Primary involvement of liver in tuberculosis is a rare entity. It is difficult to diagnose in absence of previous history of tuberculosis or concurrent pulmonary involvement. It is usually misdiagnosed as neoplastic liver lesion, which misdirects the treatment protocol and delays proper treatment. Here we are presenting a case of 36-year-old male patient with vague right upper quadrant abdominal pain. All the laboratory values were within normal limits. Radiological investigations were in favor of biliary cystadenoma but final diagnosis was primary focal involvement of liver in tuberculosis which was histopathologically proven to be tuberculous granulomas on biopsy of the resected mass. Hepatic involvement in TB is rare; however, exact incidence is unknown, likely due to underreporting and unawareness of the disease, as most hepatic TB cases are diagnosed retrospectively upon surgery or autopsy . There iHere we are presenting a focal type of primary hepatic involvement. Our aim is to highlight the fact that in endemic countries like India tuberculosis should be kept in mind as a differential of hepatic mass specially in young patients. A biopsy and histopathological examination should be done before resection of the lesion.A 35-year-old male patient presented to our hospital with right upper quadrant dull pain since 2 months. There is no history of fever or jaundice. There are no other constitutional symptoms. USG was advised which showed enlarged liver up to 15 cm and heterogeneously hypoechoic mass lesion in segment VI of liver with peripheral vascularity. There was no organomegaly seen apart from the liver or no inflamed lymph nodes were seen. Ileocaecal junction appears normal. Chest X-ray was normal. Biochemical profile was done which showed mildly raised alkaline phosphatase. Hematological profile was normal. Tumor markers like AFP and CEA were normal. In plain CT image of abdomen, axial view showed ill-defined, mixed density mass lesions in segment V of liver Figures . Based oAs the prevalence of tuberculosis is increasing in the world, rare presentations of the disease will be more frequently encountered. Hepatic TB is difficult to diagnose as only a few cases are reported. Diagnosis often requires biopsy, especially in focal involvement like in our case . PossiblX-ray and ultrasound lack sensitivity and specificity in diagnosis but are still considered first line of investigations. Chest X-ray may show pulmonary tuberculosis which may be a clue for the diagnosis , 11. UltIn contrast hepatic hydatidosis on CT imaging presents with a mass like hepatic lesion with irregular borders, accompanied by calcified or cystic components in the periphery of the lesion .MRI is actually not of much use; however, it will show T1 hypointense lesion with hypointense rim and variable T2 appearances. On contrast imaging, it will show peripheral enhancement .Resected specimen can be sent for pathological and microbiological assessment. Culture of mycobacteria is the strongest evidence of hepatic TB, but the sensitivity is very low . Newer t M. tuberculosis and is more useful for diagnosis of TB, but positivity rate is 57% [Hepatic tuberculosis has varied presentations and thus pathologic examination of liver lesions is essential by percutaneous fine needle biopsy which serves as an excellent diagnostic method. However, risks associated with percutaneous needle biopsy such as bleeding and tumor dissemination should be taken into consideration. PCR directly detects the presence ofe is 57% . The WHOe is 57% . The appe is 57% .Primary focal involvement of liver in tuberculosis is a rare entity. It is difficult to diagnose on clinical basis and on imaging. Histopathological diagnosis is required in most of the cases. As the treatment is medical therapy, a biopsy should be done before laparotomy and excision to confirm the diagnosis to avoid a surgical misadventure, especially in endemic regions like India.


Capillary hemangiomas are benign tumors found in the skin and soft tissues in younger people. They occur in the central nervous system only rarely, and intradural occurrence is extremely rare. We report here a 60-year-old man presenting with thoracic girdle pain and progressive gait disturbance. Magnetic resonance images of the thoracic spine showed a 12 × 8 × 20 mm, well-defined intradural mass at the T2 level, compressing the spinal cord laterally. Relative to the spinal cord, the mass was hypo- to isointense on T1-weighted images and relatively hyperintense on T2-weighted images, with strong enhancement on contrast-enhanced T1-weighted images. The patient underwent T1-2 hemilaminectomy with resection of the intradural extramedullary tumor, which showed characteristics of a capillary hemangioma on histologic examination. The patient's symptoms improved following the surgery and no clinical or radiological evidence of recurrence was noted at the 2-year follow-up. We present this case with a review of the literature, highlighting features for differential diagnosis. Capillary hemangiomas are benign vascular malformations, most often found in the skin or soft tissue throughout the body in younger patients. They are histologically characterized by nodules of capillary-sized vessels lined by flattened endothelium . CapillaOn magnetic resonance imaging (MRI), these lesions appear isointense and hyperintense relative to the spinal cord on T1-weighted and T2-weighted images, respectively, and exhibit a strong homogeneous enhancement on contrast-enhanced T1-weighted images. Common intradural spinal tumors such as schwannoma and meningioma have similar MRI features .In this report, a case of intradural extramedullary capillary hemangioma in the upper thoracic spine is described and the literature is reviewed.A 60-year-old man presented with a 2-month history of thoracic girdle pain, followed by 1 week of progressive gait disturbance. Physical examination revealed no abnormalities. On neurologic examination, there were no muscle weakness and no sensory disturbance, except for loss of vibration sensation below the knee. The patient was continent of urine.MRI of the thoracic spine showed a 12 × 8 × 20 mm, well-defined intradural mass at the T2 level, compressing the spinal cord laterally. Relative to the spinal cord, the mass was hypo- to isointense on T1-weighted images and relatively hyperintense on T2-weighted images. Also shown on T2-weighted images was a structure in the cranial aspect of the mass that was consistent with enlarged vessels. The caudal part of the mass showed strong enhancement on contrast-enhanced T1-weighted images and the cranial part of the mass showed a moniliform structure without enhancement . The preThe patient underwent T1-2 hemilaminectomy. On opening the dura, a well-circumscribed, dark reddish mass was seen beside the spinal cord. The mass was adherent to the arachnoid and nerve root, especially on the left side. Under an operating microscope, the mass was dissected out from the spinal cord and nerve root. The cranial part of the mass consisted of dilated vessels and was resected completely with cauterization shrinkage without significant bleeding.The surgical specimen was fixed in 10% buffered formalin, routinely processed, and embedded in paraffin. Sections were prepared and stained with hematoxylin and eosin. Histological examination revealed that the mass had a lobular architecture with numerous capillary-sized vessels lined by a single layer of endothelial cells and dissemination of dilated vessels . ImmunohAlthough the patient experienced sensory disturbance of the right T3 dermatome postoperatively, his thoracic girdle pain disappeared immediately after surgery and his gait disturbance improved gradually. Although the right T3 sensory deficit persisted, there was no clinical or radiological evidence of recurrence at the 2-year follow-up .Spinal cord tumors account for about 15% of all central nervous system neoplasms. Vascular lesions comprise about 6-7% of all spinal intradural tumors , 22. TheCapillary hemangiomas usually occur distantly, at the conus medullaris or attached to nerve roots of the cauda equina . Of the The MRI findings in the present case are consistent with those of previous reports; that is, the lesion appeared isointense relative to the spinal cord on T1-weighted images and iso- or hyperintense on T2-weighted imaging with strong homogeneous gadolinium enhancement. However, shown on T2-weighted images was a structure in the cranial aspect of the mass that was consistent with enlarged vessels. We were not able to rule out the vascular malformation by only MRI findings. However, we did not perform preoperative angiography. In the literatures, most intradural capillary hemangiomas were resected successfully without significant intraoperative bleeding, although some cases showed high bleeding tendency , 15, 17.The most common intradural extramedullary tumors are schwannoma and meningioma, both of which show marked enhancement on contrast-enhanced T1-weighted images. Schwannomas are usually hypointense on T1-weighted images and hyperintense on T2-weighted images, with no evident infrequent cystic or necrotic changes. Without these findings, it is difficult to differentiate schwannoma from hemangioma. However, in the present case, the vascular-like structure, which was cranial to the mass, suggested the presence of vascular lesions. Meningioma has an isointense appearance on T1-weighted images and an iso- or hyperintense appearance on T2-weighted images. The dural tail sign is not useful in distinguishing meningioma, since a capillary hemangioma may arise from the inner surface of the dura mater creating a dural tail sign . It is iIntradural extramedullary capillary hemangioma is rare and may be clinically or radiologically indistinguishable from other lesions, but they should be considered when making a differential diagnosis of intradural extramedullary neoplasms.


Background. Cysts in the larynx are rare and generally asymptomatic. However, large cysts in adults can be symptomatic. If they are symptomatic, they typically present with respiratory and feeding difficulties. They are usually benign in terms of pathology. Several surgical techniques may be used for treatment. Case Report. A 56-year-old man presented to our clinic with hoarseness. Routine laryngeal examination revealed a giant mass and the larynx could not be visualized. At magnetic resonance imaging (MRI), a cystic mass originating from the vallecula was detected. There was no pathology at the glottic level. We planned tracheotomy for the airway and endoscopic surgery for excision. The mass was excised using CO2 laser and was reported as benign. Conclusion. An asymptomatic vallecular cyst may cause difficult intubation in any operation. It may also cause respiratory or other complications. Airway management should be led by an ear, nose, and throat surgeon, since tracheotomy may be required. Endoscopic excision with CO2 laser is a good choice for treatment in elective cases. In this report, we discuss the diagnosis and treatment of a patient with an asymptomatic giant vallecular cyst. Ductal cysts are usually small, approximately 1–5 mm in diameter. Adult VCs are frequently asymptomatic. When seen in adults, possible symptoms include globus, voice changes, dysphagia, hoarseness, and airway obstruction. The lesion is usually fluctuant and some mucoceles may appear at palpation. VCs are benign in pathology and are not associated with other anomalies or syndromes . Giant VThe patient gave signed informed consent.2 laser with endoscopy. Hemostasis was also achieved with CO2 laser. The tracheotomy was closed after the operation. The patient was observed overnight and discharged without complication the following day. Voice quality was normal and the patient was fed without difficulty. Even though epiglottis was traumatized, this did not lead to aspiration. No recurrence was observed at 6 months postoperatively  revealed a 4 × 3 cm cystic mass, originating from the epiglottic vallecula and filling the airway . No signratively .Laryngeal cysts are classified as ductal and saccular cysts. Ductal cysts result from obstruction and retention of mucus in the collecting ducts of the submucosal glands. Saccular cysts arise from the saccule and extend to the ventricle. Ductal cysts are the most common form of laryngeal cysts, comprising 75% of cases . They maPatients with severe respiratory distress or near total obstruction of the larynx require immediate intervention. Needle cricothyrotomy or emergency cricothyrotomy with a trocar is the immediate management options . Aspirat2 laser with endoscopy is a good treatment option, as in our case. CO2 laser has ablative and hemostatic properties and also permits control over depth of penetration into the tissue [Tracheotomy can be performed before anesthesia induction to provide a more controlled airway. Using COe tissue . The emp2 laser may allow shorter anesthesia time and avoids the risk of superior laryngeal nerve injury compared with the open approach. It is important to manage the airway in these cases. This rare entity should be remembered in cases of difficult intubation.In conclusion, giant VC is a rare entity, especially in adults. Excision with endoscopic CO


