A 36-year-old woman was referred to the otolaryngology clinic of Taleghani Hospital, Shahid Beheshti University of Medical Sciences, with a right intranasal mass (January 2009). This was an incidental finding on follow-up Magnetic Resonance Imaging (MRI) which was advised her due to a history of pituitary microadenoma and galactorrhea from 1 year ago. The patient has been treated with Bromocriptine and her serum prolactin level was at normal range of value. She did not suffer from hyposmia, epistaxis, nasal obstruction, any visual disturbances, epiphora and headache.
On physical examination, there was no sign of proptosis or facial swelling but anterior rhinoscopy revealed a nonhemorrhagic mass in the right middle meatus, with the same color of the surrounding mucosa and with deviation of the nasal septum to the left side.
Computed Tomography (CT) scan images revealed a large calcified hyperdense mass in the right ethmoid sinus which obliterated the middle meatus. Fluid accumulation in the right frontal air cells as well as both maxillary sinuses was also detectable but the orbital walls appeared intact without any lytic or erosive lesion. Laboratory values were normal.
An operative procedure was performed with a transnasal endoscopic approach. Due to proximity of this lesion to the base of the skull and attachment to the lamina papyracea, en bloc resection was not advisable. Therefore, the lesion was removed in several fragments. Histopathological examination reported abundant irregular immature (woven) bone partially surrounded by an osteoblastic layer within fibrous connective tissue which was consistent with an ossifying fibroma.
Endoscopic evaluation of the right nasal cavity showed complete wound healing 3 months after surgery and the patient was clinically well. Unfortunately, the patient did not come back for follow up imaging that was advised her 6 months postoperatively.


A 48-year-old male patient presented with a tender swelling in the lower-right region of face since 6 months. On examination, swelling was present on right side of the face, in the right sub-mandibular region, measuring approximately 5 × 4 cms in size. The swelling was well defined, firm and tender and was fixed to the underlying structures. Fine needle aspiration cytology (FNAC) was done from the right sub-mandibular region. Smear showed cellular smears comprising of cohesive sheets of monomorphic, small round-to-oval cells showing mild pleomorphism and nuclear overlapping. The tumor cells were showing hyperchromatic nuclei, with inconspicuous nucleoli, scanty cytoplasm [] and tendency towards peripheral palisading in a few clusters. Occasional clusters revealing anisonucleosis were also seen []. Mitotic figures and anaplasia could not be appreciated. Rosette-like pattern with central, eosinophilic globules were appreciated [, inset]. Features were suggestive of BCA with suspicion of malignancy. However, histopathological examination was advised to confirm the diagnosis.
Patient underwent right sub-mandibular gland extirpation. Gross examination of the specimen revealed a greyish brown partially encapsulated soft tissue mass measuring 6 × 4 × 3 cms. The outer surface was nodular and cut section was lobular with minute cystic areas. Microscopically, the section showed sheets and nests of proliferating monotonous basaloid cells having hyperchromatic nuclei. Two types of basaloid cells were observed-dark basophilic cells towards the periphery and pale basophilic cells towards the centre of the proliferation. Some of these nests revealed peripheral palisading of cells. There was deposition of PAS positive basal lamina like material within and around the nests of tumor cells [, inset]. However, in some areas, nests of tumor cells revealed moderate pleomorphism, slightly irregular vesicular nucleus, inconspicuous nucleolus and atypical mitotic figures. There was evidence of vascular invasion by tumor cells. Some of the tumor nests showed central area of necrosis. Encapsulation could not be identified, and nests of tumor cells were invading the surrounding adipose tissue and skeletal muscles []. Intervening connective tissue stroma was fibrous with hemorrhagic areas. Perineural infiltration of tumor tissue was evident


A five-year-old boy presented with seven weeks’ history of a progressive and painless swelling on the right side of the forehead and temporal region []. There was no headache, vomiting, visual impairment or seizures. Examination revealed a young boy who was not pale, not febrile, had no lymphadenopathy, and there were no other features of neurofibromatosis or phakomatosis. He had a huge irregular right frontal swelling, which was painless, with no skin discoloration over it; it measured 16 × 12 cm. It was multinodular with cystic and solid components, not tender, but fixed to the underlying skull []. The Glasgow coma score was 15, there were no cranial nerve deficits; the motor and sensory systems were also normal.
Laboratory investigations, which included hemogram, electrolytes, and urea, were all within normal limits. A preoperative brain CT scan showed a huge right frontal extradural, which was enhanced with contrast administration. It had a central cystic component and a large right frontotemporal skull defect [].
The surgical plan was tumor excision and cranioplasty. The finding at the surgery was a huge soft yellowish extradural tumor, with a cystic (necrotic) center. The tumor invaded the frontotemporal bone and extended to the right ethmoidal sinus and the right temporalis muscle. The area of bony defect measured 10 cm in the widest diameter. Most of the tumor was, however, adherent to parts of the frontal bone. The patient had a one-stage bifrontal craniectomy, with complete tumor excision, and frontal cranioplasty with antibiotic impregnated methyl methacrylate []. He required blood transfusion intraoperatively. Postoperative treatment included intravenous ceftriaxone 100 mg/Kg daily, intravenous Phenobarbitone 5 mg/Kg eight hourly, and intramuscular pentazocine 1 mg/Kg eight hourly, for 48 hours. He had an uneventful recovery and was discharged home 11 days after surgery.
The histology report was consistent with neurofibroma []. Brain C T scan at eight weeks post surgery showed no residual tumor []. His neurological status remained normal.


A 55-year-old man reported to the department of dental surgery with the complaint of a severe, sharp shooting pain, which radiated to the temporal and the auricular region on the left side, in the upper left maxillary quadrant since the night before. Detailed history taking revealed that the patient had pain in the region for over 2 months. Initially the pain was of dull aching type, which increased on mastication. The pain gradually kept on increasing in intensity till it became very severe at night. The patient gave no history of trauma or any other dental intervention on the affected side. Patient's dental records showed that he was being treated for the same complaint with a diagnosis of chronic periodontitis, which of course did not give him any relief in pain.
On clinical examination, all the teeth in the left posterior quadrant appeared normal. Oral hygiene was satisfactory. Surprisingly, he had very little attrition and most of his posterior teeth had sharp and prominent cuspal inclines. Teeth #15 and 25 were showing 90° rotation. Tooth #26 was extremely tender, both, on percussion and on palpation. The tooth showed no carious involvement or restoration. His orthopantamograph revealed a hazy radiolucency on the cervical 1/3rd of the mesio-buccal root []. Considering the patient's history, which was suggestive of acute pulpitis; severe tenderness on percussion and palpation in #26; and, radiographic finding of hazy radiolucency around Mesiobuccal (MB) root of #26, a clinical diagnosis of VRF was made. An intraoral periapical radiograph was advised for clarity, which confirmed the vertical split of mesio-buccal root of #26 []. The patient was informed about the treatment options; either extraction of the whole tooth or endodontic treatment of the tooth followed by extraction of the fractured MB root (radisection) and, final restoration with a full crown. The patient opted for the first treatment option as he had already suffered severe pain over a length of time and wanted quick and permanent relief from his pain.
Hence, extraction of #26 was done under local anesthesia , taking utmost care to prevent the displacement of the fragments. The whole tooth was extracted except the fractured mesial segment of the mesiobuccal root, which was carefully teased out of the socket [Figures –]. Post extraction six weeks later, impressions were made for prosthodontic rehabilitation. The plaster model of upper arch is shown in to document rotated second premolars and relatively lesser attrition of cuspal inclines.


First patient was 33-year-old man admitted with generalized tonic-clonic seizure for 5 minutes. The mental status was deep drowsy and there were no neurological deficits. He had no previous history of intracranial hemorrhage. A computed tomography (CT) demonstrated Fisher grade IV SAH along the both sylvian fissures, interhemispheric fissure, and dominantly in the premedullary and prepontine cistern and intraventricular hemorrhage in 3rd and 4th ventricles.
A digital subtraction angiogram (DSA) revealed two left anterior inferior cerebellar artery (AICA) aneurysms located at the premeatal and meatal branches and two left lateral pontine artery aneurysms and associated AVM distal from the aneurysms (). The AVM was fed by the dilated left AICA and lateral pontine artery. These aneurysms are all irregular in shape and close to each other. We could not decide which aneurysm was a cause of bleeding.
On following day, these aneurysms and AVM nidus were embolized with 33% mixture of n-butylcyanoacrylate (NBCA) and Lipiodol () at a same time, and residual AVM nidus were treated with stereotactic radiosurgery. 2 years after stereotactic radiosurgery, a small draining vein was remained (). The patient tolerated well without any neurological deficits.


Second patient was 56-year-old man admitted with stuporous mental status. CT scan demonstrated Fisher grade IV SAH along the both sylvian fissures, basal cistern and intraventricular hemorrhage in 4th ventricle. This hemorrhagic event was first time for the patient.
A DSA revealed three irregular shaped aneurysms located at the meatal, dorsolateral branches of right AICA and AVM fed by the right AICA and right superior cerebellar artery (). We could not differentiate a ruptured pseudoaneurysm from dysplatic true aneurysms, because the shape of those was similar and location was very close each other.
On that day, these aneurysms and AVM nidus were embolized () with the same procedure as the first patient. Residual AVM nidus was also obliterated with stereotactic radiosurgery. One year after stereotactic radiosurgery, small residual AVM nidus and draining vein were noted (). There was no episode of recurrent hemorrhage during follow up period.


