Hydroxyapatite is a calcium phosphate–based biomaterial with similar properties to bone and teeth that has an isothermic reaction when hardening.In the experience of the senior author, HA cement has been easily removed and reapplied for revision cases without cochlear implantation; however, this has not been needed for a case with cochlear implantation to this point.Simultaneous cochlear implantation with translabyrinthine resection of vestibular schwannoma provides hearing rehabilitation to the patients that would otherwise have profound deafness on the affected side. The demonstrated technique is the authors’ preferred method of surgical steps, and it has been shown that cranioplasty with HA cement is a viable closure option even with cochlear implantation.Dr. Babu reports honorarium from Acclarent/Johnson & Johnson and research grants from Cochlear Corporation and Oticon Medical.Some patients who did not obtain insurance approval for simultaneous cochlear implantation received the implant provided by the cochlear implant company through research support. No financial payment was made to the authors for any part of this study.Primary surgeon: Babu, Bojrab, Jacob. Assistant surgeon: Tu, Sioshansi. Editing and drafting the video and abstract: Conway, Tu, Sioshansi, Bojrab, Jacob. Critically revising the work: Babu, Conway, Tu, Sioshansi, Jacob. Reviewed submitted version of the work: Conway, Tu, Sioshansi, Bojrab, Jacob. Approved the final version of the work on behalf of all authors: Babu. Supervision: Babu, Bojrab.Dr. Tu: Department of Otolaryngology–Head & Neck Surgery, Albany Medical Center, Albany, NY.Dr. Sioshansi: Department of Otolaryngology–Head & Neck Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.


Cases of upper tracheal stenosis due to cervical schwannoma are fairly rare; therefore, no treatment has been determined. In this case, our patient had been treated for asthma for 4 years and was admitted to our hospital because of exacerbation. Computed tomography showed a tracheal stenosis lesion just below the vocal cords, and a biopsy revealed schwannoma. Conservative therapy was preferred rather than tumour resection by surgery. Follow‐up for 5 years showed no changes on imaging. Conservative treatment is considered as an option if the extratracheal tumour does not grow. We report the diagnosis and conservative treatment for a rare case of cervical schwannoma with severe upper tracheal stenosis. Tracheal stenosis due to cervical schwannoma is extremely rare, and there is no established treatment method. Because tumours are benign, there is no consensus as to whether surgical resection or conservative treatment should be performed. We report a case of cervical schwannoma with severe upper tracheal stenosis.A 48‐year‐old woman was diagnosed with bronchial asthma and had been followed up for 4 years. There were no special notes on medical history or family history. At the time of admission, walking was possible with frequent breaks, and her level of dyspnea was considered to be IV degree modified British Medical Research Council (mMRC) according to the Fletcher, Hugh–Jones classification. There was a mildly palpable swollen tumour on the right side of the trachea and no other abnormal findings were found in blood, biochemical findings or tumour markers. Cervical computed tomography (CT) showed a solid tumour with a maximum diameter of 37 mm in the paratrachea which excluded the surrounding tissue Figure . The traThe number of cases of cervical schwannoma is relatively small, and there are no reports of surgery for upper tracheal stenosis due to cervical schwannoma. Therefore, it can be treated through multiple modalities such as primary tracheal resection or endoscopic treatment, cryotherapy, endoscopic excision and microdebridement.Akira Naomi is the primary author of the manuscript, and drafted and revised the paper. Hideyuki Hujiwara, Tatsuhiko Koizumi, Yukari Sakurai, Yasuo Kohashi, Yukiko Yoneda, Yuka Kitamura, Yoshinobu Hattori and Yuji Saitou are the attending doctors who treated the patient on admission. Yuka Kitamura diagnosed the patient pathologically. All authors read and approved the final manuscript.None declared.The authors declare that appropriate written informed consent was obtained for the publication of the manuscript and accompanying images.


Subungual melanomas are rare neoplasms that tend to debut as longitudinal melanonychia. They are primarily found in patients over 60 years of age and are usually diagnosed late, representing a diagnostic challenge. We present a case report of a 59-year-old female Hispanic patient who initially presented with melanonychia and was eventually diagnosed with subungual melanoma in situ. She was surgically treated and, after three months, remained healthy. Relevant risk factors, clinical and onychoscopic findings, diagnostic criteria, and treatment options are also discussed. Since many benign entities present similarly, high clinical suspicion is critical for diagnosing this entity. Melanonychia (ML) is defined as a black, brown, or gray pigmentation of the nail plate. It is usually caused by the activation and proliferation of melanocytes from the distal nail matrix ; howeverML has a variable prevalence between 0.8% and 23% worldwide, and it is more commonly found in Asian and African American populations .Subungual melanoma (SM) is a rare neoplasm accounting for 0.31%-2.8% of all cutaneous melanoma cases. It is primarily found in patients between 60 and 70 years of age and is commonly diagnosed late, with a poor prognosis ,6. ThereA 59-year-old Hispanic female patient presented with an asymptomatic pigmented lesion on the fifth toe of her left foot. She could not recall when she had noticed it for the first time. She did not report any history of trauma, relevant family history, or using any ointments or medications.On physical examination, a longitudinal, brown-colored, pigmented band of approximately 2 mm breadth was seen on the nail plate of the toe Figure , Panel AOnychoscopy showed a homogeneous brown pigmentation band with parallel lines, symmetrical breadth, and regular borders on the nail plate. No periungual brownish pigmentation of the cuticle (micro-Hutchinson’s sign) was observed Figure , Panel BThree months later, the lesion started to darken and become irregular; thus, a nail matrix biopsy was done. After completely removing the nail plate, the presence of pigment on the distal nail matrix was evident; therefore, an excisional biopsy of the pigmented lesion was performed Figure , Panel CSince the histological findings were subtle, immunohistochemistry was done. This showed Melan-A-positive cells and HMB45-positive cells (black arrows) Figure .Confirming the diagnosis of melanoma in situAfter discussing different treatment options, risks, and benefits, the patient was scheduled for a Mohs surgery. A wide excision with 10 mm margins was performed, achieving complete histological clearance. The patient did not show any signs of recurrence at a three-month follow-up.Misdiagnosing SM leads to an 18-month median delay in diagnosis and lower estimated five-year survival rates. It is also associated with more advanced staging at the time of diagnosis . The etiThis method can improve the early detection and survival rates of SM. As our patient did not initially have any of the associated risk factors or any of the onychoscopic findings suggesting malignancy, and only her age (she was in the sixth decade of life) was present in the ABC, she was followed up until the lesion changes were noticed during the three-month follow-up onychoscopy.There has yet to be a consensus regarding the frequency of follow-ups for ML. Some authors recommend following up every six months . HoweverIncipient ML in the fifth decade of life is concerning and can be an indication for biopsy. On the other hand, the fifth toe is not a particularly common location for SM as it is more commonly found in the thumb, hallux, or index finger . MoreoveHistopathology is the gold standard for the diagnosis of SM. According to Darmawan et al. , microscMART-1 gene found in the cytoplasm of mature melanocytes), with a sensitivity of 75% and a specificity of 96.9% for HMB45 and a sensitivity of ≥75% and a specificity of 97% for Melan A [On many occasions, identifying melanocytes in the nail matrix is difficult; consequently, immunohistochemistry can be used for confirmation. In our case, we utilized the markers HMB45  and Melan A . PRAME is a melanoma-associated antigen expressed in cutaneous melanomas and other malignant neoplasms; it has limited expression in benign tumors like benign nevi and some normal tissues  . PRAME hFor melanoma in situ, treatment options are wide local excision or Mohs micrographic surgery. The purpose is to have margins of 5-10 mm free of cancerous cells ; for thiFinally, it is relevant to mention that many primarily benign entities such as melanocytic nevi and lentigines can present as longitudinal melanonychia (LM), similar to how up to 75% of SM present during the initial stages . Hence, Subungual melanomas are rare neoplasms that tend to present similarly to benign ungueal conditions and tend to be diagnosed late, negatively impacting the patients’ survival. Hence, a high degree of clinical suspicion is essential for early diagnosis and treatment. Although some authors recommend regular follow-ups on ML every six months, changes suggesting malignancy may appear earlier, like in our case. Clinicians must be aware of the most common risk factors as well as clinical and onychoscopic findings of SM as permanent nail dystrophy can be an alarming sequela after performing a nail matrix biopsy.