Pyriform sinus fistula is a rare clinical entity and the precise origin remains controversial. The fistula is discovered among patients with acute suppurative thyroiditis or deep neck infection of the left side of the neck and is usually located in the left pyriform sinus. To the best of our knowledge, only a single tract has been reported to be responsible for pyriform sinus fistula infection. We present a case of a 13-year-old female patient with a pyriform sinus fistula that caused a deep infection of the left side of the neck and showed double-tract involvement discovered during surgical resection of the entire fistula. Both tracts arose around the pyriform sinus and terminated at the upper portion of the left lobe of the thyroid. Pyriform sinus fistula is a rare clinical entity that is incidentally found associated with acute suppurative thyroiditis or deep neck infection. This congenital internal fistula arises from the apex of the pyriform sinus of hypopharynx, penetrates the cricothyroid muscle, and terminates in or adjacent to the dorsolateral portion of the left lobe of the thyroid. Sandborn and Shafer  first reA 13-year-old female was brought to our hospital because of swelling of the left side of the neck. Several years earlier, a similar episode occurred, and administration of intravenous antibiotics improved the patient's symptoms. The left side of the neck was swollen, and her skin was slightly reddish. The patient felt pain in her neck and could not drink and eat; however, there was no dyspnea. The body temperature was 37.8°C. A blood test showed an increase of white blood cells and a high level of C-reactive protein. Her thyroid hormone levels were also increased, but thyroid stimulating hormone was decreased, which indicated acute suppurative thyroiditis. Enhanced computed tomography was performed on the same day and showed that the abscess was located between the common carotid artery and hypopharynx. The abscess extended from the height of the hyoid bone to the posterior of the left lobe of the thyroid. The inflammation partially reached beyond the thyroid capsule Figures . TherefoThe brownish tract (1 in Figures We experienced a case of pyriform sinus fistula infection with double tracts. To the best of our knowledge, there have been no other reported cases of two or more tracts contributing to pyriform sinus fistula infection. In the present case, the two tracts ran independently and showed different pathological findings.The brownish tract originated from inside of the inferior pharyngeal constrictor muscle and ran across the front of the cricoid muscle and into the thyroid. The lumen was filled with granulation tissue pathologically, which led to speculation that severe inflammation had occurred and the normal epithelium had been completely replaced as described in a previous paper . The cauPyriform sinus fistula is a congenital anomaly that arises from disturbances in the development of the fetal branchial apparatus. There are several hypotheses regarding the specific origin of these fistulae. Miyauchi et al.  pathologWe first reported a case of a pyriform sinus fistula infection with double tracts. One was a crystal violet-stained tract and the other was granulation replaced tract without internal lumen structure due to repeated infections.


Emphysematous cystitis is a very rare complicated urinary tract infection characterized by air in the bladder wall.We report two clinical cases of emphysematous cystitis of an 83-year-old Caucasian woman with diabetes mellitus and a 78-year-old Caucasian man with no past medical history. They presented with severe confusion and abdominal distension. Emphysematous cystitis was diagnosed in time with a thorough physical examination, urine analysis and computed tomography. The patients were successfully treated with antibiotic therapy and bladder drainage.This rare disorder should be recognized in time and treated properly to guarantee survival. Emphysematous cystitis is a very rare urinary tract infection. Two cases presenting as severe confusion and abdominal pain are described. Patients should be diagnosed in time by performing a thorough physical examination and selecting accurate diagnostic tests.An 83-year-old Caucasian woman was referred by her general practitioner to our emergency department due to agitation and hallucination. Because of pyuria and haematuria on dipsticks, the general practitioner started ciprofloxacin 5 days earlier.She had a medical history of Parkinson disease, atrial flutter, rheumatoid arthritis and diabetes mellitus.A physical examination revealed severe confusion, dehydration, abdominal distension and suprapubic tenderness.3) and a well-controlled glycaemia .Blood analysis revealed prerenal acute kidney failure , signs of infection  cystectomy .If not diagnosed in time, cystitis emphysematosa may result in urosepticaemia and even in death in up to 7% of patients .Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consents is available for review by the Editor-in-Chief of this journal.


Bronchogenic cysts arise from abnormal budding of the ventral diverticulum of the foregut or tracheobronchial tree during embryogenesis, are the most common cystic masses in the mediastinum, and are generally asymptomatic. A spontaneous regression in a mediastinal bronchogenic cyst (MBC) with pneumonia is rare. A 30-year-old male had a tumor shadow in the middle mediastinum. When he visited our hospital, he had a mild fever with coughing and sputum. A chest computed tomography (CT) scan showed a decrease in the tumor size and the existence of right pneumonia. MBC may be involved in the etiology of pneumonia; therefore, bronchogenic cysts need to be resected as soon as possible. A bronchogenic cyst is a relatively rare condition caused by abnormal budding, isolation, and migration of the intrathoracic airway during the fetal period. Cystic lesions account for 14 % of mediastinal tumors, among which bronchogenic cysts are commonly observed. Although most bronchogenic cysts in the mediastinum are generally asymptomatic, some cases may be accompanied by symptoms such as fever, coughing, chest pain, or dyspnea. A decrease in the tumor size of a mediastinal bronchogenic cyst (MBC) accompanied by pneumonia is very rare.A 30-year-old male visited a local doctor due to the onset of coughing with sputum. He had not previously had any health problems. A chest roentgenogram revealed a tumor in the right hilum. A tumor measuring approximately 60 mm in length was detected in the middle mediastinum by plain chest computed tomography (CT), with a small amount of pleural effusion inside the right thoracic cavity Fig . MagnetiA chest-enhanced CT scan taken at our hospital showed spontaneous regression in the tumor size and right intrapulmonary consolidation, which came in contact with the tumor Fig . TherefoWe performed tumor resection using the VATS approach. Regarding findings in the thoracic cavity, fibrous adhesion was detected between the tumor and right lung Fig . After tHistopathological findings revealed that the cyst wall was mainly composed of bronchial glands and smooth muscle tissues, with hematoxylin and eosin staining showing that it was lined by ciliated columnar epithelia Fig . TherefoThe clinical course of this patient showed that MBC may cause pneumonia with spontaneous reductions. Bronchogenic cysts appear in the respiratory primordium during embryonic development of the foregut and have a relatively high incidence among cystic diseases of the middle to posterior mediastinum. Bronchogenic cysts have been classified into intrapulmonary and mediastinal types, with the intrapulmonary type being more common than the mediastinal type in young patients . Many MBThe cause of the decrease in the tumor size of MBC with pneumonia may be weak communication between the tumor and tracheobronchial airway. We have only found three cases of pneumonia due to the rupture of bronchogenic cysts into the airway. Of these, the case from Korea was caused by fine needle aspiration biopsy via a bronchofiberscope. In the case from India, viscous cystic contents clogged up the airway due to rupture, leading to respiratory arrest –5. In ouThe diagnostic rate of bronchogenic cysts based on CT findings is approximately 60 %, with MRI often being used in combination with CT for a definitive diagnosis , 2. SincIn addition to surgical resection, other methods, such as removing intracystic contents with a bronchofiberscope and infusing ethanol, have been reported as treatments for MBC. However, the safety and radical curability of these methods have not yet been demonstrated. Therefore, surgical resection is currently considered preferable and needs to be performed as soon as possible because MBC may lead to pneumonia.Complete resection is recommended in order to avoid any recurrence due to incomplete resection . HoweverAlthough the recurrence of bronchogenic cysts is rare, it has been reported as late as 15 years after surgical treatments .We herein reported the spontaneous regression of MBC accompanied by pneumonia. Although this condition is relatively rare, it may result in a fatal outcome. Therefore, surgical resection needs to be performed as soon as possible, and such cases followed-up for a long period after surgical treatments.Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.