A girl aged 13 years reported to the out-patient clinic, Department of Pedodontics and Preventive Dentistry, with the complaint of pain and swelling in her upper left front tooth. She gave a history of a traumatic injury, about 1 year prior to the time of reporting. She mentioned that she had consulted a dentist after having a traumatic episode, and she was told that she needed to undergo a root canal treatment after the closure of the root end. She however, failed to report back to the dentist and did not pursue the treatment until the tooth begun to pain. She had a noncontributory medical history. She expressed her concerns that she will not be able to pursue treatment for multiple appointments. Examination revealed a sinus tract in the labial vestibule of the maxillary left central incisor. Radiographic examination revealed radiolucency in the periradicular area of the upper left central incisor []. Clinical and radiological examination indicated pulp necrosis with acute exacerbation of chronic apical abscess in relation to the upper left central incisor. The patient was given a detailed explanation concerning the treatment and prognosis. Considering her inability to make frequent appointments, apexification with MTA was considered after the disinfection of the periradicular area.
In the first appointment, the already existing access cavity was refined with a safe-end tapered bur (Endo-Z; Dentsply/Maillefer, Ballaigues, Switzerland) under rubber dam isolation. The root canal was irrigated with a 5.25% sodium hypochlorite solution and the final irrigation was done with a normal saline solution []. After drying, the root canal was filled with a mixture of calcium hydroxide powder and saline. The access cavity was sealed with IRM, analgesics and antibiotics were prescribed, and the patient was recalled in 1 week []. One week later, the access cavity was reopened and the canal was thoroughly irrigated with the 5.25% sodium hypochlorite solution and the canal was refilled with calcium hydroxide which was changed once within the interval of 1 week. At the third appointment, 1 week later, the sinus tract had resolved and the tooth was asymptomatic. Biomechanical preparation of the root canal was done using standard hand instruments (K-files and H-files) and the canal was enlarged up to a size of instrument number 80. All appointments were carried under rubber dam isolation. The canal was dried with paper points and MTA was dispensed and mixed according to the manufacturer's instructions. The canal was filled up to half its length with MTA and condensed with hand plugger and back-end of a paper point. The thickness of the MTA plug was almost twice that of the recommended 3–4 mm as the tooth was compromised with acute exacerbation. A moist cotton pellet was inserted into the canal to aid in setting and was left undisturbed for 15 min according to the manufacturer's instructions [].
Lateral compaction technique was used to obturate the canal with gutta-percha and zinc oxide eugenol sealer. The access cavity was restored with glass ionomer cement []. A follow-up radiograph after 4 months showed that the lesion had begun to resolve []. The patient was given a composite resin crown to show improved esthetics which will be replaced by a ceramic crown later. The preoperative and postoperative appraisal is evident from the clinical picture [].


A 25-year-old male patient was referred to İstanbul University Faculty of Dentistry by his dentist as a complicated partial edentulous case. The patient was free of systemic diseases and was not receiving any medication. He also did not have a story of allergy. The patient apparently represented physical means of Crouzon syndrome like craniosynostosis, involving high and widened forehead, parrot like nose, deep V shaped maxillary arch, proptosis of the eyes, abundant, and thick dark hair, and as the most distinct feature anteroposterior flattening of the cranium [Figures and ].
Dental history revealed that both primary and permanent dentitions were complete initially but a removable partial denture was fabricated at the age of 10 due to early tooth loss caused by severe periodontal destruction. Unfortunately, the patient had not used the dentures as he could not have adopted himself to it.
The patient's main expectation was to improve the reduced chewing ability, which was caused by excessive number of tooth loss. There were a total of 14 remaining teeth, 8 in the maxilla and 6 in the mandible, most of which were malpositioned and periodontally involved [Figures and ]. The probing depths of most teeth were 2 to 3 mm, which was 7 mm in the mesial sight of the maxillary right first molar, 5 mm in the mesial sight of the second left incisor, 4 mm in the maxillary left canine and the mandibular left first molar. The overall periodontal situation was associated with poor oral hygiene. Right maxillary first molar, left maxillary first incisor, both mandibular first incisors, and right mandibular first molar teeth exhibited a mobility of mod 1 according to Miller's index. The intermaxillary relation of the jaws was Class III resulting nearly in a circular non-occlusion [].
Diagnostic casts were prepared via alginate impressions. Casts were mounted on a parallelometer and were analyzed on the basis of present undercuts, potential guiding surfaces and retentive areas of the remaining teeth for a possible removable partial denture.
A telescopic overdenture for the maxilla and a single piece fixed prosthesis for the mandible were planned for restoring the dentition.
Among the malpositioned teeth, both mandibular first molars were severely tipped to the mesial sides but only left molar had to receive endodontic treatment for proper tooth preparation.
All teeth were prepared with chamfer type margins. The maxillary right first molar, which had a severe soft tissue recession on the buccal side, was prepared at the enamel-cement border to ease the oral care. Interim fixed restorations were fabricated from silicon impressions that were made before tooth preparations. Final impressions for ceramic veneers and telescopic copings were made with an addition type silicone (Panasil; Kettenbach, Eschenburg, Germany) three days after tooth preparations. The copings of the telescopic crowns were cast with retention pearls on the sides and mandibular framework for ceramic veneers was cast as one piece. The try in for the copings and mandibular single piece cast framework were done as in routine. Before making a secondary impression over the copings from the maxillary arch, the retention pearls on the copings were combined with self curing acrylic polymer (Pattern Resin LS, G.C., Alsip, U.S.A.) to make sure that the primers do not change position during impression making. The final impression for the telescopic crowns was also made with the same addition type silicone.
The telescopic crowns were cast over the copings with retention pearls all over to be embedded in the acrylic resin during polymerization. The framework of the removable partial denture was cast with a non-precious alloy and the telescopic crowns were soldered to the framework.
Maxillary wax rims were prepared over the retentive framework in the usual manner. The height of the rims, lip support, and inclination of the occlusion plane were adjusted in the mouth before determining occlusal vertical dimension. The occlusal vertical dimension was then determined with both Niswonger's and Silverman's methods. The centric relation was recorded with inter-occlusal registration method. In the try-in session, the consents of the patient and his family were taken on the basis of aesthetics and comfort.
The maxillary removable prosthesis was finished with conventional procedures and the mandibular fixed prosthesis was glazed []. Mandibular prosthesis was cemented with resin-type cement (Panavia F, Kuraray Dental, Okayama, Japan) and the copings of the telescopic overdenture were cemented with zinc polycarboxylate cement (Adhesor Carbofine, Spofa Dental, Jicin, Czech Republic) via closed mouth technique. Verbal and written instructions about the care of the prosthesis and the abutment teeth were given to the patient and his family. Early recalls were made on the first day, first week, and two weeks after the prostheses were delivered to the patient. As the cooperation of the patient was poor about the care of prostheses and the abutment teeth, monthly recalls were made during the following year to consolidate the oral care. Later recalls revealed positive feedback, the remaining abutment teeth and the periodontal structures were healthy and the prostheses were in good condition, still serving satisfactory function and aesthetics [Figures –]. After prosthetic rehabilitation, as stated by his family, the patient was further socialized and at the age of 25 he was employed for the first time in his life.


A 9-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry, Yenepoya Dental College, Mangalore, after sustaining an uncomplicated crown fracture to her maxillary left central incisor while playing about 24 hours ago.
The fractured tooth fragment was recovered by the patient at the site of the injury and she had kept it in an empty box. Clinical examination revealed that the teeth had fracture of the incisal angle involving the enamel and dentin []. The fractured part of the tooth was intact, with some crack and craze lines
[]. No abnormal mobility of the injured tooth was recorded and the surrounding tissues were healthy.
A periapical radiograph showed that the root formation was complete and there were no other injuries. The tooth fragment was checked for the fit with the tooth and immediately maintained in normal saline.
The treatment options were presented to the patient and her parents, which included a) no treatment; b) crown build up with composite; c) reattachment of the fractured fragments. After some deliberation about the advantages, disadvantages and prognosis, the patient opted to have tooth fragment reattached.
The tooth fragment was analyzed and tried intraorally to check for proper positioning and fit with the fractured coronal structure. The operating field was isolated with rubber dam; the fractured fragment and the tooth surface was treated with 37% phosphoric acid, followed by rinsing. The adhesive system Excite (Vivadent, Liechtenstein) was applied to the fragment and the tooth, followed by placement of a small increment of flowable composite resin, Tetric flow (Vivadent). The fragment was properly positioned on the fractured tooth surface, excess resin was removed and the area was light cured for 60 seconds while the fragment was held in place under pressure.
Margins were properly finished with diamond finishing burs and polished with a series of soflex disks. The immediate postoperative view [Figures and ] showed adequate esthetic results with restored functionality by the use of a very conservative and cost-effective approach.
Clinical and radiographic examinations were carried out regularly over a period of 9 years. During this period, the reattached fragment was intact without any distortion. Occasionally, it required polishing to remove some mild stains. Nine years follow-up showed a predictable outcome of the reattached fragment [Figures and ].


A 55-year-old female diagnosed with SCC of the right maxillary sinus had undergone hemimaxillectomy. She had a recurrence on the left side and was reoperated. Sub-total maxillectomy was performed and after proper healing, she was referred to the Department of Prosthodontics, Government Dental College, Bangalore, India.
The patient's chief concerns were relative to speech, mastication, and esthetics. Extra-oral examination revealed reduced fullness due to loss of support []. On intraoral examination, a big communication was present between nasal and oral cavity except a minor part of the palatine process of maxilla and horizontal plate of palatine bone [].
Speech pathology, head and neck, and maxillofacial prosthetics/dental oncology services were consulted to evaluate the extent of resection and functional deficits. A consensus among the specialists recommended an obturator to restore speech and swallowing abilities and esthetics.
An irreversible hydrocolloid impression was made with a stock tray []. The impression was boxed and poured in type IV stone (Ultrarock, Kalabhai Karson Pvt. Ltd, Mumbai) []. Undercuts on the cast were blocked. Record bases were made with heat cure acrylic resin (Lucitone 199, Dentsply Int.) []. The jaw relation was recorded. After the try-in, the solid obturator was processed in heat polymerized acrylic resin (Lucitone 199, Dentsply Int.).
After curing of the prosthesis, the flash was trimmed. The prosthesis was pumiced, polished, and delivered to the patient [Figures –]. The patient was instructed to correctly position, remove, and clean the prosthesis.
The prosthetic retention and stability were evaluated subjectively. Speech intelligibility improved and the patient was then referred to the speech pathology department for further evaluation of his speech and swallowing abilities. The patient returned a week later for a follow-up appointment. He was satisfied with esthetics and function of the prosthesis.


