Infection of the deep neck spaces is a life-threatening acute illness that requires prompt diagnosis and treatment. Magnetic resonance imaging (MRI) offers unsurpassed soft tissue discrimination and is therefore well suited for imaging neck infections. Recently, the feasibility, diagnostic accuracy, and clinical significance of this method have been documented in patients with acute neck infections. This review article summarizes the scientific evidence, provides a practical guide to image acquisition and interpretation, reviews the most common imaging findings, and discusses some difficult diagnoses and pitfalls in acute neck infections, to help both radiologists and clinicians in managing these critically ill patients. MRI of acute neck infections is feasible in most patients.Most common types are pharyngotonsillar and odontogenic infections.MRI has high diagnostic accuracy for abscesses in adults and children.MRI shows reproducible edema patterns that have clinical and prognostic significance. Deep neck infections are associated with a high complication rate and significant mortality . AggressEmergency neck imaging has traditionally been performed using contrast-enhanced computed tomography (CT). However, limited soft tissue contrast, uncertainty in separating purulent from non-purulent fluid collections, and artifacts from bone and dental implants may compromise accurate delineation of neck disease. More recently, magnetic resonance imaging (MRI) has proven to be a feasible, accurate, and reliable first-line imaging method in deep neck infections . MRI hasThe purpose of this pictorial review is to provide a comprehensive array of MRI studies of the most commonly encountered deep neck space infections. We will review patient selection, MRI sequences and protocoling, pertinent normal radiological anatomy, typical edema patterns, and imaging patterns of various types of abscesses with important caveats. After reading this review, radiologists should be able to confidently detect and characterize various MRI findings in deep neck infections and describe to the referring clinician the pertinent findings. Because the focus of this review is on the soft tissues of the deep neck spaces, we will not review imaging of infections originating from the orbit, paranasal sinuses, temporal bone, or spine, nor will we review intracranial complications of head and neck infections.In clinical practice, contrast-enhanced CT is considered the standard imaging modality in the emergency department because of its good availability, fast scanning times, and reasonably low cost . In manyMRI is a promising alternative modality to imaging acute neck infections . The mosAccording to a study based on a large cohort, emergency MRI is feasible in almost all patients , with anAt our institution, we have used the Philips 3 Tesla system (Ingenia). The routine protocol includes seven sequences and is completed in about 30 min Table .Table 1MT2-weighted imaging is useful for anatomy: fat has a very high signal, free fluid has a high signal, soft tissues such as lymphoid tissue and mucosa have an intermediate signal, muscles have a low signal, and cortical bone has no signal Figs. . Fat-supT1-weighted images are good for detecting fat tissue in normal anatomy, for detecting certain substances with naturally high T1 signal (such as hemorrhage or chronic secretions), and for serving as a baseline image for the assessment of contrast enhancement following intravenous administration of a gadolinium-based contrast agent. Enhancement is best appreciated on post-contrast fat-suppressed T1-weighted images. In our opinion, gadolinium-based contrast agents are mandatory to achieve optimal accuracy, because deep neck space abscesses are often inconspicuous from adjacent regions in T2-weighted  and apparent diffusion coefficient (ADC) maps from diffusion-weighted imaging (DWI) .2. DWI has two functions in the neck region: first, and most critical, is to depict the purulent nature of fluid collections as having restricted diffusion , and second, to characterize physiologically high-cellular tissue, such as lymphoid tissue in the tonsils and lymph nodes.DWI is achieved using standard echo-planar imaging (EPI) with a b-value of 1000 s/mmA practical guide on how to interpret these MRI sequences to detect specific biomarkers of neck infections is provided in Table There are no published guidelines on the nomenclature of MRI findings in the soft tissues of the neck as there are for the musculoskeletal system . In the The MRI criteria for an abscess are an abnormal T2 iso- to hyperintense collection with low ADC, surrounded by abnormal tissue enhancement on post-contrast T1-weighted images, and no enhancement in the center Table . On MRI,Gas formation is readily detectable on CT. On MRI, gas appears as focal areas of a signal void, but is, however, often difficult to detect because images often have areas of similar low signal Fig. .Fig. 5OnBecause patients with an imaging diagnosis of an abscess are much more likely to undergo surgery than patients without abscesses, the diagnostic accuracy of MRI is critical. When compared with surgical findings as the reference standard (purulent fluid or abscess cavity), MRI was highly accurate in a large sample of various types of neck infections  . This diAbscesses can breach fascial planes and affect multiple neck spaces Figs. , 8. Not On MRI, patients with neck infection often have reactive, non-suppurative edema, best appreciated as high signal intensity in fat-suppressed T2-weighted images and to a lesser extent post-contrast T1-weighted images. A summary of relevant edema patterns including their definitions and clinical significance is given in Table One pattern of reactive edema, retropharyngeal edema (RPE), has been previously described in various neck diseases, including acute infection –16 Fig.. In addiRPE is present in about half of all patients with neck infections of various origins . AnatomiIn contrast, ME is seen less often (26%) in patients with neck infection . ME occuSMSE, SLSE, and VSE are more localized forms of soft tissue edema that are important for both pharyngotonsillar  and odonTonsillitis (or pharyngotonsillitis) is an acute viral or bacterial infection of the oropharynx. The imaging characteristics of tonsillitis are edema and enhancement of the palatine tonsils and surrounding oropharyngeal mucosa, but no abscess formation Fig. . SurrounThe peritonsillar space refers to the potential space between the palatine tonsil capsule and the superior constrictor muscle, bounded anteriorly by the palatoglossus muscle (anterior tonsillar pillar) and posteriorly by the palatopharyngeus muscle (posterior tonsillar pillar) Fig. . TherefoIntratonsillar abscess (ITA) has been described as a pus collection within the tonsillar parenchyma  with a mImaging is needed when PTAs are clinically suspected of rupturing to adjacent parapharyngeal and retropharyngeal spaces. This deep extension is a serious complication, in which infection has breached the muscles and fascia that delineate the mucosal space . Once inInfections in the oral cavity can be divided into sublingual and submandibular based on the superior and inferior location relative to the mylohyoid muscle, respectively Figs. , 17 29]29]. OfteAn odontogenic origin of neck infections is usually suggested by signal changes in maxillofacial bone marrow (mandible or maxilla), present in about 80% of these patients Fig.  11]. Bo. Bo11]. Subperiosteal abscesses may be particularly difficult to diagnose because the non-enhancing T1-hypointense collection is immediately adjacent to cortical bone, which has no signal Fig. . CarefulMRI is sometimes considered inferior to CT in demonstrating the causative tooth in odontogenic infections. Although cortical bone is devoid of MRI signal, periapical soft tissue changes, such as enhancement of infectious tissue, may help pinpoint the causative tooth Fig. . These pBecause many younger children require sedation or anesthesia for MRI, choosing an appropriate emergency imaging method for a suspected neck infection is a balance between the potential harm of radiation and the possible immediate or long-term harm related to anesthesia . About aOverall, the diagnostic accuracy of MRI and the clinical significance of MRI biomarkers (such as edema patterns) are similar between adults and children . HoweverRetropharyngeal infections in children can be “true” deep infections bound by fascial planes of the deep space, or suppurative lymphadenitis  Fig. . The keyStaphylococcus aureus infections  should not be mistaken for treatable mediastinal disease. Accurate delineation of mediastinal abscesses is important Fig. . AlthougNecrotizing fasciitis of the head and neck is a rapidly progressing and life-threatening infection caused by bacteria. The infected tissue becomes necrotic as a process involving vasculitis with microthrombosis and edema of the subcutaneous tissues progresses, leading to severe systemic toxicity in the later stages. Necrotizing fasciitis of the head and neck is a rare condition, given that the incidence of 2 per 1,000,000 inhabitants per year has been reported in Denmark . PatientGenerally, findings of necrotizing versus non-necrotizing fasciitis may overlap. On MRI, necrotizing fasciitis in the neck is suggested by widespread edema, fluid collections along the fascial planes, and gas formation Fig. .Fig. 29AThe purposes of imaging after surgical treatment are to ensure proper placement of drainage tubes and to assess residual abscess collections. Drainage tubes are usually well visible as low-signal continuous, curvilinear structures Fig. . ResiduaBoth benign and malignant cystic neck masses can become infected and mimic abscesses. Benign cystic masses include vascular malformations and developmental branchial cleft cysts, and, if previously undiagnosed, are often diagnosed after the acute infection has dissipated Fig. . ClinicaIn this clinical scenario, hematomas can be spontaneous, post-traumatic, or, most commonly, post-operative . Hematomas can be mistaken for abscesses. In contrast to hematomas, however, acute neck hematomas have a low T2 signal due to susceptibility effects of blood products, whereas the T1 signal is low as it is in abscesses Fig. . Trace DBy definition, the central contents of purulent lymphadenitis  do not enhance and have restricted diffusion (low ADC). Early in the disease process, however, the lymph node can be necrotic, but not yet purulent. Necrotic lymph nodes may enhance slower than normal lymph nodes, and enhancement may not be detected if late scans (about 10 min after contrast administration) are not carefully evaluated. Thus, in early scans, necrosis and slow enhancement may be mistaken for non-enhancement. Because lymph nodes have physiologically restricted diffusion (low ADC) due to high cellularity, early necrosis may not be correctly identified and purulence may be suggested instead, possibly leading to unnecessary surgery Fig. .Fig. 34NFluid collections that are not purulent are usually sequelae of previous operations, such as incision and drainage. The clinical question is often whether the abscess has been completely drained, or whether residual purulent collections are seen. In these patients, non-purulent fluid can have a high T2 signal, low T1 signal, and no enhancement, mimicking residual abscess at first glance. Importantly, however, these sterile collections have high ADC values on DWI, in contrast to low ADC values in purulent fluid Fig. .Fig. 35SCalcific tendinitis of the longus colli muscle is an inflammatory reaction to calcification in the tendon of the longus colli muscle . Signs aSome patients with cervical tenderness and pain present with unclassified vascular and perivascular changes on imaging at the level of the carotid bifurcation, previously reported as carotidynia. More recently, this specific entity of idiopathic carotid inflammation has been introduced as TIPIC syndrome (transient perivascular inflammation of the carotid artery) . UltrasoAngioedema is a sudden swelling of the soft tissues of the face and neck that can be allergic, hereditary, or drug-induced . AngioedFrom the point of view of the head and neck surgeon, MRI imaging in suspected acute deep neck space infections has improved diagnostic accuracy. Using CT, the hypodense area with enhancing rim can often be easily detected, but the surrounding tissue appears blurry, and delineating between an abscess and edema can sometimes be difficult. Truthfully, it was not easy to get used to this new imaging modality, and especially in the beginning, the key images provided by the radiologists were priceless. Now, after nearly 10 years of experience with good availability of acute phase MRI imaging, the clinician feels quite confident with these images even without any theoretical training in MRI imaging itself. At the end of the day, good knowledge of anatomy is the key to successful diagnosis and the visualization of the anatomy is excellent using MRI. This also serves as a reliable map for surgery. As deep neck infections can be a continuum of different phases from infectious edema to a purulent abscess, repeated imaging is sometimes crucial to evaluate the healing process or to decide when to operate or re-operate. MRI provides this information without ionizing radiation which is especially important for pediatric patients.Emergency MRI is currently limited in terms of availability but might become more feasible and effective in the future due to technological advances. Possible developments for the near future include improved hardware, such as low field  and portYet, potential bottlenecks in adopting new imaging protocols are radiologists' cognitive biases that affect their decision-making about future techniques. For example, radiologists can have a fairly robust commitment bias for CT in deep neck infections that can be difficult to overcome on an individual and systemic level . Our bouImproved CT methodology may close the gap in diagnostic accuracy between CT and MRI in the future. Spectral CT, including dual-energy CT, enables a more accurate assessment of tissue attenuation by detecting attenuation data of multiple different energy spectra of x-rays . In headMRI is a nascent alternative imaging modality for acute neck infections in the emergency department. Recently, the successful implementation of MRI in the emergency department has been described, and good feasibility, high diagnostic accuracy, and derivation of clinically meaningful information from neck MRI images have been documented. These advantages pave the way for more widespread reliance on emergency neck MRI in clinical decision-making, which will ultimately benefit the patients.