Epithelioid hepatic angiomyolipoma (Epi-HAML) is a rare benign mesenchymal tumor with malignant potential. Most of Epi-HAML contains no or only a minimal amount of adipose tissue and poses a diagnostic challenge. Central vessels are characteristic imaging finding of Epi-HAML, which usually were displayed by dynamic contrast imaging. In this paper, we displayed the central vessels of Epi-HAML invisible on conventional MR images using a new developed abdominal susceptibility-weighted imaging (SWI). To the best of our knowledge, this is the first description for the role of SWI in characterization of Epi-HAML. Hepatic angiomyolipoma (HAML) is a rare benign mesenchymal tumor, which is composed of variable amounts of fat tissue, smooth muscle cells, and vessels at histopathology , 2. DepeSusceptibility-weighted imaging (SWI) is an emerging MRI technique. In neuroimaging, SWI is a 3D, fully velocity-compensated, gradient echo sequence. Brain SWI can be used to visualize smaller intracerebral veins and other sources of susceptibility effects, such as hemosiderin, ferritin, and calcium , 7. We hA 27-year-old woman complained of upper abdominal discomfort for 2 weeks without fever, jaundice, or weight loss. She denied any history of exposure to specific carcinogens. A review of family history was unremarkable. Physical examination revealed hepatomegaly. Liver function tests were normal. Serology was negative for hepatitis B and hepatitis C. Levels of tumor markers alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9) were normal.3, flip angle, 20°; bandwidth, 189 Hz/pixel; field of view 285 × 380 mm. Parallel imaging was performed using the generalized autocalibrating partially parallel acquisition (GRAPPPA) with an acceleration factor of 2. The total acquisition time was 49 seconds, including 3 times of breath-hold with 10 seconds of free breathing. SWI postprocessing was performed according to [Due to the nonspecific complaints, a biphasic contrast-enhanced CT scanning of the upper abdomen was performed using GE 64-detector CT scanner with hepatic arterial and portal venous phase imaging with delays of 30 s and 70 s. CT images revealed a large well-demarcated hypoattenuate mass with heterogeneously intense enhancement on dynamic contrast imaging in the right hepatic lobe. No fat components were detected at CT images . SubsequAt MR images, the mass showed heterogeneous hyperintensity on T1WI  and cleaAccording to the conventional MR images and clinical features of this patient, a benign hypervascular tumor of the liver, for example, focal nodular hyperplasia, adenoma, or HAML, was suspected. However, when the SWI findings were referred, the diagnosis of HAML was considered.The patient underwent surgery for tumor resection with informed consent. The cut surface of the tumor was yellowish mixed with white colored tissue and red vessels. The mass was well defined, but no fibrous capsule was observed . HistopaHepatic angiomyolipoma (HAML) is an unusual mesenchymal neoplasm composed of blood vessels, smooth muscle, and adipose cells , 2. Epi-The radiological appearance of HAML varies widely due to the fact that the distribution and relative proportion of three components varies widely. The fat content of typical HAML produces a characteristic appearance on imaging studies that can be easily diagnosed by CT or MRI , 14. HowCentral punction or filiform vessels was considered as a characteristic imaging feature of Epi-HAML compared with other hypervascular hepatic tumors , 5. LargSWI has been applied to visualize intracerebral venous structures using deoxy-Hb as intrinsic contrast agent in neuroimaging. The magnetic susceptibility of deoxy-Hb causes an average intravascular proton frequency shift and leads to a phase difference between venous blood and the surrounding tissue. To enhance the visibility of the venous structures, the magnitude images were manipulated with the phase data by the use of the phase mask to maximize the negative intensities of the veins. The unique phase mask technique renders SWI exquisitely sensitive to small susceptibility changes. Consequently, SWI was sensitive enough to susceptibility changes to visualize intracerebral venous anatomy at submillimeter resolution. In this case, numerous microvessels could be better visualized on SWI images compared with the conventional MR images , 16.Epi-HAML should be carefully differentiated with other hypervascular hepatic lesions, such as hepatocellular carcinoma (HCC) and focal nodular hyperplasia (FNH). The presence of arterial hypervascularity and venous/equilibrium washout is generally considered to be specific enhancement pattern for the diagnosis of HCC on dynamic imaging. Additionally, capsule could be found in most of HCCs but not seen in Epi-HAML. Clinical history of chronic liver disease and evaluated AFP level also suggest the diagnosis of HCC. FNH typically shows brisk homogeneous enhancement on the arterial phase except the central scar which shows hyperintensity on T2WI and delayed filling in , 5, 17.Our study has a limitation as a case report. We only previously described the fact that SWI was superior to conventional MRI sequences for visualizing microvessels in only one Epi-HAML patient. Hence, it is necessary to determine its statistical significance with large clinical series in further studies.In summary, our case report shows that SWI may be a potential too for visualizing central microvessels of Epi-HAMs, which may be useful for making correct preoperative diagnosis.


Tuberculosis remains one of the most prevalent and fatal infectious diseases in spite of considerable improvements in medical science. Tuberculosis is an important health problem in developing countries. There are few cases of solitary splenic tuberculosis reported in the literature internationally. Solitary splenic tuberculosis is extremely rare and is mostly seen in individuals with immunosuppression. Patients susceptible to acquiring splenic tuberculosis usually have some risk factors such as immunosuppression, pyogenic infections, splenic abnormalities, spleen trauma, sickle cell disease, and so on .Here we report a case of surgically confirmed mass-forming solitary splenic tuberculosis in a 64-year-old woman who presented with abdominal discomfort for two months, but with no other symptoms. Laboratory data provided no specific information for diagnosis. Abdominal ultrasonography revealed a large hypoechoic lesion within the spleen. Computed tomography scan of the abdomen showed a solitary hypodense lesion. A diagnosis of solitary splenic tuberculosis was confirmed after a splenectomy was performed and histopathological examination revealed splenic tuberculosis.Solitary splenic tuberculosis is rare and associated with an immunocompetent patient is extremely rare. It is hard to correctly diagnose it by US or CT scan. Despite medical improvement in the diagnosis and treatment of infectious diseases over the years, tuberculosis continues to be a major health problem in developing countries. There are few cases of solitary splenic tuberculosis reported in the literature internationally, especially single large mass-forming splenic tuberculosis. Splenic tuberculosis is extremely rare. Approximately 15–20 % of all cases of tuberculosis are extrapulmonary; of these 3–11 % are abdominal. Splenic tuberculosis is very unusual with only a few case reports. In a series evaluated retrospectively, the rate of splenic tuberculosis was reported as 8 %, while in the literature the rate of micronodular type of involvement was reported at around 5 %. Splenic tuberculosis presents with diverse clinical symptoms. The most common symptoms that patients present with are fever (82.3 %), fatigue and weight loss (44.12 %), and splenomegaly (13.2–100 %). Therefore, it is likely to be misdiagnosed as carcinoma of the spleen, metastases tumor, lymphoma, hemangioma, or splenic abscess. The misdiagnosis rate is high if there is no tuberculosis history in any other organs. Through the literature retrieval, at present, there are no reports about splenic tuberculosis mortality rate data.In this case report, we present the case of a 64-year-old woman solitary splenic tuberculosis and with no other significant past medical history.A 64-year-old Chinese woman presented to our outpatient service with abdominal discomfort associated with nausea for two months, but no other symptoms. There was no history of fever, cough, chest or abdominal pain, night sweats, weight loss, or anorexia. Her history included a 4-year cholecystectomy. Her medical history did not include any tuberculosis and human immunodeficiency virus (HIV) infection. On physical examination, her body temperature was 36.5 °C. Palpation of the abdomen revealed epigastric tenderness and no hepatosplenomegaly. Routine blood analysis revealed mild anemia, hemoglobin level was 100 g/L, blood platelet count was 242 × 109/L. Liver function tests were within normal limits . Tumor markers were within normal limits and HIV antibody reaction was negative. Chest radiography and cardiac ultrasound (US) revealed no abnormalities.Abdominal US showed the spleen with a large hypoechoic lesion. The mass size was 6.9 × 6.9 × 6.7 cm with regular margins and homogenous internal echo. Contrast-enhanced US showed that splenic hypoechoic lesion appeared with a rounded, clear boundary, heterogeneous enhancement, and centrally irregular necrosis. Our diagnosis was lymphoma Fig. .Fig. 1UlAbdominal computed tomography (CT) scan showed a large hypodense lesion (6.4 × 6.5 cm) on the spleen with an unclear boundary which became clear after enhanced scanning and heterogeneous lesion enhancement. Centrally irregular necrosis can be seen in the mass. Our diagnosis was inflammatory pseudotumor Fig. .Fig. 2AbThe patient did not have a magnetic resonance imaging examination before surgery.Due to the position of the mass and the risk of gastrointestinal tract injury and tumor bleeding, needle biopsy of the spleen mass was excluded. The patient therefore underwent laparoscopic splenectomy for diagnostic and therapeutic purposes. The histopathological report showed splenic granulomatous inflammation with large inflammatory necrosis and caseation necrosis. We finally diagnosed splenic tuberculosis. After surgery, the patient was started on quadruple anti-tuberculosis therapy  Fig.  and b.Fi9/L. Liver function tests were within normal limits, purified protein derivative test was negative. Chest radiography and abdominal CT scan revealed no abnormalities.Three months after splenectomy, the patient presented to our outpatient service for re-examination. Routine blood analysis revealed mild anemia, hemoglobin level was 108 g/L, blood platelet count was 258 × 10Tuberculosis is a multi-system disease and pulmonary tuberculosis is the most common manifestation. Extra pulmonary disease accounts for almost 15–20 % of all tuberculosis . Sharma Despite the reliability of common methods such as US and CT in distinguishing such lesions, from primary or metastatic tumor of the spleen, it has its limitations. The misdiagnosis rate is high if there is no tuberculosis history in other organs.In our case, a single and solid mass was seen on the spleen with contrast-enhanced US. The splenic hypoechoic lesion appeared with a rounded, well-demarcated, heterogeneous enhancement, and centrally irregular necrosis. At first, we misdiagnosed this as lymphoma.Contrast-enhanced CT showed a splenic hypodense lesion appearing with a rounded, clear boundary, heterogeneous enhancement, and irregular necrosis, which at first we misdiagnosed as an inflammatory pseudotumor. There are many situations that may have presentations of single and solid masses, splenic hypodense lesions on CT, and hypoechoic lesions on US such as malignant lymphoma, metastatic tumor, acute leukemia, hemangioma, or even infectious diseases. Our patient was misdiagnosed at first.In almost all the reported cases, the diagnosis was first made by radiological findings followed by pathological examination of a fine-needle aspirate, splenic biopsy, or splenectomy. Needle biopsy of the spleen is an important method of diagnosis. If biopsy fails, laparoscopic splenectomy has been used in the diagnosis of splenic tuberculosis and has proved to be a minimally invasive approach. Surgery remains the gold standard for definitive diagnosis of such cases with an undefined etiology.In our case, because of the position of the mass and the risk of gastrointestinal tract perforation and tumor bleeding by needle biopsy of the spleen mass, laparoscopic splenectomy was carried out.So far, histopathological examination is still an ideal method to confirm the diagnosis. There are five types of pathomorphological classifications for splenic tuberculosis including miliary tuberculosis, nodular tuberculosis, tuberculous spleen abscess, calcific tuberculosis, and mixed type tuberculosis.Like the treatment of pulmonary tuberculosis, antitubercular treatment is the primary modality in treating splenic tuberculosis. Splenic tuberculosis must be carried out in accordance with the following principles: timely treatment in combination, regularly and properly through the whole course whether or not an operation is performed .Solitary splenic tuberculosis is rare and associated with an immunocompetent patient is extremely rare. It is hard to correctly diagnose it by US or CT scan. We hope that more detailed information about the differential diagnosis, especially non-invasive imaging techniques, will be constantly updated.CT, computed tomography; HIV, human immunodeficiency virus; US, ultrasound


