Evaluation of Normal Epiglottis on Computed Tomography with Special Attention to Thickness.

To our knowledge, this is the first study to investigate the thickness of the normal epiglottis on computed tomography (CT) in a Japanese population. The focus was on determining the thickness of a normal epiglottis, which could then serve as a reference in detecting abnormalities. We believe that this would facilitate diagnosing and determining the extent of cancerous invasion of the supraglottis and secondary invasion of the epiglottis. This retrospective study was based on a review of radiographic data in patient charts. Cervical CT scans obtained from 79 Japanese patients (44 men [55.7%] and 35 women [44.3%]; age range, 28-85 years; mean, 58.9 years) showing a normal epiglottis under laryngoscopy were evaluated. The thickness of the epiglottis was measured on CT scans and the results analyzed with the Student's t-test, an analysis of variance, and the Tukey-Kramer test. The epiglottis in men was significantly thicker than that in women (p<0.05). A statistically significant difference was observed in thickness depending on longitudinal height (p=<0.001). The thickness at the median was larger than that bilaterally in all patients (p=<0.001). No statistically significant difference was observed in thickness depending on side or age. The thickness of the normal epiglottis was established at each level. We believe that these data could serve as a reference in diagnosing and detecting abnormalities of the epiglottis.

Periorbital Pilomatrixoma: a Report of a Case Difficult to Diagnose.

Background: Pilomatrixoma is a benign tumor that arises from matrix cells of hair follicles. In ophthalmology, pilomatrixoma is relatively rare, yet there are reports on eyelid pilomatrixomas that were visible and/or palpable. Our case is the first report on pilomatrixoma that was found as a subconjunctival lesion and neither readily visible or palpable. Case: A 32-year-old woman presented with a chief complaint of conjunctival hyperemia of the left eye with sensation of foreign body. A previous doctor suspected allergic conjunctivitis, but the prescribed antihistamine treatment had failed. Physical exam revealed hyperemia localized to the left temporal bulbar conjunctiva, as well as a 5 mm-diameter hard mass located underneath the lateral palpebral conjunctiva. With a suspicion of inflammatory reaction to a foreign body, enucleation of the mass was performed by opening and detaching the conjunctiva using surgical scissors. Findings: The mass was hard, spherical and 5 mm×10 mm in size without adhesions. The pathology revealed hair follicles, basophilic cells, as well as shadow/ghost cells, which led to the definitive diagnosis of pilomatrixoma. Conclusion: Pilomatrixoma is a benign tumor that arises from matrix cells of hair follicles. This case shows that pilomatrixoma from lateral canthus can extend underneath the conjunctiva.

A new screening test for idiopathic normal pressure hydrocephalus using bimanual coordination: A preliminary study.

BACKGROUND: The clinical spectrum of idiopathic normal pressure hydrocephalus (iNPH) comprises the triad of gait disturbance, cognitive impairment, and urinary incontinence. However, motor abnormalities involving the upper extremities in iNPH patients have few quantitative studies. OBJECTIVE: The present study was designed to quantitatively assess bimanual tapping tasks in iNPH patients and to compare with the control groups. METHODS: The subjects were divided into three groups: iNPH patients, older healthy group, and younger healthy group. The tasks were three synchronization finger-to-thumb tapping tasks with the auditory stimuli specified at 1 Hz by metronome: unilateral, bimanual simultaneous, and bimanual alternate. Two-way ANOVA was used to compare the outcomes of the three errors (absolute error: AE, variable error: VE, and constant error: CE) for tapping cycles. RESULTS: In the iNPH group, the absolute and variable errors increased in bimanual alternate tapping task with statistical significance (AE: p < 0.05 and VE: p < 0.05). There were no significant differences in errors between the older and young healthy groups (AE: p = 0.62, CE: p = 1.00 and VE: p = 0.31). CONCLUSIONS: We could quantitatively evaluate the bimanual coordination on iNPH patients using the bimanual alternate tapping task, potentially useful for evaluating patients unable to walk.