Over the last year, a 40-year-old man had complained of weekly episodes of facial flushing, diaphoresis, irritability,and diarrhea, which were triggered by emotional stress or exercise. He also presented with chest discomfort and had lost 6 kg. He had poorly controlled essential hypertension that had lasted over the last six years. On examination, his systolic blood pressure was 160 mm Hg, his diastolic blood pressure was 110 mm Hg, his heart rate was 110 beats/min, and his body mass index was 32 kg/m2; he did not present with postural hypotension. A small goiter without nodules and a slight lid retraction were noted. He had no facial flushing or hand tremor. During the chest discomfort investigation, the chest X-ray revealed an anterior mediastinal enlargement.
A thoracic computed tomography (CT) scan revealed a homogeneous mass with no adjacent structure invasion or calcification at the topography of the thymus enlargement (). Goiter was also detected but did not extend to the intrathoracic compartment. A carcinoid syndrome caused by a primary neuroendocrine tumor was suspected.
The patient´s exams depicted normal values of urinary 5-hydroxyindoleacetic acid (2.8 and 3.1 mg/24 h, normal values-NV 2-6), urinary metanephrines (1.0 and 0.09 mcg/mg creatinine, NV <1.2), serum calcitonin (7.3 pg/mL, NV <11.5), negative tumoral markers β-hCG and alpha-fetoprotein. Thyrotoxicosis was diagnosed from the following fluoroimmunoassay measurements: total T3, 371 ng/dL (NV 40–180 ng/dL); total T4, 20.9 mcg/dL (NV 4.5–12 mcg/dL); free T4, 4.9 ng/dL (NV 0.7–1.5 ng/dL); and a suppressed TSH<0.03 mUI/L (NV 0.4–4.5 mUI/L). Serum antiperoxidase and antithyroglobulin antibodies measured by fluoroimmunoassay were positive (859 and 72 U/mL, NV<35 U/mL), with levels of TSH-receptor antibody (TRab) of 49% (radioimmunometric assay NV<8%). Ultrasound thyroid imaging revealed a 43.2 g homogeneous hypoechogenic goiter, which did not have nodules and was limited to the neck.
Therefore, Graves' disease was diagnosed, and a thymus growth was then attributed to hyperplasia caused by Graves' disease.
Methimazol (20 mg/day) was initiated, and after four months of treatment, symptoms had improved, and thyroid hormones had normalized. Goiter and TRab values had reduced. After six months of thyroid hormonal control, a new CT revealed marked thymus shrinkage ().
After 24 months, the patient was in remission of Graveś disease, with negative TRab values and a normal thoracic CT scan. Graveś ophthalmopathy was never presented.


A 79-year-old male presented with history of neck swelling since 2 months. Airway examination revealed malampatti class III, short and thick neck swelling of right side covering the angle of the mandible interfering and limiting the mouth opening [].
The patient received 1 g paracetamol infusion, and 50 mcg dexmedotomidine over 30 minutes, 0.6 mg atropine intramuscular (IM) injection plus nebulization with 5 ml of 4% lignocaine hydrochloride topical solutions via nebulizer and face mask over 15 minutes, 30 minutes before intubation.
The oropharynx topically anesthetized with two puffs of 10% lignocaine.
Bonfil's fibroscope (preloaded with an 7.5 mm cuffed endotracheal tube) was advanced via the lateral side of mouth to the hypopharynx and advanced toward the posterior pharynx; when Bonfil's fibroscope was positioned immediately in front of the vocal cords an additional 2 ml of 2% lignocaine was injected via the tube adaptor [Figures [Figures and ]. After 30 seconds Bonfil's fibroscope was advanced further until the tip off the scope passed the glottis opening; an additional 2 ml of 2% lignocaine was injected onto the trachea. The endotracheal tube was advanced over the scope []. Bonfil's fibroscope was then removed leaving the endotracheal tube in place.


A 17-year-old boy fell from a height of 15 meters and landed on both feet. After a delay of 6 hours, he presented with hypovolemic shock and was treated for the same. The abdomen was tender on palpation. Local examination of the spine revealed tenderness and bruising over the lower lumbosacral area. The sacrum was unusually prominent. Neurological examination revealed complete motor paralysis except for a flicker of movement in the left toe. The deep tendon reflexes were absent in the lower limbs. Sensation was reduced below the groin. Sacral sensations were preserved. Anal wink and the bulbocarvernosus reflex were present. The patient had a painful distended bladder and had to be catheterized.
The following injuries were diagnosed using radiographs, CT, and MRI [Figures and ]:
Transverse sacral fracture at S3, with 82° of kyphosis Pedicle fractures of L3 to L5 (bilateral) and S1 (left) Intrapelvic intrusion of spine between L3 and S2, causing a shortened vertical height of the lumbar spine, with L5-S1 and L4-L5 intact discs Dislocation of L3-L4 and L2-L3, with retrolisthesis Superior end-plate fracture of L3, with retropulsed fragments Bilateral sacroiliac joint disruption Left trimalleolar ankle fracture Bilateral intra-articular calcaneum fractures Splenic laceration
The patient was operated in the prone position 12 hours after presentation. The fractured ‘floating’ laminae (L3–L5) were excised. Bilateral roots were identified from L3 to S3. The right L5 root was discontinuous at the level of the dorsal ganglion and the cut end was severely contused and crushed underneath the fractured L5 pedicle. The distal end of the root had retracted into the muscle and could not be found. No dural leak was detected. Retropulsed fragments of the L3 fracture were excised. Distally, the broken pedicles of L5 were directly cannulated. Longer screws were used for a bicortical purchase. The right S1 was used as the distal-most fixation point. The vertebral column was reduced using contoured rods. The surgery lasted for 6 hours, with a total blood loss of 1000 ml.
The patient regained ability to void and the catheter was removed on the 7th postoperative day. Two weeks later, with an anterior retroperitoneal approach, the disrupted L3-L4 and L4-L5 discs were fused using cages and autogenous iliac crest bone graft. An anterior rod-screw construct was used between L1 and L5 []. The surgical time was 5 hours and the blood loss was 500 ml.
The patient was nursed in bed for 6 weeks. Lower limb power recovered to grade 5/5 except for the right ankle and toe dorsiflexors, which remained grade 0. The patient started ambulating with support at 2 months and resumed college at 6 months. Followup CT scan was done after 6 months []. The sacral fracture had fused in a kyphotic position (77°). Standing radiographs were used to analyze sagittal and coronal alignment []. At 5 years, the patient has occasional pain at the sacral prominence on prolonged sitting. He stands adopting a crouched posture. He has a slight truncal shift to the right side []. He does not complain of bowel, bladder, or sexual dysfunction.


A 51-year-old woman presented with recurrent right upper quadrant pain without jaundice or weight loss.
Ultrasound and magnetic resonance cholangiopancreatography (MRCP) revealed calculi in her gallbladder and a prominent common duct without intrahepatic duct dilatation or stones. A 15 mm focal small cystic pancreatic lesion with fluid collection lying adjacent to the posterior uncinate process was also reported on MRCP. An endoscopic ultrasound (EUS) showed this cyst to be a multiseptate cystic lesion in the head of pancreas raising possibility of intraductal papillary mucinous tumour (IPMT). She had deranged liver function tests (LFTs). Tumour markers including CA19-9, CEA and CA 125 were within the normal range.
Following discussion at our multidisciplinary meeting, the patient underwent a laparotomy with a view to perform a duodenum preserving pancreatic head resection to remove this cystic lesion and cholecystectomy. After Kocherisation to mobilize the duodenum, the resection of the head of pancreas was commenced during which there suddenly appeared to be a diverticulum arising from the second part of the duodenum close to the ampulla of Vater (Figure ). This was embedded within the substance of the head of the pancreas cavitating the uncinate process (Figure ). The diverticulum was then invaginated with 3-0 prolene sutures. After intravenous injection of Secretin, a tiny pancreatic duct was revealed at the excision bed. A Roux en Y loop was brought up to form a pancreaticojejunostomy at the head of pancreas with insertion of a pancreatic stent.
The patient had a protracted postoperative period which was complicated by postoperative sepsis, bilateral pleural effusions and a contained anastomotic leak which was managed conservatively. Patient was discharged home two months following surgery. The patient has been doing well 36 months post surgery.


A 67-year-old woman presented with a solitary asymptomatic black plaque on the areola of the right breast, which had been present for about 30 years prior to presentation. Since the lesion was initially a small black papule without any subjective symptoms, the patient never had it evaluated or treated. Recently, it had become bigger in size and hyperkeratotic. At first, the patient visited the department of general surgery where, after a regular medical checkup including a mammography, the lesion was suspected to be breast cancer showing a periareolar microcalcification. Under the impression of malignancies such as Paget's disease, an ultrasonography-guided biopsy was conducted. However, pigmented BCC was revealed. Then, the patient was referred to the department of dermatology for further management. A physical examination revealed a 3×3 cm-sized, black plaque on the right NAC (). There were neither palpable masses of the breast nor axillary lymph node enlargement. The patient had been taking oral medications for cardiac arrhythmia and osteoporosis for about 1 year. The patient had no family history of skin cancer or a history of sunbathing, radiation, or arsenic exposure. An evaluation, including positron emission tomography-computed tomography (PET-CT), was done to determine if the tumor was metastatic. The focal hypermetabolic lesion thought to be the BCC was seen on the periareolar skin of the right breast but there was no abnormal 2-fluoro-2-deoxy-D-glucose uptake, suggesting lymph node involvement or distant metastasis ().
The tumor including a 5 mm safe margin was widely excised. The postoperative histopathologic examination revealed basaloid cells forming cords and nests extending to the dermis with palisading peripheral nuclei and melanin pigment (). The basaloid cell nests were separated by clefts in the dermis and a clear resection margin was verified. However, there was no invasion of the underlying lactiferous ducts. No recurrence was noted during the 14-month follow-up.


A 3 year old boy presented at our heart centre with a cardiac murmur that had been noticed first 2 weeks prior to admission. The mother described a mildly limited physical activity most likely due to asthmatic bronchitis. There was no history of chest pain, oedema, cyanosis, or loss of consciousness. On physical examination, he presented in a good general condition. His pulse rate was 150 bpm and regular, and the blood pressure was 75/50 mmHg. A 2/6 mid-systolic murmur was audible above the heart apex. No definite splitting of the second heart sound was detected. The lungs were clear on auscultation with good bilateral air entry. No hepatosplenomegaly. There was no peripheral oedema. His haemoglobin was 6.9 mmol/l, the haematocrit 33 %. White blood cell counts and differentiation, platelet count, creatinine, ASAT, C-reactive protein, coagulation parameters were within normal limits. The electrocardiogram was unrevealing. Chest X-ray films showed a slightly increased size of the heart silhouette and moderately increased pulmonary vascular markings.
Transthoracic echocardiography disclosed a tumor in the left atrium that arose with a stalk from the upper part of the interatrial septum reaching a size of 3×3×2 cm. In diastole the tumor prolapsed through the mitral valve into the left ventricle (Figures and ).
The tumor had a flaccid structure and slipped partially with the blood flow back and forth through the mitral valve into the left ventricular inflow and outflow tract. The moving images convey the impression of potential embolization.
The patient was immediately referred to surgery for excision of the tumor. The operation was performed under cardiopulmonary bypass. The left atrium was opened. There was a 3×3×2 cm colloid mass originating from the atrial septum. The tumor had macroscopically the shape of a sea anemone. Histopathological examination revealed a typical papillary fibroelastoma. The tumor was fully resected including its attachment, and the defect in the atrial septum was closed by a pericardial patch. The postoperative course was uneventful.