Giant cell tumor of tendon sheath is one of the most common soft tissue tumors of the hand. These tumors typically occur in the third or fourth decade of life and present as solitary nodules on a single digit. Currently, the greatest reported number of lesions found within a single digit is five. Although uncommon, giant cell tumor of tendon sheath does occur in the pediatric population. Herein we present a report of a rare case of GCTTS in a child in which seven lesions were identified within a single digit—the greatest number of lesions within a single digit reported to date.  Giant cell tumor of tendon sheath (GCTTS) is the second most common soft tissue tumor of the hand, second to ganglion cyst –3. This Though uncommon, GCTTS has been seen in the pediatric population. A case series performed by Gholve et al. demonstrated that GCTTS in the pediatric population behaves similarly to the adult lesion . These lInformed consent was obtained from the patient's guardian for print and electronic publication.A 9-year-old female, right hand dominant, presented to our institution with a one-year history of left middle finger pain and palpable growing masses. The patient was first evaluated by her pediatrician. Plain radiographs were performed by her pediatrician and the report stated no significant findings. Her past medical history is significant for hypothyroidism which is being treated with levothyroxine. Magnetic resonance imaging (MRI) was performed to further evaluate the masses. The study demonstrated multiple hypodense masses and seven identifiable masses, on the volar aspect of the proximal, middle, and distal phalanx of the left middle finger Figures .Three months after obtaining the MRI, the patient was seen in the clinic for evaluation by the orthopaedic hand service. Physical examination revealed mild swelling and tenderness throughout her left middle finger; however, no sensory deficits were noted, and brisk capillary refills were present. Three palpable small masses could be felt throughout the volar aspect of her finger. Bluish discoloration could be seen over some of these masses . The ranThe patient initially underwent excisional biopsy of two of the masses that were abutting each other. Definitive diagnosis was not obtainable from the initial frozen section. The third mass was located more proximal and a decision was made to not excise this lesion until a definitive diagnosis could be made. Tissue was submitted for further histological examination. Standard sections revealed a cellular process including giant cells and mononuclear stromal cells within a collagenous matrix . HemosidAt this time, the patient is two years from her second surgery. She denies any pain and has full range of motion of her left middle finger. Her incisions are well healed and no foci of recurrence are noted at this time .GCTTS is a common benign soft tissue tumor found in the hand which originates in the synovium of the flexor sheath. They typically go through stages of dormancy and increased activity making these lesions suddenly symptomatic or noticeable. Although they most often occur in the hand and fingers, these tumors can also occur in larger joints like the feet, ankles, knees, and elbow. In the hand, they typically occur adjacent to the distal interphalangeal joint of the index or long finger.With recurrence rates reported up to 45% , carefulIn 2001, Al-Qattan described a classification system for GCTTS. The classification systems were macroscopically divided into two main types, tumor with or without a single pseudocapsule [Our case also represents the largest number documented discrete GCTTS lesions in a single digit in current literature. Singh et al. reported a case in an adult with five lesions within a single digit . That paIn 2007, Gholve et al. published the largest case series of GCTTS in the pediatric population . The resIn conclusion, our case represents a rare case of GCTTS in a child with seven lesions found within a single digit. To our knowledge, this is the first case where more than five solitary lesions were found within a single digit. In addition, these lesions were found in a child which is even less typical. Due to the relatively high rate of recurrence found with these tumors, especially those with multiple solitary lesions, complete and meticulous resection of these tumors with magnification equipment is recommended.


Dear Sir[1] and want to mention our own case where a misdiagnosis led to inadequate management resulting in loss of 30cm of small bowel. A 12-hour-old male baby delivered via Caesarian section due to prenatal diagnosis of omphalocele. He was attended by a surgical resident and labelled as omphalocele major and advised mercurochrome paint. Next day, the neonate became lethargic. Abdominal examination showed protrusion of bowel through the umbilicus into an omphalocele like sac with dark maroon discoloration on one side . There was not abdominal wall defect and umbilicus was normally sited. At the base there was a skin collar of about 2 cm. The patient was immediately prepared for laparotomy with a suspicion of bowel necrosis. On opening the sac, serosanguineous fluid was drained. The part of ileum was necrotic while most of jejunum and ileum were edematous. The incision extended cranially in midline and small bowel was delivered. Grossly necrotic ileum measuring 30cm was excised and end to end anastomosis was done. Malrotation was also present and corrected. Primary closure easily achieved due to bowel resection. The postoperative recovery was uneventful with a follow-up of 6 months. Our case is unique since large sac with hemorrhage was giving appearance of herniated liver causing the condition to be misdiagnosed as omphalocele major. It is mandatory to look carefully in a case of omphalocele for presence of any true abdominal wall defect, umbilical ring, and the base for presence of skin collar so that the condition is not misdiagnosed.We read with interest case series of “Hernia of umbilical cord: Report of three unusual cases” Source of Support: NilConflict of Interest: None


Granular cell tumour (GCT) is mostly benign lesion first described by Abrikossoff and named after him. Most cases are reported in the head and neck area, where the tongue is the most common site. Here we review previous cases in the literature for GCT in the orbit and present a new case. A 49-year-old male presented with apparent exophthalmos. Examination of the patient revealed the presence of a mass in the bottom side of the orbit. A substantial progress was noted after two months from the initial examination using computed tomography (CT) scan. An orbital mass was extracted and histological analysis showed signs typical for GCT. Immunohistochemistry was positive for S-100; the biopsy showed no mitotic or necrotic areas. Proptosis was resolved after surgery and a six-year follow-up CT scan was performed. We conclude that rapid progress of the tumour does not necessarily suggest malignancy. Granular cell tumour (GCT) is a commonly benign soft tissue lesion of neural origin according to histochemical and ultrastructure studies . It was A 49-year-old male patient presented with a history of progressive exophthalmos. Initially, he presented with a minor proptosis. Two months later, a significant progress was noted and ophthalmologic examination revealed a subcutaneous mass with partial occlusion of the lids . Vision Abrikossoff's tumour is a rare tumour with commonly benign evolution. CT scan is essential for the correct localization of the mass and early diagnosis is very important to preserve the eye globe. The aim of this report is to describe a case of granular cell tumour in the orbit, to provide a comprehensive summary of previous reports of this case, and to review the malignancy incidence rate of this tumour. The case presented here was suspected to be a malignant tumour due to its fast progress within two months from the first examination; however, histological analysis suggested that it was a benign tumour. This was confirmed by examining the patient regularly for six years. Benign and malignant counterparts are known; the latter are rare, comprising fewer than 2% of all granular cell tumours. In fact, according to previously reported data , 3 out oLiterature review of previous 31 cases shows no age related incidence of GCT in the orbit. Cases reported in age range from 4 years to 72 years, with most cases being reported in patients with 40 years or more. Three cases of GCT malignancy were reported, and the latest was in the year 2000 .


This paper presents a case report of an HIV-negative, supraglottic Kaposi's sarcoma patient. The 80-year-old male patient was admitted with complaints of hoarseness, difficulty in swallowing, and a stinging sensation in his throat for approximately six months. The endoscopic larynx examination revealed a lesion which had completely infiltrated the epiglottis, reached right aryepiglottic fold, was vegetating, pink and purple in color, multilobular, fragile, and shaped like a bunch of grapes, and partially blocked the bleeding airway passage. The case was discussed by the hospital's head-neck cancer committee and a surgery decision was made. A tracheotomy was performed under local anesthesia before the operation due to respiratory distress and endotracheal intubation difficulty. Direct laryngoscopy showed that the mass was limited in the supraglottic area, had invaded the entire left aryepiglottic fold and one-third of the front right aryepiglottic fold, and completely covered epiglottis. It should be remembered that although rare, Kaposi's sarcoma may be encountered in larynx malignancy cases. Disease-free survival may be achieved through local excision and postoperative radiotherapy. Kaposi's sarcoma is a vascular tumor that was first described by Kaposi in 1872 . Its mulThe 80-year-old male patient complained of hoarseness and a stinging sensation in his throat for approximately six months and was then transferred to our clinic. The endoscopic larynx examination revealed a lesion that completely infiltrated the epiglottis and reached the right aryepiglottic fold. It was vegetating, pink and purple in color, multilobular, fragile, and shaped like a bunch of grapes and was covering the bleeding airway passage .Before arriving at our clinic, a punch biopsy was done and suggested a diagnosis of Kaposi's sarcoma. The patient reported that he used to smoke approximately fifty packs of cigarettes per year but had not smoked in the last five years. He had no history of systemic disease or infection. Nothing was remarkable in routine blood analyses. ELISA tests for HIV-1, HBV, and HCV were negative. A positron emission tomography (PET-CT) showed that no other areas were affected. The case was discussed by our hospital's head-neck cancer committee and a surgery decision was made. A tracheotomy was performed under local anesthesia before the operation due to respiratory distress and endotracheal intubation difficulty. The direct laryngoscopy showed that the mass was limited in the supraglottic area, had invaded the entire left aryepiglottic fold and one-third of the front right aryepiglottic fold, and completely covered epiglottis. The laryngeal ventricle, vallecula, arytenoids, interarytenoid area, and glottic and subglottic areas were intact. The mass was found to be bleeding and fragile.An epiglottectomy was conducted with a diode laser and partial resection was performed on the aryepiglottic folds .In the histopathological examination of the mass, a tumoral mass consisting of fusiform cells under the surface epithelium was observed in preparations stained with hematoxylin-eosin . Some ofKaposi's sarcoma, which is a vascular tumor, has four described types: common, endemic, immunosuppression or transplantation-related, and epidemic or AIDS-related. The most aggressive form is epidemic, observed in HIV-positive patients . IatrogeHIV-1, HHV-8, CMV, mycoplasma, and Chlamydia infections have been associated with the etiology of common Kaposi's sarcoma. It is generally observed in extremities and rarely in oral cavities, as a cutaneous, red to purple lesion. The majority of patients reported in the literature are AIDS or immunosuppressed patients; HIV-negative and nonimmunosuppressed cases are rare –11.Six Kaposi's sarcoma cases were reported in 1996 by Friedman et al., which involved the larynx . In 1997Aphonia, dysphagia, hoarseness, and stridor are symptoms that may arise in tumors on the larynx. Red or purple mass lesions may be observed in the endoscopic larynx examination . Since iTreatment for HIV-negative cases involves local excision, cryotherapy, radiotherapy, vinblastine injection into lesions, and systemic single-agent or combination chemotherapy . SeriousAlthough rare, common Kaposi's sarcoma may be encountered on the larynx. Disease-free survival may be achieved through local excision and postoperative radiotherapy.


