Ultrasound in Causes of Stridor in Children.

Airway ultrasound (US) is an easily available, portable, radiation-free imaging modality for quick, non-invasive, dynamic evaluation of the airway without sedation. This is useful in children with stridor, which is an emergency due to upper airway obstruction requiring immediate management. Several causes of stridor including laryngomalacia, laryngeal cyst, subglottic hemangioma, vocal cord palsy, and lymphatic malformations can be evaluated accurately. Thin musculature and unossified cartilages in children provide a good acoustic window. Thus, airway US is valuable, but underutilized for the evaluation of children with stridor. In this case-based review, we describe the technique, indications, anatomy, and pathologies on airway US.

Prophylactic bilateral internal iliac balloon occlusion to control hemorrhage in placenta accreta spectrum: a boon for obstetricians.

BACKGROUND: Placenta accreta spectrum (PAS) is abnormal placental adhesion beyond superficial myometrium, which may lead to severe life-threatening hemorrhage requiring massive blood transfusions in the peripartum period. Prophylactic balloon catheterization of bilateral internal iliac arteries with or without additional embolization with Cesarean hysterectomy in patients with PAS prevent excessive intraoperative hemorrhage and may also obviate the need for hysterectomy. PURPOSE: To study the efficacy of intervention radiological procedures in controlling intraoperative hemorrhage in patients with PAS. MATERIAL AND METHODS: This ethically approved prospective study was conducted between November 2017 and October 2019 and written informed consent was obtained from all patients. Consecutive patients diagnosed with PAS during the antepartum period were evaluated. A total of 18 patients with PAS underwent prophylactic balloon catheterization of the bilateral internal iliac arteries followed by delivery of the infant. Interventional and intraoperative data of these patients were collected and compared with retrospectively collected data of patients (control group) who underwent hysterectomy without prophylactic balloon occlusion over the past four years (January 2016-November 2019). RESULTS: Significantly lower intraoperative blood loss (2.8 L vs. 4.7 L; P = 0.048) and pure red blood cell (PRBC) requirement (P = 0.026) between patients who had hysterectomy with and without interventional radiological management was observed. Significantly higher blood loss (P = 0.006) and fluid requirement (P = 0.007) was observed with a higher degree of placental invasion. Only 1 (6%) major procedure-related complication was observed. CONCLUSION: Interventional radiological procedures are effective in significantly reducing intraoperative blood loss and blood product requirement in patients with PAS.

Intraoral Ultrasound in Early Stage Tongue Carcinoma.

Preoperative assessment of depth of invasion (DOI) is critical in the surgical management of early stage carcinoma tongue. Intraoral ultrasound (IOUS) has been recently described as a cost-effective alternative to MRI in the accurate measurement of DOI. We describe the technique of IOUS in different types of lesions (surface, ulcerative, and exophytic); and provide key imaging pearls for the routine use of this novel ultrasound application.

Split-bolus, single-phase contrast enhanced CT: a one-stop shop for invasive fungal sinusitis.

Contrast-enhanced magnetic resonance imaging is considered the imaging modality of choice for invasive fungal sinusitis (IFS); however, it is not feasible to perform emergency CEMRI especially in the setting of COVID-19. The CECT protocol for evaluation of suspected IFS can be modified by using split-bolus, single-phase CT as it provides an optimal soft tissue demonstration of sinonasal disease; extrasinus spread to orbit, and intracranial involvement along with simultaneous opacification of the internal carotid artery and cavernous sinus. The extent of bone erosion can also be well delineated on the multiplanar reconstructions (MPRs) in the bone window. Further a structured reporting format can help provide optimal surgical guidance in cases of IFS.

Effect of rehabilitation by using the shortened dental arch concept on the thickness of the masseter muscle and occlusal force: A pilot study.