A 51-year-old female had palpitations and radiating back pain and underwent whole-aorta angio 3D computed tomography (CT). The CT revealed a horizontal axis right kidney with a 4.2 cm, lobulating contour multilocular cystic mass at the lower pole. There were multiple irregular, enhancing septations with an enhancing solid portion and central calcification in the mass. The renal artery was located ventrally and the renal vein was located dorsally. The renal pelvis was located caudal to the renal vessels (). She was diagnosed as having cystic RCC in the horizontal axis right kidney and underwent hand-assisted laparoscopic radical nephrectomy in September 2010.
Under general anesthesia, the patient was positioned in the left lateral decubitus position. A 7 cm laparoscopic hand-assist device was placed in the right lower quadrant with the placement of two additional 10 mm ports directly cephalad along the lateral rectus border, allowing 8 cm of separation between the ports and the hand-assist device. Following dissection into the retroperitoneal space, the kidney was separated from the psoas muscle, adjacent bowel, and liver. There was a 4 cm cystic mass in the horizontal axis right kidney (). The ureter was carefully isolated and divided. The renal artery and renal vein were adhered together, so we used an Endo-GIA universal stapler (Covidien Surgical, Dublin, Ireland) and divided them, thereby isolating the entire right kidney. The specimen was entrapped in a laparoscopic sac and extracted. The procedure was completed successfully with a surgical time of 1 hour and an estimated blood loss of 100 ml. Patient-controlled analgesia with morphine was discontinued on postoperative day one. Postoperatively, the patient did not develop any complications. Pathology revealed the tumor to be a clear cell carcinoma (Fuhrman grade 3) with the tumor limited to the kidney (T1a) and with negative resection margins. In December 2010, follow-on CT revealed no recurrence of the disease.


A 46-year old, female patient visited our clinic with the main complaints of back pain and numbness at the left lower limb, which had begun six months earlier. The patient stated that the pain had become severe since she had undergone discectomy at L4/5 for the back pain in April, 2010, which was one month before visiting our clinic. In the physical examination, the result of the straight leg raising test was 90°/60° and that of the Patrick test was negative. Numbness was found along the posterolateral aspect of the left lower limb, but t no weakening of muscular strength was observed. Tender points were present on the left gluteus medius and piriformis. The patient had no history of allergic reaction to any drugs, foods, or pollen. The MRI finding was "L4/5 bulging disc with annular tear, decompressed state and L5/S1 bulging disc." Under the diagnosis of post-laminectomy syndrome, a transforaminal epidural block was performed at the left L5 with 0.18% levobupivacaine 3 ml, triamcinolone 20 mg, and hyaluronidase 1,500 IU (). The procedure was performed under real-time fluoroscopic guidance, and the drugs were injected after insuring that there was no vascular uptake. The postoperative vital signs of the patient were stable with no allergic symptoms, such as skin rash. Since the back pain and the numbness at the left lower limb became severe again three months later, the procedure was repeated in the same manner with the same drugs and dosages. Immediately after the epidural injection, nausea, skin flare, generalized urticaria, respiratory distress, and hypotension (70/30 mmHg) occurred in the patient (). The symptoms were relieved after immediately injecting Ringer's lactate solution and performing an intravenous injection of ephedrine 5 mg, dexamethasone 5 mg, and chlorpheniramine maleate 4 mg.
Among the skin allergy tests, the skin prick test showed a negative finding for hyaluronidase and the contrast media, while the intradermal test showed a positive finding to hyaluronidase 15 IU/ml (1 : 100) with a wheal and flare at 8 mm. The intradermal test also showed a negative finding for the contrast media. The blood test showed that the total Ig E level was 86 IU/ml (0-183 IU/ml), which was normal.


A 35-year old, male patient visited our clinic with the main complaints of back pain and numbness in the right lower limb that had begun three years earlier. The patient had no history of allergic reaction or other specific findings. The patient had never undergone a nerve block that included hyaluronidase. However, the patient had had several bee venom injections as a form of treatment at an oriental medical clinic. We performed caudal epidural injection with 0.18% levobupivacaine 8 ml, triamcinolone 20 mg, and hyaluronidase 1,500 IU (). The procedure was performed under real-time fluoroscopic guidance. The drugs were injected after insuring that there was no vascular uptake. Immediately after the epidural injection, the patient experienced nausea and vomiting, skin flare, general urticaria, and hypotension (75/35 mmHg). The symptoms diminished immediately after injecting Ringer's lactate solution and giving an intravenous injection of ephedrine 5 mg, dexamethasone 5 mg, and chlorpheniramine maleate 4 mg.
Among the skin allergy tests, the skin prick test showed positive findings with a wheal and flare of 10 mm and 4 mm in diameters to hyaluronidase 1,500 IU/ml (1 : 1) and 150 IU/ml (1 : 10), respectively. Both the prick test and intradermal test showed a negative finding to the contrast media. The blood test showed that the total IgE level was 213 IU/ml (0-183 IU/ml), which is an elevated value.


A 53-year-old woman was transferred to our hospital with abnormal findings on chest computed tomography. She had been taking medications for reflux esophagitis for 3 years but her symptoms persisted. She had no unusual past histories and had undergone gastrofibroscopy several times in the past with no abnormalities. Chest CT scan showed a cystic mass at the posterior mediastinum ().
Laboratory findings and a chest X-ray showed no abnormalities. Gastrofibroscopy showed reflux esophagitis and erythematous change with a suspicious submucosal mass in the upper thoracic esophagus. The gastric body and fundus also showed erythematous change. Endoscopic ultrasonography showed a normal esophageal wall and a cystic mass next to the aortic arch. A small polypoid mass was found in the cyst ().
With general anesthesia, thoracoscopic resection of the mass was done. A vascular structure that seemed to be the thoracic duct was found in connection with the cystic mass superiorly and inferiorly (). Careful dissection of the cystic mass and the thoracic duct was done with care not to rupture the cyst or the duct. The thoracic duct was ligated above and below the mass and the cystic mass was successfully removed. The content of the mass was clear fluid.
The patient was sent to the general ward without any problems or hemodynamic instability. Postoperatively, the patient was well without any complications such as hemothorax or chylothorax. The chest tube was removed on the second postoperative day and she was discharged the next day.


A 42-year-old male patient was admitted to the hospital complaining of chest pain and progressive shortness of breath. He was an active smoker (1 pack per day for 15 years) without any other notable disease history. Physical examination revealed bilateral smooth breathing sounds with no other abnormal findings. Chest X-ray revealed left upper lobe atelectasis; this was followed up with chest CT, which revealed an endobronchial mass ().
On flexible bronchoscopy, an endobronchial mass with a smooth shining surface was observed nearly totally obstructing the left upper lobal bronchus. A biopsy specimen was taken and the patient was diagnosed with chondroid hamartoma. Endoscopic resection of the benign endobronchial mass was planned.
General anesthesia was induced with a No. 8 single lumen endotracheal intubation tube. A flexible bronchoscope was inserted into the intubation tube while the patient was ventilated using a T-connect device. The mass was found to be totally obstructing the bronchus. It was a sessile polypoid mass with a wide base located on the posterior wall of the bronchus ().
The patient underwent cryosurgery using a flexible cryoprobe (Erbokryo; ERBE, Medizintechnik GmbH, Tubingen, Germany). Repetitive 2 minute cycles of freezing and thawing were performed, after which the tumor was removed by traction as it was attached to the tip of the cryoprobe. The tumor was removed in two pieces and hemostasis of the tumor bed was achieved by a single freezing cycle.
The tumor grossly consisted of 2 pieces of soft tissue that measured 0.9×0.7 cm, and 0.9×0.5 cm, respectively (). The histologic diagnosis was a chondroid hamartoma that consisted of fibrous connective tissue and portions of cartilage.
On the first postoperative day, the patient expectorated small amounts of blood-tinged sputum, which stopped the following day. No other complications were noted and the patient was discharged five days after the procedure. At 6 months follow up, a bronchoscopic examination showed no remnant of the mass lesion and no tumor recurrence ().


An 80-year-old woman, 155 cm in height and 70 kg in weight, was admitted to our institution via the emergency room due to a right femur fracture. The patient had a 5-year history of hypertension, which was relatively well controlled with the medication regimen of an antihypertensive agent and aspirin. She did not exercise much due to obesity and depression. She showed delirium symptoms after admission and underwent brain computerized tomography (CT) to exclude organic brain diseases. A brain CT showed severe stenosis of the middle cerebral artery (MCA), an old localized infarction of the basal ganglia, and diffuse atrophy of the brain. She exhibited cardiomegaly on the preoperative chest X-ray, 1 degree A-V block on EKG, an ejection fraction of 65% on echocardiography and other blood studies, and her vital signs are within the normal limits. The preoperative PT/PTT was 12.7/24.4 seconds, INR was 1.15, and arterial blood gas analysis (ABGA) revealed the following: pH 7.376, PaO2 78.6 mmHg, PaCO2 27.5 mmHg.
On the 4th hospital day, she was scheduled to undergo total hip replacement surgery and aspirin was maintained until the 3rd hospital days. Upon arrival at the operating theater, standard monitoring devices were applied and the left radial artery was cannulated for continuous blood pressure monitoring. The patient's blood pressure (BP), heart rate (HR) and O2 saturation was 140/70 mmHg, 80 beats/min, and 98%, respectively, through a simple facial mask with 4 L/min of oxygen. Spinal anesthesia was administered with the patient in the right lateral position using a 26-gauge Quincke spinal needle at the L3-4 interspace with 0.5% hyperbaric bupivacaine 8 mg under standard aseptic conditions. The patient was then placed in the supine position. During the pin-prick test, the patient became unresponsive with BP 70/40 mmHg and HR 40-45 beats/min. Repeated ephedrine administration intravenously (IV) followed by epinephrine 10 µg and full dripping of the crystalloid did not increase the BP. Endotracheal intubation was performed after 7-8 minutes of manual ventilation and norepinephrine 0.1 µg/kg/min, dopamine 2 µg/kg/min were administered continuously. The patient's BP and HR was still 60/40 mmHg and 110 beats/min, respectively, and IV epinephrine 0.02 µg/kg/min was started. The ABGA at that time revealed the following: PaO2 = 488.9 mmHg, PaCO2 = 30.8 mmHg at FiO2 1.0, and EtCO2 = 28 mmHg and O2 saturation = 99%. The cause was suspected to be high spinal anesthesia rather than a pulmonary embolism because of the ABGA findings. Central venous catheterization via the right internal jugular vein was performed to administer the drugs and for hemodynamic monitoring. The central venous pressure was 30 mmHg and emergent TEE was performed immediately. TEE revealed an enlargement of the right atrium (RA) and right ventricle (RV), straightening of the interventricular septum and hypokinesia, which were consistent with PE. IV heparine 5,000 IU was administered and maintained at 1,000 IU/hr. 50 µg/kg of milrinone IV was loaded for 10 minutes and maintained at 0.5 µg/kg/min to manage RV failure. The ABGA results exhibited pH 7.224, PaO2 55.2 mmHg and PaCO2 52.8 mmHg, which were also consistent with PE.
The operation was postponed and the patient was transported to the intensive care unit (ICU). Twenty minutes later, her heart beat decreased to 30 beats/min and cardiopulmonary resuscitation was performed. Chest 3 dimensional PTCA and non-contrast brain CT were performed when the patient's hemodynamic parameter became temporarily stable.
A low density ovoid thromboembolism from the lobar pulmonary artery of the left lower lobe to the entire segmental pulmonary artery of the left lower lobe and enlargement of the right atrium and ventricle, which suggested a poor prognosis, was observed on the enhanced PCTA (). In addition, a low density large acute infarct at the right MCA territory with gyral swelling of the right insula and temporal lobe were noted on the non-enhanced brain CT scan (). After 17 hours admission to the ICU, her heart rate decreased to 30 beats/min, resuscitation was ineffective and she died.