We report the rare occurrence of a temporal glioblastoma multiforme (GBM) showing transdural tumor extension into adjacent mastoid cells. As the dura mater provides a barrier to intraaxial tumors, GBM seldom penetrates into the skull base, even though it is a high-grade astrocytoma with a tendency to spread. Yet, some mechanisms of GBM-induced skull invasion have been identified, making this entity a very rare but nonetheless relevant differential diagnosis in otherwise ambiguous cases of an intracerebral tumor extending into the skull base. In addition, imaging markers that may assist in distinguishing extra- from intraaxial tumor infiltration of the temporal bone are described. GBM is the most common primary malignant tumor of the central nervous system (CNS). It accounts for approximately 45% of tumors in this category, with an annual incidence of up to 5 per 100,000 persons [Although a rare finding, GBM metastases have been reported. Organs affected by extraneural metastases in GBM patients include the pleura and/or lung (60%), lymph nodes (51%), bones (31%), and liver 22%). In those cases with skeletal metastases, the spine (73%), ribs (23%), sternum (18%), skull (14%), and acetabulum (9%) were the most common sites of GBM metastases [2%. In thThe incidence of extraneural metastasis of GBM has been defined as being as low as 0.2% . PrimaryA 61-year-old male patient presented to the emergency department because of left-sided brachiofacial hemiparesis. The patient's history was otherwise unremarkable. The cranial computed tomography (CCT) on admission disclosed a right temporal mass lesion with perifocal edema and lytic changes of the adjacent petrous bone , indicatTumor resection was subsequently performed via temporal craniotomy. Neuromonitoring and 5-aminolevulinic-acid (5-ALA)-fluorescence were used during surgery.Intraoperatively, glioblastoma-like tissue with necrotic areas, thrombosed vessels, and an infiltration zone at the tumor margins was encountered. Following macroscopically complete resection, re-resection was performed under 5-ALA fluorescence, resulting in a 5-ALA-negative tumor resection cavity.Early postoperative MRI confirmed complete intracranial resection, while questionable residual tumor was disclosed in the deep right mastoid cells.Histopathology, as shown in Figures Adjuvant treatment according to the CeTeG protocol was started including standard radiotherapy with 60 Gy (30 × 2 Gy) and six 42-day cycles with oral administration of Lomustine (CCNU) on days 1 and temozolomide (TMZ) on day 2–6 . The adjOur case showed typical features of a glioblastoma: an irregularly circumscribed, contrast-enhancing tumor with central necrosis, extensive vasogenic edema, and evidence of peritumoral neovascularization.In 2009, Kwak and Shatzkes  cited alExtracranial GBM dissemination is explicable in the case of prior skull base injuries, such as craniotomies, biopsies, or shunt placement . PossiblIn our case, no previous skull base surgery was present, making iatrogenic dural defects as the route of infiltration less probable. Yet, the mastoid tegmen is known as a thin bony plate, which may develop defects for various reasons, one of which being tumorous lesions and increased intracranial pressure .In our case, we hypothesize that the combination of a rapidly growing tumor within the medial cranial fossa in combination with the low-resistance mastoid tegmen may have facilitated herniation and subsequent infiltration of tumorous tissue into the upper mastoid cells.Regarding imaging-based tumor assessment, the absence of a peritumoral cerebrospinal fluid (CSF) boundary (the CSF cleft sign) and a relatively narrow dural attachment  helped to differentiate the GBM from a common extraaxial mass such as a meningioma.Our case illustrates that in the setting of an ambiguous intracerebral tumor with transdural skull base invasion, glioblastoma represents a rare but nonetheless relevant differential diagnosis.


Nasopalatine duct cyst (NPDC) is a non-odontogenic, developmental epithelial cyst that accounts for 1% of maxillary cysts. It often arises due to the spontaneous proliferation of the epithelial tissue remnants, although trauma, bacterial infection, and mucous retention may also trigger the proliferation. Owing to its slow-growing, asymptomatic nature, the cyst is often discovered as an accidental finding during routine clinical and radiographic examinations. However, the majority of cases present as a tiny, asymptomatic swelling just posterior to the palatine papillae. Radiographically, it appears as a well-defined oval or round radiolucency in the maxillary anterior teeth region and should be differentially diagnosed with inflammatory periapical lesions and a wide incisive foramen. A pulp vitality test is essential to rule out lesions of endodontic origin. Microscopically, NPDCs display a mixed pattern of the epithelial lining and exhibit neurovascular bundles , and minor salivary glands in the cystic connective tissue, a distinctive feature facilitating a confirmatory diagnosis. Enucleation and marsupialization remain the treatment of choice. NPDC associated with impacted mesiodens is an extremely uncommon entity. A comprehensive literature search carried out on the PubMed and Google Scholar search engines revealed only three cases of NPDC with impacted mesiodens to date. The purpose of this study is to report an extremely rare case of NPDC associated with an impacted inverted mesiodens in a 19-year-old male patient who presented with an asymptomatic swelling in the maxillary anterior teeth region. To the best of our knowledge, this is only the fourth reported case of NPDC with impacted mesiodens. Supernumerary teeth refer to an extra tooth as compared to normal dentition, with a reported prevalence rate of 0.3–0.8% and 0.5–3.8% in the primary and permanent dentitions, respectively .The precise etiopathogenesis of supernumerary teeth is still debatable, although trauma, drugs, infections, radiation, genetic, environmental, and hormonal factors may serve as potential triggers that might have an impact on tooth development. Phylogenetic reversion (Atavism) theory, dental lamina hyperactivity theory, and dichotomy theory are the different recommended theories in etiopathogenesis , 3. VariStudies have demonstrated that panoramic radiographs are inaccurate in the identification of supernumerary teeth due to a narrow image layer in the maxillary anterior region and spinal superimposition , 6. AbouLocalization of supernumerary teeth is cardinal to ascertain the surgical technique and also to avert the potential iatrogenic injury to the adjacent anatomic structures during the surgical procedure . PublishSupernumerary teeth may be associated with an array of complications, such as delay/failure of permanent teeth eruption, rotation/displacement/impaction/crowding and dilacerations of adjacent permanent teeth, and mid-line diastema. Resorption of the adjacent tooth roots, dentigerous cyst, and ameloblastoma development has also been reported with supernumerary teeth , 12. DenNasopalatine duct cyst (NPDC) is a development, non-odontogenic, epithelial cyst that constitutes 1% of all maxillary cysts . Meyer iNPDC associated with impacted mesiodens is an extremely uncommon entity. A comprehensive literature search carried out on the Google Scholar and PubMed search engines revealed only three case reports of NPDC with impacted mesiodens –18. The A 19-year-old male patient presented with a slow-progressing, painless swelling in the maxillary anterior teeth region for the last 4 months. The initially smaller swelling has gradually increased with time to reach the present size. The past medical and family anamnesis was non-contributory, with no history of preceding trauma. The patient consulted a private practitioner one month back, who prescribed him antibiotics and analgesics for 7 days (tablet Augmentin 625 mg twice daily and tablet Ketorol DT 10 mg twice daily). However, the swelling persisted, and the patient visited our outpatient department. On physical examination, a diffuse swelling roughly 5cm × 5cm in size, involving the left mid-facial region, was seen. The swelling extended up to 2 cm below the left infra-orbital margin to about 2 cm inferior to the lower aspect of the upper lip with a slight elevation of the upper lip and anteroposteriorly extended from the right nasal alae to about 3 cm anterior to the left tragus of the ear. A slight superior deviation of the left nasal alae with left nasolabial fold obliteration was also noticeable. Palpatory findings elicited a non-tender, firm-hard consistency swelling with no increase in the surface temperature Figures . On intrThe maxillary anterior teeth elicited a positive response  with pulp vitality tests. Fine-needle aspiration yielded a brownish-yellow, blood-tinged cystic aspirate . An intrCone-beam computed tomography (CBCT) was advised to ascertain the extent of the lesion and three-dimensional (3D) location of the mesiodens and their relation with the adjacent vital structures. However, the patient denied the radiographic investigation due to financial constraints; thus, the exact localization of the mesiodens and its relationship with the lesion and adjacent structures could not be ascertained. Hence, in the absence of a CBCT scan, it is likely that the patient had a cystic lesion and also a mesiodens without a relationship between them.Considering the patient's age, location, and radiographic features, radicular cyst, dentigerous cyst, and adenomatoid odontogenic tumor were considered in the differential diagnosis.Surgical enucleation of the lesion was considered . A crevicular incision from the right maxillary canine to the left second molar was made, and the flap was reflected. Eight milliliters of blood-tinged, straw-colored fluid was aspirated from the cystic cavity, and impacted mesiodens was seen between the two maxillary central incisors. The impacted mesiodens was attached to the bone and not adherent to the cystic lining. Carnoy's solution was used to completely remove the cystic lining. Iodoform gauze was inserted in the cavity, and one end of the gauze was taken out from below the alae of the nose. Sutures were placed, and the enucleated specimen was sent for histopathologic evaluation Figures .The submitted hemotoxylin and eosin (H&E) sections (100×) showed a cystic epithelial lining with a fibrous connective tissue wall. The epithelial lining displayed a combination of epithelial varieties with the dominant type being ciliated pseudostratified columnar epithelium with goblet cells. Non-keratinized stratified squamous epithelium and primitive flat epithelium resembling reduced enamel epithelium were also present in places. Few areas show prominent juxta-epithelial hyalinization. The cystic wall revealed numerous mucous acini, muscular arteries, small veins, and nerves. Inflammatory cells along with cholesterol clefts and giant cells were also noted in some sections. These microscopic features were suggestive of a NPDC Figures .There was uneventful postoperative healing, and no recurrences were noted during the 3-month-periodic follow-up.Mesiodens occurring in the maxillary anterior tooth region is the commonest reported supernumerary teeth, with a prevalence of 0.15–1.9%. . They deGenerally, mesiodens has no evident manifestations and only present as an increase in the tooth number . HoweverMesiodens is usually identified as incidental findings on routine radiographic investigations or in cases where the tooth fails to erupt normally . PublishIn the present case, only 2D imaging (IOPAR and panoramic radiography) was carried out and revealed a well-defined unilocular radiolucency with impacted inverted mesiodens. However, 3D imaging (CBCT) was imperative in this case to ascertain the precise extent of the lesion and 3D location of the mesiodens, and their relation with the adjacent vital structures. CBCT could not be carried out as the patient was not willing due to financial constraints.A surgical extraction is the primary treatment of mesiodens, and repositioning it in the dental arch may be another treatment option. However, the timing of extraction of unerupted mesiodens is still debatable . Most auHence, an impacted mesiodens should be extracted at a young age when it appears to cause injury to the adjacent tissues. The optimal age for mesiodens extraction has been documented to be 6–7 years, after which more complications may be anticipated . Other aThe NPC, also referred to as the incisive canal or anterior palatine canal, is generally seen in the midline, just posterior to the maxillary central incisors. The anterior oral opening and the nasal opening of NPC are known as incisive foramen (IF) and Stenson's foramina, respectively . NPC conThe content of the NPC comprises a neurovascular bundle  encircled by the connective tissue, fat, and seromucous glands . AnotherThe etiopathogenesis of these cysts is still ambiguous, although some researchers have suggested that NPDCs arise from the spontaneous proliferation of the epithelial tissue remnants , 35–38. However, in our case, there was no history of trauma, and the clinical evaluation did not exhibit periodontal pockets in the maxillary anterior teeth region. Hence, cystic development in our case could not be attributed to any factor other than spontaneous proliferation.NPDCs associated with impacted mesiodens are an extremely uncommon entity. A detailed literature search was carried out on the Google Scholar and PubMed search engines using the following keywords: NPDC, supernumerary teeth, impacted teeth, and mesiodens. Case reports published in the English language up to August 2022 were extensively searched. This comprehensive literature search finally revealed only three cases of NPDC with impacted mesiodens, as summarized in NPDC is one of the many gnathic pathologies but is distinctive in that it is site-specific (seen in only the midline of the maxillary anterior region) , 39. NPDOur patient was a 19-year-old male who reported a slow-progressing, painless swelling in the maxillary anterior teeth region for the past 4 months.Owing to their slow-growing asymptomatic nature (40% of cases), they are usually observed as incidental findings during regular clinical and radiographic investigations , 44. A tRadiographically, NPDC generally exhibits a well-circumscribed, unilocular midline radiolucency, with an oval/round shape , 40, 43.Radiographic appearance in our case was in sync with the previously published literature. Radiographically, a well-circumscribed unilocular radiolucent lesion with corticated borders, encompassing an impacted inverted mesiodens, was seen in the maxillary anterior region. Root resorption of the involved teeth, with a distal displacement of central incisor roots and superior displacement of the floor of the left maxillary sinus, was also noticed.CBCT could not be performed as the patient was not willing due to financial constraints.Microscopically, NPDCs display mixed patterns of epithelial linings. Ciliated columnar epithelium and squamous epithelium predominate the nasal floor and the oral cavity region, respectively, and the intermediate region is lined by the cuboidal epithelium , 37, 45.Our case demonstrated a combination of epithelial varieties, with the ciliated pseudostratified columnar epithelium in predominance. Numerous mucous acini, muscular arteries, small veins, nerves, and inflammatory cells were also appreciated microscopically.Inflammatory lesions, such as periapical cysts and granulomas , 44, 46,A positive pulp vitality test with the associated teeth was seen in the present case, thus negating any periapical inflammatory lesion.NPDCs may be clinically differentiated from a widened IF by aspiration of the lesion. An ill-defined radiolucency with a diameter of 0.6–0.8 cm in the maxillary central incisor region is often considered a wide IF. On the other hand, NPDCS usually appear as well-circumscribed, spherical radiolucent lesions, often with the superior cystic margin at a higher position than that of an IF , 37, 44.Odontogenic keratocysts often exhibit an aggressive growth pattern and appear as ostelytic lesions with defined borders in the inter radicular/periapical areas of maxillary anterior teeth. However, they are mostly seen as multilocular radiolucent lesions in the mandibular posterior teeth . FurtherNasolabial cysts are soft tissue cysts and do not exhibit bone involvement, hence not apparent on the radiographic examination. In addition, the nasolabial cysts most commonly occur in the nasolabial sulcus, lateral to the midline , 47.Adenomatoid odontogenic tumors most commonly occur in the maxillary anterior teeth region of young females. The radiolucency extends apically beyond the cementoenamel junction. In addition, these lesions display a mixed radiolucent-radiopaque radiographic pattern .Enucleation, marsupialization, and decompression are the frequently employed treatment regimens. NPDCs are generally managed with enucleation, although marsupialization is recommended for large aggressive cystic lesions . Cystic In our case, the lesion was surgically enucleated, and uneventful postoperative healing was observed. There was no recurrence during the 3-month follow-up period.The main limitation in this case report was that a CBCT scan could not be performed due to the lack of facility and the patient's unwillingness due to financial constraints. Hence, a 3D extent of the lesion, the precise localization of the mesiodens, and its relation with the contiguous structures could not be ascertained. The 2D radiographic imaging (IOPAR and panoramic radiography) performed in this case was not sufficient to ascertain the 3D localization of the mesiodens and its relationship with the cystic lesion and adjacent vital structures.Mesiodens seen in the maxillary anterior tooth region is the most frequently occurring supernumerary teeth. However, NPDCs in association with mesiodens are an extremely uncommon finding with only three reported cases to date. This study aims to report a case of NPDC with an impacted inverted mesiodens. Surgical enucleation was carried out and favorable healing with no recurrences was observed during the 3-month follow-up.A 3D radiographic examination, such as CBCT, is essential to delineate the exact shape, orientation, and location of the mesiodens, and also to evaluate their relationship with the contiguous vital structures.NPDCs should also be given a place in the differential diagnosis of the radiolucent lesions in the anterior maxillary region.Pulp vitality should be carried out to exclude the lesions of endodontic origin and ensure precise diagnosis and treatment strategy.The patient experienced uneventful favorable healing after the enucleation of the cystic lesion and was completely satisfied with the treatment protocol. The patient has been carefully examined and followed up for 3 months, during maintenance visits scheduled every 4 weeks. The patient did not report any signs of recurrences and was completely asymptomatic during the follow-up period.