STATEMENT OF PROBLEM: Knowledge of the effect of a shortened dental arch on masseter muscle thickness and occlusal force is sparse but could help clinicians understand how a shortened dental arch might affect the stomatognathic system. PURPOSE: The purpose of this pilot clinical study was to evaluate and compare the masseter muscle thickness and occlusal force of participants rehabilitated by using a shortened dental arch with matched completely dentate individuals. MATERIAL AND METHODS: Twelve partially edentulous participants with a minimum of 1 posterior occluding pair on each side of the arch were enrolled in the study. The mandibular arch of these participants was rehabilitated by using a single posterior mandibular implant crown (group S). The maxillary arch of all participants in group S was intact. Masseter muscle thickness (cm) and occlusal force (N) were recorded before (T1) and 6 months after implant rehabilitation (T2) for each participant. Twelve participants were selected as controls (group C). They were matched for age, sex, height, and weight with group S and evaluated for masseter muscle thickness and occlusal force. Masseter muscle thickness was evaluated by using ultrasonography during the rest position and maximum volumetric clenching. Occlusal force was measured with an occlusal force measuring appliance. All recordings were done for the left and right sides of the arch. Descriptive analysis was followed by comparison between groups and within group S by using the paired t test (α=.05). RESULTS: Higher masseter muscle thickness and higher occlusal force were observed in group C than in group S before and after rehabilitation. An increase in masseter muscle thickness in the rest position and in maximum volumetric clenching was observed within group S after rehabilitation. Before rehabilitation, a difference in the masseter muscle thickness between group S and group C was statistically significant for the left side at the rest position (P=.017) and during maximum volumetric clenching (P=.016). After rehabilitation, the difference between group S and group C was not statistically significant for masseter muscle thickness at the rest position (P=.890 for right side and P=.555 for left side) and during maximum volumetric clenching (P=.109 for right side and P=.755 for left side). The difference in occlusal force between group S and group C was statistically significant for the right side and left side (P<.001) before rehabilitation and statistically not significant after rehabilitation (P=.161 for the right side and P=.134 for the left side). CONCLUSIONS: Rehabilitation following the concept of a shortened dental arch increased masseter muscle thickness and occlusal force in partially edentulous individuals, making the masseter muscle thickness and occlusal force comparable with those of a completely dentate arch.

Diverse clinical manifestations and intrafamilial variability due to an inherited recurrent MYRF variant.

MYRF monoallelic variants have been described in syndromic forms characterized by cardiac-urogenital syndrome and isolated nanophthalmos with/without minor systemic manifestations. We describe a large family with a paternally inherited pathogenic variant in MYRF that manifested as congenital diaphragmatic hernia (CDH), cardiac and urogenital abnormalities, and/or nanophthalmos with significant intrafamilial variability.

Transvaginal Shear Wave Elastography for Assessment of Endometrial and Subendometrial Pathologies: A Prospective Pilot Study.

OBJECTIVE: To assess the role of shear wave elastography (SWE) in characterizing different endometrial and subendometrial pathologies. METHODS: Seventy-three women with pathologically proven endometrial and subendometrial pathologies were enrolled in this prospective study and assessed with transvaginal SWE. The elasticity values (in kiloPascals), and the ratio of mean elasticity of the endometrial lesion to myometrial elasticity (E/M ratio) were compared in different pathologies. RESULTS: There was a statistically significant difference (P <.001) in the mean, minimum, and maximum elasticity of the pathologies as well as the E/M ratio (P <.00001). In the analysis of the subgroups, the mean elasticity of endometrial polyp was statistically significantly lower than other subgroups (P <.01), while submucosal leiomyoma and focal adenomyoma had significantly higher values than other subgroups (P <.01). No statistically significant difference was noted in the mean elasticity of carcinoma and hyperplasia (P-.19). CONCLUSION: SWE is a potential adjunct to ultrasound that provides an additional paradigm to characterize endometrial and subendometrial masses.

Diagnostic dilemma in an infant with stridor: ultrasound to the rescue!

Stridor is one of the most important signs of partial or complete upper airway obstruction. Subglottic hemangioma (SGH) is a well-recognized however infrequent cause of infantile stridor. It is a potentially life-threatening condition. Thus, early diagnosis and management are crucial. Diagnostic evaluation includes ultrasound, cross-sectional imaging such as contrast-enhanced CT/MRI, and tracheobronchoscopy. Ultrasound (US), although not a widely used modality for the diagnosis, provides good assessment of its presence, extent, and degree of subglottic airway narrowing. Moreover, color Doppler helps to establish the vascular nature of the lesion. There are many advantages of US over tracheobronchoscopy and CT in an emergency setting which include its easy availability, non-invasive nature, and can be done quickly as a bedside procedure, enabling early initiation of treatment. However, there are some disadvantages as well, which include limited field of view and operator dependency. Also, extension into the thoracic cavity and more deeply located soft tissue locations can be missed. We present a case of subglottic hemangioma in which US solved the diagnostic dilemma and provided a definite diagnosis when CT and tracheobronchoscopy failed to do so in a 6-month-old infant presenting with stridor to the ER.