A 40-year-old Chinese lady presented with the history of vague headaches and blurring of vision bilaterally for three months. There was no other significant history. Magnetic resonance imaging (MRI) of the brain was performed as part of routine work-up for headache. No intracranial space-occupying lesions were detected; however, the lacrimal glands appeared diffusely enlarged []. A dedicated MRI study of the orbits was recommended, with thin section, fat suppressed, gadolinium-enhanced axial and coronal T1-weighted sequences, which showed bilaterally symmetrical diffuse enlargement of the lacrimal glands [Figures –]. A fine needle biopsy of the right lacrimal gland was performed, which showed multiple well-formed non-necrotizing granulomas in the gland parenchyma with scattered multinucleated giant cells and lymphocytes. Acid-fast bacilli or fungi were not identified and there was no evidence of malignancy. The features of granulomatous inflammation were compatible with sarcoidosis. Other relevant laboratory investigations revealed an elevated angiotensin-converting enzyme level of 71 U/L. Chest X-ray was within normal limits. No other systemic evidence of disease was found.


A 25-year-old male, otherwise healthy, presented with diffuse thinning of hair over scalp, especially of the vertex and occipital area, since childhood. He also complained that the nails had an abnormal morphology and had showed inadequate growth since childhood. There were no similar complaints in the family and he had no associated primary dermatologic ailments. He also denied history of any chemical trauma to hairs. There was no history suggestive of any neurological disorder.
Cutaneous examination revealed sparse, fragile, and thin hairs over scalp, specially vertex and occipital area [], and dystrophy of all finger [] and toe nails with thickened nail plates, ridging and distal onycholysis. Beard, moustache, eyebrow, and axillary hairs appeared to be normal clinically. Mucosae, teeth, and sweating were normal. Rest of the cutaneous examination was also normal. Systemic examination was also within normal limits.
We did trichoscopic examination of scalp hairs. It showed fraying of cortical fibers resulting in “thrust paint brushes” appearance. Both proximal and distal hair shaft breakage was seen []. Hairs from vertex, occipital area, beard, and eyebrow showed similar features on trichoscopy. Routine blood chemistry including hemogram, total and differential leucocyte count, liver and kidney function tests, and routine urine examination was normal. Patient refused a scalp biopsy.
Based on above history, examination, and trichoscopic finding, a diagnosis of TN with 20 nail dystrophy was made.


A 59-year-old, right-handed female with 12 years of school education visited our clinic because of difficulties comprehending spoken language over the previous 2 years. She had been a housekeeper and her past medical history was unremarkable except for well-controlled hypertension of 5 years duration.
The patient complained of a difficulty understanding spoken language that had developed insidiously 2 years previously and had subsequently progressed gradually. The patient described spoken conversation as sounding like a noise, and sometimes buzzing, which was worse in crowded public areas. The patient was unable to understand spoken questions when interviewed, but was able to comprehend and give correct answers by lip reading or responding to gestural cues. She was unable to understand what television actors were saying while watching Korean dramas, and preferred watching foreign movies with Korean subtitles. The patient had no problems understanding the context or plot of subtitled movies. In contrast to her defects in verbal comprehension, the patient perceived environmental noises such as door bells or ringing telephones, oriented towards their sources, and responded appropriately.
Despite the patient's deficiencies in verbal comprehension, her family noticed no impairment in her abilities to express her own thoughts, recall events, get directions, or use public transportation to travel around Busan where she had been living. She did not have problems with household activities such as cooking and cleaning, financial management, or participating in social meetings.
A few months after the onset of the first symptom, the patient visited the otolaryngology clinic of a general hospital and was prescribed a hearing aid, which did not improve her comprehension deficits. At 1 year postonset, the patient began to have difficulties with simple mathematics, such as making errors while paying a bill at a shop. Her comprehension of spoken language declined significantly, so that she could barely understand what people around her were saying, but she was still able to read and communicate in writing. However, the patient's husband reported that her writing style changed, becoming rough, and that she often committed errors in spelling. The patient was sometimes forgetful, but not to the extent that it affected her daily life. She began to have difficulty recalling the names of familiar neighbors, although she recognized them visually. Despite these problems, the patient's demeanor remained appropriate and her personal and social relationships remained intact.
Upon examination, the patient scored 17 out of 30 on the Mini-Mental State, Examination (-4 for calculation -3 for recall, and -6 for language). The results for the remainder of her neurological examination were unremakable, except for mild rigidity in her right upper extremity. We administered the Korean version of the Western Aphasia Battery to the patient. Her spontaneous speech output was fluent, but was characterized by phonemic paraphasia and intermittent repetition of syllablesyllable suggestive of mild neurogenic stuttering. She exhibited severe impairments in comprehension (2.1/10) and repetition (0/10), and mild impairments in visual confrontational naming (52/60) and word generation (7/20). In contrast, the patient was able to read aloud and understand written words and sentences without problem. She was also able to communicate in writing, although she did make some literal errors.
A subsequent audiological examination with pure-tone threshold audiometry revealed a mild bilateral sensorineural hearing loss (pure-tone thresholds of 30 dB in the left ear and 35 dB in the right ear within the range of 500-2,000 Hz). Her speech audiometry thresholds were 50 and 60 dB in the left and right ears (i.e., higher than her pure-tone thresholds), and her speech discrimination ability was 32% at 80 dB in the left ear and 20% at 85 dB in the right ear. The patient's brainstem auditory evoked potential responses were normal.
The patient was able to recognize and identify six out of eight nonverbal stimuli from a tape recording of animal sounds including the noises made by a cat, dog, horse, bee, cow, pig, fowl, and owl. When requested to listen to music and then point to the name of the song being played on a written list, she correctly matched the written song title to the presented song in four out of six trials.
All instructions for neuropsychological tests had to be given in written form. The patient performed below the normal range on the Korean version of Boston Naming Test, ideomotor praxis, Rey figure-copying test, calculation, finger naming, and semantic subtest of controlled oral association word recall test. In a Navon figure task, she recognized only small letters in all five items, suggestive of simultanagnosia. She exhibited difficulty naming famous people (14/40), but was able to describe the occupations of 17 whom she was unable to identify by name.
Routine laboratory tests revealed no evidence of comorbid disease. Brain MRI demonstrated mild atrophy in both temporal lobes, with the left side more affected. An 18FDG-PET scan revealed hypometabolism in bilateral temporoparietal areas, with greater effects on the left, suggestive of AD (). To confirm the diagnosis of AD, we performed [11C] PIB-PET after obtaining informed consent, which revealed elevated PIB binding in diffuse cortical areas, especially in the temporoparieto-occipital cortices (). We also compared the patient's cortical thickness to those of 100 healthy controls using surface-based morphometry with 3D volume MRI, as described previously. ANCOVA with an adjustment for age showed cortical thinning distributed within the bilateral Heschl's gyri, planum temporale, and superior temporal sulcus ().


A 19-year-old male subject with a one year history of painless swelling in the posterior region of the left mandible was referred to the Department of Oral and Maxillofacial Surgery, ShahidBeheshti University of MedicalSciences on April 18, 2007.
Clinical examination showed mild facial asymmetry with expansion of the left mandible. A tangible lymph node in the left submandibular region was also found. Intraoral examination revealed a minimal expansion of the body and ramus of the mandible extending from the left second premolar to the anterior border of the ramus. Lingual expansion was more pronounced. The swelling had caused an eggshell cracking sensation on palpation. The overlying mucosa was normal, whereas the first and second molar teeth were moderately mobile. Radiographic examination demonstrated an extensive multilucular radiolucency extending from the left second premolar to the left sub-condylar region (). In computed tomography views, perforations of the lingual side of the mandible were noted and yellow liquid was also aspirated from the lesion. Intra-oral incisional biopsy confirmed the diagnosis of odontogenickeratocyst. Due to the wide extension of the lesion, intra-oral hemimandibulectomy was selected as the treatment of choice for the patient. Sulcular incision extending from the left first premolar to the ascending ramus parallel to the external oblique ridge was made and periosteum was gently elevated from both buccal and lingual sides. Muscular attachments were released from the posterior ramus to the condylar region.
Lingual cortex perforations—previously detected in CT views—were obvious intraoperatively. The first premolar was extracted and osteoctomy was made through the extraction socket. The left hemimandible was then disarticulated from the glenoid fossa (). A well shaped reconstruction plate that simulated the curvature of the mandible was used to preserve the surgical bed and improve the facial contour ().
Three layer tension free closure of the wound was obtained after rigid fixation of the reconstruction plate.
Postoperative recovery was uneventful and the patient was discharged 5 days after the surgery.
One year radiographic follow-up of the patient revealed spontaneous healing of the mandible with a well shaped condyle and coronoid process ().
CT scan views also confirmed the evidence of denovo mandibular regeneration (). During removal of the reconstruction plate, an incisional biopsy was performed from the newly regenerated bone.
The obtained specimen was embedded for 24 hours in 10% formalin for fixation and underwent a 7-day treatment with 10% formic acid for decalcification. Subsequently, the specimen was cut into 40-micron-thick sections. Sections were stained with hematoxylin and eosin which appeared to be consolidated, well-shaped trabecular bone. The bone marrow space was also filled with dense fibrous connective tissue ().