Schwannomas are benign tumors originated in the neural crests derived from Schwann cells. They are often encapsulated, well circumscribed, and connected to nerve tissue. In microscope examination they present a combination of two growth patterns, Antoni A and B, both with elongated cells and regular oval nuclei. Malignant schwannomas occur in only 2% of the cases, although local recurrence is common in cases of incomplete tumor resectionThe vestibulocochlear nerve ranks first among involved sites, accounting for 80% of the cases. Only 4% of the tumors of the head and neck are found in the nose or sinusesCT scans of paranasal schwannomas usually show low-density areas in their center with contrast uptake in the bordersThis paper described the evolution of a patient with a unilateral tumor diagnosed as a schwannoma of the nasal septum.A 78-year-old male patient was referred to our service with progressive nasal obstruction evolving for two years.Physical examination was normal and endoscopic examination of the nose revealed an exophytic grayish tumor with uneven borders, with a pedicle in the posterior septum region close to the upper corner of the right choana.CT scans showed a nodular, low-density, well-delimited homogeneous tumor and some bone thinning in the medial wall of the right maxillary sinus .Figure 1The patient was submitted to endoscopic endonasal surgery. The tumor was removed with margins from the posterior septum periosteum. The procedure was uneventful.Pathology tests showed proliferation of spindle-shaped cells arranged in a short fascicle pattern with oval wavy nuclei and acidophilic indistinct cytoplasm, characteristically seen in schwannomas .The literature comprises approximately 70 case reports of nasal schwannoma. Most cases involve adults in their forties to sixties, with little difference between genders. Complaints usually revolve around nasal obstruction, anosmia, deformity of the nasal pyramid, and epistaxisCT scans usually show lesions in the surrounding bone structures; erosion is more commonly seen in large schwannomas. MRI outperforms CT in differentiating tumors from inflammatory disorders and normal tissue, in addition to providing better information on tumor intracranial invasionDifferential diagnosis for unilateral tumors includes nasal polyps (22.2%), antrochoanal polyps (19%), chronic rhinosinusitis (12.7%), concha bullosa (11.1%), retention cysts (6.3%), mucocele (3.2%), and schwannomas in 1.6% of the casesUnilateral tumors must be thoroughly investigated, ideally with biopsy, particularly to diagnose cases of malignancyTreatment is mostly curative and can be offered in the form of surgical removal by lateral rhinotomy or endoscopic endonasal surgeryThe diagnosis and management of patients with schwannoma can be challenging, as clinical and imaging findings of unilateral tumors may be deceiving. Schwannomas must be regarded as one of the possible diagnoses in such cases. Endoscopic endonasal surgery provides for a less invasive approach and offers an improved procedure to completely remove the tumor.


Mucoceles are pseudocysts of the paranasal sinuses; they are lined with pseudostratified respiratory epithelium and have a mucous or mucopurulent (mucopyocele) content2The purpose of this paper is to report an extremely rare case of a maxillary mucocele in a lactating infant with no predisposing factors. Therapy was done with endoscopic surgery.M.I.M.B., a female 4-month-old patient presented progressively worsening nasal block since birth. Videonasolaryngoscopy revealed secretion filling and obstructing the right nasal cavity, making it impossible to advance the optic fiber. Computed tomography (CT) of the paranasal sinuses showed a hyperdense mass in the right maxillary sinus, with medial bone loss and invasion of the ipsilateral nasal cavity, suggesting a mucocele  and 1B.FEndoscopic surgery was undertaken to remove the lesion. The specimen was sent to pathology, which confirmed the diagnosis of a mucocele. Videonasofibroscopy and CT were done eight months after the procedure, showing edema of the mucosa in both maxillary sinuses and no recurrence of the mucocele  and 1D. Mucoceles are pseudocysts lined with a respiratory mucosa that tend to grow slowly and expansively, leading to bone resorption of neighboring structures such as the orbit and the intracranial area. The prevalence is highest between the third and fourth decades of life; mucoceles are rare in children.Clinical findings vary according to the site of the mucocele and whether there is involvement of adjacent structures.CT is the exam of choice for the diagnosis of mucoceles; it not only demonstrates sinus involvement, but also provides information about bone erosion and other effects on neighboring structures.5In this case, the mucocele was in the right maxillary sinus, it eroded the medial wall and invaded the nasal cavity, which explained the nasal block. Although maxillary sinus mucoceles are associated with prior surgery and - in children - with cystic fibrosis, the patient had none of these two factors.Treatment is always surgical,Outpatient follow-up is mandatory to promptly identify recurrences.Although extremely rare, mucoceles in children should not be neglected. Notwithstanding the benign nature of these lesions, expansion may cause severe intracranial and orbitary complications, particularly when these lesions are infected. Surgery is indicated in all cases.


A 2‐year‐old child presented with a lymphatic malformation (LM) in the arm and the axilla. The neurovascular structures encased by the LM were preserved during the excision surgery, and a “lympholith” was found within a cyst of the LM. Lymphatic malformation (LM) in the arm can extend into deeper planes to encase the vital neurovascular structures. A “lympholith” can occur in the LM and could suggest a low‐flow/ hypodynamic LM. They are caused by abnormal development of the lymphatic system. Cyst formation occurs due to lymphatic accumulation from abnormal or absent communications between the central venous sacs and the peripheral lymphatic system.Lymphatic malformations tend to be soft, spongy, nontender masses. The clinical features vary based on the location and size and can range from local swelling resulting in a superficial mass to a large area of lymphatic channel infiltration resulting in elephantiasis.Herein, we report a case of a 2‐year‐old child with lymphatic malformation encasing the neurovascular structures in the arm and with a stone‐like content within a cyst, which we would prefer to refer to as a “lympholith” similar to a phlebolith found in veins in other conditions.2A 2‐year‐old female child from southern Nepal was brought to the outpatient plastic surgery clinic with the complain of a large swelling in the left arm and axilla since birth. The swelling was progressively increasing in size with no associated pain or skin changes. The child did not have fever or loss of weight. There was no history of trauma or swelling in other parts of the body.Examination revealed a large swelling extending from the axilla to the proximal forearm. The swelling was soft, spongy, nontender, and without prominence of superficial veins. Pulsations could not be palpated over the swelling, and no bruits were heard on auscultation.Magnetic Resonance Imaging (MRI) showed a complex multiloculated mass in the medial aspect of arm encasing the neurovascular bundle, extending to the axilla proximally and elbow and forearm distally. Cystic components of different sizes were noted within the mass with variable thickness septations. Some components showed T1 and T2 hyperintense content with low signal intensity in fat suppressed T2‐weighted images, while the others showed variable signal intensities. There was associated edema in the subcutaneous plane in the arm and the axilla. Humerus showed normal cortical and marrow signal intensities without any evidence of bony erosion or destruction , vascular anomalies can be classified into tumors  or malformations . Vascular malformation (VM) can further be simple or combined. Under simple VM lie capillary, lymphatic, venous, and arteriovenous malformations. Common (cystic) lymphatic malformation is classified under the heading of LM, which is further classified as macrocystic, microcystic, or mixed.Vascular malformations can also be classified as low‐flow and high‐flow according to their hemodynamic characteristics.Lymphatic malformations account for 5%–6% of all benign soft tissue masses in children.Lymphatic malformations usually present as asymptomatic masses with parental aesthetic concern. Even large lesions may not cause symptoms as they grow within an overlying elastic skin and subcutaneous tissue.Though ultrasonography may be the first‐line imaging modality for the diagnosis of LMs, contrast‐enhanced MRI is the preferred imaging. MRI is of value for deep and extensive lesions, providing valuable information relating to size, extent, tissue involvement, and pre‐procedural planning.The main treatment options for LMs are sclerotherapy, surgery, laser therapy, radiofrequency ablation, or a combination of these modalities. Minimally invasive modalities are of use in situations when there are contraindications for anesthesia, in high‐risk surgery or to down‐stage the size of the lesion.Surgical excision remains the mainstay of treatment for giant macrocystic lesions. The aim of surgery is to preserve/regain the function of an affected area and to prevent disfiguring complications. LMs most commonly involve the subcutaneous tissue, but can extend deeper insinuating deeper structures as in our case. Though most of the LMs occur in the head and neck region and the axilla, they can also occur in other parts of the body such as the arm and encase vital structures. In our case, the lesion involved most of the arm extending up to the axilla proximally and elbow region and proximal forearm distally. Surgeons should be mindful to preserve the vital neurovascular structures during excision. From our case it can be seen that LMs in the limbs can disregard anatomic and fascial boundaries and can involve multiple tissue planes not just limiting themselves to the subcutaneous plane. The damage to the median and ulnar nerves and the brachial artery could be detrimental to the patient, and hence, meticulous dissection was carried out to preserve those structures and their function in addition to preventing the mass effect, the swelling might have in the future. This makes such surgeries tedious and time‐consuming yet challenging and worthwhile. The proximity and adherence of the LM to important and vital structures may at times warrant only partial removal or debulking of the lesion. Moreover, very difficult cases may be staged for a later setting after partial removal/debulking as was done in our case.Another important finding in our case was that of a stone‐like content in one of the cysts, which we want to refer to as a “lympholith.” Though some cases of phleboliths and angioliths have been reported, we could not find any literature on “lympholith” when searched on popular databases. Angiolithiasis is vascular‐based formation of calculi and an angiolith, a calcified thrombus within venules, veins, or sinusoidal vessels of a hemangioma. Phleboliths are intravascular stone formation in the veins. Pathogenesis of angioliths and phleboliths is probably the same; formation of intravascular thrombosis under the influence of proliferating fibroblasts, which organizes and becomes secondarily mineralized.4Lymphatic malformation can rarely occur in the arm and involve multiple tissue planes extending deeper to encase neurovascular structures, which the surgeon should be mindful of during the dissection for surgical excision/debulking. Lympholiths can present in an LM and could suggest a slow‐flow or hypodynamic LM.SS and AR: involved in concept, collecting information, manuscript writing, and participated in literature review and edited the draft. SS and JMS: involved in patient care team and also independently reviewed the manuscript. SS, AR, and JMS: re‐edited the draft and reshaped it into this manuscript. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.The authors declare that there is no conflict of interest regarding the publication of this paper.Need for ethical approval waived. Consent from the patient's father deemed to be enough.Written informed consent was obtained from the patient's father for publication of this case report and any accompanying images. A copy of the written consent will be available for review if asked by the editor‐in‐chief of this journal.