A pantaloon hernia occurs when an indirect and direct hernia develop at the same time. The urinary bladder is a rare component of pantaloon hernias. There is a lack of literature regarding an ipsilateral pantaloon with a herniated urinary bladder. Clinically, it has a vague presentation associated with abdominal pain and urinary retention symptoms. The best diagnostic modality is an abdominal CT scan. Surgery is the treatment of choice, rendering a good prognosis. Untreated bladder hernia may lead to strangulation and necrosis of the urinary bladder. We present a rare case of a right-sided pantaloon hernia with a bladder herniation in a 65-year-old man. A pantaloon hernia is defined as a combination of two adjacent hernia sacs in the inguinal and or femoral regions on the same side. The sacs are thus present on both sides of the inferior epigastric vessels . Almost A 65-year-old male presented for elective surgery with a four-week history of painful scrotal swelling associated with right lower quadrant abdominal pain. He complained of an associated mild suprapubic tenderness that extended to the scrotal mass. He had a history of urinary symptoms including haematuria and voiding problems. A physical exam of the abdomen showed a right inguinal hernia with a reducible scrotal mass. The patient’s vital signs showed heart rate of 66 bpm, respiratory rate of 20 breaths per minute, axillary temperature of 97.9 degrees Fahrenheit, and blood pressure of 155/88 mmHg.A decision was made to approach this case with imaging studies. A non-contrast abdominal and pelvic computed tomography (CT) scan showed a large right inguinal hernia protruding to the scrotum (Figures The patient was admitted to surgery under general anesthesia. A Lichtenstein technique was indicated to repair the hernia by applying a polypropylene mesh to decrease the risk of recurrence. The patient tolerated the procedure well without any complications and the follow-up was uneventful. A decision was made not to open the bladder to remove the calculus during this surgery in order to minimize the risk of bacterial contamination of the mesh and surgical field. The patient was sent home two days postoperatively, and was also referred to urology for a further evaluation, cystoscopy, and stone removal after recovery. A pantaloon hernia or a saddlebag hernia is characterized by a combination of both indirect and direct hernias ipsilaterally. A pantaloon hernia has an incidence of three times more in males than females . This caA herniated bladder occurs in a direct inguinal hernia, wherein the sac contents include the bladder along with a layer of peritoneum. It is implicated in around 2-4% of diagnosed cases of inguinal hernia and its incidence increases up to 10% in the elderly male population . The mosRadiological investigation is not a usual diagnostic modality for inguinal hernias, more so for the detection of a bladder hernia. Cystography is the gold standard for diagnosis ,11. AftePantaloon bladder hernias are a rare occurrence that have vague clinical presentations. Patients usually have localized mild abdominal pain, along with urinary symptoms such as recurrent urinary tract infections, and bowel obstruction due to herniation. Complications can be grave such as incarceration, strangulation, and necrosis. It is therefore important to consider a bladder hernia as part of differential diagnoses and offer prompt treatment given this constellation of symptoms to reduce the risk of necrosis, sepsis, and death.