Two girls were delivered by caesarean section at 37 weeks of gestation from the third pregnancy of a 29-year-old woman. Baby A and B, whose placenta was defined as singleton weighed, 2850 g and 2000 g. Both babies received mechanical ventilation due to respiratory distress. The chest radiographs of both revealed left diaphragmatic hernia (Bochdalek type) []. Baby A was operated on the 6th and baby B was operated on the 7th day after delivery. Primary diaphragmatic repair was performed. Small intestine, spleen and a big proportion of the colon were located in the thorax in both the babies, and the stomach was in the abdomen. The postoperative recovery was uneventful. Both children were thriving at 15 months follow-up [].


A 27-year old male patient with a history of progressive fatigue and pain at the left hip since three months presented at the Emergency Department, Ospedale Maggiore Policlinico, Milano, in 2008. On plain X-ray wide osteolytic shadows of the ileopubic and ischeopubic left branches were detected. Computed tomography (CT) scan confirmed several osteolytic areas bilaterally in the ilium and femoral necks. Bone scintigraphy with 99mTc-methylene diphosphonate (MDP) demonstrated diffuse tracer activity in the skeleton. Laboratory values were remarkable for serum calcium of 16.2 mg/dL (normal: 8.4-10.2), which prompted the immediate treatment with fluids and frusemide. Moreover, serum phosphorus and alkaline phosphatase concentrations were 2.0 mg/dL (normal: 2.4-4.5) and 1098 IU/L (normal: 42-98), respectively. Strongly suspecting neoplastic hypercalcemia, a thorough investigation was then conducted, with the following results. A bone biopsy did not confirm the cancer hypothesis, showing only the presence of osteoclasts in large number. Biochemical and imaging studies excluded the neoplasms most frequently responsible for bone secondarisms. A fludeoxyglucose positron emission tomography/CT (FDG PET/ CT) with a dedicated PET/TC tomography (Biograph plus, Siemens, Erlangen, GER) was then planned: the maximum intensity projection image demonstrated multiple foci of increased FDG uptake, mimicking bone metastasis or myeloproliferative disease (). A diffuse pattern of FDG uptake was also assessed in some long bones of the limbs.
On the basis of the negative bone biopsy findings and of FDG focal uptake at the left thyroid region, parathyroid function was studied, revealing unexpectedly high parathyroid hormone (PTH) levels (906 pg/mL; normal: 15-65). Urinary calcium excretion and serum 25-hydroxyvitamin D levels were checked at that time, showing abnormal results (urinary calcium, 24-hour 520 mg, normal: < 300; vitamin D 20 ng/mL, normal: 8-40). Neck ultrasonography (US) revealed a hypoechoic oval structure, 3.4 cm in diameter, near the left lower thyroid pole that suggested the possibility of an enlarged parathyroid gland. Color Doppler US demonstrated plentiful pulsating blood flow. According to these results, a bilateral neck exploration was performed in which the left parathyroid tumor was removed and the remaining three glands identified as normal. The pathological diagnosis was parathyroid adenoma.
Intraoperative PTH value dropped by 68% prior to completion of parathyroidectomy and serum calcium levels restored to the normal range a few hours after surgery. Oral calcium supplements (2.0 g daily) were provided as soon as oral intake was reestablished and moderate doses of 1,25 (OH)
2vitamin D3 (1.0 meg daily) were added. Two months after the operation, the patient's bone pain completely disappeared and he became able to walk without crutches after another three months. Persisting normalization of serum PTH value was detected after one year. Bone densitometry demonstrated a significant increase of lumbar and femoral mineralization, and plain X-rays confirmed the disappearance of the osteolytic areas after two years.


A 73-year-old man was referred to our hospital after gastroscopy had shown an elevated lesion in the posterior wall of the stomach. On admission, he appeared in good health, without peripheral adenopathy, and laboratory data, including serum lactate dehydrogenase (LDH), were all within normal limits. Gastroscopy showed a pigmented, elevated lesion, approximately 2 cm in diameter, in the posterior wall of the stomach (Fig. ). A biopsy was performed and histologic examination revealed sheet-like malignant cells with large nuclei and eosinophilic cytoplasms containing dark brown pigment (Fig. a). Immunohistochemically, the tumor cells were positive for S-100 proteins (Fig. b) and HMB-45 antibodies (Fig. c), and negative for pan-cytokeratin antibodies (AE1/AE3) and leukocyte common antigen. Based on these findings, we diagnosed MM. Ophthalmologic, dermatologic, and oral examinations were negative, as were computed tomography of the chest and anoscopy. Furthermore, F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) showed no accumulation of tracer, except in the tumor of the stomach (Fig. ). Therefore, we performed distal gastrectomy for assumed primary MM of the stomach without metastases. The resected specimen contained a brown-pigmented fungiform tumor, 2 cm in diameter, in the posterior wall of the stomach (Fig. ). Postoperative histological and immunohistochemical examinations confirmed the diagnosis. Tumor cells were spreading through the submucosal layer of the stomach, but the resection margins were clear of tumor. Six of 27 resected lymph nodes were positive for metastases. The patient was discharged from our hospital after an uneventful recovery, and was followed up at another hospital. He was readmitted to our hospital 9 months later with abdominal pain, general fatigue, and anorexia. A subcutaneous tumor in his back was resected and pathological examination revealed a metastasis of MM (Fig. ). Computed tomography showed ascites and pleural effusions, but cytological examinations of the fluid were negative. He became extremely cachectic and died approximately 2 months later; 1 year after the gastrectomy.


A 60-year-old man visited our clinic for operation of gastric cancer incidentally detected by the Nation Health Welfare program. SIT was diagnosed via chest radiography and abdominal computed tomography (CT). Upper endoscopy identified a superficial elevated lesion on the lesser curvature of the antrum (), and well-differentiated adenocarcinoma was diagnosed based on tissue biopsy. No other physical abnormalities were noted. Routine laboratory tests yielded normal results. Chest radiography showed dextrocardia from the posteroanterior view (). Abdominal CT showed that all organs inside the abdomen were inversely positioned () without enlarged lymph node, distant metastasis and abnormal co urse of vascularity. Abdominal ultrasonography revealed a 1 cm-sized gallstone in the fundus of the gall bladder ().
A LADG and D1+β dissection and laparoscopic cholecystectomy were performed. The surgeon stood on the right side of the patient (usual side of surgery in our hospital). We did not change the operator's position in our case to prevent confusion of right and left hand roles. A 10-mm camera port was created 2 cm below the umbilicus by open technique, and pneumoperitoneum was induced by using pressure of up to 12 mmHg carbon dioxide. 4 trocars were inserted in the left and right subcostal area and lateral abdominal region for operator and assistor ().
Laparoscopic view showed inversus of intraabdominal organ including stomach and spleen (). The gastrocolic ligament was along the border of the transverse colon using ultrasonic shears (Harmonic Ace, Ethicon Endo-Surgery Inc., Cincinnati, OH, USA). The position of the spleen was confirmed and the left gastroepiploic vessels located on the right side were ligated. In the pyloric region, the location of the pancreas was confirmed, and the area between this and the mesocolon was cut using ultrasonic shears to expose and ligate the right gastroepiploic vein located on the left side. The right gastroepiploic artery located on the left side bifurcating from the gastroduodenal artery was then confirmed and ligated (). Next, the lesser omentum was dissected, and the right gastric artery located on the left side bifurcating the proper hepatic artery was confirmed and ligated. The lymph node above the pancreas was dissected, and the coronary vein and left gastric artery located on the right side were ligated (). The perigastric lymph nodes were dissected along the lesser curvature up to the esophagogastric junction. Additional laparoscopic cholecystectomy was performed via antegrade method (). A 5-cm incision was made by right subcostal transverse incision. Through this minilaparotomy, the distal stomach was pulled out of the peritoneal cavity, and the distal two-thirds of the stomach was resected using a linear stapler. For Billroth I anastomosis, the duodenum was opened and the anvil of a circular stapler was inserted. The body of the circular stapler was introduced into the remnant stomach. Billroth I reconstruction was performed through end-to-side anastomosis (). After performing a stapling gastroduodenostomy, the opening in the remnant stomach was closed by an additional linear stapler. A closed suction drain was placed through the left upper trocar wound.
The operating time was 200 minutes and blood loss was 70 mL. No clear signs of abnormal bleeding were evident. The number of retrieved lymph nodes was 36. Based on a histopathological examination, a 1.5 × 1.5 cm, submucosal (sm3), moderately differentiated adenocarcinoma (pT1, pN0, sH0, sP0, sM0, stage IA) was diagnosed (). The postoperative course was favorable, and the patient was able to resume drinking water on postoperative day (POD) 3 and eating on POD 4. Thereafter, he was discharged on POD 7.


A 35-year-old man presented with anal bleeding after defecation for 2 weeks. It is not associated with the symptoms of abdominal pain, fever or weight loss. He had taken oil mixed with a trace of benzopyrene for 3 years because of his job of checking oil type in the edible oil plant. He had been treated for variant angina and underwent herniorrhaphy for inguinal hernia 12 years ago. Vital signs, physical examination, and peripheral blood analysis (hemoglobin 14.5 g/dL, hematocrit 43.2%) were in the normal range. Colonoscopy demonstrated a 4.0 cm sized-mass with shallow ulceration in the central area and irregular margin accompanied by intact mucosa (). Microscopic examination of biopsy specimens showed chronic inflammation. Computer tomography showed a well-demarcated and homogenous solitary mass in the descending colon. On contrast enhanced view, the mass had enhanced homogeneously in delayed phase (). Colonoscopy was performed for clipping and tattooing and the patient underwent a laparoscopic anterior resection. On laparoscopy, a considerable amount of ascites (about 30 mL) and enlarged mesocolic lymph nodes were shown. The lymph nodes were resected and frozen biopsy concluded all lymph nodes were negative for malignancy. Because the main tumor was found to arise from descending colon, left colic branch of inferior mesenteric artery (IMA) and inferior mesenteric vein were ligated while IMA was preserved, then laparoscopic anterior resection was performed. After the main mass was resected, hand-sewing colocolic anastomosis was performed. The 3.9 × 3.8 cm sized mass grossly presented a fungating surface, white to yellow color and invaded muscularis propria (). Consistency of the mass was harder than adenocarcinoma. The histopathologic examination of the specimens showed the tumor was composed of a proliferation of spindle-shaped cells arranged in hyaline material with chronic inflammatory cells, composed mainly of plasma cells and lymphocytes, not neutrophils. The specimens did not have celluar atypia or hyperchromatism in the cells (). Immunohistochemical staining suggested that fibroblastic tissue was of myofibroblastic nature. Immunohistochemically, tumor cells were positive for smooth muscle actin, and vimentin, and negative for desmin, CD117 (c-kit), anaplastic lymphoma kinase (ALK)-1 ().
These findings were compatible with an IMT. The patient's postoperative course was uneventful, and he was discharged on the 7th postoperative day. He has been free of complication after 1 month of follow-up.