Desmoplastic ameloblastoma of the jaw: CT and MR imaging findings.

OBJECTIVES: Desmoplastic ameloblastoma (DA) is one of the rare pathological variants of ameloblastoma. The purpose of this study is to investigate CT and MR imaging findings of DA. METHODS: We retrospectively evaluated six DA cases that were gathered from four different hospitals and confirmed histopathologically with resected specimens. Two radiologists who specialized in head and neck imaging retrospectively interpreted and reviewed pretreatment CT and MR imaging findings. RESULTS: On CT, all DAs presented with well-defined border and low internal attenuation. Regarding locularity, five cases showed honeycomb-like lesions and one showed a unilocular lesion. Bone expansions were seen in all patients and located on the labial side in four cases. On MR imaging, all DAs showed well-defined borders and solid moderately low signal intensities with small cystic high signal intensities on T2-weighted images and intermediate signal intensity on T1-weighted images. Five DAs showed linear low signal intensity on T1- and T2-weighted images. Gd-DTPA-enhanced MR imaging was performed in three cases, and all cases showed moderate enhancement. Dynamic-enhanced MR imaging was performed in two of them, and persistent enhancement was detected. CONCLUSION: Our findings strongly suggest that MR imaging should also be consulted, particularly for honeycomb-like lesions with well-defined margins, bone expansion and anterior location on radiographs or CT. Additionally, findings by MR imaging such as solid low-signal-intensity, hyperintense cystic foci and persistent enhancement pattern will suggest the diagnosis of DA.

Dose-response of rPMS for upper Limb hemiparesis after stroke.

INTRODUCTION: Repetitive peripheral magnetic stimulation (rPMS) therapy is an innovative and minimally invasive neurorehabilitative technique and has been shown to facilitate neural plasticity. However, there is at present no research that clarifies the dose-response of rPMS therapy on the recovery of upper limb hemiparesis after stroke. This trial aims to clarify the dose-response of rPMS therapy combined with intensive occupational therapy (OT) for chronic stroke patients with moderate to severe upper limb hemiparesis. METHODS AND ANALYSIS: This multicenter, prospective, assessor-blinded, randomized controlled study with 3 parallel groups will be conducted from January 20, 2020 to September 30, 2022. Fifty patients will be randomly assigned in a ratio of 1:2:2 to the control group, the group receiving daily 2400 pulses of rPMS, or the group receiving daily 4800 pulses of rPMS, respectively. From the day after admission (Day 1), rPMS therapy and intensive OT will be initiated. The primary outcome is the change in the motor function of the affected upper extremity (Fugl-Meyer Assessment) between the time of admission (Day 0) and the day after 2 weeks of treatment (Day 14). Secondary outcomes will include the changes in spasticity, active range of motion, motor evoked potential, and activity of daily living. ETHICS AND DISSEMINATION: The study was approved by the Jikei University Certified Review Board for all institutions (reference number: JKI19-020). Results of the primary and secondary outcomes will be published in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients. TRIAL REGISTRATION NUMBER: jRCTs032190191.

Surfers' knots in the anterior chest.

A history of frequent surfing can be a key finding when a patient comes in with subcutaneous lesions on bilateral anterior lower chest. MR imaging could lead to the diagnosis with its characteristic finding for collagenous mass lesions, though most cases do not require imaging unless with atypical presentation. This enables clinicians to avoid unnecessary invasive procedures.

Convexity subarachnoid hemorrhage presented with loss of consciousness.

When patients present with transient loss of consciousness without headache and head computed tomography is performed, clinicians should pay attention to cortical high densities as convexity subarachnoid hemorrhage can be a differential diagnosis.

Magnetic resonance imaging findings of styloglossus and hyoglossus muscle invasion: Relationship to depth of invasion and clinical significance as a predictor of advisability of elective neck dissection in node negative oral tongue cancer.