Sinonasal IgG4-related disease: a rare and emerging entity broadening the differential diagnosis in the sinonasal universe.

BACKGROUND: IgG4-related disease (IgG4-RD) is a multi-organ immune-mediated disorder characterized by fibroinflammatory mass-forming lesions, mimicking malignancy or infection. While well-documented in salivary glands, orbit and thyroid in the head and neck, sinonasal IgG4-RD is rare. METHODS: Cases of sinonasal IgG4-RD were retrieved, and clinicopathological features reviewed. RESULTS: Seven cases of sinonasal IgG4-RD were identified over a 2-year period, including three males and four females, with an age range of 13-48 years (median: 32 years). Patients presented with cheek swelling, pain and visual disturbances. Serum IgG4 levels were mildly elevated. Storiform fibrosis, obliterative phlebitis and plasma cell infiltration were seen in varying proportions. Destruction of bone and subepithelial mucoserous glands was present. ALK-1 negativity distinguished from inflammatory myofibroblastic tumor. CONCLUSION: Sinonasal IgG4-RD expands the growing spectrum of IgG4-RD. A high degree of suspicion is required to include IgG4-RD in differential diagnosis of sinonasal masses, and perform detailed histological and immunohistochemical workup for accurate diagnosis.

Revisiting rhino-orbito-cerebral acute invasive fungal sinusitis in the era of COVID-19: pictorial review.

COVID-19 patients have been found to have an increased incidence of superadded fungal infections because of multiple factors such as impaired cell-mediated immunity, immunosuppressive therapy, and coexistent diabetes mellitus. Recently, there has been a significant rise in the COVID-19-associated mucormycosis and aspergillosis cases involving the sinonasal cavity and the lungs. Rhino-orbito-cerebral acute invasive fungal rhinosinusitis (AIFR) is a potentially life-threatening, invasive fungal infection. Early diagnosis followed by prompt medical management and surgical intervention is crucial for patient survival. The role of cross-sectional imaging (CT/MRI) is not only to suggest a diagnosis of invasive fungal sinusitis but also to delineate the complete extent of disease. Mapping the extent of orbital and intracranial disease has prognostic as well as management implications, as involvement of these sites marks a worse prognosis. A stepwise approach to evaluation of imaging of AIFR along with a pictorial depiction of the key imaging findings is presented.

Can imaging suggest the aetiology in skull base osteomyelitis? A systematic literature review.

PURPOSE: To assess differentiating features between bacterial, Aspergillus, and Mucor skull base osteomyelitis (SBO) with regard to clinical presentation and imaging appearances. MATERIAL AND METHODS: A literature search was performed in April 2020 for studies on SBO with a minimum sample size of 10 patients. Studies that reported presenting symptoms, cross-sectional imaging findings, complications, and mortality were included in the analysis. The quality of included articles was tested using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. A data extraction form was used to retrieve relevant parameters from each of the articles. RESULTS: Thirteen articles were included in the final analysis. Diabetes mellitus was the most common predisposing factor (12.5-91.0%). Presenting complaints in all bacterial SBO studies were otogenic, while fungal SBO patients had nasal/ocular complaints. Rates of mortality and surgical intervention in the fungal group were 50-100% and 50%, respectively, as compared to the bacterial group - 7-87% and 10%, respectively. On imaging, the site of initial infection in bacterial SBO was the external auditory canal, while in fungal SBO it was the paranasal sinus. The incidence of orbital extension was < 5% in bacterial and 44-70% in fungal SBO, among which Mucor had rates of 65-70%. Bone erosion was less extensive in bacterial SBO, and the patterns differed. The highest incidence of vascular involvement and non-enhancing lesions (23-36%) was seen in Mucor. Aspergillus showed highest sino-cranial extension (52-55%) and homogenous bright enhancement. CONCLUSIONS: Systematic analysis of the clinico-radiological parameters in each of the studies revealed differences in presentation, clinical course, extension, bone erosion, and enhancement.

Is There a Difference in Volumetric Change and Effectiveness Comparing Pedicled Buccal Fat Pad and Abdominal Fat When Used as Interpositional Arthroplasty in the Treatment of Temporomandibular Joint Ankylosis?