Nasal polyps are benign prolapsed mucosal lesions which commonly arise from the paranasal sinuses and lateral walls of the nose especially the contact areas of osteomeatal complex. Though nasal polyps arising from the nasal septum have been reported, those arising from its anterior part are extremely rare and present a diagnostic dilemma. Aetiology is multifactorial and is mainly a result of the inflammatory response of the lining mucosa.The case of a 28-year-old male, with a history of progressively increasing nasal complaints since 4 months and with a nasal mass arising from the anterior nasal septum on examination, is reported. Diagnosis of an inflammatory nasal polyp was made on histopathological examination after surgical excision of the mass.The diagnosis of an inflammatory nasal polyp was not only unusual in terms of its location but also in its appearance on anterior rhinoscopy and tomographic scanning images. The definitive diagnosis in such cases can only be achieved through surgical resection and detailed histopathological examination.  Nasal polyps are benign abnormal mucosal protrusions associated with nasal mucosa or paranasal sinuses. They were first reported 4000 years ago. Hippocrates referred to these nasal masses as “polypus” due to its resemblance to the sea–polyp (many footed). They appear as fluid filled semitransparent tear drop-like structures. The prevalence in the adult population is estimated to be around 1-4% (Increasing prevalence suggests multiple factors contributing to its pathogenesis. Nasal polyps are thought to result from inflammation of the mucosa resulting from allergy or even from anatomic obstruction because of altered air currents and increased air pressure. Polyps may be a presenting feature of fungal sinusitis, allergic rhinitis, asthma, ciliary dyskinesias, or aspirin intolerance. Polyps may arise from the mucosa of the nose or paranasal sinuses. The most commonly involved sinuses are ethmoids, maxillary, sphenoid, and frontal, respectively in that order. These may also arise in the middle meatus from the uncinate process and the ethmoidal infundibulum. Ethmoid and antral polyps need important mention. Ethmoidal polyps are allergic in nature and their clinical spectrum may extend from a limited disease, which responds to conservative treatment, to a very extensive one, which shows frog faced deformity and requires functional endoscopic sinus surgery or even multiple surgeries. Unilateral polyps are most commonly described as antrochoanal polyps, but there are other disorders which need to be evaluated: these are mainly Inferior turbinate hypertrophy, inverted papilloma, septal papilloma, big mucosal blob, olfactory neuroblastoma, rhinosporidiosis, rhinoscleroma, juvenile nasal angiofibroma, or angiofibroma of the septum. However, solitary lesion arising from the anterior nasal septum, as in the case presented here, is extremely rare and can present a diagnostic dilemma requiring radiological and histological assistance to conclude the diagnosis.A 28-year-old male with a history of progressively increasing nasal obstruction since 4 months, was presented to the clinic. This nasal obstruction was associated with a mass in the nasal cavity seen through the anterior nares, which was initially small and probably arose from the septum, but had gradually increased to obstruct almost the whole right nasal cavity. There was no history of nasal discharge, post nasal drip, allergy, epistaxis, headache, facial fullness, alteration in smell, or other nasal complaints. There was broadening of the right nasal cavity with prominence of the right nasal vestibule. On anterior rhinoscopy a pinkish mass was seen filling the right nasal cavity . When probing the mass; which was attached to the septum, vestibule, and roof with a broad pedicle; it was observed to be firm in consistency, non friable, non tender, and did not bleed on touch. Posterior rhinoscopy was insignificant. Detailed nasal endoscopy revealed that the middle meatus was clear and there was no other mass or anomaly. The left nasal cavity was within normal limits. The rest of the otolaryngological examination did not reveal any noteworthy abnormality. A probable diagnosis of a granulomatous mass, septal papilloma, hemangioma, polyp, and rhinoscleroma was made.Fine needle aspiration cytology of the mass suggested abundant eosinophilic cells and a differential diagnosis of nasal polyp, eosinophilic granuloma, and eosinophilic angiocentric fibrosis was considered. CT Scan confirmed the presence of a right nasal mass arising from the anterior part of the nasal septum and the adjoining roof, which was obstructing the right nasal cavity. Aeration of the associated sinuses were clear . Prior to surgical intervention an informed consent was taken. The patient was put under local anaesthesia using 1:100000 lignocaine in adrenaline and, using endoscopic guidance, the mass was excised with an adjacent margin of normal healthy tissue. The specimen macroscopically measured 2.5 X 2 cm in size, was pink in colour, firm in consistency, and had a lobulated smooth surface . The mass was sent for histopathological examination, which suggested features consistent with an inflammatory nasal polyp . The posTraditionally nasal polyps are said to arise from the mucosa of the sinus and enter the nasal cavities through the ostium. They are mainly classified into antral and ethmoidal types depending on the sinus of origin. Nasal polyps may also arise from the middle turbinate, ethmoidal infundibulum, and contact areas of the uncinate process. However, a review of literature suggests polyps from various other unusual sites i.e posterior nasal septum, floor of the nose, cribriform plate, and sphenoid sinus have been reported -6. The first case of septal polyp was reported by Bailey in 1979 . StammbeThe exact aetiopathogenesis is not known and several theories have been postulated in the past 150 years. Allergy and chronic inflammation are commonly implicated factors. Some of the proposed mechanisms include the adenoma and fibroma theory by Billroth, an increase in tubuloalveolar glands, structural defects like deviation of the nasal septum, mucosal oedema, mucosal inflammation , and epithelial rupture. More recently the role of inflammatory mediators like Interleukins ,5,8, traBernstein proposed the multivariate theory for the pathogenesis of polyps . PrepondIn rare cases, like the one presented here, where the site of origin is from an unusual site like the anterior nasal septum, the exact cause is still unknown. Vinayak S reported a similar case of an allergic polyp of the ala of the nose associated with a deviation of the nasal septum . In the Diagnosis of nasal polyps is by anterior rhinoscopy and a detailed endoscopic examination is necessary especially in cases where the site of origin is rare. Preoperative nasal endoscopy is essential to make a tentative diagnosis for further investigations and for planning the surgical course. A preoperative CT scan is essential to confirm the diagnosis, to evaluate the extent of the pathology, and to rule out anatomical variations contributing to the origin. Treatment of nasal polyps include an adequate trial of corticosteroids that can be taken orally as well as in the form of nasal sprays. In the case of resistant polyps, endoscopic sinus surgery is the treatment of choice. In cases of isolated septal polyp, excision with a wide healthy margin gives good results. The postoperative outcome was favourable in this case: there was no recurrence and the patient is on regular follow up.To conclude, the diagnosis of an inflammatory nasal polyp was not only unusual in terms of its location but also in its appearance observed in anterior rhinoscopy and tomographic scanning images. The definitive diagnosis in such cases can only be achieved through surgical resection and detailed histopathological examination. Further research should be directed to evaluate definitive pathogenesis of polyps; including the role of chemical mediators, triggering factors, and genetic susceptibility; as it may play an important role in evolving future management strategies.