A 48-year-old male presented with a unilateral palpable mass in the left breast. None of the risk factors for male breast cancer such as prior irradiation of the chest, exogenous estrogen treatment, liver disease, hyperestrogenism, androgen deficiency or family history had been positive.
On routine mammography, there was a lobulated homogenous well-circumscribed soft tissue mass in the left breast with a large axillary lymph node showing loss of central fatty hilum. No calcifications (micro/macro) could be detected.
Ultrasound (US) (Philips HD11XE; Philips Ultrasound, Andover, MA, USA; Probe: 12 to 3 Mhz Broadband linear array transducer) revealed a homogenous, lobulated, hypoechoic mass showing mildly increased vascularity (, ).
On conventional MRI (Philips MR Systems Achieva; Philips Medical Systems, The Netherlands; 1.5 T MRI machine), the lesion was seen as a well-defined lobulated lesion involving the superomedial and inferomedial quadrants of the left breast, measuring 3.8 × 3.5 × 2.8 cm, appearing isointense to muscle on T1- and mildly hyperintense to muscle on T2-weighted images (, ). The lesion was best delineated on fat suppressed T1-weighted images (T1 SPIR) and showed mild homogenous contrast enhancement and Type II perfusion curve, which indicates initial rapid or slow rise followed by a plateau in the delayed phase () on MRI suggestive of neoplastic etiology.
Primary breast lymphoma was the leading diagnosis in this case, based on the combination of clinical and imaging findings. There was no evidence of abdominal or cervical lymphadenopathy. US-guided fine needle aspiration cytology followed by trucut biopsy () confirmed the diagnosis of diffuse large B cell lymphoma which was CD 20 positive on immunohistochemical analysis ().
The patient was followed-up for last 7 months and underwent chemotherapy with cyclophosphamide, hydroxydoxorubicin, vincristine and prednisone (CHOP) regimen-14 cycles, resulting in a significant reduction in the size of the mass on physical examination.


A 29-year-old man presented with a 1-year history of pain in left ankle, with nocturnal exacerbation, which was relieved by the use of acetylsalicylic acid or anti-inflammatory drugs. The clinical examination indicated tenderness of the medial face of the left ankle without swelling. Plain radiographs showed a lytic area, homogeneous, smaller than 1 cm, associated with a perifocal dense bone reaction evoking osteoid osteoma of the distal third of left tibia [].
The CT confirmed a hypodensity associated with peripheral sclerosis, located at the distal third of the left tibia, near to the tibio-talar joint [Figures and ].
The bone scan showed uptake of radiotracer in the lower third of left leg [], confirming the diagnosis of osteoid osteoma. Due to its deep location, near to the tibio-talar joint, and small size of the lesion with important peripheral sclerosis as shown in the scan [], it was decided to perform an intraoperative isotope detection and to guide the surgical excision. We used a gamma probe counter, which is a scintillation counter used for isotope detection. It is equipped with a collimator connected to the electronics box by a flexible cable of 3.5 m []. The results are displayed digitally in counts per second (cps). The gamma probe counter has the advantage of being in contact with the uptake seat and being oriented to the higher counting rate. This will be displayed later with sound, demonstrating the localization of osteoid osteoma. Three hours before surgery, the patient received intravenously a marked molecule, dihydroxymethylphosphonate (HMDP) which is a bone matrix tracer. In the operating room, we were able to guide the surgical resection through the radiodetection displayed on the electronic box. The patient was taken in decubitus position under spinal anesthesia; the surgical approach was guided by a percutaneous tracking with the probe. After incision and bone access, the osteoid osteoma location was confirmed by probe counting that indicated a major mounting point located in the posterior and interior distal quarter of left tibia. Recording series, inch by inch in the four cardinal directions, allowed mapping the radiolabeling around the optimal point of fixation []. We performed an excision of a bone window of 1 cm / 2 cm around the hyperfixant seat; we recognized the absence of abnormal signal on the residual bone. The postoperative course was uneventful, marked by absence of pain after 24 hours of the surgical procedure. Then, the patient was immobilized by plaster cast for 3 weeks. Pathological examination confirmed the diagnosis of osteoid osteoma with the presence of the nidus. After 24 months, the patient was asymptomatic, and the bone scan performed did not indicate any recurrence of osteoid osteoma.


A 24 year-old female, teacher by profession, with normal birth and developmental history, presented with a history of generalized tonic clonic seizures since three years and frequent episodes of bizarre posturing of limbs followed by unresponsiveness since one and half years.
She was well until three years back when she had the first episode of sudden loss of consciousness with repetitive tonic clonic movements of all four limbs and tongue bite. This was not associated with any prodrome, aura or any postictal automatisms or autonomic symptoms. The episodes were short lasting (usually about a minute) and not followed by any focal neurological deficit and the frequency being two to three episodes per month. There was no history of myoclonic jerks or any definite relation to sleep deprivation or menstrual cycle and no family history of seizures. MRI of Brain and a routine EEG done prior to coming to this hospital were normal. At some other hospital, based on a diagnosis of Juvenile Myoclonic Epilepsy, sodium valproate with a maximum total dose of 1250 mg/day and clobazam with dose of 20 mg/day, was started. As per the patient the seizure frequency had not changed significantly on treatment. She had gained weight and also developed menstrual irregularities on medications and hence she left all her medications nearly an year ago.
Nearly one and half years ago, she started to have episodes which were more prolonged with a gradual progression of symptoms. She would start having bizarre, flinging movements of all four limbs and neck, without tonic clonic movements, jaw clenching, tongue bite or incontinence. At the onset of the episode she would be partially responsive but would lapse into drowsiness over the next few minutes. These would be precipitated whenever she would delay her meals or miss meals but had no relation to exercise or movement. Also the mother used to feed her in this state of reduced responsiveness and over next few minutes she would gradually improve. There was history of amnesia for these episodes As a result the mother had started giving her meals every two to three hours and even wake her up at midnight to feed her. The duration of these would range from few minutes to about half an hour. She had also started feeling hungry more frequently and had gained weight in the last one year. During the same period she also continued to have generalized tonic clonic seizures.
A provisional clinical diagnosis of generalized tonic clonic seizures, probably idiopathic generalized epilepsy with Non epileptic attacks, was made.
She was admitted for evaluation. On examination she was found to be obese. Rest of her general physical examination including the vitals revealed no abnormality. Examination of her nervous system including higher mental functions, cranial nerves, sensorimotor system and extrapyramidal system were all normal.
The patient was instructed to miss her meals and concomitant video-EEG monitoring was done.
A typical attack was induced after 2 hours. Her extremities became cold and she started sweating profusely. She was confused but able to respond to questions. Almost simultaneously she started having involuntary, unpurposeful, non-rhythmic, asynchronous bizarre movements of her limbs, abnormal posturing, opisthotonous posturing, tongue darting, facial grimacing and limb thrashing. There were no tonic or clonic components. A random blood glucose level was done by finger prick method and was found to be 24 mg% (normal 55-100 mg%). She was infused intravenous dextrose and within a few minutes she regained consciousness and the movements subsided.
Regular monitoring of her blood glucose revealed spontaneous asymptomatic hypoglycemia at several occasions per day (as low as 35 mg%), precipitated by fasting. However, the attacks occurred only when her blood sugar decreased to < 25 mg%.
One episode of generalized tonic clonic seizure with tongue bite, lasting for a minute was witnessed in the ward during the morning hours. A random blood sugar done at that time was 45 mg%.
In view of the abnormal movements being a combination of chorea, ballism and dystonia with prolonged duration, no temporal relation to movement or any form of startle, we diagnosed them as being Paroxysmal non-kinesiogenic dystonic choreoathetosis. As a possible etiology for symptomatic recurrent hypoglycemia and weight gain, Insulinoma was suspected. Serum fasting insulin levels were done and were found to be markedly elevated in the range of 106 IU/L (Normal lab values 2.6-24.9 IU/L). MRI of abdomen with contrast revealed a hypoechoic mass lesion in the distal pancreas, size 2 × 3 cm with no evidence of local or distant metastasis, possibly Insulinoma Figures and .
EEG done during the episode showed intermittent sharp waves and spike and wave discharges in the period preceding the episodes. Blood sugar levels were also done simultaneously and the electrographic discharges were found to appear only during hypoglycemic periods and subside when normoglycemia was restored. Interictal EEG record, however, was normal.
She was given frequent small meals and was given intravenous dextrose only if she became symptomatic. She underwent a laparotomy and was found to have a 3 × 3 cm firm tumor in the postero-superior aspect of distal pancreas adherent to the splenic vein, without any distant metastasis. A distal pancreactectomy with splenectomy was performed. Histopathology of the mass confirmed the diagnosis of insulinoma with an uncertain malignant potential, with the pancreatic resection margin and lymph nodes free of the tumor.
Presently she is doing well after the surgery and has been totally symptom-free since last 6 months. She has been off all antiepileptic drugs with no recurrence of seizure or abnormal movements.