PURPOSE: There is limited evidence in the literature about fat grafting in the management of temporomandibular joint ankylosis (TMJA). The purpose was to investigate which interpositional fat grafting technique is superior in the operative management of TMJA. The specific aim was to compare the volumetric change and maximal mouth opening (MIO) when pedicled buccal fat or abdominal fat is interposed in patients being treated for TMJA. PATIENTS AND METHODS: A randomized controlled trial was conducted on TMJA patients divided into 2 groups: Pedicled buccal fat pad was used for interposition in group A, whereas abdominal fat was used in group B. At the end of 1 year, the volumetric change in fat was analyzed by comparing immediate postoperative and 1-year follow-up magnetic resonance imaging (MRI). MIO and re-ankylosis were recorded. Categorical variables were analyzed by the χ2 test or Fisher exact test. Continuous variables were compared using the t test and Wilcoxon signed rank test. Linear regression analysis was performed. RESULTS: A total of 36 patients (51 joints [15 bilateral and 21 unilateral]) were included, comprising 18 in group A and 18 in group B. The mean preoperative MIO measured 6.8 mm in group A and 4.2 mm in group B. The mean immediate postoperative MRI fat volume was 4.3 cm3 in group A and 10.8 cm3 in group B. One-year follow-up MRI showed a fat retention rate of 32.44% in group A and 58.17% in group B. The rate of volumetric shrinkage was 67.5% in group A and 41.9% in group B (P < .001). Analysis of variance showed a statistically significant difference between volumetric shrinkage and both treatment groups (P < .001). MIO improved to 30.6 mm in the pedicled buccal fat pad group (group A) and 41.9 mm in the abdominal fat group (group B) (P < .001). No re-ankylosis occurred in either group at 1-year follow-up. CONCLUSIONS: Our study results suggest that the percentage of retention of interposed abdominal fat at 1 year is more than that of pedicled buccal fat pad. Volumetric shrinkage is greater with buccal fat pad, which is a paradox considering the pedicled blood supply. Abdominal fat is better than pedicled buccal fat pad when used for interposition in TMJA treatment.

Quantitative Sonoelastographic Assessment of the Normal Uterus Using Shear Wave Elastography: An Initial Experience.

OBJECTIVES: To describe the sonoelastographic characteristics of the normal endometrium, myometrium, and cervix and to assess their variability with age and different menstrual phases. METHODS: A total of 56 women were enrolled in this prospective study, who underwent transvaginal ultrasound examinations, including B-mode imaging and shear wave elastography. The elasticity parameters (in kilopascals) of the normal endometrium, myometrium, and cervix were studied. The variability of the mean elasticity value of the endometrium in different menstrual phases and age groups was analyzed. The variability of the mean elasticity of the cervix across different age groups was also studied. RESULTS: The mean age of the participants was 40 years (range, 25-69 years). The normal mean elasticity values ± SDs were 25.54 ± 8.56 kPa for the endometrium, 40.24 ± 8.59 kPa for the myometrium, and 18.90 ± 4.22 kPa for the cervix. A mean endometrial-to-myometrial elasticity ratio was calculated, which was found to be 0.65 ± 0.22. There was no significant difference in the mean endometrial elasticity values for women in different menstrual phases (P = .176) or in different age groups (P = .376). There was no significant difference in the mean cervical elasticity with age (P = .192). CONCLUSIONS: Shear wave elastography is a promising adjunct to ultrasound for the evaluation of the uterus, and the results from this study may provide normal data, which may further help in diagnosing various uterine diseases.

Effect of intravenous administration of zoledronic acid on jaw bone density in cases having skeletal metastasis: A prospective clinical study.