Primary and metastatic malignancies of the clavicle are extremely uncommon and difficult to treat. It carries a high morbidity rate. Total or partial claviculectomy is the recommended treatment option.A 59-year-old male was admitted with a large left clavicular huge mass; biopsy showed poorly differentiated adenocarcinoma. Treatment started with chemoradiotherapy followed by complete excision of the tumor surgically.For treating this rare, difficult case, partial claviculectomy performed by a multispecialty team integrating three surgical skill sets: thoracic, ENT, and orthopedic surgeons, yields the best results. Clavicular carcinoma of known primary (CUP) is rare, and chemoradiotherapy showed preferable results in management.MDT reviews with surgeons, radiologists, pathologists, oncologists, and radiation oncologists are required in rare and complex cases of clavicular malignancy. Multispecialty surgical involvement is required for the safe excision of clavicular tumors with appropriate oncologic margins and fewer complications. •A huge Clavicular tumor is challenging and rare.•Multiple specialty surgeons and physicians are needed for resection and treatment.•Primary malignancy is rare, and Unknown primary clavicular tumor is extremely rare. He had no neurological or vascular clinical signs or symptoms in the left upper limb. He has no family history of malignant diseases and is not on any chronic medications.We present the case of a 59-year-old male ex-smoker with insidious onset of a left clavicular mass (6.5 × 5 cm) over six months . He presRadiological investigations, including contrast-enhanced computed tomographic scan (CT-scan), magnetic resonance imaging (MRI), and a positron emission tomography CT scan (PET-Ct), revealed a solid mass extending from the middle third of the clavicle to the sternoclavicular joint , Fig. 3.Given the negative investigations, the tumor mass was diagnosed as carcinoma of unknown primary (CUP) with local disease progression only with no regional or distant disease. The tumor was staged as a TxN0M1b oligometastasis.This work has been reported in line with the SCARE 2020 criteria 3After a discussion with the patient, he agreed to go for chemoradiotherapy first, and the surgical option will be next. The patient received six cycles of FOLFOX chemotherapy and local radiotherapy, which was well tolerated. The mass had increased to 10 × 8 cm by the time of completion of neoadjuvant treatment.A multispecialty approach involving thoracic, orthopedic, and ENT surgeons were employed for the partial claviculectomy.Under general anesthesia with IV antibiotic prophylaxis, the anatomic landmarks and incisions were planned and marked . A curviThe patient had routine postoperative care, and his recovery was uneventful. He was discharged on postoperative day 4 with good pain control, a healthy wound, and no neurovascular deficit. Passive mobilization with progressive active-assisted rehabilitation was initiated two weeks after surgery.The histopathology results showed Huvos grade 4 complete response to chemoradiotherapy, indicating the absence of active cancer cells in multiple high-powered fields.A chest CT showed no evidence of tumor recurrence at one year of follow-up. Excellent active range of motion of the shoulder was noted with a Constant score of 98/100. There was no clinical evidence of recurrence nor any new clinical finding to suggest a potential primary source.4Whether primary or metastatic, tumors involving the clavicle may require partial or total clavicular resection for local control or cure. The rarity of clavicular tumors, the pathological diagnosis of CUP, the size of the lesion, and the necessity for a multispecialty surgical approach highlight the importance of this case report. In addition, the tumor was invading the neck structures and encasing the external jugular vein, which makes our case unique because we describe the surgical approach for such challenging cases.Clavicular reconstruction has been performed with allograft, autograft, and mega-prosthesis variations, none of which reliably led to clinical outcomes superior to isolated partial or total claviculectomy. Excision of the clavicle without reconstruction was associated with faster rehabilitation and a lower risk of further surgery Carcinoma of unknown primary (CUP) accounts for about 3–5 % of all malignancies. CUP is associated with increased morbidity and mortality as it is, by definition, metastatic at the time of diagnosis, with a median survival between 8 weeks and 24 months Surgical management in these cases requires a detailed surgical plan and a multidisciplinary team approach. The complex anatomy of the clavicle and its surrounding structures, such as the brachial plexus, thoracic duct, subclavian artery, subclavian vein, innominate vein, carotid artery pleura, and lung bridges the surgical comfort zones of cardiothoracic surgeons, ENT surgeons, and orthopedic surgeons.5For rare and complex cases of clavicular malignancy, MDT reviews with surgeons, radiologists, pathologists, oncologists, and radiation oncologists are necessary. Multispecialty surgical involvement is frequently required for the safe excision of clavicular tumors with appropriate oncologic margins.No source of funding.Not applicable.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.Not applicable.Mohammad Aladaileh.Not commissioned, externally peer-reviewed.Mohammad Aladaileh: Analysis and interpretation of data, drafting the article, final approval of the version to be submitted.Tom Moran: drafting the article, final approval of the version to be submitted.Austin Duffy: diagnostic and treatment supervision, drafting the article, final approval of the version to be submitted.Karen Redmond: editing and supervision, drafting the article, final approval of the version to be submitted.David O'Briain: drafting the article, final approval of the version to be submitted.None.


Although dermatofibromas are not uncommon benign dermal nodules, palms are rarely involved. Herein, a rare case of palmar dermatofibroma was described, which occurred in a patient with porokeratosis. Dermatofibromas (DFs) are common, benign dermal nodules that frequently occur on the extremities, shoulders, and buttocks of middle-aged women. DFs rarely occur on the digitsMellitus, angina, and hypertension. Biopsy taken from the edge of the plaque revealed mild hyperkeratosis and a narrow stack of parakeratotic corneocytes (cornoid lamella), corresponding with the features of porokeratosis. He had been under treatment with topical corticosteroid ointment and etretinate (TigasonR) (10‒20 mg/day) for 5 years, but without any significant sufficient improvement. During the course, he complained of a slightly tender nodule on his palm which had appeared 2 months previously. Physical examination revealed a 5-mm sized, brownish firm nodule on the right palm (A 69-year-old male visited our clinic, complaining of multiple brownish plaques on the trunk, heel, and buttocks . He had ght palm . Histopaght palm . StorifoDF often develops due to fibroblastic cell proliferation as a reactive process in response to some stimuli,None declared.Toshiyuki Yamamoto: Approval of the final version of the manuscript; Critical literature review; Data collection, analysis and interpretation; Effective participation in research orientation; Intellectual participation in propaedeutic and/or therapeutic; management of studied cases; Manuscript critical review; Preparation and writing of the manuscript; Study conception and planning.None declared.


Actinomycosis is a rare opportunistic bacterial infection. It most commonly affects the cervicofacial area and is less common in the gastrointestinal area. Because of the ambiguous clinical pictures, there is a low preoperative diagnosis rate and a high rate of misdiagnoses. In this case report, we have an unusual presentation of disseminated abdominal actinomycosis in a diabetic male patient with no previous history of surgery or trauma. He presented with abdominal pain for two years. Abdominal imaging showed rectal wall thickening with adhesion and attachment to the bladder, and small bowel with omental and peritoneal deposits, mimicking colorectal cancer with abdominal carcinomatosis. Histopathological examination, however, revealed actinomyces infection with no evidence of malignancy. In such cases, the recovery rate with antibiotic therapy is very high in conjunction with surgical resection. Actinomycete is a non-spore-forming gram-positive rod with branching filaments. These bacteria are a part of normal human flora in multiple systems . Within The pathogenicity of actinomyces starts with the invasion of normal tissue to the surrounding structures following a mucosal barrier breach, which can trigger an inflammatory process . UsuallyAs the bacterial disease progresses, atypical and non-specific symptoms can arise, which can be misdiagnosed as malignancy. In addition, clinical pictures and imaging modalities are not always adequate in differentiating malignancy from inflammatory conditions for a variety of reasons, leading to a 10% lower rate of presurgical diagnosis . AnotherIn this case report, we present a case of a 62-year-old man with no prior surgery presenting with disseminated abdominal actinomycosis mimicking colorectal carcinoma with diffuse abdominal carcinomatosis and metastatic disease.A 62-year-old male with a short medical history of diabetes mellitus and long-term smoking (40 pack-years) presented with a history of abdominal pain for the past two years, which has recently gotten worse, and is associated with loss of appetite, and significant weight loss. The patient denied any previous surgical treatment. Physical examination was significant for lower abdominal pain with no tenderness on palpation. All laboratory investigations were within normal limits with no abnormality in the levels of the following tumor markers: CA-125, CA-19.9, and carcinoembryonic antigen. Further investigation was done with computed tomography (CT) scan, which revealed sigmoid demonstrate asymmetric circumferential wall thickening with bladder wall attachment Figure , 1b. In The patient was booked for and underwent an elective exploratory laparotomy with cryo-reductive surgery, omentectomy, rectal, bladder dome, and part of small bowel resection and ileostomy. Surgery revealed an abdominal wall tumor on the right side of the abdomen involving the omentum, urachal, and pelvic disease. There was partial obstruction caused by the tumor.During gross dissection, there were rectal adhesions to both the small bowel Figure  and bladUnder the microscope, the rectal-small bowel adhesion area shows fibrosis, mixed chronic, and inflammatory infiltrate with granulation tissue formation with abscess formation Figure  and branAs a result of the histopathological diagnosis, the patient received intravenous penicillin treatment for 7 days during his hospitalization, followed by oral penicillin treatment for 30 days at home following his discharge, then will continue a course of 9 months.In this case, the symptoms were similar to those of actinomycosis, a disease that exhibits a slow progression and nonspecific symptoms such as bowel obstruction . There aThe patient has also been smoking one packet a day for the past 40 years. It is known that smoking affects the immune system response, thereby increasing the vulnerability of the mucosa to invasion by the pathogen and the occurrence of infections . MoreoveIt is challenging to diagnose actinomycosis. In the absence of typical symptoms, cultures will not be performed to rule out the possibility of bacterial origin. Since actinomycosis can mimic malignancy, inflammation, and infection, it is difficult to distinguish between the two using a CT scan . It is nActinomycosis is rare in the gastrointestinal tract. Radiological images do not provide any specific information. Therefore, misdiagnoses in patients with atypical signs and symptoms are quite common. It is warranted that clinicians should suspect actinomycosis as part of their differential diagnosis, especially in patients with major risk factors. A course of antibiotics is the treatment, and an early diagnosis may significantly reduce the need for surgery and the complications associated with the disease.