PURPOSE: By comparing styloglossus and hyoglossus muscle invasion (SHMI) of oral tongue squamous cell cancer (OTSCC) on MR imaging to pathological depth of invasion (DOI) and prognosis, we aimed to evaluate the clinical significance of MR imaging findings of SHMI. METHOD: Forty-five, early stages and clinically N0 OTSCCs were retrospectively reviewed. Data included pathological DOI, DOI on MR imagings, two-year potential cervical lymph node positive, locoregional control, disease-free survival, and overall survival. Data were statistically compared between the groups with MR evidence of SHMI (SHMI+) and without MR evidence of SHMI (SHMI-). RESULTS: There were 17 SHMI + and 28 SHMI-. Elective neck dissections performed on 13 cases revealed five node positive cases, all of which were SHMI + . Pathological DOI in SHMI + was significantly larger than SHMI- (average 9.0 vs 4.6 mm, p < 0.001). All SHMI + revealed pathological DOI larger than 4 mm. The two-year potential cervical lymph node positive rate of SHMI + was significantly higher than SHMI- (p =  0.01). Locoregional control rate and disease-free survival of SHMI+ were significantly lower than in SHMI- (p =  0.02). There was no significant difference in overall survival. Interobserver agreement in evaluation of SHMI on MR imaging was good (kappa value = 0.72, p <  0.001). CONCLUSIONS: Pathological DOIs of SHMI + were all larger than 4 mm, which is the cut-off point that National Comprehensive Cancer Network recommends for neck dissection, and SHMI + had a worse prognosis than SHMI-. SHMI + can be used as a criterion for elective neck dissection.

Undetectability of oral tongue cancer on magnetic resonance imaging; clinical significance as a predictor to avoid unnecessary elective neck dissection in node negative patients.

METHODS:: We retrospectively reviewed early stage oral tongue cancer patients treated with radical surgery with clinically N0, between May 2009 and February 2016. Collected data include age, sex, pathological DOI, DOI on MRI, locoregional control rate, disease-free survival rate, and overall survival rate. These data were statistically compared between the detectable lesion (DL) group and undetectable lesion (UL) group on MRI. Interobserver agreement in evaluation of detectability of the oral tongue cancer was assessed by k statistics. RESULTS:: Total of 53 patients were studied, and 28 were DLs and 25 ULs. Pathological DOI in UL was significantly smaller than that of DL (average 1.7 vs 4.6 mm, p < 0.001). Cut-off value between UL group and DL group was 3.5 mm (sensitivity 96 %, specificity 75 %). 96 % of ULs had pathological DOI smaller than 4 mm, the recommended cut-off value for neck dissection. There was no significant difference in locoregional control rate (p = 0.24), disease-free survival rate (p = 0.24) or overall survival rate (p = 0.92). Interobserver agreement in evaluation of detectability on MRI was very good ( k-value = 0.89, p < 0.001). CONCLUSIONS:: When oral tongue cancer is not detected on MRI, it indicates pathological DOI being smaller than 4 mm, which may imply that elective neck dissection is unnecessary.

Schwannoma assumedly originating from the submandibular ganglion or glandular branches radiologically mimicking a submandibular gland tumor.

Schwannoma is a benign nerve sheath tumor composed of Schwann cells. Schwannomas originating from ganglia are rare, and schwannomas of the submandibular ganglion or glandular branches have not been reported to date. We present a case of a Japanese woman in her sixties with a submandibular schwannoma originating from the submandibular ganglion, mimicking a submandibular gland tumor on radiological findings. As the radiological findings were nonspecific, the key finding in the present case may be the characteristic location of the tumor suspended from the undersurface of the lingual nerve and situated above the deep portion of the submandibular gland.

CT imaging features of antiresorptive agent-related osteonecrosis of the jaw/medication-related osteonecrosis of the jaw.