Hirschsprung’s disease is a rare disease characterized by the complete absence of ganglionic cells in the colon, thereby causing loss of peristalsis movement of the bowel. Most cases are diagnosed before the age of one. Here, we present a case of a newborn baby boy who was not feeding well and then developed a distended abdomen and began bilious vomiting. Blood mucoid stools were also observed. The diagnosis of Hirschsprung’s disease was confirmed through a full-thickness rectal biopsy, and the Duhamel surgical procedure was performed as a course of treatment all within the first few days of birth. No complications were reported, and the baby was safely discharged after seven days. This case demonstrates the importance of timely treatment after prompt diagnosis due to the early recognition of the severe symptoms. Even though this disease is rare, pediatricians should be trained to recognize and treat the child to prevent further detrimental outcomes. Hirschsprung’s disease (HSCR) is distinguished by the absence of ganglionic cells in the submucosal and myenteric plexus contained in the intestines . AgangliHSCR has been proven to be a hereditary condition with 10%-20% of cases with a positive family history. The condition occurs in both males and females; however, studies have shown that it is three times more prevalent in males than in females ,5,6. TheHSCR can be classified into three types: long segment, short segment, and total colon aganglionosis ,8. In arSymptoms that arise include HSCR-associated enterocolitis, intestinal obstruction, intestinal perforation, and gastroenteritis ,10. SurgConsequently, with advancements in surgical treatment for HSCR, mortality has significantly decreased and ranges between 1% and 10% . NeverthIn this article, we present a rare case of HSCR in a newborn who was diagnosed and treated successfully all within the first few days of birth, preventing serious complications.A 26-year-old female (primigravida) underwent an emergency cesarean section (C-section) at 40 weeks after failed induction. The surgery was completed under spinal anesthesia, and a male neonate was delivered . There was no history of complications during pregnancy, and all the prenatal sonographic exams were deemed to be normal. The newborn examination was normal with no dysmorphism noted. There were no issues following the C-section, and the baby was transferred to the nursery for routine care and feeding.However, 24 hours post-delivery, the baby was moved to the neonatal intensive care unit (NICU) because it was noticed that the baby was not feeding well. He had begun bilious vomiting, and his abdomen was distended. Upon a physical examination, his vitals were normal. Upon palpation, persistence of abdominal distension was noted, and the baby’s movements were sluggish. Bloody mucoid stools were also observed.In view of these symptoms, the baby was put under nil by mouth. A nasogastric tube was inserted, revealing a light greenish aspirate. An x-ray was done, which showed multiple loops of dilated small bowel which indicated obstruction Figure . IntraveConsequently, the case was then referred to pediatric surgery. A contrast enema was performed, and Hirschsprung’s disease was suspected due to a transition in diameter between the two parts of the gut Figure .A full-thickness rectal biopsy above the pectinate line was done, and the findings were consistent with Hirschsprung’s disease, confirming the diagnosis. The reports stated that there was an absence of ganglion cells in the rectal and distal sigmoid colon, categorizing this condition as short-segment Hirschsprung’s disease. The parents were counseled about the condition, and its prognosis was outlined with the possible complications that may occur (colonic perforations and enterocolitis). The doctors, after obtaining consent, decided to perform the Duhamel procedure as the course of treatment. Prior to the surgery, an injection of vitamin K (0.5 mg) was administered to prevent any coagulation problems. The surgery went well, with 15 cm of the bowel resected.IV antibiotics  along with a nalbuphine infusion (10 mg/mL) for pain relief were given for the first two days postoperatively. Oral diet was started two days postoperatively coupled with IV fluids with electrolytes, and the total length of stay in the hospital was seven days. There were no other complications following discharge, and the baby is doing well.This case highlights that an early diagnosis is key to providing accurate and timely treatment for neonates with HSCR. Neonates and infants are at the greatest risk of complications compared to older children . In unfoAbdominal distention (>90%), bilious vomiting >85%), and failure to pass meconium within 24 hours of life (60%) are common clinical symptoms of newborns with HSCR [5%, and fNewborns often swallow quantities of air after birth and can become distended in the large intestine in the presence of HSCR, primarily due to an obstruction at the proximal aganglionic segments . Given tSimilarly, more recent studies demonstrated that barium enema had high sensitivity and specificity in detecting the transitional zone at 90% and 80%, respectively, over PARTZ . ConsideDespite the lack of consensus that determines the superiority of different imaging modalities, the European Reference Network for rare Inherited and Congenital digestive disorders (ERNICA) guidelines advocate rectal suction biopsies with acetylcholinesterase (AChE) immunohistochemistry as the gold standard for HSCR ,16. HistA retrospective study conducted by Keyzer-Dekker et al.  found thTherefore, it is reasonable to conclude that the adequacy and success of rectal suction biopsy samples can be age-specific; there is usually a better yield in neonates as with age advancement, the tissue obtained would less likely contain adequate submucosa for identification of ganglion cells . Yet, skFortunately, the quick diagnosis made by the consultant accounted for prompt surgical action, free of complications. The ERNICA guidelines recommend a trans anal endorectal pull-through (TERPT) or Duhamel pull-through as the definitive operation for HSCR, both of which can be performed laparoscopically . In the Postoperative care recommends following the enhanced recovery after surgery (ERAS) protocol in optimizing care after major procedures and focuses on pain management, infection control, and nutritional supplements, which likely contributed to the rapid recovery of our patient upon follow-up . Though The favorable outcomes in our case yielded positive results in the early diagnosis and management of HSCR. This is largely attributed to the rapid time of recognition of symptoms to definitive diagnosis. However, the current literature lacks case reports of HSCR in neonatal periods. In one notable case study by Neumann et al. , a 17-daBoth case studies show that though HSCR in neonates is prevalent, it is detrimental if recognition and treatment are delayed. Prato et al.  corroborThere are a few limitations to our study. As this case report is based on a single-center experience, it lacks generalization to a larger community. While this study shows the importance of early diagnosis in HSCR and its diagnostic modalities, the sample size limits these outcomes. Moreover, genetic testing was not carried out; therefore, we could not draw conclusions about the etiology of this patient’s congenital anomaly. Further multicentric cross-section studies should be conducted to evaluate the incidence of HSCR in neonates, the efficacy of imaging and biopsy techniques, and the relevance of genetic anomalies in HSCR to yield robust data that can support the conclusions drawn from this case study.HSCR is a rare condition, which can potentially prove to be detrimental and fatal if not promptly recognized in neonatal life. HSCR is infrequent and uncommon in neonates, hence being potentially detrimental and fatal if diagnosed late. It is critical that physicians can identify the typical symptoms of the disease, which include a distended abdomen and no passage of meconium within the first 48 hours of birth. Therefore, we hope this article allows pediatricians to include HSCR as a potential diagnosis in cases of bowel obstruction, preventing any delay in the diagnosis and treatment.