Intersigmoid hernia is a hernia of an abdominal viscus into the intersigmoid fossa, and it is one of the rare forms of internal hernia that can present with bowel obstruction. Intersigmoid hernia poses challenges in its diagnosis and treatment due to its rarity and vague signs and symptoms. As such, a high index of suspicion should be maintained, and early diagnostic examination should be done that includes an abdominal CT that may show signs suggestive of internal hernia. Managing this condition relies mainly on surgical intervention (open or laparoscopic) in a timely manner to prevent further complications, such as bowel ischemia. We present a case of intersigmoid hernia in a 51-year-old Bahraini male who presented with vague abdominal pain and vomiting. An internal abdominal hernia is defined as a protrusion of a viscus through a normal or abnormal mesenteric or peritoneal aperture . In otheWe report a 51-year-old Bahraini retired male, who had a medical diagnosis of ischemic heart disease, with previous history of percutaneous coronary intervention and no past surgical history. The patient was complaining of intermittent left-sided abdominal and flank pain for a duration of 3 months. Additionally, it was associated with occasional vomiting of food content with history of alternating bowel habits.The patient presented to the emergency department and was diagnosed clinically as left renal colic. He was investigated with non-contrast computed tomography (NCCT) in the urology clinic during his follow-up. The surgical team was notified by the radiology department of findings that a swirling sign in left lumbar region was present, raising the suspicion of internal hernia. The patient was called to the emergency department for further evaluation and management.On clinical examination, his vital signs were within normal limits, with a heart rate of 94 beat/minute, BP 105/73 mmHg, temperature 36.9°C, RR 18 breath/minute, and oxygen saturation of 98% on room air. The patient was having mild left-sided abdominal pain. Additionally, his abdomen was soft and non-distended, with no visible superficial veins, and tenderness was noted on the epigastric and left upper quadrant region, with no guarding or rigidity, as well as no organomegaly. A digital rectal examination was performed, no palpable masses were felt, and there was no blood on the gloved finger.The patient was further investigated with blood tests that were unremarkable and with no leukocytosis or acidosis .An erect chest X-ray was done and was unremarkable, with no subdiaphragmatic air, while an erect and supine abdominal X-rays showed only colonic fecal and gas content with no other abnormalities .The previously done NCCT abdomen was reviewed and showed a left lumbar regional mesenteric swirling sign with mildly dilated abnormally located proximal jejunal loops at the left upper quadrant, more caudally projecting lateral to the medially located descending colon, raising the probability of internal hernia .The patient was admitted, kept nil per os, and was started on intravenous fluids. A CT abdomen and pelvis with IV, oral, and rectal contrasts was done, and showed regression of the previously seen left lumbar regional mesenteric swirling sign, with regression of the left upper quadrant located proximal jejunal loops distension, more caudally, the jejunal loops project lateral to the sigmoid in the left lumbar region suggesting medially located distal descending colon due to a dolichocolon extends up to left upper quadrant with no evidence bowel obstruction .The patient was taken to the operating room the following day where he underwent diagnostic laparoscopy which revealed collapsed distal jejunal loops and dilated proximal loops , a V-shaThe patient was started on an oral diet on the same day, which he tolerated well. The following day, he passed motion and was vitally stable with no abdominal pain. He was discharged on day 1 postoperative with a follow-up appointment in the outpatient clinic, in which he was seen and discharged with no active complaints.Internal hernias which are defined as protrusion of an internal organ through an anatomical or pathological opening within the peritoneal cavity cause intestinal obstruction in up to 5.8% of all small-bowel obstructions . They inSigmoid mesocolon internal hernias are further divided into intersigmoid, transmesosigmoid, and intramesosigmoid hernias which account for about 6% of internal hernias, and with intersigmoid hernia representing the majority of cases . IntersiOur patient had an intersigmoid hernia as the hernia orifice represented by the intersigmoid fossa located on the fusion fascia in the dorsal sigmoid colon.Clinically, patients with internal hernias can be asymptomatic with no distinctive findings upon history or physical examination. Moreover, they can present with significant symptoms which includes colicky abdominal pain, nausea, and vomiting as observed in our patient who was complaining mainly of colicky abdominal pain and frequent vomiting episodes. The severity of the symptoms is related to the presence or absence of incarcerated or strangulated viscus and to the duration of symptoms .The best diagnostic non-invasive method for internal hernia especially in patients with evidence of obstruction is CT of the abdomen and pelvis which become the first-line imaging technique due to its availability, speed, and multiplanar reformatting capabilities . CT findOur case was diagnosed as intersigmoid hernia using CT of the abdomen which showed mesenteric swirling sign and dilated abnormally located proximal jejunal loops at the left upper quadrant.The treatment approach for these patients is surgical exploration (laparotomy or laparoscopy) with reduction of the hernia and either obliteration or dissection of the intersigmoid fossa, and bowel resection might be necessary in cases of bowl ischemia .Laparoscopic approach has the advantage of being both diagnostic and therapeutic, in addition to reduced postoperative pain, morbidity, and length of hospital stay when compared to laparotomy. On the other hand, laparoscopy is more challenging in cases of bowel distension and poses a risk for iatrogenic bowel injury .Absolute contraindication to laparoscopic approach is related to contraindications to establish pneumoperitoneum such as hemodynamic instability or cardiopulmonary impairment .Luckily our patient was diagnosed in a timely manner and surgical management using laparoscopic approach was successful.There is no clear evidence in the literature regarding the recurrence rate of intersigmoid internal hernia.Intersigmoid hernia is a rare cause of internal hernia which can be difficult to be diagnosed preoperatively due to the ambiguous signs and symptoms, all of which might lead to delay in the treatment. Prompt diagnosis is essential as delayed detection of the condition can lead to small-bowel ischemia and gangrene which increases the morbidity and mortality of patients. CT scan of the abdomen represents the main preoperative diagnostic method nowadays that allows precise localization of the abdominal obstruction. Surgical approach is the mainstay of management of intersigmoid hernia and should be performed as soon as possible.


Cervical vagal schwannoma is a rare clinical entity that requires a different clinical approach than other neck swellings. Magnetic resonance imaging is the preferred initial diagnostic test. Complications may arise due to vagal stimulation in unsuspecting open biopsies. Surgical excision with perioperative vagal monitoring is recommended for the treatment of vagal schwannomas. Cervical vagal schwannoma is a rare differential of neck swelling. The usual approach to neck swelling is ultrasonography and, if required, FNAC for diagnosis. However, biopsy should be avoided in cases of cervical vagal schwannoma. We further reviewed the literature and described the approach to the diagnosis, surgical management, and possible operative complications of a vagal schwannoma.2A 24‐year‐old lady presented to our institute with a 3‐year history of painless and progressive swelling in her right neck. She did not have difficulty breathing or swallowing and had no change in her voice. She had no change in her body weight and appetite, no cough, night sweats, or on/off fever. She had no prior medical history of significance and had no previous exposure to tuberculosis (TB). There was no history of similar swelling or any neurogenic tumors in the patient's family.The lump was noticeable on the right level 2 region of the neck and felt firm on touch, was non‐tender, mobile on a horizontal plane, well‐demarcated, and measured about 4 × 3 cm in dimensions. There was no cough on palpation, and the swelling did not move with deglutition. Oral examination revealed no distortion of the anatomy. Ear examination and hearing were regular. No other findings were noted on systemic examination.With the suspicion that the swelling arose from a level 2 lymph node, an ultrasonography‐guided fine needle aspiration biopsy (FNAB) was arranged. The tissue sample was sent for histopathological examination, TB smear, and culture for TB and GeneXpert. The reports came in negative for TB, and the biopsy reports were consistent with Schwannoma with tumor cells staining positive for IH558 and S‐100. Other routine blood investigations and chest X‐rays showed no findings. An MRI of the neck was then arranged to find out the extent of swelling, which revealed a 2.4 × 2.4 × 2.8 cm sized T1 iso, T2/STIR heterogeneously high oblong shaped lesion displacing the internal carotid artery, external carotid artery and internal jugular vein anteriorly, and avid heterogeneous enhancing lesion in right carotid space suggestive of vagal schwannoma  interspersed with areas of sparse cells (Antoni B) are classical microscopic patternThe treatment of choice for cervical vagal schwannoma is intracapsular enucleation with nerve‐sparing techniques. End‐to‐end anastomosis or nerve grafting may be mandated in special cases where nerve preservation is not possible.4Vagal schwannoma is a rare clinical entity that should be considered a differential for slow‐growing neck lump, mainly when arising anterior to the sternocleidomastoid muscle and mobile in a single horizontal plane. MRI is the preferred diagnostic modality that also helps rule out mimics such as paraganglioma and sympathetic chain schwannoma. It also informs the surgeon regarding postoperative vocal palsy. FNA and biopsy are best avoided even though they are frequently performed in evaluating other neck masses. Intracapsular enucleation with intraoperative nerve monitoring provides a better outcome.RP, AT, JKY, and AK wrote the draft manuscript. ML, PS, and PG revised the manuscript. All except AT and AK were involved in the patient's direct care. All authors agreed on the final draft for submission.None of the authors has any conflict of interest to disclose.Ethics approval of a case report is not needed in accordance with local ethical guidelines.The patient provided written informed consent for publication of this case report and accompanying images.