OBJECTIVES: Antiresorptive agent-related osteonecrosis of the jaw (ARONJ)/medication-related osteonecrosis of the jaw (MRONJ) include both bisphosphonate-related osteonecrosis of jaw (BRONJ) and denosumab-related osteonecrosis of jaw (DRONJ). The purpose of this study is to study radiological characteristics of ARONJ/MRONJ. These imaging features may serve as one useful aid for assessing ARONJ/MRONJ. METHODS: CT scans of 74 Japanese patients, who were clinically diagnosed by inclusion criteria of ARONJ/MRONJ, obtained between April 1, 2011 and September 30, 2016, were evaluated. We investigated the CT imaging features of ARONJ/MRONJ, and clarified radiological differentiation between BRONJ and DRONJ, BRONJ due to oral bisphosphonate administration and due to intravenous bisphosphonate administration, BRONJ with respective kinds of medication, BRONJ with long-term administration and short-term administration, BRONJ with each clinical staging respectively. Fisher's exact test, χ2 test, Student's t-test and analysis of variance were performed in the statistical analyses. RESULTS: Unilateral maxillary sinusitis was detected in all patients with upper ARONJ/MRONJ (100%). DRONJ showed large sequestrum more frequently than BRONJ (3/4, 75 vs 3/35, 8.6%, p < 0.05). DRONJ showed periosteal reaction more frequently than BRONJ (4/10, 40 vs 7/65, 10.1%, p < 0.05). Patients of BRONJ resulting from intravenous bisphosphonate administration showed larger and more frequent buccolingual cortical bone perforations than BRONJ resulting from oral bisphosphonate administration (7/8, 87.5 vs 11/30, 36.7%, p < 0.05). There was no significant correlation between CT findings and respective kinds of medication, long/short-term administration, clinical stages of BRONJ. CONCLUSIONS: ARONJ/MRONJ has characteristic CT image findings which could be useful for its assessment.

Catheter-related thrombosis diagnosed by computed tomography.

Catheter-related bloodstream infection can be detected with CT. Although it is not mandatory for its diagnosis, it is strong evidence as a cause of fever if detected incidentally.

Odontogenic cutaneous fistula mimicking malignancy.

It is important for the dentists to make accurate diagnosis and appropriate treatment of odontogenic cutaneous fistula. Although large facial skin lesions may bring up malignancy on top of the differential list, careful evaluation including physical observation, imaging, and pathology can rule out malignancies.

Eagle syndrome.

Although rare, Eagle syndrome should be always considered in the differential diagnosis in patients with chronic orofacial pain refractory to conventional treatments. Treatment is surgery and exeresis of the styloid process via a transoral or cervical approach depending on clinical and radiological features.

Surfer's ear.

Exostosis in external auditory canal is common among surfers. Common symptoms are decreased hearing or loss of hearing, ear infection, and/or plugging sensation. Repeated exposure to cold water is a key clinical history to suspect this condition. Based on symptoms and existence of infection, surgical removal of the exostosis is recommended.

Giant cell arteritis with polymyalgia rheumatica on FDG-PET/CT.

If there is no pain in the temporal artery, the diagnosis of giant cell arteritis (GCA) may be delayed and blindness may occur. Therefore, FDG-PET/CT is important as a modality for diagnosis of GCA. When GCA is suspected and F-18 FDG-PET/CT is performed, it is worthwhile to pay attention to shoulder and hip joints as polymyalgia rheumatica commonly presents with GCA.

A rare presentation of Klippel-Trenaunay syndrome with bilateral lower limbs.

Klippel-Trenaunay syndrome (KTS) is a vascular lymphatic malformation underlying with bony and soft tissue hypertrophy. It is a rare condition presenting in 1 out of 10 000 people. The growth disturbance due to KTS is more commonly unilateral (85%) than bilateral (12.5%), and most rarely crossed-bilateral (2.5%). A man in his 40s presented to our hospital with a complaint of lower limb discomfort. Radiograph, ultrasonography, computed tomography venography, magnetic resonance (and venography) showed various radiological findings characteristic for KTS. Because the patient was symptomatic, he underwent stripping of bilateral great saphenous vein and varicectomy of bilateral legs. The surgical procedures were undertaken successfully, and there has been no recurrent symptom for about 2 years and a half. In this study, we report a very rare case of bilateral KTS diagnosed by radiological and clinical manifestations with some literature review.

Wandering carotid arteries: Reciprocating change between normal and retropharyngeal positions on serial CT studies.