Schwannoma arising from the cervical sympathetic chain are rare slow-growing tumors which represent a diagnostic challenge. We report a 80-year-old female patient presented with anterior neck triangle swelling. The radiological assessment was based on computed tomography and magnetic resonance imaging, which led to a preoperative diagnosis of vagus nerve schwannoma. However, surgical treatment revealed a cervical sympathetic chain mass rather than a vagus nerve mass. A complete removal was performed, and the anatomopathological examination was in favor of a schwannoma. In post-operative state, the patient presented a well-tolerated Horner’s syndrome.  Schwannoma is a benign mesenchymal tumor developed exclusively from Schwann’s sheath cells that surround nerve fibers of the peripheral nervous system. Schwannomas are found in 25% of cases at the cervical level, most often at the expense of the vagus nerve. The other localizations are rarer in particular the schwannoma of the cervical sympathetic chain . We repoOur patient was a 80-year-old female, who had no medical history and consulted for a left cervical mass progressively evolving over 3 years and associated with dysphagia without dysphonia or dyspnea. Physical examination revealed a left laterocervical swelling measuring 6 × 5cm in size. It was firm, smooth, regular in margins and pulsatile. No nerve palsies noted.Computed tomography (CT) scan of the neck described a left neck mass , hypodense, heterogeneous and not enhanced after injection of the contrast product. The mass displaced the common carotid artery (CCA), the external carotid artery (ECA) as well as the internal carotid artery (ICA) anteriorly and the internal jugular vein (IJV) anterolaterally. Magnetic resonance imaging (MRI) showed a low signal intensity T1-weighted and a high signal intensity T2-weighted mass . These rThe patient underwent surgical excision with a transcervical approach. Intra-operatively, the mass was found lying medial to the CCA, the ICA and the ECA. The vagus nerve was visualized running over the top of the mass, uninvolved in the tumor formation . InsteadCSCS is an unusual diagnosis. Although the schwannoma in this case atypically developed in the midcervical portion of the carotid space, cervical schwannomas are commonly reported in the parapharyngeal space. The vagus nerve is the most common nerve of origin .Schwannomas are typically seen in patients between the ages of 30 and 70, with a sex ratio of 1. The diagnosis of a schwannoma is difficult not only because of the wide differential diagnosis of cervical mass but also because of the rarity and nonspecific clinical presentation, usually presenting as an asymptomatic, slow-growing mass. A CSCS is more easily evoked when the cervical mass is associated with a Horner's Syndrome by compression of the cervical sympathetic nerve. However, the latter is rarely found at the time of diagnosis . An unceSurgical excision is the preferred treatment for these tumors. In most cases, extra-capsular resection is performed with resultant nerve sacrifice. Intracapsular enucleation, as an alternative approach, has been shown to result in less morbidity due to nerve preservation but is frequently difficult to achieve due to the intimate contact with CSC and dense attachment of the tumor. Our patient developed a well-tolerated partial Horner’s syndrome post-resection, which is the most common sequelae associated with extracapsular excision of the tumor .This case presents a rare case of a CSCS masquerading as a VNS. This case highlights recently enhanced diagnostic criteria to improve preoperative accuracy and unusual post-operative sequalae.


As the third most common malignancy of childhood, Neuroblastoma has a great propensity to metastasize to multiple organs. The most common site of metastasis is the bone and bone marrow. Concerning the central nervous system, neuroblastoma usually involves the calvarium and the external dural surface. The skull metastases may show different appearances, including: multiple lytic bone lesions, bone thickening, hair-on-end periosteal reaction, irregular suture widening and/or plaque like epidural deposits. Here we present a case of metastatic neuroblastoma, appearing as multiple multi-loculated cystic epidural masses with internal blood-fluid levels as a rare imaging manifestation of calvarial metastasis.An 8-year-old boy with known history of autism, presented to the emergency department with a 3-month history of intermittent fever, malaise and myalgia and headache along with significant weight loss. Laboratory examination revealed elevated ESR and CRP and anemia. On Abdomino-Pelvic imaging a well-defined, 45*30*24 mm, solid-cystic mass was observed, replacing the normal left adrenal gland. On brain MRI, multiple multi-loculated cystic, lentiform masses were observed on the external surface of cerebral hemispheric dura. Multiple fluid–fluid levels were noted in the locules in some of which the dependent fluid was hyperintense on T1w and FLAIR and hypointense on T2w sequences, compatible with blood, representing blood-fluid level. The wall and septa of the masses, enhanced after contrast administration. Associated abnormal marrow signal and aggressive type periosteal reactions were identified in the overlying bone. All of the lesions had increased uptake in MIBG scan. Bone marrow biopsy revealed small round cells, diagnostic for neuroblastoma. The patient underwent chemotherapy treatment. All calvarial/epidural metastatic lesions resolved after chemotherapy and residual adrenal tumor was resected.Cystic epidural lesions, especially when associated with adjacent abnormal bone marrow signal, or periosteal reaction and containing blood-fluid level should raise the suspicion of a calvarial metastasis. As the third most common malignancy of childhood, Neuroblastoma has a great propensity to metastasize to multiple organs. The primary tumor originates from the adrenal gland or sympathetic ganglia. The most common site of metastasis is the bone and bone marrow. Concerning the central nervous system, neuroblastoma usually involves the calvarium and the external dural surface, which acts as a barrier against direct invasion to leptomeninges; thus metastasis to brain parenchyma and leptomeninges are rare –3. The pth right rib suggested bony metastases. On brain MRI, multiple multi-loculated cystic, lentiform masses were observed on the external surface of cerebral hemispheric dura. Multiple fluid–fluid levels were noted in the locules in some of which, the dependent fluid was hyperintense on T1w and FLAIR and hypointense on T2w sequences, compatible with blood, representing blood-fluid level. The wall and septa of the masses, enhanced after contrast administration. Associated abnormal marrow signal and aggressive type periosteal reaction were identified in the overlying bone (Fig. An 8-year-old boy with known history of autism, presented to the emergency department with a 3-month history of intermittent fever, malaise and myalgia and headache along with significant weight loss. Other than autism, no past medical history existed. His drug history included Imipramine and Haloperidol. Except for fever [38 degrees centigrade], pale conjunctivae and palpable soft bulging in forehead, physical examination was unremarkable. Laboratory examination revealed ESR: 125 mm/hr, CRP: 90 mg/L, Hb: 7.1 g/dL, LDH: 1789U/L, ferritin: 2570 µg/L and TSH: 7.77mIU/L. On Abdomino-Pelvic ultrasound, a well-defined, 45*30*24 mm, solid-cystic mass was observed, replacing the normal left adrenal gland, with multiple pathologic lymph nodes in the para-aortic chain. Thoraco-Abdomino-Pelvic CT scan (Fig. As the most common extracranial solid tumor of childhood, neuroblastoma accounts for 10% of childhood malignancies, and 15% of malignancy-related deaths , 5, 6. IThe skull metastases may show different appearances, including: multiple lytic bone lesions, bone thickening, hair-on-end periosteal reaction, irregular suture widening and/or plaque like epidural deposits , 4. DuraNecrosis and hemorrhage have been mentioned as the secondary histologic features of neuroblastoma . AlthougOur patient, who first presented with non-specific symptoms, and last was confirmed to be a case of neuroblastoma, showed an atypical imaging appearance of calvarial metastasis: multiple multi-loculated cystic masses, with enhancing wall and septa, which contain blood-fluid levels, and were located on the external dural surface. No previous case of calvarial/epidural metastasis of neuroblastoma with cystic-hemorrhagic degeneration has been reported in the literature, which may cause unfamiliarity of the radiologists with this appearance of the entity, thus leading to incorrect interpretations , 3, 5. ACystic-hemorrhagic epidural lesions, especially when associated with adjacent abnormal bone marrow signal or periosteal reaction should raise the suspicion of a calvarial/epidural metastasis. Neuroblastoma should be kept in mind in children as the most common primary of these metastatic lesions, in the appropriate clinical setting.


Transvaginal intestinal evisceration is an extremely rare surgical emergency with potentially fatal consequences. Only a few more than 100 cases with this pathology have been described in the literature. Aetiology is also unclear and multifactoral.We report the case of an 80-year-old female who presented with sudden severe abdominal pain and spontaneous small bowel evisceration through the vagina along with associated high-grade uterine prolapse. The loops and their mesentery appeared edematous, thickened and dusky, but without apparent necrosis. An urgent laparotomy was performed with subsequent reduction of the prolapsed small bowel into the abdomen, hysterectomy, partial resection of the vagina and vaginal closure. Additional cholecystectomy was necessary because of the visible pathologic changes of the gallbladder. The postoperative period was uneventful. The unique feature of our case is that there was no trigger factor , provoking the vaginal rupture and intestinal evisceration through it in the context of pelvic floor weakness.Early detection and surgical management are crucial for preventing bowel ischemia and abdominal sepsis. If the eviscerated intestine is ischaemic and non-viable, this requires resection and anastomosis. The approach should be individualized and performed by a multidisciplinary team. Transvaginal intestinal evisceration is a rare surgical emergency with potentially fatal consequences –6. A limOur patient presented with sudden severe abdominal pain and spontaneous small bowel evisceration through the vagina along with associated uterine prolapse requiring emergent surgical intervention. This case report is compliant with the CARE Guidelines .An 80-year-old female living independently presented with sudden severe abdominal pain, weakness, and dizziness. The patient reported she had no constipation or a coughing episode that would increase the intra-abdominal pressure. She did not experience any recent trauma. The patient’s obstetric history included one full-term vaginal delivery and long-standing presence of uterine prolapse (grade 3) treated with pessary placement. However, she stopped using it 2 years ago. Other concomitant diseases were arterial hypertension and anxiety disorder managed with Diazepam. After examination by a gynaecologist, the patient was referred to our department because of established an irreducible small-bowel prolapse through the vagina and suspected changes of the intestinal vitality.2 79%, tCO2 16.5). Fluid resuscitation and intravenous broad-spectrum antibiotic administration (Metronidazole and Cefoperazon) were timely initiated.The physical examination revealed impaired general condition, pale skin, a pulse rate of 90 per minute, and blood pressure of 109/60. The patient’s position in the bed was passive. The abdomen was significantly tender in the lower quadrants with hypoactive bowel sounds. Perineal examination showed 40–50 cm of small bowel prolapsing through the vagina along with associated high-grade uterine prolapse. The loops appeared edematous and thickened, with changed colour, but without obvious necrosis. The mesentery was dusky red and ecchymotic with signs of impaired venous return Figs. . RoutineBecause the intraperitoneal reposition of the eviscerated intestine was not possible and the diagnosis was visible from the examination, CT was not performed to save time. The decision for an early as possible operation was taken into account the status of the prolapsing intestine, and the goal was the preservation of intestinal vitality and avoidance of intestinal resection, if feasible.The eviscerated intestine was wrapped with warm, sterile, saline-soaked packs. The surgical procedure started with a lower midline incision which later was extended proximally. After assessing the damage, the prolapsed small bowel was reduced into the abdomen. The exploration revealed a laceration of the peritoneum of the Douglas cavity and a defect in the posterior vaginal fornix. The vagina was distended and thickened in its upper third, probably due to the long-term uterine prolapse and pessary use. The affected intestinal loop was localized 30 cm proximally to the ileocecal valve. After the reposition, the small bowel loop restored its vital colour, so bowel resection was not required. Several small mesenteric tears were found and sutured subsequently. The uterus was enlarged due to the presence of several fibroids, and the uterine round ligaments were highly distended. There were no visible signs of malignancies. Intraoperative consultation with a gynaecologist was made because of the changes in the uterus and upper part of the vagina. A hysterectomy with resection of the upper third of the vagina was performed. Vaginal closure, plication of the uterine round ligaments, and fixation to the vaginal cuff were carried out. The peritoneum from the lateral pelvic sidewalls was mobilized, and the repair was performed. Subsequently, the peritoneal cavity was washed with saline. The additional pathological finding was the highly enlarged gallbladder with thickened walls and multiple gallstones inside. So, cholecystectomy was performed. Three drains were inserted—one was placed in the subhepatic space, one over the restored peritoneum of the pelvis, and the last was extraperitoneal, near the vaginal cuff. The same antibiotic regimen initiated prior to surgery was undertaken postoperatively. The postoperative period was uneventful, and the patient was discharged on the 11th postoperative day. Two years later, the patient has no complaints related to the surgery.Hypernaux et al. described the transvaginal prolapse of abdominal content for the first time in 1864 . Later iTransvaginal small bowel evisceration is related to 6–8% mortality and a high morbidity rate 15–20%) [5–20% 1,, 4, 21. Transvaginal intestinal evisceration is an extremely rare emergency. Early detection and surgical management are crucial for preventing bowel ischemia and abdominal sepsis. If the eviscerated intestine is ischaemic and non-viable, this requires resection and anastomosis. The approach should be individualized and performed by a multidisciplinary team.