Spinal dural arteriovenous fistulas (SDAVFs) are rare entities and are often misdiagnosed. They usually occur in adults above the age of 50 and 60 years. While they most commonly involve the thoracolumbar region, they can occur anywhere along the spinal cord. Clinical symptoms are insidious and not specific and may progress slowly, over several years, to severe myelopathy with paraplegia. Early diagnosis is critical because the deficits are potentially reversible if carefully treated. Delayed treatment may result in severe and irreversible neurological disability. Imaging diagnosis relies on MRI and conventional spinal angiography. Once identified, the dural arteriovenous fistula should be immediately treated by either endovascular embolization or surgical ligation. In this report, we present a case of SDAVF in a 65-year-old male that was managed by open surgery. Vascular malformations of the spine are very rare, accounting for only 2% of vascular neurological pathologies . They arA 65-year-old male, with a remarkable medical history involving poorly managed diabetes mellitus and hypertension, was admitted for the evaluation of progressive paraplegia for 18 months. This was associated with tingling in the lower extremities. On admission, his blood pressure was 170/90 mmHg, and his heart rate was normal at 75 pulses per minute. He was alert and oriented but had difficulty standing up. Physical examination revealed a complete impairment of muscle function in both lower extremities. Osteotendinous reflexes were polykinetic and the Babinski sign was positive in both feet. Sensory perceptions of pain, vibration, and touch were impaired. Based on these findings, we graded his condition as Frankel grade B. We performed an MRI of the spine and brain, which revealed no compression but a tumefied thoracolumbar spinal cord, revealing a high signal intensity in T2-weighted images  and veins (a radicular vein) . These cThe typical clinical presentation is progressive myelopathy associated with motor disorders (up to 78% at the time of diagnosis) most often involving the lower limbs, accompanied by sensory (up to 69%) and sphincter disorders (up to 80%), and usually micturition disorders . Up to 1Radiological diagnosis of SDAVF is based on MRI and conventional angiography. The main findings on MRI that suggest the possibility of SDAVF include swelling of the spinal cord with corresponding T2 hyperintensity and T1 hypointensity, predominantly affecting the lower thoracic region and the conus. The margins are often described as "flame-shaped" . Both grThe most specific MRI findings are as follows:- Enlarged vessels on the surface of the cord, which is only found in approximately 50% of patients with SDAVF. Multisegment hyperintensities with associated subarachnoid flow voids are pathognomonic of SDAVF .- A heterogeneous enhancement showing some regions of non-enhancement describing the missing-piece sign .Spinal angiography remains the gold standard for diagnosis and confirmation. Typical findings are contrast stasis within radiculomedullary arteries, delayed venous return following injection, and retrograde contrast uptake within radiculomedullary veins .Treatment of SDAVF usually involves endovascular embolization  or open surgery. Embolization is typically the preferred option for extradural arteriovenous fistulas, whereas the treatment of intradural fistulae is performed via either embolization or open surgery . Open suConservative management may be appropriate for asymptomatic SDAVF but should be carried out under close clinical and imaging surveillance. The most suitable imaging modality is MRI, which can reveal features of developing edema myelopathy. Once clinical or radiological symptoms appear, appropriate treatment should be implemented to stop the evolution and improve functional outcomes.This case report illustrated a rare cause of progressive paraplegia. When encountering cases of a tumefied spinal cord associated with perimedullary flow voids, a diagnosis of SDAVF should be considered and confirmed by conventional angiography. Thus, radiologists should be familiar with the imaging features of SDAVF so that unnecessary delays in diagnosis and treatment can be avoided, as well as further invasive testing for pathologies with similar presenting symptoms.


Undifferentiated pleomorphic sarcoma (UPS) is a malignant soft tissue tumor that has been reclassified from malignant fibrous histiocytoma with the development of the pathological diagnosis. It principally occurs in the extremities but rarely occurs in the rectum. We herein report a rare case of UPS arising in the rectum.A 85-year-old woman was referred to our hospital with a complaint of anal pain, which had persisted for several months. Computed tomography (CT) showed a 53 × 58 × 75 mm mass on the left side of the rectum. Colonoscopy revealed a submucosal elevation in the rectum without any exposure of the tumor to the surface. Contrast-enhanced CT and magnetic resonance imaging revealed an 80-mm mass that originated in the rectal muscular propria, and we suspected a gastrointestinal stromal tumor. No lymph node metastasis or distant metastasis was observed. We performed a laparoscopic Hartmann’s operation. Intraoperatively, severe adhesion around the tumor caused tumor injury and right ureteral dissection. Thus, laparoscopic right ureteral anastomosis and ureteral stenting were additionally performed. The operation time was 6 h and 3 min, and the estimated blood loss was small. The patient was discharged without complications 25 days after surgery. A pathological examination showed that the tumor was composed of highly heterogeneous cells with no specific differentiation traits, leading to a diagnosis of UPS. Contrast-enhanced CT performed 2 months after surgery showed bilateral pelvic lymph node enlargement, which indicated recurrence. Considering the patient’s age, we performed radiotherapy (50 Gy/25 Fr targeting the pelvic region). At present, 16 months have passed since the completion of radiotherapy. Contrast-enhanced CT shows that the recurrent lymph nodes have disappeared, and no new distant metastasis has been observed.We reported a case of UPS arising in the rectum. The surgical procedure and indication of preoperative therapy should be carefully selected because complete removal of the tumor is desirable in UPS. Undifferentiated pleomorphic sarcoma (UPS) is a malignant soft tissue tumor that was reclassified from malignant fibrous histiocytoma (MFH) by the World Health Organization (WHO) in 2002 and 2013 due to changes in the pathologic diagnosis [In 2020, an 85-year-old woman presented to her family doctor with a complaint of anal pain that had persisted for months. Abdominal computed tomography (CT) showed a 53 × 58 × 75 mm mass on the left side of the rectum. She was admitted to our hospital for further examination and treatment. She had a medical history of open appendicectomy for appendicitis, open total hysterectomy for uterine fibroids, femoral head replacement for right femoral neck fracture, hypertension, and dyslipidemia. None of her family had a clear history of cancer. A hematological examination showed no elevation in tumor or inflammation markers, with the exception of CA125 (55 U/mL). On visual examination, there were no obvious abnormalities of the anus. On digital anorectal examination, an elastic hard mass was palpated on the left side of the rectum, and tenderness was present in the same region. Colonoscopy showed submucosal elevation and reddening of the mucosal surface in the central and lower rectum, but no obvious exposure of the tumor to the mucosal surface  that has been reclassified from MFH with the development of the pathological diagnosis. MFH was first documented as malignant histiocytoma and fibrous xanthoma by Ozello et al. in 1963 and was described as malignant fibrous xanthoma by O'Brien and Stout in the same group in the following year . In 1978The primary treatment for UPS is complete resection of the tumor, with the widest possible margins. Complete resection of the tumor has been reported to be closely related to the prognosis . HoweverA search of PubMed revealed that 28 cases of MFH/UPS occurring in the colorectum and anus were reported in the relevant English literature. Including our case, a total of 29 cases were reviewed. The male to female ratio of incidence was 20:9. The average age of the patients was 58 years (12–85 years). It occurred in all sites of the colorectum and anus, and this was the eighth case in the anorectal region. All patients were symptomatic, and the most common symptoms were abdominal pain, abdominal mass, abdominal distension, bloody stool, and diarrhea. The median diameter of the tumor was 7.2 cm (1.7–19 cm). All cases were treated by surgery with the exception of one autopsy case. Almost all surgery was performed by laparotomy, probably due to the large size of the tumor at the diagnosis. Our case is the first report of laparoscopic surgery for MFH/UPS in the colorectum and anus. Adjuvant chemotherapy was administered in 4 cases, adjuvant radiotherapy was administered in 3 cases, and adjuvant chemoradiotherapy was administered in 1 case; however, no patients had received neoadjuvant therapy. Among the nine patients with local or distant recurrence, mortality was reported in all but our case (Table In our case, the resection of other pelvic organs should have been considered to achieve complete resection of the tumor. However, extended surgery is controversial because it is expected to impair quality of life. Preoperative treatment could have been considered if the pathological diagnosis had been obtained preoperatively. With the accumulation of evidence, preoperative treatment with a combination of radiotherapy, cytotoxic chemotherapy, immune checkpoint inhibitors, and molecular targeted agents may be performed in cases similar to ours.We reported a case of UPS arising in the rectum. The surgical procedure for UPS should be carefully selected because complete removal of the tumor is desirable. Indications for preoperative chemotherapy and radiotherapy should also be considered.