Quadrilateral space syndrome (QSS) is a rare nerve entrapment disorder that occurs when the axillary nerve and posterior circumflex humeral artery (PCHA) become compressed in the quadrilateral space. QSS presents as vague posterolateral shoulder pain that is exacerbated upon the abduction and external rotation of the shoulder. Diagnosis of QSS is difficult because of the vague presentation of QSS. In addition, even though MRI and MR angiography can be used in QSS diagnosis, there is currently no “gold standard” diagnostic imaging studies for QSS. In this case report, we describe a novel ultrasound-guided technique for a diagnostic quadrilateral space block and present a case where the diagnostic block was used to diagnose QSS. We believe that a diagnostic block of the quadrilateral space is a useful adjunct in the evaluation of patients with suspected QSS, especially in cases where examination findings and other diagnostic modalities are indeterminate. Quadrilateral space syndrome (QSS) is a rare disease caused by the compression of the axillary nerve and possibly the posterior circumflex humeral artery (PCHA) as they course together through the quadrilateral space. QSS is a diagnosis that is difficult to achieve by history and physical exam alone and there are no tests which considered the diagnostic “gold standard” .In some musculoskeletal conditions, due to the low specificity of physical examination maneuvers and lack of a good diagnostic study, local anesthetic blocks often remain as the diagnostic “gold standard” , 3. In tIn this case report, we describe a novel ultrasound-guided technique for a diagnostic quadrilateral space block and present a case where the diagnostic block was used to diagnose QSS. We believe that a diagnostic block of the quadrilateral space is a useful adjunct in the evaluation of patients with suspected QSS, especially in cases where examination findings and other diagnostic modalities are indeterminate.A 42-year-old female with no significant past medical history presented to our outpatient musculoskeletal clinic with left posterior-lateral shoulder pain for 9 months. Prior to her consultation in our clinic, she was evaluated by the orthopedic surgery service, who ordered an MRI of the left shoulder. The MRI revealed edema and enhancement of the teres minor muscle and posterior part of the deltoid muscle. There was also evidence of degeneration of the superior glenoid labrum. The patient desired nonoperative management, so a subacromial bursa steroid injection was performed by the orthopedic surgeon, which was ineffective for pain relief. The patient was then referred to our service for further nonoperative management.On presentation to our clinic, the patient reported pain in the posterior-lateral shoulder. The pain was described as a constant dull ache without any radiation. Examination of the shoulder revealed a mildly protracted left scapula with no visible atrophy of the shoulder or spine musculature. Range of motion was within normal limits, and results of Neer, Hawkin, Scarf, and Obrien test were negative. There was mild tenderness to palpation at the posterior aspect of the glenohumeral joint inferior to the acromion. Due to the examination findings and MRI evidence of edema in the teres minor and posterior part of the deltoid muscles, we suspected a diagnosis of QSS. An ultrasound-guided local anesthetic block of the quadrilateral space was performed. Subsequent to the block, the patient received 100% relief of her pain and the diagnosis of QSS was confirmed.The patient was placed in a prone position with both upper extremities at her side. The transducer was placed medial to the glenohumeral joint in an orientation perpendicular to the axis of the spine of the scapula . The spiAnatomically, the quadrilateral space is bordered superiorly by the teres minor, laterally by the proximal humerus, medially by the long head of the triceps tendon, and inferiorly by the teres major . These bThe signs and symptoms of QSS are typically secondary to the compression of the axillary nerve. On examination, patients may demonstrate point tenderness in the quadrilateral space . PatientDiagnosis of QSS using history and physical exam alone is difficult since it may present as shoulder pain that is not necessarily localized to the quadrilateral space. Furthermore, paresthesias may or may not be present in patients suffering from QSS . AdditioCurrently, there is no “gold standard” diagnostic test for QSS. However, magnetic resonance imaging of suspected QSS patients is often used as it may show selective fatty atrophy of the teres minor and possibly the deltoid muscles, both of which are innervated by the axillary nerve , 10. In In addition to MRI, angiography may be used as a diagnostic test for QSS. There is currently no data regarding the sensitivity of angiography in diagnosing QSS. Multiple studies have used subclavian arteriogram or MR angiography to confirm QSS diagnosis , 12. PCHWith the advancement of ultrasound, sonographic evaluation has also become a recent option to aid with QSS diagnosis. Axillary nerve compression can manifest as teres minor fatty change in ultrasound as well as diffuse increase in teres minor echogenicity, in addition to a small loss of muscle bulk with the absence of rotator cuff abnormalities , 14, 15.In the case above, our patient presented with nonspecific signs and symptoms of posterior-lateral shoulder pain. On MRI, the patient had findings of enhancement in the teres minor and posterior part of the deltoid muscles. Even though these findings were suggestive of QSS, the patient had evidence of degeneration of the superior glenoid labrum, a condition which may also manifest as posterior-lateral shoulder pain. These nonspecific findings ultimately led to our decision to perform an ultrasound-guided diagnostic block of the quadrilateral space. After the successful block, we were able to confirm the rare diagnosis of QSS.We strongly believe that the procedure is an extremely helpful adjunct in the evaluation of patients with suspected QSS. More studies should be conducted to assess the sensitivity and specificity of an ultrasound-guided diagnostic block of the quadrilateral space in the diagnosis of QSS.


Thymic neuroblastoma is a rare tumor with only few reports in modern literature. Whereas most data is taken from childhood neuroblastoma, little is known about the characteristics of the disease in the adult and elderly population.There are significant differences between adult and childhood neuroblastoma which are reviewed below.We report a case of a 62-year-old male who presented with neurological symptoms of ataxia and opsoclonus and an anterior mediastinal mass. Ultimately, the patient underwent a resection of the mass and pathologic review identified a thymic neuroblastoma. This is the first case of thymic neuroblastoma associated with symptomatic central nervous system disease; it is presented with an up-to-date review of the previous cases in the field as well with a review of the literature of post adolescent neuroblastoma. Neuroblastoma is a tumor originating from the neural-crest cell, arising from the sympathetic nervous system. Most of the reported cases arise in infants and children below the age of 10 years. In the adult and elderly population, it is a rare tumor.While neurological symptoms may be associated in adults with thymic mass (as in myasthenia gravis), thymic neuroblastoma was never described as a cause for neurological symptoms in the adult population.We present a case of a 62-years-old male who presented with neurological symptoms and was found to have thymic neuroblastoma. After a comprehensive workup, surgical resection with complete removal of the tumor was done. The patient recovered well, and his neurological symptoms subsided. Up to date, review of the current literature is presented with suggested workup and treatment plan based on the current limited literature.A previously asymptomatic 62-year-old male presented with ataxia and oscillopsia with progression over a 6-week interval. On physical examination, the patient was noted to have horizontal and vertical opsoclonus, truncal ataxia, right eye ptosis, and a hoarse voice. A chest CT was done and an anterior mediastinal mass was found Figure . A magneFurther investigations included a brain MRI which revealed only chronic microvascular changes with an old lacunar infarction. Electromyography (EMG) including eye musculature did not show decrement in muscle activity with repetitive stimulation and was not consistent with myasthenia gravis. A spinal tap did not reveal malignant cells or oligoclonal bands.The patient was commenced on treatment for a paraneoplastic cerebellar syndrome with intravenous immune globulin which provided no further improvement in his symptoms. Investigations previously yielded a negative serum panel for myasthenia gravis and serum alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) serum levels were within normal limits; the patient’s serum and urine studies did not suggest syndrome of inappropriate anti diuretic hormone secretion (SIADH).Following these investigations, the patient underwent a trans-sternal thymectomy, with adjacent pericardiectomy. The mass was dissected free from the superior vena cava and innominate vein without evidence of invasion of these structures. Three months after his surgery, the patient subjectively reported a slow progressive improvement in his neurologic symptoms and was able to walk independently with mostly resolved ocular flutter and mild dysarthria. Unfortunately, his ataxia and dysarthria became worse 6 months following surgery. Metastatic workup yield no evidence of recurrent disease. The patient was treated with chest irradiation and systemic immunosuppression with progressive improvement.Pathology revealed a 7.5-cm neuroblastoma without capsular invasion. The tumor was adherent to the pericardium but without invasion of neighboring structures including the pericardium. Resection margins were negative for tumor. One removed lymph node was negative for tumor. Immunohistochemistry staining was positive for synaptophysin, chromogranin, and NSE and negative for AE1, AE3, and CD99 , whereaIn a large surveillance, epidemiology, and end results (SEER) database between 1973 and 2007, 3,818 neuroblastoma patients , and 35 elderly patients (>60 years)) were identified with this disease. The most common primary site for the elderly population was the heart and soft tissue (60%), respiratory system and mediastinum as a group (31.4%), and testis (5.7%). Only 2 of the 3,818 patients over the 30 years of data acquisition were found to have a primary mediastinal tumor site [Thymic neuroblastoma is common in children less than 18 years of age; 42.9% of childhood neuroblastoma originates in the thymus and endocrine glands . Adult oMortality rate is unknown for the elderly population. Most reports define follow-up after surgery as an end point, and they do not define standard disease-free intervals or mortality data. The survival rates observed for a group of 125 adults (age >20 years) with neuroblastoma in all locations was 45.9% and 36.3% for 3 and 5 years, respectively. A third of the patients had metastatic disease on presentation and they had lower survival rates than that of infants, children, and adolescents. Furthermore, long-term survival of adult patients has revealed a continuous decrease in survival over the first 7 years of follow-up with stabilization thereafter to a 33.3% survival at 10 years [Reviewing the modern literature 1966-2014), for adult onset neuroblastoma, we found only nine reports (not including our patient) of elderly patients (>60 years) with primary mediastinal neuroblastoma; five of these were reported in the thymus, three cases in the anterior mediastinum, and one case in the superior mediastinum  attributable to immune-mediated injury of the cerebellum and likely other targets within the central nervous system. The syndrome manifests itself as opsoclonus, myoclonic jerks, ataxia, and/or encephalopathy. A search of the literature reveals no reports of adult patient with neuroblastoma and OMS ,11.There are scattered case reports in adults of mediastinal neuroblastoma and increased secretion of anti diuretic hormone (ADH) -7. SIADHAs compared to childhood neuroblastoma, adult onset neuroblastoma has a worse outcome independent of stage, primary site, and clinical course on presentation. This is possibly due to chemotherapy which may be less active in adults than in children . ClinicaNeuroblastoma occurring in children may express n-myc oncogene which is a sign of aggressive disease , and somGiven the rare incidence, the natural history of elderly (>60 years) thymic neuroblastoma is unknown. In childhood neuroblastoma, prognosis is inversely related to the age of presentation (infants carry the best prognosis); there is a consensus that in adults, the disease is more indolent but carries a worse prognosis. However, mediastinal neuroblastoma carries a better prognosis in the elderly compared to the other groups .Surgery with or without chemotherapy is the mainstay of treatment for neuroblastoma in childhood (radiotherapy is reserved for tumor progression). However, in the adult population, given the rarity of the disease and limited data, there are no standard treatment guidelines and most pediatric protocols are not tolerated by the adult population. Expert opinion suggests surgical resection with negative surgical margins as the main treatment and adjuvant chemotherapy or radiotherapy for advanced disease .This is the first report of elderly patient with thymic neuroblastoma presenting with positive neurological symptoms which improved following resection of the tumor.Thymic masses presenting in the elderly should be thoroughly investigated and in the absence of metastatic disease should be resected with negative margins if possible. Neuroblastoma should be considered in the differential diagnosis of thymic mass with SIADH-related syndrome or nonmyasthenic neurological symptoms. Surgery with negative margins for adult neuroblastoma is recommended; however, recurrence may occur.Written informed consent was obtained from the patient for publication of the case report and any accompanying images. A copy of the written consent is available for review by the editor in chief of this journal.