Paragangliomas are rare tumors that may present with cranial neuropathies when located along the skull base. Supratentorial paragangliomas are less likely to secrete catecholamines but should be worked up, nonetheless. We highlight a case of a female in her fourth decade found to have a petroclival lesion following initial presentation that included one month of tooth pain, dysphagia, diplopia, hoarseness and right hemifacial hypoesthesia. Magnetic resonance imaging of the brain demonstrated a T2 hyperintense lesion favored to be a petroclival meningioma. Pre-operative angiography demonstrated a hypervascular tumor. She underwent a combined presigmoid craniotomy with posterior petrosectomy performed by both neurosurgery and neuro-otology. Pathology demonstrated paraganglioma. She had small volume residual tumor and is planned for continued outpatient radiotherapy. Paragangliomas should be on the differential for skull base lesions. Management paradigm involves multidisciplinary care and a combination of surgical resection and post-operative radiation. In this paper, we discuss underlying pathophysiology as well as appropriate workup and management. These t2.A woman presented in her fourth decade with one month of tooth pain, dysphagia, diplopia, hoarseness, and right hemifacial hypoesthesia. She also reported diminished manual dexterity bilaterally and gait instability. Physical exam was notable for dysconjugate gaze with abduction of the left eye, incomplete left lateral gaze palsy, decreased sensation throughout the face bilaterally, and a House-Brackmann Grade II left facial nerve palsy. Audiogram demonstrated normal hearing and laryngoscopy demonstrated normal vocal cord function. MRI brain demonstrated an avidly enhancing and T2 hyperintense retroclival mass with significant mass effect on the adjacent brainstem, cranial nerves, and vascular structures .Given the patient’s progressive symptoms and the lesion’s compression of nearby neurovascular anatomy, the patient was recommended for surgical resection. Preoperatively, the patient underwent preoperative angiography to better delineate the tumors relationship to the posterior circulation . A hyperPostoperatively, the patient woke with a stable left House-Brackmann Grade II facial nerve palsy. She also had left CN VI palsy, diminished facial sensation in the V1 and V2 distribution, and left ear sensorineural hearing loss confirmed by audiogram. Postoperative MRI demonstrated small volume residual tumor along the left petroclival junction. Pathologic examination revealed fibrous tissue consisting of nests and clusters of cells that display hyperchromatic nuclei, coarsely granular chromatin, and moderate to abundant eosinophilic cytoplasm. Tumor cells are diffusely and strongly immunoreactive for synaptophysin and chromogranin. This pathologic profile was consistent with a paraganglioma . AdditioThe patient had ventilator dependent respiratory failure postoperatively and underwent a tracheostomy. She was subsequently able to be weaned from the ventilator and her tracheostomy was downsized and decannulated prior to discharge from the hospital.One month postoperative, MRI brain demonstrates stable residual. A discussion regarding management of residual was held with the patient and a multi-disciplinary tumor board, and the decision was made to refer to radiation oncology for fractionated conformal radiotherapy of small residual disease . She has3.3.1Head and neck paragangliomas are rare, accounting for about 0.6% of head and neck tumors . ParaganParagangliomas in the head and neck region present with mass effect rather than catecholamine excess , 12. Fre3.2The paraganglion system is an important source of catecholamines during fetal development, and typiclly regresses after birth, leaving sparse autonomic nervous system cells in the carotid, aorticopulmonary system, jugular body, and other anatomic locations –18. ThesRET, VHL, SDHB, and SDHD mutations -DOTATATE PET/CT compared to standard imaging modalities, including the current gold standard [18F]-FDOPA) PET/CT [68Ga]-DOTA-peptides bind effectively [68Ga]-DOTATATE PET/CT is more effective in detecting head and neck paraganglioma metastases, compared to [18F]-FDOPA) PET/CT and traditional PET/CT [Functional imaging is highly capable of finding specific lesions by using tumor-specific ligands connected to radiotracers , 25. Ioddalities . Head an) PET/CT . This fuectively . Further3.4While glomus jugulare tumors are technically of the skull base, other paragangliomas of the skull base are quite rare. Paraganglioma cases involving the skull base outside the jugular foramen described in the literature have a variety of clinical presentations –33. Unde3.5The British Skull Base Society recently established a consensus for management of skull based paragangliomas. The consensus recommendations include multidisciplinary management, endocrine assessment, genetic assessment, and MRI of the head, neck, abdomen, and pelvis. Observation is reasonable for asymptomatic patients without catecholamine surges . For sym4.We present a unique case of a paraganglioma that mimicked a meningioma in that it was homogenously enhancing and appeared attached to the dura. MRI is the investigation of choice with typical findings for paraganglioma including a well-circumscribed, intensely enhancing mass lesion with few areas of cystic compartments. T2-weighted imaging (T2WI) occasionally will show a “cap sign” or “salt and pepper” appearance. When differential is in question, PET/CT may be helpful to differentiate. Once recognized, catecholamine levels should be measured and attempted resection with embolization of arterial feeders should be performed. Depending on approach and/or adherence to cranial nerves, residual can be treated with radiation therapy. Patients should be monitored closely and counseled appropriately regarding expected deficits and recovery.


We present a case of a surgically treated latissimus dorsi (LD) and teres major (TM) tear with a one-year outcome. The postoperative course was complicated by wound dehiscence requiring operative intervention and neuropraxia of the posterior cutaneous nerve of the arm. The report highlights previously unreported surgical risks associated with repair of LD/TM tendons. Tears of the latissimus dorsi (LD) and teres major (TM) are relatively uncommon and are typically observed in professional and high-level recreational athletes. Insertion of the LD and TM away from the humerus' axis of rotation subjects these tendon units to extreme forces in activities like overhead sports and cable watersports . While LThere is no consensus regarding ideal treatment of LD/TM tears as both surgical and nonsurgical interventions have been reported with comparable outcomes , 3. As sThe index patient is a 31-year-old right-handed dominant male who presented after a wakeboarding accident in which he heard an audible pop accompanied by sharp left shoulder pain after a sudden pull by a tow cable. Physical examination was remarkable for extensive ecchymosis around the posterior aspect of the arm and left hemithorax, as well as swelling in the posterior axillary region . MagnetiPrimary repair of the LD and TM tendons was performed in a sloppy lateral position via a single axillary-based incision (Video 1). The posterior cutaneous branch (PCN) of the radial nerve was identified and protected during subcutaneous dissection. Deep dissection demonstrated a seroma covering the stumps of the torn LD and TM tendons, which were avulsed off their insertion from the bicipital groove.Both tendons were mobilized and able to reach their insertional footprint for a direct primary repair . Two higPostoperatively, the arm was placed in a sling for six weeks. Active adduction and internal rotation, passive overhead abduction, and external rotation were not permitted during this initial phase of immobilization. Active ROM was started at six weeks with the introduction of LD and TM strengthening exercises at three months.The patient reported serous drainage from the incision and was found to have wound dehiscence in the central part of the incision (1 cm) three weeks after surgery. He underwent irrigation and debridement in the operating room with primary wound closure, and the incision healed uneventfully thereafter. The patient also reported decreased sensation in the distribution of the PCN of the arm. The sensation progressively improved throughout the year after surgery. The primary repair and PCN of the arm were both intact upon observation during the debridement surgery.At one-year follow-up, the patient reported no pain and was able to return to preinjury sporting activity without limitations. He had normal contour of the left posterior axillary fold and full shoulder ROM . He rateSurgical repair of LD and TM offers improvement in strength in adduction and extension, as well as cosmetic improvement in the posterior axillary fold contour. Despite these advantages, the close proximity of the surgical site to neurovascular structures poses an inherent risk for injury . In thisThe PCN of the arm is encountered in an axillary-based approach for LD repair and is at risk for injury. However, this complication has not been previously reported with LD/TM tendon repairs. As the presentation for PCN of the arm neuropraxia can vary and potentially be underreported, awareness of this complication is pertinent to patients undergoing repair and those treating them. Previously reported neuropathies in studies involving LD tendon transfers include those of the axillary nerve, ulnar nerve, and brachial plexus injury . In our There continues to be debate regarding ideal treatment of LD/TM tendon tears. Surgical treatment is an acceptable treatment option for combined LD and TM tendon tears, but patients must be counseled for potential risks and complications. Although there is paucity of literature on surgical outcomes, wound complications and neurological injuries are important risks in addition to retear or failure of repair.