Desmoid fibromatosis is a rare, aggressive borderline lesion arising from soft tissues. Treatment will depend on the structures that the tumor has involved. Surgery with negative margins is the recommended strategy as it can usually achieve disease control; however, the tumor's location sometimes does not allow it. Therefore, a combination of medical therapies along with strict surveillance is crucial. We present the case of a 6-month-old boy with a chest mass. After further evaluation, a rapidly growing mediastinal mass involving the sternum and costal cartilage was detected. Desmoid fibromatosis was the final diagnosis. Desmoid fibromatosis is a rare soft tissue neoplasm that does not metastasize but presents an aggressive growth and local invasion . It can Patient is a 6-month-old who was born with clinodactyly in both hands, and without a history of familial adenomatous polyposis. He presented with a two-month history of a small, hard, nonmobile, and painless mass in his chest. The mass was initially small and did not disturb the child's development. However, a couple of months later, as the child began to crawl, his mother noticed that he had some discomfort and realized that the mass had doubled its size, so she visited his pediatrician.On clinical examination, an otherwise healthy young boy was found. Over the xiphoid process, a 2 × 2 cm solid mass with rounded edges was discovered. The mass was attached to the xiphoid process and nearby structures. With these findings, an ultrasound was requested, discovering an echogenic mass measuring 2.3 × 1.8 cm without vascularization and cardiac involvement .Due to this, a chest computed tomography (CT) revealed the presence of a 3.5 × 2 cm soft tissue density mass in the anterior mediastinum. It infiltrated the subcutaneous tissue and involved the ribs and sternum. Magnetic resonance imaging also proved that the pericardium was not compromised .With these findings, surgery was decided, and after partial distal sternotomy, the 3.5 × 2 cm solid whitish mass was discovered; it was in contact with the diaphragm, xiphoid process, and costal cartilages. Biopsy was taken for intraoperative frozen section; however, the results were inconclusive, malignancy was not confirmed, but atypia could be observed; because of this, and considering the risk of malignancy, complete resection of the mass, including the distal third of the body of the sternum, xiphoid process, diaphragm, and four bilateral costal cartilages was completed. A bioabsorbable mesh was used to repair the diaphragmatic defect and rigid fixation was placed on the ribs with stainless steel wires to reconstruct the thoracic wall, since bioabsorbable prosthetic material was unavailable; drains were placed, and the procedure was completed without complications .Pathology reported a proliferation of fusiform cells without nuclear hyperchromatism or mitosis; some areas showed multiple nodular, hypocellular, and hyalinized areas surrounding and invading muscle fibers. In addition, surgical margins were compromised on the diaphragmatic side. Immunohistochemistry was positive for Beta-catenin in the nuclear cells and negative for CD34, Desmin, and S100. Desmoid fibromatosis (DF) was the final diagnosis .His postoperative course was uneventful. He was discharged on postoperative day five, and he is on close follow-ups a year after surgery, there has been no sign of recurrence or complications, and this disease has not impaired his development. He is entirely normal at this time.β-catenin gene) (DF is an extremely infrequent tumor (2 to 4 cases per million per year) , 2. It'sin gene) , 4. In cin gene) –5.DF can present in two ways; the sporadic form, which more frequently affects women, and the condition associated with familial adenomatous polyposis (FAP) , 6. DF cTreatment will be based on the symptoms and the tumor growth, especially in critical locations where an earlier surgical decision may potentially prevent a higher risk of morbidity . The priEven with successful surgery the risk of relapse is high especially in children where pediatric DF is associated with a high recurrence rate 24%–76%) , 6. Ther% , 6. ThOther therapies include radiation therapy as an adjuvant treatment; however, the risk of adverse effects, such as fibrosis, paresthesia, skin ulcers, and, in children, a significant risk of long-term functional sequelae and radiation-induced cancers, must be taken into account. Several cytotoxic and non-cytotoxic drug treatments have been proposed for desmoid tumors, and several have had partial or complete responses in multiple trials , 12. NewWhen facing a desmoid tumor and its treatment, especially in pediatric patients, there are still many gray areas between surgery, observation, and medical therapies. Deciding between them is not always easy, as we should always avoid or limit any possible harm from the disease and our treatments. Still, quality of life must be the single central dimension to weigh when facing these tumors, a decision that must always be made following the wishes of the parents and the child. This article has been prepared according to CARE Guidelines .His parents found it difficult at first to accept the disease, especially after the pathology and the positive margins of the tumor were explained to them. However, after the patient's successful recovery and normal development, they have come to accept its nature. They have changed their approach and have learned to accept the nature of the disease in a way that has surprised the entire medical team. We are grateful to the parents for allowing us to treat the patient, and we are on close watch.The management of DF is complex and even with treatment, it can still behave like an aggressive disease. Further research is needed to determine which patients will benefit from surgery, medical therapies, or close surveillance. We will always have to weigh the risk of treating the disease with all the complications and recurrences that it entails or waiting and losing the opportunity to offer a chance of a complete cure.


Disorders of salivary glands especially the parotid gland very rare among neonates and children other than cytomegaly and parotitis epidermica. Venolymphatic malformations are very rare in children. Such presentation around the parotid region yet to be reported. This case report describes a rare presentation of a neonatal venolymphatic malformation on the parotid duct. A 4-week-old termly delivered male infant referred to by a general practitioner bruising over the left buccal area for 1 day from non-consanguine healthy parents. On examination a bluish discoloration in the buccal mucosa over a firm mildly tender area without signs of inflammation was seen. Ultrasound examination of the lesion showed fluid and solid soft tissue suggestive of haematoma and magnetic resonance imaging scan confirmed the rupture of the parotid duct with venolymphatic malformation. The child has been referred to the vascular malformation clinic and plastic surgical clinic in a tertiary care hospital for follow-up. Disease of the salivary gland is very rare in the neonates and children except in parotitis epidemica and cytomegaly . Very raVascular malformation of the children can appear from the antenatal period up to childhood and 60% of them are confined to the head and neck region . There aThis is the first reported case of venolymphatic malformation of the parotid region in a neonate.Four-week-old male infant was referred to the hospital by a general practitioner due to a swelling and bruising over the left buccal area for 1 day according to the history given by the mother. There was no history of trauma, coagulopathy, fever, irritability, poor feeding nor documentation of discolouration or patch during the first neonatal examination. The child was fed well, and the urine output and bowel frequency were normal.This child was born as the second child to non-consanguine healthy parents with no family history of coagulopathies, after an uneventful antenatal period of 35 weeks by an emergency lower segment caesarean section due to foetal tachycardia. His birth weight was 2.62 kg. Then he was treated for suspected sepsis and neonatal hyperbilirubinemia at the special care baby unit and spent the first 2 days of life establishing feeding with nasogastric tube and formula top ups.The clinical examination on admission showed bluish discoloration on the centre of the left buccal area measuring 3 cm horizontally and 2.5 cm in vertical plane . Firm miThe laboratory investigations including full blood count, coagulation screen, inflammatory markers, renal profile, liver profile and bone profile were within normal limits . Due to The child has been referred to the vascular malformation clinic and plastic surgical clinic in a tertiary care hospital  for further follow-up.Disorders of the salivary gland including parotid gland acute and chronic inflammation and infection  are exceCongenital vascular malformation arises because of structural malformations of vascular development , which aMajority of vascular malformation ~60%) in the children and neonate are confined to the head and neck region and it gives enormous psychological and physiological problems to both the child and the parents. All the congenital vascular anomalies are categorized into two main categories under vascular tumours and vascular malformation. Nomenclature of the vascular malformations depends on the predominant type of the vessel  0% in the. VasculaVascular malformation around the parotid gland is an extremely infrequent entity that needs a specific diagnostic and management approach. Up to now, a few cases have been reported and all of them were adults .When a nonmobile child, especially a neonate, present with bruises, NAI and coagulation disorders need be excluded. However, very rarely can neonate be presented with bruises due to the rupture of underlying vascular malformations. In this case, all the probable causes of bruises in neonate have been excluded, and the rupture of the parotid duct and venovascular malformation has been diagnosed by the MRI and repeated ultrasonography of the head and neck.et al. (2021) [The plan of management for this child was watchful waiting for 3 months and then to be decided on further management depending on the nature of the residual lesion. According to Ana Paula Pinho Matos . (2021) , 15% (3/. (2021) , which i. (2021)  and 12.5. (2021) .et al. in 2015) combined therapy that was initially failed to respond to the sildenafil treatment and sclerotherapy may have a place in management.The medical options available are sclerotherapy, minimally invasive surgical resection, laser therapy and radiofrequency ablation. Systemic pharmacological treatment with sirolimus  is considered for patients with diffuse and infiltrative lymphatic malformations refractory to previous therapy and/or when surgical approach is not feasible due to the risk of permanent iatrogenic damage (e.g. blindness). According to the single case report of successful improvement of a complex periorbital venolymphatic malformation with sirolimus and prednisolone (Kim D.