A 4-year-old female child was referred to the medical genetics out patient clinic for investigation of dysmorphic features and developmental delay. She was the second child of natural conception to nonconsanguineous parents. She was born after 40 weeks of gestation by caesarean section. There was no history of antenatal problems, exposure to drugs or medical illness during pregnancy. Her mother and father were 27 and 31 years old, respectively, at conception. The child was born 8 years after marriage, and the pedigree analysis revealed mental retardation in the paternal first cousin. Her elder 10-year-old female sibling is normal.
On physical examination at 4 years of age, her height was 97.2 cm (25th centile), weight 15 kg (25th centile) and head circumference 49 cm (appropriate for age). She had epicanthic folds, blue sclera, long palpebral fissures, everted lower eye lids, long eye lashes, large ears, high arched palate, open mouth, mild fifth finger clinodactyly, persistent fetal finger pads and single palmar crease on the right side, with mild learning disability.
Her electrocardiogram was within normal limits. Her renal ultrasound was performed, and it was normal. Intelligence quotient (IQ) assessment revealed borderline range (IQ of 82). Hearing assessment (BERA) showed severe bilateral hearing loss.
Metaphase chromosome preparation from the proband was made from phytohemagglutinin-stimulated peripheral blood lymphocytes cultured for 72 h and stained with Giemsa (GTG banding at approximately 550-band stage) according to the standard techniques. Of the 50 metaphases analyzed, 28 cells showed 45,X and 22 cells showed 46,X,i(X)(q10). Chromosome analysis showed mosaicism for 45,X and one normal X chromosome and an isochromosome for the long arm of one X chromosome. Parental chromosome analysis was normal [Figures and and ].


A 31-year-old male, non-smoker, presented to us with a history of attacks of chronic intermittent cough since childhood. These attacks usually last for two to three days. Sometimes initiated and aggravated after heavy meals. It was also associated with recurrent chest infections. No significant history of hemoptysis, shortness of breath, difficulty of swallowing, or chocking was reported. Systemic examination was unremarkable. He used inhalers and cough suppressants as required.
Chest X-ray showed bilateral apical pleural thickening with fibroatelectatic changes at the right upper lobe. Barium studies showed significant dilatation of the whole esophagus, more at the proximal 3rd, with free passage of the contrast into the stomach without any stricture or narrowing at the distal end or at gastroesophageal junction; these findings were suggestive of some neurological causes or esophageal motility disorder. For further evaluation, the patient underwent esophageal manometry study and upper gastro-intestinal (GI) endoscopy. Esophageal manometry showed aperistaltic esophagus, but the lower esophageal sphincter could not be assessed. Upper GI endoscopy revealed the presence of smooth tracheoesophageal opening (fistula) in the upper 3rd of the anterior wall of the esophagus at 25 cm from the incisor teeth []; however, biopsy and wash aspiration from this fistula was negative for tuberculosis (TB) culture.
Computed tomography (CT) scan of chest confirmed the presence of the TEF at the level of sternoclavicular joint along with dilated esophagus. Also, there was evidence of cystic, cylindrical, and varicose bronchiectatic changes in both the right upper, middle lobes, and in the lingula. There were also subpleural fibroatelectatic changes in the posterior segment of the right upper lobe, most likely due to recurrent aspirations [Figure –].
Patient explored in the operating room through cervical approach along the anterior border of the left sternocleidomastoid muscle. Fistula was identified between the posterolateral wall of the trachea and the anterior wall of the esophagus. Adhesions separated and the fistula isolated completely and then closed by endo-GI stapler. Esophageal side reinforced with muscular patch to buttress this repair and to minimize the postoperative esophageal leak and to prevent long-term recurrence. Postoperative recovery was uneventful. Patient started oral fluids on the second postoperative day, the drain removed on the third day, and he was discharged home on fourth postoperative day. Patient remained asymptomatic and well at 12-month regular follow-up, as he underwent during this follow-up a barium swallow study which showed normal swallowing process and no hold up of the contrast with no evidence of gastroesophageal reflux and there was no evidence of recurrence of the TEF; however, he remained under regular follow-up with the gastroenterologist team for the esophageal motility disorder which has improved significantly clinically and radiologically.


A 22-year-old female presented with intermittent headache of two year duration, easy fatigability of one year duration, facial puffiness for one year, coarseness of facial features, and hoarseness of voice for the last six months []. She developed diplopia and diminution in vision for the last 15 days. There was no history of altered sensorium. She was having constipation off and on for two to three years and oligomenrrhea since 10 years. Her appetite was normal. Based on these clinical features, a diagnosis of sellar mass lesion was suspected at a peripheral hospital, and a CT scan and magnetic resonance imaging (MRI) of brain showed diffuse pituitary enlargement [Figures and ]. On examination, pulse rate was 72 beats/minute and regular. She was conscious, but dull. Cranial nerves normal except right lateral rectus paresis. Fundus and vision in both the eyes was normal. There were no focal neurological deficits. Deep tendon reflexes were normal. Routine blood investigations were normal, except low hemoglobin (8.1 gm / dL). Her hormonal profile showed raised thyrotrophin stimulating hormone (TSH) (150 microIU/dL, range 0.30-5.5) and low T3 (17 ng/dL, range 60-200) and T4 (1.90 microgram/mL, range 4.5-12.0). Prolactin was 35 IU/dL. Further investigation showed positive anti-thyroglobulin antibodies (1:15 dilution) but negative antimicrosomal antibodies. A diagnosis of autoimmune thyroiditis and primary hypothyroidism with pituitary hyperplasia was suspected. She was started on tablet L-thyroxin and low dose of steroids. At two-year follow-up, she was doing well and T3, T4 and TSH levels were in normal range. Follow-up imaging was not performed.


A 27-year-old man was introduced to our hospital with a 1-year history of gait disturbance. On admission, he had mild left hemiparesis, transcortical motor aphasia, and amnesia, with 80% of Karnofsky Index of Performance Status (KPS). Magnetic resonance (MR) imaging revealed an intraparenchymal mass lesion near the left ventricular trigone []. Computed tomography (CT) revealed a slightly high density mass with punctuate calcification. The serum levels of beta-human chorionic gonadotropin (β-HCG) and alpha-fetoprotein (α-FP) were within normal range. Cytology of the cerebrospinal fluid did not reveal any abnormalities. In the preoperative differential diagnosis, germinoma was highly suspected rather than high-grade glioma or malignant lymphoma, as there were atrophic changes in the left thalamus near the lesion.
Navigation-guided endoscopic biopsy was performed for differential diagnosis. First, the patient's head was fixed with a Mayfield frame under general anesthesia. A transparent sheath was inserted into the front of the target lesion via the burr hole under the control of the navigation system (StealthStation®; Medtronic, Inc., Minneapolis, MN, USA) []. After the front of the lesion was observed with the rigid endoscope (EndoArm®; Olympus Corp., Tokyo, Japan), the lesion was removed partially with 30% of removal rate because a rapid diagnosis of probable germinoma was made by intraoperative pathology (IOP), made from a part of the photodynamic diagnosis (PDD)-positive specimen using 5-aminolevulinic acid in the targeted tissue. On histopathology, the tumor tissue contained a lot of large neoplastic cells, some of which had mitosis. Immunohistochemical examination showed the tumor cells were immunoreactive for placental alkaline phosphatase (PLAP) and c-kit, and negative for leukocyte common antigen and CD30. Syncytiotrophoblastic giant cells (STGC), which are positive for β-HCG, were not observed. The histological diagnosis was pure germinoma with a concentration of large neoplastic cells, although a typical two-cell pattern was not observed.
Totally four cycles of carboplatin and etoposide (CarE) therapy were performed. Concurrent with third cycle of the CarE therapy, 30.6 Gy of whole-brain radiotherapy was also performed. MR imaging just after the initial cycle of the CarE showed that the tumor disappeared []. The patient's neurological symptoms did not change during these therapies. One month after the initial therapy, he was able to walk without any assistance and had no deterioration of transcortical motor aphasia or amnesia (80% of KPS). Follow-up MR imaging and Thallium 201 single-photon emission CT 1 year after the initial therapy showed no evidence of recurrence or dissemination.


A one-and-half-year-old male child born of full-term normal delivery after a nonconsanguineous marriage was brought by his mother with complaints of progressively increasing weakness in lower limbs with inability to stand since 1 month. On examination, the child was found to be conscious, alert, and active. Neurological examination revealed grade 4 power in the left lower limb. Local examination revealed a lipomatous swelling in the lumbar region. The patient also had a congenital groove at the left costal margin which was not investigated at birth. Chest x0 -ray revealed irregular fusion of left sided ribs and scoliosis of thoracolumbar spine []. Magnetic resonance imaging and computerized tomography of the spine were done which revealed spina bifida defect at multiple levels in lumbosacral region. There was evidence of diastematomyelia with a large intraspinal bony bar at L2–L3 vertebral level. The two hemicords were asymmetric; left smaller than right and each hemicord was seen in a separate dural sac [Figures and ]. Tip of conus medullaris was low in position at L4 vertebral level. The patient underwent L1 to L3 laminectomy. A large bony spur was identified on the left side which was dividing the spinal canal into two parts. Two dural sacs were identified which were separated by the bony spur. The right dural tube was larger than the left. The spur was excised with microrongeurs till it was flush with the vertebral body. The dura was then opened and the two hemicords were converted into one sac. The patient had no added neurological deficit postoperatively. The patient has been on follow-up since the last 3 years, but remains unable to walk without support.


A 32-year-old female dietitian was referred to the Plastic Surgery Unit with multiple axillary and perineal ulcers and sinuses, following incision and drainage of slowly growing nodular lesions over a one-year period. There was associated severe weight loss and constipation due to pain. However, there was no history of fever, cough, ingestion of steroids or any immunosuppressant drugs. A year before the onset of symptoms, she conducted a research on aspergillus contamination of palm oil over a six-month period and admitted to shaving her axillae and pubic region with a safety razor several times within that period. Physical examination revealed multiple ulcers in the axillae and multiple ulcers and few discharging sinuses in the perineum. The vaginal and rectal examinations were done under general anesthesia and revealed no communication with the vagina or rectum. [Figures and ]. There was no significant finding on systemic examination. The biopsy specimens were taken for culture and histopathology. The results revealed a significant growth of aspergillus species and the histological features confirmed invasive aspergillosis. Other investigations, including a chest x-ray, abdominal ultrasound scan, fasting blood sugar, and Mantoux test were all unremarkable. Human immunodeficiency virus (HIV) screening was negative, PCV was 26%, and ESR 150 mm / hour. A diagnosis of primary cutaneous aspergillus infection was made. She was commenced on itraconazole 200 mg b.i.d and daily wound dressing with pure honey. Two weeks after admission, she had wound excision of the right axilla with rhomboid flap cover. Three weeks later, the left axilla and perineum were done. Immediately after surgery, she had weakness of the left upper limb, which recovered fully with physiotherapy and her wound healed completely [Figures and ]. She was discharged and has remained disease-free, five years after discharge.