The periurethral mass in the female is a rare clinical entity and most of the lesions are benign. We present an unusual case of a periurethral mass found to be intestinal-type adenocarcinoma which has not been previously reported in the literature.A 58-year-old woman was referred to our hospital with acute urinary retention. She complained of frequency, urgency and progressive obstructive urinary symptoms for the last 3 months. A pelvic magnetic resonance imaging scan showed a soft tissue mass of 5 × 4 cm surrounding the entire urethra. A needle biopsy was done and revealed adenocarcinoma with intestinal-type features. The tumor was removed by a simultaneous laparoscopic abdominal and transperineal approach. The pathological results showed a positive surgical margin and urethra and vagina wall invasion. The neoplastic cells were positive for CK20, CDX-2, CerbB-2, MSH2, MSH6, MLH1, PMS2 and P53. The patient received adjuvant systemic chemotherapy comprising S-1 and oxaliplatin. Follow-up with pelvic MRI 6 months after surgery showed no signs of local recurrence.We have reported the first case of the primary periurethral adenocarcinoma of intestinal type. There are currently no standardized protocols for the diagnosis, clinical course, and treatment of this rare tumor. This case study can aid decision-making regarding the diagnosis and treatment of this tumor. The periurethral mass in the female is a rare clinical entity. However, the differential diagnosis of the mass is extensive as it comprise a wide spectrum of pathologies. The most frequently encountered periurethral masses are Urethral diverticulum, leiomyomas, vaginal cyst, Skene duct cysts, leiomyoma and fibromyoma , 2.Intestinal-type adenocarcinoma is a high-grade malignancy which is most frequently localized in the ethmoid sinus 40%), the nasal cavity (25%) and the maxillary antrum (20%) , 4. The 0%, the nA 58-year-old woman was referred to our hospital in September 2021 with acute urinary retention. She complained of frequency, urgency and progressive obstructive urinary symptoms for the last 3 months. She denied pain, haematuria or bleeding. Her surgical history revealed a hysterectomy due to hysteromyoma 8 years prior. Her past medical and family histories were unremarkable.The ultrasound in emergency department showed urinary retention, but no other abnormalities were found. To find the possible cause of urinary retention, we performed a pelvic Computerized Tomography (CT) scan and a periurethral mass was found Fig. a. On phyConsidering the high malignancy of this tumor, radical cystourethrectomy was suggested. But the patient refused the plan and insisted on bladder preservation. The tumor was removed by a simultaneous laparoscopic abdominal and transperineal approach. The mass was firmly adherent to its surrounding tissue and part of the anterior vagina wall was resected. Gross examination of the resected specimen revealed a solid mass 5 × 4 × 3 cm) with irregular margins Fig. b. The pa cm with Periurethral mass in women is an uncommon diagnosis, which is a challenge to the medical professionals due to the nonspecific clinical presentation and a broad differential diagnosis. Urethral diverticulum is the most common pathology (84%), whereas vaginal cyst (6%) and leiomyoma (7%) comprise the majority of the remaining pathologies . Most ofIntestinal-type adenocarcinomas are aggressive malignancies which are most frequently localized in in the sinonasal tract. To our knowledge, this is the first reported case of intestinal-type adenocarcinoma arising in the periurethral region. In present case, immunohistochemical stains showed positive reaction for CK20 and CDX2, supporting the diagnosis of intestinal-type adenocarcinoma. As the tumor mimic the appearances of carcinomas or adenomas of intestinal origin, extensive research including gastrointestinal tract fiberscope, cystoscopy and CT scan should be performed to rule out the primary colorectal adenocarcinoma.Due to the rarity of this tumor, there is no data in literature regarding strategy for their optimal treatment. As Intestinal-type adenocarcinomas behave as high-grade malignancies , radicalIn conclusion, we have reported the first case of the primary periurethral adenocarcinoma of intestinal type. There are currently no standardized protocols for the diagnosis, clinical course, and treatment of this rare tumor. This case study can aid decision-making regarding the diagnosis and treatment of this tumor.


Appendiceal mucocele is an uncommon entity that may arise due to benign or malignant processes. The radiologic exploration of this entity is necessary for diagnosis, and its imaging manifestations vary, with some findings being more common than others. More specifically, the radiological findings of a superinfected mucocele are rare, with few reports in the literature. Herein we present the case of a 68-year-old male patient with a superinfected appendiceal obstructive mucocele caused by a fecalith, which was diagnosed by abdominal CT evaluation. Mucocele of the appendix is a rare clinical entity that may have either benign or malignant behavior regarding its type. Simple obstructive mucocele may be caused by fecalith or stricture or epithelial hyperplasia, and its incidence is up to 29% . On the A 68-year-old male was presented to the Emergency Department of our hospital due to mild pain in the right iliac and peri-umbilical region without any other symptoms such as nausea and anorexia. The patient reported that the pain started 10 hours ago, in the same region, without any other reflection of it. His past medical history was unremarkable. On arrival, his vital signs were normal, and the clinical examination revealed slight tenderness at the right iliac region, a negative McBurney sign, and normal bowel sounds. Full blood examinations and electrocardiogram (ECG) showed slight elevation of the white blood cells (WBC) and C-reactive protein (CRP). ECG was normal. The patient was then referred to the Radiology Department for an abdominal ultrasound which revealed a tubular hypoechoic cystic mass with no peripheral or internal vascularity at the right lower quadrant. An appendicolith with posterior acoustic shadowing was observed inside the cystic mass. No peri-appendix edema or wall-thickening was detected  contrast material due to a history of allergic reaction to a prior CT exam. The abdominal CT scan revealed a well-circumscribed, low attenuation tubular mass that was continuous with the base of the caecum. At the initial segment of the appendiceal mucocele, an appendicolith was observed, which causes mucus retention due to obstruction Figure . Mild faAppendiceal mucocele (AM) is a rare clinical entity caused by benign or malignant appendix lesions, and its incidence is estimated up to 0.7% . The defThe most common non-neoplastic cause is a simple mucus retention cyst due to luminal obstruction. Simple mucus retention cysts usually measure less than 2 cm, whereas neoplastic mucoceles tend to be larger at presentation . In ultrOn CT, the mucocele appears as a dilated appendix filled with homogeneous low attenuation material. Features like mural nodularity and irregular wall thickening are associated with malignant mucoceles due to adenocarcinoma . The murThe management of appendiceal mucocele is exclusively surgical; however, the type of surgery depends on whether the mucocele is benign or malignant . Among oAppendiceal mucocele includes a diverse clinical entity regarding its behavior, cause, diagnosis, and treatment. We highlight the necessity of correct evaluation of radiological findings to determine the right treatment plan for the patients. Moreover, independently of the presence of benign or malignant mucocele is important; the intact removal of the specimen while rupture may lead to pseudomyxoma peritonei.


Primary meningeal melanocytomas are extremely rare, benign tumours arising from the leptomeninges. While they are considered to be benign lesions, there is potential for their growth and transformation into malignant melanomas. They are commonly found in the cervical spine, with a decreased incidence in the thoracic and lumbar regions. We present a case report of a 56-year-old man who presented to our unit with a 4-month history of lower limb weakness and a sensory level at T6. Magnetic resonance imaging shows an intradural extramedullary tumour. The patient underwent a thoracic debulking of the lesion with neurophysiological monitoring. Histopathology confirmed the diagnosis of melanocytoma of meningeal origin, with a low mitotic count. Our patient recovered well post-operatively with no complications. Surgical resection is an effective method to manage this tumour; however, adjuvant radiotherapy is advised due to the risk of recurrence and malignant transformation. Meningeal melanocytomas are extremely rare benign tumours arising from the leptomeninges; 1 case presents per 10 million people every year . They tyIn this paper, we present a 56-year-old male with neurological decline secondary to this rare, intradural extramedullary tumour.A 56-year-old male presented with a 2-month history of recurrent falls and a past medical history of diabetes mellitus, hypertension and primary hyperparathyroidism. He fell down a flight of stairs 10 weeks prior to admission, resulting in a back injury and a significant decline in the power of his legs.On presentation to A&E, his lower limb power was MRC 4/5 in the right leg and 5/5 in the left leg. Muscle power, sensation and reflexes in the upper limb were intact. He had upgoing plantars and normal lower limb reflexes, except for hyporeflexia in the right ankle reflex. Pinprick sensation was intact until T6 level, however, perianal light touch and pinprick sensation were absent. Urinary function and anal tone remained intact. An magnetic resonance imaging (MRI) spine was requested and discussed by the multidisciplinary team (MDT) .The patient was started on methylprednisolone (1 g/day) for 3 days under the neurology team; however, this did not improve his neurological status, and subsequently, his neurology progressively worsened to a lower limb weakness to an MRC grade of 1/5 bilaterally with faecal incontinence. A second MRI spine was performed with contrast .The patient underwent gross-total resection (GTR) of the intradural extramedullary lesion via a T6 laminectomy with intraoperative neuromonitoring. The monitoring revealed that the MEPs were stable throughout the procedure, with no MEP recording seen in the right lower limb muscles from the beginning of the recording.On Day 1 post-operatively, the patient was able to move his toes, however, had bilateral 0/5 power for ankle dorsiflexion and plantarflexion and 1/5 power for knee extension and flexion. High-dose dexamethasone was started post-operatively.On the second day post-operatively, the patient gained 4/5 power in his hips, knees and right ankle and gained 3/5 power in his left ankle. The patient’s urinary catheter was removed 10 days post-operatively. A post-operative MRI was performed after 19 days showing GTR of the lesion .The patient recovered well with intensive physiotherapy and prior to discharge had a 5/5 power bilaterally and was mobilizing with a frame.At the neuro-oncology MDT, a prognostic outcome was not provided due to the rare histopathological diagnosis.At 3-month follow-up, the patient reported improvement in mobilizing, bladder and bowel control. He also experienced significant improvement in the lower limb power and sensation.Biopsy demonstrated a well-demarcated tumour with a storiform growth pattern composed of spindle tumour cells with mild nuclear pleomorphism. Intracellular and extracellular deposits of melanin were noted with occasional mitotic figures. Immunostaining for HMB-45 was positive, and ki67 proliferative index was estimated at 5%. Immunostaining for GFAP, STAT6 and EMA was negative. Methylation profiling resulted in the classification of melanocytoma [A preoperative differential of spinal meningeal melanocytomas is challenging due to their non-specific clinical and neurological presentations . ClinicaRadiologically, they appear as well-defined, extra-axial, isodense-to-hyperdense, homogeneous, contrast-enhancing mass lesions on CT. Their appearance is variable on MRI depending on melanin concentration . MRI hypMacroscopically, these tumours appear to be black, red or nonpigmented. Microscopically, tumour cells are spindled or oval-shaped and contain melanin in nestlike structures . CytologComplete GTR is the treatment of choice, however, may not always be appropriate due to intraoperative haemorrhage risk . The risn = 17). The mean age at which patients first presented was 40.6 years (5–72) [n = 8) [n = 5) [n = 4) [n = 10) cases were in the cervical region, 43% (n = 10) were in the thoracic region, 9% (n = 2) were in the sacral region and 4% (n = 1) were in the lumbar region of the spinal cord.Twenty-three patients were identified, who were predominantly males (s 5–72) , 10. Com2 , 10. C [n = 8) , 11–15,  [n = 5)  and back [n = 4) , 21. Then = 13) of patients, GTR was achieved. The remaining patients  underwent STR, with the extent of resection determined by the surgeon; 43% (n = 10) of patients experienced complete resolution of their symptoms after surgery. Post-operative complications were infrequently reported, however, the most reported was genitourinary dysfunction (n = 5) [In 57%  , 22, 23.In conclusion, despite the rarity of spinal meningeal melanocytoma, timely management can optimize the clinical outcomes for these patients, and more studies are required to gain an understanding of the prognostic outcome of these rare tumours.None declared.No funding was received for this research.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Consent was gained from the individual included in this study. For this type of study, formal consent is not required.razna.ahmed@kcl.ac.uk.Data is available upon request. Requests to access the dataset should be sent to


