Transoral penetrating upper cervical injury: a case report.

Transoral penetrating foreign body injury of the neck involving the cervical spine is a rare condition. We present an injury caused by transoral penetration of a broken piece of a wooden plank into the neck with injury to the upper cervical spine in a 31-year-old male patient. The foreign body was removed transorally with the patient making a full recovery under close observation and was discharged and followed up with no complications. This paper highlights the types of neck injuries, the key points to be considered in zone III neck injury in light of existing literature and a discussion on the management of these patients.

Oral Lipoma Resembling Popeye's Pipe: A Case Report.

Lipomas are benign neoplasms of mesenchymal origin. Although they are frequently seen in other parts of the body, they are rare in the oral cavity. In the oral cavity, they most often develop from buccal mucosa. They tend to grow slowly, so they may remain asymptomatic for a long time and go unnoticed. Lipomas in the oral cavity may cause deterioration in chewing-speaking and esthetic problems over time, depending on the increase in their size. The most reliable imaging method for differential diagnosis is magnetic resonance imaging. Complete excision of the lipoma is essential for treatment. In this study, a case of an unusual oral lipoma, causing nutrition-speaking difficulties in a geriatric male patient is presented.

A Giant Diving Ranula Extending to the Skull Base in Pediatric Age.

ABSTRACT: Ranula is a retention cyst that develops from the salivary glands. It has 2 subtypes, oral and diving. There are differences in the clinical features of ranula subtypes. In particular, diving ranula is more prone to extend in the neck spaces than oral ranula. The enlargement of the diving ranula is generally downward in the neck. If the opposite occurs, we may encounter very interesting and difficult cases. Diving ranula should be kept in mind in the differential diagnosis of cystic neck masses in the pediatric age group and its treatment should be done surgically.A 15-year-old girl admitted to our clinic with the complaint of swelling in the floor of the mouth and neck. In physical examination of the patient, a mass with cystic content was observed adjacent to the left Wharton canal. In addition, a 4 × 3 cm, soft, fluctuant, nonfixed, painless mass was palpated in the left submandibular area. Magnetic resonance imaging revealed that the neck mass was a diving ranula extending from the parapharyngeal space to the skull base. In the surgery, submandibular and sublingual salivary glands were removed together with the diving ranula. We observed no complications in the postoperative period.Magnetic resonance imaging should be used to confirm the diagnosis of diving ranula. In the treatment of diving ranula, excision of the ranula alone is not enough surgically. We also recommend excision of the submandibular and/or sublingual salivary glands associated with ranula to reduce the recurrence rate.

Alternative hepatic arterial reconstruction technique in a case of total pancreaticoduodenectomy after celiac artery resection in pancreas cancer: Iliac-hepatic bypass.

Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department due to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss. Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, surgical margin reliability in frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. Hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX® graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.

Alternative hepatic arterial reconstruction technique in case of total pancreaticoduodenectomy after celiac artery resection in pancreas cancer: Iliac-hepatic bypass.

Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department owing to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss. Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, the surgical margin reliability in a frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. The hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX® graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.

Endoscopic retrograde cholangiopancreatography for biliary system parasites.

OBJECTIVE: Endoscopic retrograde cholangiopancreatography may be useful in the diagnosis and management of biliary system parasites. MATERIAL AND METHODS: Investigators retrospectively evaluated patients with biliary system parasites who underwent endoscopic retrograde cholangiopancreatography procedures over an eight-year period. We collected data regarding patient demographics, clinical features, and parasite type. We aimed to determine the utility of endoscopic retrograde cholangiopancreatography as a diagnostic and therapeutic intervention in patients with biliary system parasites. RESULTS: We identified 22 patients with biliary system parasites from a total of 3,450 endoscopic retrograde cholangiopancreatography procedures performed during an eight-year period. Parasite types included Echinococcus granulosus (n=19), Fasciola hepatica (n=2), and Ascaris lumbricoides (n=1). Fifteen patients with liver hydatid cysts underwent endoscopic retrograde cholangiopancreatography prior to surgery due to obstructive jaundice. The endoscopic retrograde cholangiopancreatography procedure enabled definitive treatment without the need for surgery in the remaining two patients. Two patients with fascioliasis underwent endoscopic retrograde cholangiopancreatography due to clinical presentation of cholangitis, cholecystitis, and obstructive jaundice, leading to presumptive diagnosis of cholangiocarcinoma. However, the final diagnosis was made using endoscopic retrograde cholangiopancreatography following inspection of flat, leaf-shaped, motile flukes extracted from the bile duct. In one patient with ascariasis, a longitudinal tubular structure was identified in the bile duct; emergency surgery was required. CONCLUSION: The diagnosis of parasitic diseases is clinically challenging, and definitive diagnosis requires endoscopic retrograde cholangiopancreatography in some cases. Moreover, endoscopic retrograde cholangiopancreatography provides a therapeutic option for ascariasis, fascioliasis, and some forms of hydatidosis. Accordingly, the use of endoscopic retrograde cholangiopancreatography may change preoperative management and treatment strategies for biliary system parasite infections.