Large bowel obstruction (LBO) accounts for nearly 25% of all bowel occlusions. LBO is managed as a surgical emergency due to its increased risk of bowel perforation. Nearly, 2% to 4% of all surgical admissions are a result of LBO. The most common pathological development of LBO remains colonic malignancy, representing approximately 60% of cases. Other etiology includes abdominal adhesions, diverticulosis, hernia, inflammatory bowel disease (IBD), and in rare cases endometriosis. In this report, the patient is a 36-year-old female with an LBO, originally thought to be a complication of diverticulitis. However, it was confirmed that the obstruction was a result of endometriosis tissue adherence to the colonic wall narrowing the intestinal lumen. The patient presented to the emergency department (ED) with nausea, vomiting, and abdominal pain that started six weeks prior. In this case report, we will discuss the rare complication of endometriosis causing LBO, clinical presentation, diagnosis, and management. Large bowel obstruction (LBO) is classified into three distinct categories: partial or complete, intrinsic or extrinsic, and benign or malignant . Nearly,In the United States, adenocarcinoma of the colon and rectum is the most common cause of bowel obstruction representing 50% to 60% of all cases . The comIntrinsic LBOs are associated with clinical conditions such as Crohn’s disease and ulcerative colitis. The inflammatory changes of the mucosa, submucosa, or serosa cause thickening of the bowel, leading to strictures . The acuThe most common etiology of extrinsic LBO in industrialized nations is postsurgical adhesions. It is estimated that two-thirds of patients with a past medical history of abdominal surgery will have symptomatic or asymptomatic adhesions. Large intestine adhesion causes torsion and strictures of the bowel, leading to obstruction. Intestinal herniation through the abdominal wall or umbilicus results in strangulation or incarceration of the bowel, leading to ischemia and obstruction of the large or small bowel .The clinical presentation of acute LBOs usually presents abruptly or after one to two days of symptoms. The patient can present with bloating, abdominal pain, and constipation. The characteristic of abdominal pain is described as infraumbilical, with cramping occurring every 20 to 30 minutes [The diagnostic modalities used to diagnose LBOs include plain radiography (X-ray) and CT scan . In hemoThe patient is a 36-year-old female with a past medical history of endometriosis, a brain tumor diagnosed at the age of 9 years and treated with radiation and chemotherapy, bipolar disorder, seizures, and a hysterectomy 10 years ago. The patient presented to the emergency department (ED) with diffuse abdominal pain, nausea, and vomiting that began six weeks prior and had progressively worsened. The patient had experienced nausea and vomiting after most meals, which consisted mainly of undigested food. She complained of diffuse abdominal pain centered in the lower abdomen with no radiations. The patient also denied passing of flatulence or having a bowel movement for one day. The patient reported a weight loss of 80 lbs over the past six to eight months. Physical examination revealed a rigid abdomen tender in all four quadrants, with no rebound or guarding. The patient's comprehensive metabolic panel (CMP) on arrival is given in Table  The results from the CT scan indicated diffuse small and large bowel dilatations Figures , 2. The The small and large bowels were examined for ischemia or perforations. The sigmoid colon was located, and a distal sigmoid stricture was visualized. The proximal and distal attachments of the sigmoid colon were slowly dissected, with special emphasis on avoidance of injury to the ureter and retroperitoneum. During the dissection of the distal sigmoid, the right ovary and fallopian tube had significant adherence to the sigmoid wall. Dark brown ovarian cysts were encountered during the distal dissection. After complete mobilization, the sigmoid colon was resected and sent to pathology. The distal portion of the rectum was closed creating a rectal stump. Due to severe dilatation and the size difference between the descending colon and the rectum, we decided to create an end colostomy rather than perform a primary anastomosis. The descending colon was then used to create an end colostomy. The midline incision was closed, and the patient was extubated and transferred to the recovery room for further monitoring. The patient had a stable postoperative course. The end colostomy was functional on postoperative day 2, and her diet was advanced as tolerated. She was discharged in stable condition with no immediate complications.The pathology findings of the resected sigmoid colon showed endometriosis and endometrioma with endometriotic cysts and serosal adhesions involving the muscular layer of the colon. At the site of the sigmoid stricture, revealed a firm 3 cm × 3 cm × 3 cm mass below the mucosa within the muscular wall. Histology of the colonic mass showed glandular endometriotic cysts with central stroma  in combination with oral contraceptive pills (OCPs) . The addEndometriosis-induced LBO is a rare complication seen in women of reproductive years. It remains a difficult condition to diagnose due to the physiological adhesion of the endometrial tissue to the colonic wall. While diagnostic modalities such as US and MRI are effective at evaluating extrapelvic endometrial tissue, the extent of the invasion cannot be visualized with imagining studies. In female patients, with a past medical history of endometriosis who are showing signs and symptoms of bowel obstruction, endometriosis-induced bowel obstruction should be a top differential. In patients with endometriosis, it is of high importance to provide effective pharmacological management to help control pain and reduce the size of the endometrial tissue. Early diagnosis and management of endometriosis can help decrease the risk of related complications, including LBO.


Cholelithiasis is very common, affecting around 10-15% of the general population, but giant gallstones measuring 5 cm or more are very rare with only a few cases reported in the literature. Laparoscopic cholecystectomy (LC) is very difficult in such cases, especially in emergency situations, but can be safely performed by skilled surgeons. One such 47-year-old male with a giant gallstone measuring 8.7 cm x 4.2 cm x 3.4 cm was safely managed by laparoscopic approach and is presented due to its rarity. Cholelithiasis  is the commonest biliary pathology in most Westernized societies. In Saudi Arabia, the prevalence has been found to be 8.6-11.7% . The majA 47-year-old male presented to the emergency department with a history of about 12 hours of pain in the right upper quadrant of the abdomen. The pain score was 7/10 on numerical rating scales (NRS) and radiated to the right scapular region. There was nausea and anorexia. In the past two to three years, the patient had experienced episodes of self-resolving post-prandial upper abdominal pain. He was otherwise not known to have any significant past history. On examination, blood pressure was 114/76 mmHg, pulse was 90 beats per minute, and temperature was 37.8 C. The right hypochondrium was tender and Murphy's sign of cholecystitis was positive. Laboratory tests showed an increased white blood cell count (WBC) of 9.4x10^9/L; other blood tests including urine analysis, liver function tests, and serum amylase were within normal limits.Abdominal ultrasound revealed a distended gallbladder containing sludge and a single significant large calculus with wall thickening reaching 7mm and pericholecystic fluid Figure .The diagnosis of acute cholecystitis secondary to cholelithiasis was made and the patient was admitted to the hospital while the laparoscopic cholecystectomy was undertaken on the second day of admission.At the operation, the patient was placed in the supine position and an 11 mm infra umbilical camera port was inserted after the creation of pneumoperitoneum with a Veress needle. One 10 mm epigastric working port with two additional 5 mm supporting ports were inserted under vision. There were minimal dense adhesions between the greater omentum and gallbladder and adhesiolysis was achieved with the help of electro-cautery. The gallbladder was nearly completely filled with the gallstone, making the wall tense and difficult to grasp using non-traumatic forceps. The critical view of safety was achieved and the clipping of the cystic artery and duct was done. The gallbladder was dissected off the cystic plate, put in an endo bag, and extracted out after the necessary extension of the infra umbilical incision. The gallbladder specimen measured 12 cm x 6.6 cm x 5.3 cm Figure .The postoperative course was uneventful and the patient was discharged on the second postoperative day. The histopathological report showed features of acute on chronic follicular cholecystitis and no evidence of malignancy.Cholelithiasis is one of the commonest surgical problems and is attributed to various factors including cholesterol hypersecretion, reduced excretion of bile salts and/or phospholipids bile salts, hypomotility of gallbladder, and haemolytic disorders. While 20-25 million people have gallstones in the USA, the majority of patients experience no symptoms and hence only 300,000 cholecystectomies are performed annually . AccordiDue to the proven relationship between the greater size of gallstones with gallbladder cancer, patients with giant gallstones even when asymptomatic are recommended cholecystectomy. In addition to that, it is considered a risk factor for fistula formation with the possibility of bowel obstruction and Mirrizzi syndrome . And regHowever, even with the giant gallstones, LC performed by a skilled laparoscopic surgeon is the best initial course of action, in the opinion of the author, unless the technical challenges or an inability to expose the anatomy led to conversion to open cholecystectomy. The author was able to conduct safe LC without any conversion even in emergency settings. Similar experiences have been reported in other published case reports in the peer-reviewed literature ,9,11-12.Different-sized giant gallstones have been reported in the literature and most of them are solitary. Singh et al.  removed Giant gallstones are rare and although they pose technical challenges, laparoscopic cholecystectomy can be safely carried out by skilled surgeons and specimen retrieval may be achieved by extension of umbilical port site incision. However, if the anatomy cannot be properly delineated, conversion to open cholecystectomy is a safe management strategy.