Basal cell carcinoma (BCC) is generally uncovered in sun-exposed areas, secondary to chronic unprotected UV exposure. The most common sites for nodular basal cells are the face, especially the nose, cheeks, forehead, nasolabial folds, and eyelids, with a history of crusting and friability. The commencement of BCC is 10 to 15 years from epidermal damage.Here, we report the case of a 52-year-old Caucasian female who presented to her primary care with an enlarging bump on the scalp for the past five years, which became tender and friable two months before the visit. The patient was clinically diagnosed with a solitary cyst and was referred for surgical excision. The pathology of the excised specimen revealed it to be a BCC. Basal cell carcinoma (BCC) is a common skin cancer with rare metastatic risk and is commonly found on the head and neck region due to protracted unprotected UV exposure . Some stThere are various morphological subtypes of BCC that exist, and they include nodular (solid), micronodular, superficial, cystic, infiltrating, infundibulocystic, pigmented, adenoid, metatypical, basosquamous, and fibro epitheliomatous tumors . The mosA 52-year-old Caucasian female patient referred by her primary care provider (PCP) came to the clinic with a chief complaint of an enlarging cyst on her scalp that was making her self-conscious because she could no longer cover it with her hair. Past medical history was notable for primary hypertension, depression, and migraines. Family history was significant for her father, who had been diagnosed with primary hypertension and leukemia, and a sister with primary hypertension. Surgical history was notable for hysterectomy roughly eight years ago.The patient in this study is an immigrant to America from Poland who spent most of her youth working as a farmerette. While working on the farm, the patient identifies not being concerned about utilizing prophylactic protection for regular sun exposure. She is currently employed as a housekeeper in America, predominantly working weekdays while spending weekends engaged in various outdoor activities such as trips to the beach or skiing.The patient inquired about the possibility of numerous trauma to the region as the probable cause of the enlarging cyst. There have been instances of trauma to the crown of her head. The most recent trauma occurred two weeks before coming to the clinic when she struck her head while exiting her car. This incident led to mild bleeding from the enlarging cyst.The cyst first appeared four to five years ago as a small bump and slowly grew over the years. The patient started feeling mild-to-moderate pain with moderate friability in the area during the last two months. On physical examination, a solitary, round, non-tender cyst was seen on the anterior scalp. The skin surrounding the cyst was intact with mild crusting. There was no family history of such lesions. Vitals were stable.With the tentative clinical diagnosis of a solitary cyst, incision and drainage of the cyst were planned. An elliptical incision of the mass down to the deep subcutaneous layer was made. A 2 cm x 3 cm mass was excised, and the specimen was sent to pathology. Per the pathology report, the specimen received in formalin labeled "scalp cyst" was gray/brown skin excision with underlying soft tissue measuring 2.4 cm x 1.3 cm x 1.0 cm. The epidermal surface is rough and consists of multiple hair follicles and one outgrowth measuring 10 mm x 8 mm. The interior is tan and homogenous upon sectioning. The specimen was confirmed as nodular BCC  at a high dosage at a young age . The patPTCH1 gene that occurs in 70% of people with sporadic BCC [P53 gene. Mutations in the CDKN2A locus also have been detected in a smaller number of sporadic BCCs. Genetic contributions remain a possibility, but this patient was not genetically tested.The most often altered gene in BCC is the On histology, BCC presents as islands or nests of basaloid cells, with cells palisading at the periphery in a haphazard arrangement in the centers of the islands . These sIncisional, excisional, shave, and punch biopsies are generally used to diagnose BCC. In patients with obvious BCC and for whom the cosmetic outcome is not a priority, an excisional biopsy involving the removal of the entire lesion is done for histologic diagnosis and definitive therapy. Once confirmed through biopsy, treatment of BCC would depend on the location, type, and size. Mohs surgery is a micrographically controlled surgery under local anesthesia where the tissue is examined layer by layer. This method has the lowest recurrent rate for primary BCC. It has been reported that the five-year recurrence rate is 1.4% . Other tThe tentative diagnosis was a solitary cyst prior to the E&D of this lesion in this report. The patient desired the removal of the lesion due to increasing pain, discomfort, and mild friability. The belief that the lesion was a solitary cyst remained due to its location until pathology confirmed it as a nodular BCC. Nodular BCC remains a rare finding on the scalp.Among skin cancers, BCC is common. Typically present as a shiny, pink papule or nodule with surface telangiectasia. Lesions can often enlarge over time or bleed. Most commonly found on the face, the disease usually develops due to chronic exposure to UV radiation, causing direct DNA damage. Due to its highly variable presentation and insidious onset, diagnosing BCC comes with its challenges. Its ability to disguise as other more benign lesions makes it easy to misdiagnose. Patients can also delay diagnosis, such as in this case, especially when there are no alarm symptoms, such as bleeding or itching in the area, leading to continued growth without interruption. The primary care physician was acquainted with the lesion after it became friable because the patient became alarmed.This case adds to the discussion of BCC as there are many unique features. The location was noteworthy as the most common sites for nodular basal cells are the face, especially the nose, cheeks, forehead, nasolabial folds, and eyelids. In this patient, BCC was found on the scalp with moderate friability. The time of onset and the growth rate was also significant as BCC in this patient presented itself as a slow-growing cyst with a prolonged growth rate, initially presenting itself approximately five years ago. This case highlights the importance of using protective gear such as hats, especially with chronic exposure to sunlight. Patients should be educated concerning seeking medical care even in the absence of alarming symptoms, preventing delays in diagnosis and intervention.