Effects of Parenchymal Thickness and Stone Density Values on Percutaneous Nephrolithotomy Outcomes.

BACKGROUND It is unclear whether parenchymal thickness (PT), in combination with stone density measured by Hounsfield Units (HU), affects stone-free rates after PCNL. The aim of the present study was to investigate the relationship between PT in combination with stone density values and the outcomes of PCNL. MATERIAL AND METHODS From 2009 to 2014, data from 216 PCNL patients were prospectively analyzed. In total, 120 patients were included in the study. Using NCCT images, stone burden, stone localization, stone density as HU values, PT, and operative-postoperative parameters were recorded. RESULTS Stone localization, stone type, stone burden, and presence of hydronephrosis were statistically significant factors affecting stone-free status (p<0.001, p<0.001, p<0.01, and p<0.01, respectively). The stone-free rate in patients with thicker renal parenchyma was higher than in patients with lower parenchymal thickness (p<0.01). No correlation was detected between stone density and success rate (p>0.05). Drop in Hb (%) was only correlated with parenchymal thickness (p<0.01). In univariate analyses, factors that affected blood transfusion requirement were PT, BMI, and operative times (p<0.01, p<0.05, and p<0.05, respectively). CONCLUSIONS Stone location, stone burden, and presence of hydronephrosis detected with NCCT were factors affecting PCNL outcome. Stone density values did not correlate with the rate of bleeding or success of PCNL. PT measured by NCCT may predict bleeding and may guide surgeons in determining preoperative blood requirements. The outcome of PCNL appeared to be better in patients with thicker renal parenchyma and should be taken into consideration in the clinical evaluation of patients undergoing PCNL.

Spontaneous postoperative choledochoduodenal fistula due to bile duct injury following laparoscopic cholecystectomy.

INTRODUCTION: Bile leak after cholecystectomy which is the frequency less than 2% is an important problem for patients. Some bile duct injuries occuring after laparoscopic cholecystectomy are the complex bile duct injuries and can cause bile leak and fistula. PRESENTATION OF CASE: A 74-year-old woman has high output bile drainage from abdominal drain after laparoscopic cholecystectomy so an ERCP was performed. It was clear that there was a complete transaction of bile ducts, however this finding was inconsistent with the patient's clinical situation. The bile drainage of the patient was ceased and she was discharged to home without any problem. Four months later the patient was admitted again for recurrent cholangitis episodes. Patient was operated to perform a biliary-enteric diversion for the suspicion of biliary stricture. There was a thin fistula tract over the duodenum that was previously seperated from the proximal choledochus. The distal part of the bile duct was ended blindly. A hepaticojejunostomy anastomosis over a transhepatic stenting was performed. DISCUSSION: The circumferential injuries are the most common and devastating injuries leading to bile leak, peritonitis and varying degrees of sepsis. The probability of a bile fistula to close spontaneously is almost impossible in cases of iatrogenic circumferential full thickness injuries. CONCLUSION: In the present case we have reported a case of Bismuth type 2 (Strasberg type E2) injury in which the biliary drainage was closed spontaneously with the formation of spontaneous biliary-duodenal fistula. It is an extremely interesting case that has not been reported in the literature previously.