AIM: The objective is to evaluate the effect of intravenous (i.v.) administration of bisphosphonate (zoledronic acid) therapy on the jaw bone density and incidence of any other bony patholog. SETTINGS AND DESIGN: Observational - prospective study. MATERIALS AND METHODS: A total of 57 patients having a history of bony metastasis (excluding the jaw bone) were enrolled following the inclusion/exclusion criteria. Each patient received six doses of 4 mg i.v. bisphosphonate once a month. Multidetector computed tomography (MDCT) of jawbones for each patient was performed before the start of therapy (baseline) and subsequently at 6 and 12 months. Bone density was assessed at 24 predetermined sites (8 sites in maxilla and 16 sites in mandible) and any pathological change in either of the jaw bones was noted. STATISTICAL ANALYSIS USED: Shapiro-Wilk test ,Pearson's Chisquare test and repeated measures analysis of variance. RESULTS: The result showed no statistically significant increase in mean bone density over a period of 1 year in maxilla and mandible. However, a significant increase in bone density was observed from 6 months to 1 year in mandibular anterior cancellous bone. The detailed observation of each MDCT scan showed no pathological change in either of the jaw bones during the study period. CONCLUSION: The administration (i.v.) of six doses of 4 mg bisphosphonate did not lead to a significant change in bone density over a period of 1 year.

Phacomatosis pigmentovascularis type 2b (phacomatosis cesioflammea) with double superior vena cava, abdominal varicosities, and natal tooth: Novel associations.

Phacomatosis pigmentovascularis is characterized by coexistent extensive cutaneous vascular (capillary) and pigmentary anomalies. We describe a 2-month-old infant presenting with classic features of phacomatosis pigmentovascularis 2b (phacomatosis cesioflammea). He was also found to have hitherto unreported associations in the form of extensive venous anomalies presenting as striking abdominal wall varicosities and persistent left superior vena cava and natal tooth.

Hypereosinophilia with Multi-organ Dysfunction - A Diagnostic Conundrum.

Eosinophils are predominantly tissue-dwelling cells (spleen, lymph nodes, thymus, digestive tract) and counts <500/mm3 in the peripheral blood are considered to be normal. The functions of eosinophils are not completely understood, however there can be a significant rise in their levels in the peripheral blood and/or tissues in a variety of disease states. Hypereosinophilic syndromes (HES) are a group of disorders characterised by blood eosinophilia greater than 1500/mm3 on at least two occasions and eosinophilic infiltration and damage to multiple organs. Eosinophils on activation release substances that can lead to tissue damage. However, it is important to note that the degree of tissue damage is not directly proportional to the level of eosinophilia. A significant number of cases of HES are commonly missed and therefore a systematic approach is necessary for all such patients. Through our case, we have tried to summarise how to systematically approach a case of HES and manage it.

An Unusual Case of Intractable Vomiting: Unravelling the Present, Through the Past!

A 54 year old lady presented to our institute with a history of low grade fever for one week associated with occasional loose stools, vomiting and severe malaise. Initial evaluation revealed low serum sodium. An initial diagnosis of acute gastroenteritis with secondary hyponatremia was made. Work up for infective causes of gastroenteritis was however negative. ENT evaluation and review of drug history did not contribute towards a diagnosis. The patient's symptoms persisted and did not respond to symptomatic treatment. Ultrasound of abdomen revealed cholelithiasis with no evidence of cholecystitis. Further evaluation revealed hypotonic hyponatremia with normal levels of urinary sodium excretion. With other causes of hyponatremia ruled out, an endocrinopathy was suspected as the likely culprit. Follow up hormonal studies revealed hypopituitarism and MRI of brain revealed a partially empty sella. On reviewing the case, a past history of amenorrhea immediately after the birth of her third child (almost 20 years ago!) was elicited. Intractable vomiting is quite an unusual presentation for Sheehan's syndrome, but a thorough case history coupled with a high index of suspicion can contribute towards identifying the cause among a series of confounding clinical and radiological findings, as in our case.

CRAB Manifestations in a Middle-Aged Female: A Diagnostic Dilemma.

A 56 year old lady, presented to our institute with six months history of low grade fever, generalized weakness, decreased food intake and fluctuating sensorium. Initial investigations revealed hypercalcemia, renal dysfunction and anemia. Initial working diagnosis of likely underlying hematological malignancy such as lymphoma or multiple myeloma (MM) was kept after hyperparathyroidism was ruled out. Her skeletal survey revealed lytic lesions in the skull, bone marrow aspirate showed 12% plasma cells and beta-two microglobulin level was markedly elevated. However, the criterion for MM was not fully satisfied. In view of persistent altered sensorium, MRI brain was done which suggested the diagnosis of disseminated tuberculosis and was further confirmed through MR spectroscopy, bone marrow biopsy (showing granulomas) and whole body PET. She was started on anti-tubercular therapy along with steroids with marked response within a week. We describe the details of this interesting case through a systematic approach to the various features.