Positional change in the retropharyngeal carotid artery, a rare phenomenon over time, is even rarer in previous reports, and it is important to be aware of this before any neck surgical procedure. A woman in her 50s underwent an anterior maxillectomy for upper gingival cancer, without neck dissection. The patient had medical histories of diabetes mellitus and liver dysfunction, with unremarkable family histories. Serial neck contrast-enhanced computed tomography for detecting locoregional recurrence had been performed as a follow-up during 4 years. A radiological course of moving carotid arteries in serial computed tomography studies showed reciprocating positional changes (wandering) between normal and retropharyngeal regions. There was no locoregional recurrence of the gingival cancer. This is the first case to describe a so-rare presentation of wandering carotid arteries. It is important for clinicians to be aware of a wandering carotid artery to avoid potentially fatal complications.

Corneal Higher Order Aberrations in Granular, Lattice and Macular Corneal Dystrophies.

PURPOSE: To evaluate the corneal higher-order aberrations (HOAs) in granular, lattice and macular corneal dystrophies. METHODS: This retrospective study includes consecutive patients who were diagnosed as granular corneal dystrophy type2 (GCD2; 121 eyes), lattice corneal dystrophies type 1, type 3A (LCDI; 20 eyes, LCDIIIA; 32 eyes) and macular corneal dystrophies (MCD; 13 eyes), and 18 healthy control eyes. Corneal HOAs were calculated using anterior segment optical coherence tomography, and the correlations between HOAs and visual acuity were analyzed. RESULTS: HOAs of the total cornea within 4 mm diameter were significantly larger in GCD2 (0.17 ± 0.35 µm), in LCDI (0.33 ± 0.27), LCDIIIA (0.61 ± 1.56) and in MCD (0.23 ± 0.18), compared with healthy controls (0.09 ± 0.02µm, all P < 0.01). HOAs of the total cornea within 6 mm diameter were significantly larger in GCD2 (0.32 ± 0.48), in LCDI (0.60 ± 0.46), LCDIIIA (0.83 ± 2.29) and in MCD (0.44 ± 0.24), compared with healthy controls (0.19 ± 0.06, all P < 0.001). In GCD2, there was no significant correlation between logMAR and HOAs (r = 0.113, P = 0.227). In MCD, LCDI and LCDIIIA, logMAR was positively significantly correlated with HOAs (r = 0.620 and P = 0.028, r = 0.587 and P = 0.007, r = 0.614 and P < 0.001, respectively). CONCLUSIONS: Increased HOAs occur in eyes with corneal dystrophies, especially in eye with LCD and MCD. Larger amount corneal HOAs are associated with poorer visual acuity in patients with LCD and MCD.

Petersen hernia after open gastrectomy with Roux-en-Y reconstruction: a report of two cases and literature review.

Petersen hernia is a rare internal hernia that occurs after Roux-en-Y (R-Y) reconstruction. To our knowledge, there are a few reports on internal hernia, especially Petersen hernia after open gastrectomy for gastric cancer. Two rare cases of Petersen hernia are presented in this report. A man in his 70s was referred to our hospital due to a complaint of postprandial sudden abdominal pain. He had a history of open total gastrectomy with R-Y jejunal reconstruction through the antecolic route for gastric corpus cancer. On computed tomography (CT), bowel obstruction and strangulation of the small intestine were suspected. Emergency laparotomy was done, and an internal herniation of the small intestine through Petersen space was observed. A man in his 50s was referred to our hospital due to a complaint of severe sudden abdominal pain. He had a history of open gastrectomy and abdominal/lower intrathoracic esophageal resection with R-Y jejunal reconstruction of an antecolic jejunal limb for esophagogastric junction carcinoma. On CT, internal herniation of the small intestine was suspected. During emergency laparotomy, an internal herniation of the bowel through the Petersen space was observed. Though history of R-Y reconstruction surgery may be helpful, preoperative diagnosis of Petersen hernia is difficult to establish. Here we present two rare cases of this type of internal hernia.