Cystic adenomyosis is a rare type of adenomyosis that often occurs in adolescents or women of childbearing age. Due to the few reports of this case, its clinical characteristics have not been clearly established.We treated a 32-year-old married patient with cystic adenomyosis that reported persistent abdominal pain and massive vaginal bleeding, so an emergency laparotomy was performed. The intraoperative findings and post-operative pathology proved that the diagnosis was correct. The prognosis of the patient is good, and there is no recurrence within 3 months after surgery.Surgery is the most effective way to treat cystic adenomyosis. Ultrasound and magnetic resonance are the most effective auxiliary examinations for diagnosing the disease.Cystic adenomyosis is a sporadic disease. This article summarizes this condition's clinical manifestations, pathological features, diagnosis, treatment, and prognosis by reviewing the existing literature and the case presented in this report. It is noteworthy that early diagnosis and individualized treatment strategies can improve patients' quality of life. Cystic adenomyosis is a rare type of adenomyosis, and only 46 cases of this disease have been previously reported, including the one presented in this study . It is iA 32-year-old woman referred regular menstrual cycles lasting 7 days with a normal flow and had no previous history of period pains. She was admitted to our hospital for abnormal vaginal bleeding for 2 months and lower abdominal pain for 4 days. The abnormal vaginal bleeding was described as persistent and the amount of blood loss was less than her normal menses. The lower abdominal pain was sudden and progressively worsening which she described as dull pain in nature, located over the lower abdomen, and resolved by changing to side lying position.Physical examination revealed a well-healed cesarean section scar tenderness on palpation of the lower abdomen. Bimanual examination revealed that a cyst palpable in front of the uterus about 10 cm in diameter. It appeared to be attached to front of the uterus.*10∧12/L, hemoglobin of 77 g/L. The C-reactive protein level was 24.4 mg/L.Laboratory examination showed red blood cell count of 3.2*10.2*9.3 cm cystic mass in the front of the uterus  can also be a means to relieve the symptoms of dysmenorrhea. However, drug administration only temporarily relieves the symptoms, and the condition is likely to relapse after ceasing the treatment, which is not ideal. Furthermore, oral drugs might be ineffective for younger patients with evident symptoms that can affect fertility, so surgery is still considered the most effective method to treat the disease . LesionsFor patients with no fertility requirements, a total hysterectomy can be performed. For patients with specific fertility requirements, resection is the best option. Whenever possible, doctors may opt for minimally invasive procedures, e.g., laparoscopy, hysteroscopy, which will help patients recover fast after surgery. Hysteroscopy is suitable for submucosal cystic adenomyosis, which protrudes in the uterine cavity but it is not ideal for larger cysts. There are still cases treated with traditional open surgery, mainly because it is difficult to diagnose the disease before, and it can be challenging to determine the location and nature of the lesion. Xiao-Jing et al.  proposedConsidering the 46 cases retrieved to support this study, most patients underwent laparoscopic surgery to remove the lesions. Three patients with larger lesions underwent hysterectomy, four underwent hysteroscopic surgery, four underwent high-intensity ultrasound-focused treatment, and one underwent sclerotherapy. One very young patient was treated with oral contraceptives because the clinical symptoms were not so evident. However, three patients underwent radical surgery for malignant transformation of cystic adenomyosis. Two of them received post-operative adjuvant chemotherapy, and one refused post-operative adjuvant therapy. Except for three cases of malignant transformation, most of the other patients were completely cured, and three of them gave birth after the operation. We chose to adopt traditional open abdominal exploratory surgery in our patient to guarantee the complete removal of the lesion. We combined this method with a post-operative adjuvant GnRH drug treatment and achieved remarkable results. Follow-up after operation revealed that the patient recovered well, and the cyst did not recur. We show the diagnosis and treatment process of the patient in the form of tables .Cystic adenomyosis is a less common type of adenomyosis that can also manifest as subserous cystic adenomyosis in some rare cases. Taking into consideration the previous findings about this condition, its clinical manifestations are atypical. Some patients may have no corresponding clinical symptoms, or many manifest the disease with other related symptoms such as dysmenorrhea and abnormal uterine bleeding. Pelvic ultrasound, magnetic resonance, and CA-125 examination can assist in diagnosing this disease, but the final call still depends on intraoperative exploration and post-operative paraffin pathology. Therefore, it can be challenging to effectively diagnose cystic adenomyosis patients before surgery. When another patient has symptoms of abdominal pain and vaginal bleeding, imaging examination shows cystic mass in front of the uterus, we should think that it may be cystic adenomyosis.This condition can reduce the quality of life of patients, and, in some cases, lead to secondary cancer, which is more life-threatening. Among the 46 cases officially reported previously by other scholars, only three patients with malignant transformation underwent radical surgery and post-operative adjuvant chemotherapy. Therefore, timely diagnosis and treatment is particularly important. In future clinical work, we should comprehensively understand and learn the disease's diagnosis and treatment plan to improve the clinical cure rate. This is the best way to guarantee that patients can receive timely and effective treatment, so we can upgrade their quality of life and post-operative pregnancy rates.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.TX completed most of the writing work. YL and TX reviewed the literature and participated in the drafting of the manuscript. LJ and QL prepared radiographic images. KL was responsible for revising the manuscripts of important knowledge content. All authors gave final approval to the version to be submitted.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Apart from meconium ileus, amniotic fluid plug syndrome, malrotation of the gut, Hirschprung’s disorder, trauma, and other rare causes, bowel atresia is one of the most common causes of bowel obstruction in newborns. Jejunal atresia can affect multiple lengths of the bowel. The higher the level of atresia, the greater the severity. The outcome of bowel atresia related to surgical repair is favorable. In general, both mortality and morbidity are affected by affiliated medical conditions such as preterm birth, cystic fibrosis, and other congenital anomalies; the sophistication of the lesion; and surgical complications. We present the case of a one-day-old baby who had two episodes of bilious vomiting with abdominal distension within 10 minutes of birth. The baby was advised to undergo ultrasonography of the abdomen and pelvis for further evaluation, and the findings were reported. Jejunal atresia can affect multiple lengths of the bowel. The severity increases with the level of atresia. The consequence of bowel atresia because of surgical repair is favorable . AtresiaWhen analyzed anatomically, an ectopic pancreas is a pancreatic tissue that is abnormally located and lacks morphological or vascular continuity with the normal tissue. It has an overall prevalence of 1% to 13% but rarely affects newborns. An endodermal pancreas is most typically found in the intestinal system 25%-38%), a portion of the small intestine 17%-36%), and the jejunum (15%-21%). It is also found in the liver, Meckel’s diverticulum, navel, spleen, and reproductive organs [%-38%, a %, and thMeckel's diverticulum is one of the most common birth gastrointestinal anomalies, with an occurrence of 1% to 3%, but it affects 4% to 6% of infants aged below two years . In 1809A one-day-old male baby was delivered by full-term cesarean section, with a significant antenatal history, and was suggestive of dilated bowel loops in the antenatal scan Figure . HistoryIn the current scan, ultrasonography of the abdomen and pelvis revealed dilated large bowel loops with minimal interbowel-free fluid. The baby was then taken for an exploratory laparotomy on an emergency basis. It was discovered intraoperatively that he has type IV jejunal atresia Figure  involvinIntraoperatively, a 2 cm × 1 cm mass was seen over the early part of the jejunum, which was sent for histological evaluation and found to be histopathologically evocative of the heterotopic pancreas. The baby was started on parenteral nutrition postoperatively, which was well tolerated, and small volume nasogastric feeds were started on postoperative day 7, with no clinically significant complaints. On a postoperative day 12, the feed volume was increased. On postoperative day 15, the baby had one episode of bilious vomiting and a deranged liver function test, after which he started on intermittent infusion feeds.An ischemic shock to the gut during growth in the delayed intrauterine phase is the most likely cause of bowel atresia. The principal reason for most small bowel and small intestinal atresia is late intrauterine mesenteric vascular impairment. According to reports, volvulus and jejunal atresia can exist side by side, without causing mesenteric vascular irregularities. Bowel atresia can be caused by a variety of factors .In this case, the patient had a heterotopic pancreas, Meckel's diverticulum, atretic jejunum sections, and type IV jejunal atresia. Health conditions for jejunal atresia involve prematurity (50%), polyhydramnios (25%), Crohn's disease (20%), pyloric stenosis, midgut volvulus, and brief gut syndrome . CigaretOther congenital abnormalities affiliated with the annular pancreas in children are well known, with Down's syndrome being the most common birth chromosomal anomaly, with a 10% to 30% occurrence . In addiThe most common symptoms are persistent abdominal cramping, bilious vomiting, and the inability to eliminate meconium. Nevertheless, in addition to the standard underlying diseases of jejunal atresia, characterized by a triple bubble emergence for a proximal blockage, there could be several dilated small intestinal loops anterior to the atresia . The maiJejunal webs are far less prevalent than jejunal atresia. These clinical signs can be comparable to those of malrotation and midgut volvulus. The mainstay of planning is early detection and intervention. The surgical strategy is determined by the findings. When the anterior part of the bowel is distended, the first anastomosis is made toward the distal part. To avoid common nutritive complications, primary anastomosis either with or without an enteroplasty is preferred.


Colonic bezoar is a rare condition of accumulation of foreign bodies or non-nutritious material in the large intestine, usually presenting with symptoms of obstruction. Colonic lithobezoar is an even more rare type of condition with only 12 cases reported in the literature to date. We present a case of a young, intellectually disabled kid, who was diagnosed incidentally with lithobezoar after a road traffic accident. The first-line treatment for uncomplicated non-obstructed bezoar is a medical treatment with laxatives and fluids. For acutely obstructed bezoars, the treatment of choice is evacuation under general anesthesia. Surgical evacuation may be considered a last resort in complicated or refractory cases. Moreover, regardless of obstruction, all cases must be treated as inpatients and must receive a psychiatric and hematologic evaluation. Bezoar is the term used for the accumulation of indigestible material in the gastrointestinal tract, whether food particles or foreign bodies . The mosWe present this interesting case of a 14-year-old female child with mental and developmental delay, who was incidentally diagnosed with massive colonic bezoar. The patient was brought to the emergency department of Hayatabad Medical Complex after a road traffic accident (pedestrian vs. vehicle) in September 2021. She was clinically stable during the primary and secondary surveys. She was complaining of mild bruises and pain in the right upper and lower limbs. To rule out any abdominal trauma, an abdominal X-ray was done, which revealed multiple irregular radiopaque shadows with the typical "corn on the cob" appearance extending from the cecum to the rectum. Figure After her trauma evaluation was complete, further history was elicited, which revealed that she had been seen eating stones (pica) multiple times, by her community members, for the past seven years. Since she remained asymptomatic, no medical care was sought. On examination, we found a moderately pale-looking child with abnormal facial features, expressionless face, polydactyly, tachycardia, and an ill-defined heart murmur, suggestive of congenital disorders . Abdominal examination showed mild tenderness on deep palpation and slightly hyperactive bowel sounds. A digital rectal examination was not performed due to the patient's irritability. We immediately admitted the patient to the surgery ward for conservative management. She was started on laxatives and parenteral fluids, which helped her pass the stones in stools daily. Figure Her blood investigations Table  suggesteBezoar can be of many types. The name of bezoar is based on the constituent material, more commonly including the trichobezoar (hair), phytobezoar (vegetable and fruit particles), lactobezoar (milk and curd accumulation), and rare items like metal  or stones (lithobezoar) . The mosAlmost all the cases in the literature are associated with pica, and most of them have iron deficiency anemia. However, only two of the 13 cases reported intellectual disability. Most of the reported cases are from India (seven out of 12) and Turkey (four out of 12). The management in most of these cases was the digital evacuation of the stones under general anesthesia (GA) to relieve the acute obstruction. In contrast, our case was treated conservatively with laxatives and fluids only, as there was no acute obstruction. Most surgeons prefer the former method, as it is safe, quick, and pain-free. Though, in otherwise stable and cooperative patients, one may choose to opt for only conservative management, like colonic lavage and laxatives. Surgical evacuation should be the last line option, only for refractory or complicated cases, if laxatives and manual or colonoscopic decompressions fail. Also important is the fact that in cases of acute obstruction, the surgical evacuation should be done on an emergent basis to avoid a closed loop obstruction of the large bowel between the bezoar and the ileocecal valve.It is concluded that lithobezoar is a rare condition that should be excluded if a young child presents with abdominal pain or bowel obstruction. Moreover, primary care physicians should evaluate intellectually disabled kids for pica and bezoars during wellness visits. Regardless of presentation, whether incidental or obstruction, colonic bezoar patients must be treated as inpatients with oral laxatives or enema to help with the spontaneous evacuation of the lithobezoar, followed by regular follow-up visits with serial X-rays to prevent any complications and recurrence of the condition. If conservative management fails, then manual evacuation should be done as a second-line treatment. Furthermore, all the patients must receive a psychiatric, genetic, and hematologic evaluation. Occupational and physical therapy assessments should be requested. Finally, any associated iron deficiency must be treated with oral or parenteral supplements.