A 14-month-old female patient presents with a progressively enlarging right thumb mass. Her mother states that the mass developed shortly after birth. The patient had tenderness on palpation of the lesion, and she was noted to have difficulty grasping objects.What important history and clinical examination findings differentiate this lesion from similar ones?How is this lesion diagnosed?What are the treatment options?What is the risk of malignant transformation?,1,Lymphangiomas are lymphatic malformations that result from failure of lymphatic channels to connect to their central drainage system, leading to poor lymph flow and fluid accumulation.12) or macrocystic (>2 cm2).Presentation of these masses is vague and may be easily confused with hemangiomas or venous malformations. Magnetic resonance imaging is useful in demonstrating characteristic lymphatic septa and venous channels that display low signal on T1 and high signal on T2 imagesTreatment of lymphangiomas is challenging, and current treatment regimens are suboptimal. A multidisciplinary approach can be invaluable to coordinating the best care possible for these patients. Noninvasive techniques such as external compression and observation are ineffective in limiting growth.Lymphangiomas present virtually no risk of malignant transformation.Lymphangioma of the hand is a rare tumor with a vague presentation. Magnetic resonance imaging is an important diagnostic modality. These cases are challenging, and current treatment options to reduce size include sclerosing agents, laser embolization, and surgical excision. Our patient underwent surgical excision with wide margins. Patients must be followed closely for recurrence. Risk of malignant transformation is low.


Objective: Infantile hemangioma (IH) is a benign vascular tumor that gradually shrinks over several years. Involuting or involuted IHs usually retain their shape, however, and result in redundant skin or conspicuous scarring due to ulceration in the proliferating phase. We present a case series of 12 patients who underwent intralesional excision and primary closure for treatment of involuting or involuted IH. Methods: Twelve patients  underwent our treatment method for involuting or involuted IH. A blinded assessor evaluated clinical result of each patient. Results: Surgical results were excellent in 4 patients, good in 6, and fair in 2. A small dog ear was prominent in 1 patient; nevertheless, all parents were satisfied with the results. Conclusions: Intralesional excision and primary closure for treatment of involuting or involuted IH is an easy and simple procedure that does not result in dog-ear formation or elongated residual scarring. Infantile hemangioma has a high incidence rate, affecting approximately 10% of children.3Between 2004 and 2012, a total of 12 patients  underwent surgical resection for involuting or involuted IH in the Department of Plastic Surgery of Himeji Medical Center, Himeji City, Japan. For each patient, age at surgery, lesion location, operative indication, and previous interventions were noted. Results were divided into 4 categories based on cosmetic outcome (scarring and deformity) as follows: (1) excellent, little, or invisible scarring without deformity; (2) good, visible scarring without deformity; (3) fair, visible scarring with minor deformity; and (4) poor, conspicuous scarring or deformity. Three plastic surgeons who were blinded to the treatment method independently assessed the clinical result of each patient based on patient photographs, the worst of which was adopted as the final result.For lesions with thin and excessive residual skin, intralesional elliptical resection with dull apical angles and primary closure was performed as the initial procedure. If the scar following ulceration was apparent, an incisional line was drawn along the margin of the scar. Consequently, a zig-zag incision was selected in certain cases. Important aspects of the procedure were that the incisional line was made within the lesion and never across the normal skin, and that the outermost portion of the lesion was intentionally preserved. If the residual lesion was very small and limited after the first operation, we performed routine follow-up without additional treatment. If the residual lesion was large, this surgical procedure was repeated 2 or 3 times in a similar manner. At the second or third operation, the residual lesion was relatively more oval in shape. Consequently, we excised the residual lesion with a lenticular shape. The time interval between each operation was at least 3 months. For lesions that mainly consisted of a deep component, minimal excision of the blemished skin and scooping out of the deep lesion was performed. After the procedure, dog ear and operative scar formations usually were not conspicuous .The mean age at surgery was 38.6 months (range: 18–62 months), and the mean follow-up period from the last operation was 12.3 months. The hemangioma was located in the head and neck region in 6 cases, the trunk in 3, and the extremity in 3. The indication for surgery was an esthetic improvement in all cases. Five patients underwent flashlamp-pulsed dye laser treatment preoperatively. The mean number of surgeries was 1.5 (range: 1–3). Surgical results were excellent in 4 patients, good in 6, and fair in 2 . A smallA 23-month-old boy presented with a hemangioma in the right zygomatic region , for whiA 55-month-old girl presented with fibrofatty tissue and a scar due to a large hemangioma on the lower lip . Two excSurgery for IH is controversial, because the lesion would involute with time. However, even with involuted lesions, the scar resulting from blistering, fibrofatty bulks, or residual excess of thin skin is occasionally esthetically problematic and can cause psychological stress to parents. Couto et al,Mulliken et al8Klubersh et al,In the present report, the cases described were involuting or involuted IHs, and not alarming hemangiomas, which are functionally problematic in the proliferating phase. For alarming hemangiomas, nonsurgical treatment modalities, such as corticosteroid or propranolol administration, are recommended.3We present 12 cases of involuting or involuted IH treated with intralesional excision and primary closure—an easy and simple procedure that does not result in dog-ear formation or elongated residual scarring.


The Ewing sarcoma family of tumors (ESFT) encompasses a group of highly aggressive, morphologically similar, malignant neoplasms sharing a common spontaneous genetic translocation that affect mostly children and young adults. These predominantly characteristic, small round-cell tumors include Ewing's sarcoma of the bone and soft tissue, as well as primitive neuroectodermal tumors (PNETs) involving the bone, soft tissue, and thoracopulmonary region (Askin's tumor). Extraosseous ESFTs are extremely rare, especially in the head and neck region, where literature to date consists of sporadic case reports and very small series. We hereby present a review of the literature published on ESFTs reported in the maxilla and maxillary sinus region from 1968 to 2016. Since the latest WHO classification of 2013 , who desEwing's sarcoma, the second most common primary bone tumor in children and adolescents, was initially described by Ewing in 1921  as an unEwing's sarcoma cells, unlike PNETs, have been generally described to fail immunohistochemical staining with antibodies against neuron-specific enolase and S-100 protein –21, suppMeanwhile, cytogenetic studies have led to the identification of the nonrandom t chromosome rearrangement , 27 in EDifferent fusions of the EWS gene (EWSR1) on chromosome 22q12 with various members of the ETS gene family  have been described , 29. Theβ3 chain of laminin-5. Laminin-5 is frequently found to be strongly expressed in the cytoplasm of invading cancer cells, suggesting its role at the invasive front of colorectal, gastric, pancreatic, and breast tumors, alongside various others [The EWS-ETS fusion proteins have been shown to activate human telomerase activity in Ewing's sarcoma through upregulation of TERT (telomerase reverse transcriptase) gene expression, probably by functioning as a transcriptional coactivator . The oncs others . Many mas others , supports others –37.Although rare in adults, classical osseous Ewing's sarcoma constitutes the second most frequent primary bone cancer in children after osteosarcoma. Nevertheless, with an annual incidence of approximately 0.6/million total population, affecting 13/million 0–24 year olds each year in the UK , this isWe performed a concise electronic research for reported cases of Ewing sarcoma family of tumors published in English medical literature, involving the maxilla and maxillary sinus only. The PubMed database was systematically searched for the terms Ewing's sarcoma, Ewing sarcoma family of tumors, Ewing, and PNET, in combination with the anatomical location sites:maxilla, maxillary sinus, upper jaw, and face, as well as head and neck. Single cases and case series describing ESFTs in this region were studied meticulously and the data extracted. Those cases of PNETs and Ewing's sarcomas not strictly limited to the maxilla or maxillary sinus, for instance, involving the mandible, the orbit, the palate, or the lower jaw, were then excluded, as were those cases that did not specify the exact location of the primary tumor.From 1968 to 2016, we found a total of 93 cases of ESFTs involving the maxilla or maxillary sinus published in the English medical literature . Of thesIn the head and neck region, the differential diagnosis of small round-cell tumors includes lymphoma, malignant melanoma, rhabdomyosarcoma, olfactory neuroblastoma, undifferentiated carcinoma, and Ewing's sarcoma/pPNET. Melanoma, lymphoma and rhabdomyosarcoma can be identified with immunohistochemistry for S100, CD45, and desmin, respectively. In those cases of ESFTs which display focal positivity for S100 or desmin, additional immunohistochemical stains for melanoma markers  and specific skeletal muscle markers  can be utilized to exclude melanoma and rhabdomyosarcoma. Carcinomas are generally diffusely positive for multiple keratins, whereas ESFTs typically stain focally for only one keratin marker . SometimTwo-thirds of patients initially present with localized disease, which, when using multimodality treatment, is nowadays amenable to curation in approximately 70% of cases. However, patients presenting with primary metastatic disease  generally have a poor chance of long-term survival, as this is the most important adverse prognostic factor. Therefore, complete staging, including at least CT of the chest and MRI with or without CT of the primary site, as well as PET scan and/or bone scan is regarded obligatory. In the staging of ESFTs, the combination of PET or PET/CT with conventional imaging has demonstrated sensitivity and specificity > 90% . Other eClassical Ewing's sarcoma, typically involving the long bones, radiologically presents as “onion skinning” periosteal reaction; although also described as a characteristic feature of neuroectodermal tumor lesions, this feature is definitely less frequently observed in the facial skeleton , 103. OsAlthough there are no randomized studies comparing surgery and radiotherapy, data from retrospective analyses suggest better local control of early ESFTs achieved by surgery (with or without postoperative radiotherapy) than by radiotherapy alone . CombineMorbidity of local therapy is one of these key issues, which, when facing ESFTs in the maxilla and maxillary sinus region, will tremendously impact the choice of local treatment modality. Surgery of the middle face and skull is technically demanding. Radical tumor excision is often limited by the proximity of adjacent critical structures and complicated by the wish to preserve function and cosmesis. Extensive, mutilating facial surgery, leading to loss of physiognomy, functional defects, and cosmetic problems, will often provoke a multitude of further complications and severely compromise patients' quality of life, without therapeutic benefit in the long run. Major concerns related to surgical management, especially in children and adolescents, include deleterious effects on respiratory function, nutrition and deglutition, speech, and vision as well as overall facial appearance and cosmesis. On the other hand, the use of modern surgical techniques, implementing microvascular flaps, immediate reconstruction using PEEK (Polyetheretherketone) implants, titanium grid-plates, titanium-enforced Medpore-foils, obturator prosthesis, dental prosthesis, and other reconstructive surgical materials, often enable the surgeon to perform excellent functional and esthetical results nowadays . Taking While high-dose chemotherapy followed by hematopoietic stem cell transplantation, although employed in some trial protocols in high-risk localized and metastatic ES , is stilData from the IESS-I and IESS-II trials could show that adjuvant chemotherapy with VACD  leads to a significantly better 5-year relapse free survival (60% versus 24%) and overall survival (65% versus 28%) compared to VAC  when applied together with radiotherapy in localized nonmetastatic disease .When ifosfamide and etoposide were added to this regimen (VACD-IE) in the Pediatric Oncology Group-Children's Cancer Group (POG-CCG) study, the 5-year event free survival rate (69% versus 54%) and the 5-year overall survival rate (72% versus 61%) were superior to VACD . VACD-IEComplications and toxicities caused by chemotherapy are numerous and agent dependent. Besides the most common and often expected adverse effects, like fatigue, mucositis, and hemotoxicity, many cytostatic substances can cause agent-specific toxicity. For example, anthracyclines, including doxorubicin, may induce a dose-related cardiomyopathy leading to congestive heart failure. Alkylating agents, like cyclophosphamide and ifosfamide, are associated with infertility, especially male infertility, so that sperm cryopreservation should be offered to postpubertal boys and men wishing to father children, prior to the initiation of chemotherapy. Chemotherapy has also been associated with inducing secondary malignancies. There have been reports of 1%-2% increased rates of secondary leukemia following a sequence of chemotherapy protocols utilized for treating Ewing's sarcoma, and usually these malignancies occurred within 3 years of initial ESFT-diagnosis and therapy .Upon completion of multimodality treatment for ESFTs of the maxilla or maxillary sinus, patients should be controlled clinically and radiologically in regular fixed intervals. In our review of the literature of ESFTs involving the maxilla and maxillary sinus, follow-up was reported in the majority of 79 cases  mass of the upper jaw and nasal congestion or obstruction, as well as unexplained nose bleeding, we recommend further timely diagnostic procedures. These should at least include meticulous clinical examination of the jaw and oral cavity, endoscopy, biopsy for histology, and local imaging by X-ray or if necessary computed tomography. Once histologically confirmed, ESFTs should then be transferred to, or treated under close supervision of, a sarcoma center from an early stage. The necessity for further imaging , neoadjuvant treatment strategies, and precise preoperative surgical and/or radiotherapeutical planning is vital and needs to be evaluated by the involved MDT-specialists as soon as possible. This interdisciplinary decision-making process is just as important as the definitive skills and expertise of the sarcoma surgeon or radiooncologist involved in the next steps of treatment. In localized ESFTs of the maxilla and/or maxillary sinus, we recommend always preoperatively consulting a team of experienced maxillofacial surgeons alongside surgeons with profound experience in the field of plastic reconstructive surgery of the upper jaw and surgical dentistry. Radiooncologist and medical oncologists should be included in preoperative decision-making as well. Whenever feasible, neoadjuvant chemotherapy ideally within a clinical trial, containing a well-known and efficacious regimen like VIDE, should be administered and closely monitored by an experienced team of medical and/or pediatric oncologists. Therapeutic success (tumor-shrinkage) should be checked in regular 8–12-week intervals, radiologically as well as clinically if possible. The aim hereby should always be to boost the probability of complete R0-tumor-resection leading to microscopically free margins by maximum tumor-shrinkage, as well as destroying occult micrometastasis. If the risk of debilitating surgery causing serious personal morbidity to the patient, or the risk of incomplete tumor excision itself, is deemed high, then alternatively IMRT to the radiologically predefined tumor-bed should be evaluated by experienced radiooncologists. Decisions concerning the modality of adjuvant treatment following local tumor control should, when applicable, be made upon the defined histological regression grade, that is, pathologically reported vitality of the remaining tumor tissue (see above) excised after neoadjuvant systemic treatment. This treatment, once again, should ideally be performed under the umbrella of a randomized clinical trial; if not available, however, then at least it should be performed in close analogy to renown therapeutic protocols as, for instance, the EWING 99 study. Upon completion of multimodality treatment for ESFTs of the maxilla or maxillary sinus, patients should be controlled clinically and radiologically in regular fixed intervals. As most relapses have been reported to occur within the first two years after treatment , we woulAlthough rare and potentially highly aggressive, ESFTs limited to the maxilla and maxillary sinus seem well manageable when utilizing modern multimodality treatment strategies. As described in the literature to date, outcome and prognosis of this specific entity seem more favourable compared to ESFTs occurring in the common primary sites located in the long bones or pelvis. This may in part be due to the fact, that patients presenting with ESFTs in the maxilla or maxillary sinus frequently experience symptoms like facial swelling, nasal congestion or even epistaxis at an early stage of tumor growth, ultimately leading to earlier diagnosis and successful treatment. Contrary to expectations, ESFTs occurring in the confined spatial proportions of the maxilla and maxillary sinus, often less amenable to complete surgical resection with clear tumor margins, may be equally successfully treated with a combination of radiotherapy and chemotherapy without surgery. Especially in those cases, in which the risk for morbidity by mutilating surgery seems high or complete surgical excision technically impossible, radiotherapy (combined with neoadjuvant and/or adjuvant chemotherapy) may prove to be similarly efficacious for achieving good local control without compromising long-term survival. In general we recommend consulting a sarcoma reference center early on in treatment planning, thereby ensuring for multidisciplinary expertise in favour of best clinical practice. As always, when available, patients with such rare tumor entities should definitely be enrolled in clinical trials or at least treated in accordance with modern trial protocols. So using well-established chemotherapy regimens neoadjuvantly and adjuvantly, in combination with surgery and/or radiotherapy for local control, will aim to achieve maximum possible treatment outcome.


Intramuscular haemangioma (IMH) is a benign mesenchymal tumour. It appears as a deep, nontender mass within the soft tissue, particularly in the extremities. This tumour may not be obvious on clinical examination. Head and neck IMHs represent only 13.5% of the total IMHs. The most common site for a head and neck IMH is the masseter muscle, followed by trapezius, sternocleidomastoid, and very rarely temporalis muscle. We present a patient with left nasal bridge swelling which was excised and histologically confirmed as intramuscular hemangioma. Intramuscular haemangioma (IMH) is a rare tumour. It is benign in nature and never regresses spontaneously unlike the cutaneous hemangioma of infancy . MajoritA 22-year-old Malay man presented with a swelling over the left nasal bridge of one-year duration. The mass was slowly increasing in size but did not cause any pain. There was no history of trauma or any other nasal and eye symptoms.Clinical examination revealed a swelling with the dimension of 2 × 3 cm, which was soft, nontender, and mobile in all directions . It was The histopathological examination was reported as intramuscular hemangioma (infiltrating angiolipoma) . No pleoIntramuscular hemangiomas (IMHs), which are also called infiltrating angiolipomas, are benign adipose tissue tumour that represents 5% to 17% of all lipomas in the body . These tIMHs differ from typical lipoma and cutaneous hemangioma of infancy in that they usually arise around the time of puberty. 80% of patients will have multiple lesions and they may have a familial component .Owing to its rarity in the head and neck region, the diagnosis is difficult to be obtained preoperatively. Preoperative imaging studies such as CT scan or MRI can offer a correct diagnosis and a complete resection can be performed to minimise the risk of recurrence. However, it is rarely performed in such a superficial small cystic lesion as in this indexed case. Imaging study may be indicated in the deeper seated or a bigger lesion, for example, in the IMHs of the mylohyoid or sternocleidomastoid muscle .The treatment of choice for IMH, if diagnosed preoperatively, is complete wide resection of the mass including the cuff of surrounding muscle because of the infiltrative nature of the tumour . AlthougIn conclusion, IMH is a rare lesion especially in the head and neck region. Being a non encapsulated vascular neoplasm which possesses the infiltrative property. Preoperative definite diagnosis is often difficult and it may lead to inadequate resection and recurrence. A wide resection with a normal cuff of muscle should be aimed to ensure a complete cure is achieved. Long term follow-up is crucial.


A 23 year-old-woman was referred to point out for pain on the left side of her face and mucopurulent rhinorrhoea lasting for 07 months with long history of recurrent sinusitis. Antibiotics and pain-killers were prescribed to him in the first time. On examination of the oral cavity, all the permanent teeth were present. At nasal endoscopic examination we found a mucopus trickling from the left middle meatus.clinical diagnosis is for sinusitis of dental origin, fungal sinusitis or chronic rhinosinusitis Coronal computed tomography (CT) of the paranasal sinuses revealed the presence of a supernumerary molar tooth (Arrow) within left maxillary sinus floor (A). The tooth was extracted by traditional approach  from the maxillary sinus under general anesthesia , and the patient has been asymptomatic for more than 02 years. The presence of ectopic or supernumerary tooth in the maxillary sinus is most often asymptomatic but on rare occasions can be a cause of recurrent sinusitis. The supernumerary ectopic tooth is a very rare condition, usually it's localized on the maxillary sinus, and other sites were described like nasal cavity or chin. Coronal computed tomography is sufficient to determine extract localization. The extraction can be made by conventional approach or by transnasal endoscopic approach with less morbidity.