Uncinate Process Variations and Their Relationship with Ostiomeatal Complex: A Pictorial Essay of Multidedector Computed Tomography (MDCT) Findings.

The ostiomeatal complex (OMC) is a key area for the drainage and ventilation of the paranasal sinuses. Stenosis created by inflammation and anatomic variations in this region causes an ideal ground for parasanal sinus infections, by preventing the drainage and ventilation of the sinuses. In today's diagnostics of paranasal sinus infections, the role of evaluation of OMC anatomical variations and soft tissue pathology has increased.. Knowing the anatomical details is important in terms of directing both medical and surgical treatment. The uncinate process (UP) constitutes the most important structure of the ostiomeatal complex, playing a role in mucociliary activity. UP variations can cause mucociliary drainage and ventilation problems, causing complications during surgery. Therefore, knowing and identifying their appearances in multidetector computed tomography (MDCT), the most frequently used radiological imaging method for these variations, becomes a very important consideration.

A Fatal Complication: Intestinal Perforation Secondary to Migration of a Biliary Stent.

BACKGROUND: Stent insertion is widely performed to restore biliary drainage in hepatic, biliary, and pancreatic obstructive conditions. Intestinal perforation due to the migration of these stents is an extremely rare late-term complication that is associated with a high rate of mortality. The current report aimed at presenting the radiological findings of a case of extraluminal biliary stent migration into the pelvic region that caused intestinal perforation. CASE REPORT: We report a case of an 85-year-old male with a history of previous stent insertion who presented with a sudden - onset severe abdominal pain. An abdominal multidetector computed tomography (MDCT) revealed a tubular foreign body density, compatible with intestinal perforation due to migration of the biliary stent. CONCLUSIONS: Biliary stent insertion becomes a more common procedure. This serious complication must always be remembered in patients presenting with abdominal pain after stent insertion.

The Prevalence of Incidentally Detected Idiopathic Misty Mesentery on Multidetector Computed Tomography: Can Obesity Be the Triggering Cause?

PURPOSE: Misty mesentery appearance is commonly reported in daily practice, usually as a secondary finding of various pathological entities, but sometimes it is encountered as an isolated finding that cannot be attributed to any other disease entity. We aimed to assess the prevalence of cases with incidentally detected idiopathic misty mesentery on computed tomography (CT) and to summarize the pathologies leading to this appearance. METHODS: Medical records and initial and follow-up CT features of patients with misty mesentery appearance between January 2011 and January 2013 were analysed. The study included cases with no known cause of misty mesentery according to associated CT findings, clinical history, or biochemical manifestations, and excluded patients with diseases known to cause misty mesentery, lymph nodes greater than a short-axis diameter of 5 mm, discrete mesenteric masses, or bowel wall thickening. RESULTS: There were a total of 561 patients in whom misty mesentery appearance was depicted on abdominopelvic CT scans. A total of 80 cases were found to have isolated incidental idiopathic misty mesentery, giving a prevalence of 7%. The common indication for CT examination was abdominal pain. There was a slight female predominance (51.3%). 67.5% of all patients were classified as obese and 17.5% as overweight. CONCLUSIONS: The results of the present study show that idiopathic incidental misty mesentery appearance has a significant prevalence. Also, the high body mass index of these patients and the growing evidence of obesity-induced inflammatory changes in adipose tissue are suggestive of an association between obesity and misty mesentery appearance on CT.

Alterations in pituitary gland volume in polycystic ovary syndrome: a structural magnetic resonance imaging study.

The purpose of this prospectively designed cross-sectional observational study was to evaluate the effect of polycystic ovary syndrome (PCOS) on pituitary gland volume (PGV) under the hypothesis that endocrinologic changes may lead to morphologic changes of the pituitary gland. Twenty-six PCOS patients and 31 control subjects underwent magnetic resonance imaging (MRI) of the pituitary. Informed consent was obtained from all subjects. PGV was significantly larger in PCOS patients than in control subjects. Luteinizing hormone/follicle-stimulating hormone ratio was the only predictor of PGV. The association between pituitary gland enlargement and PCOS should be kept in mind when pituitary hypertrophy is detected on MRI.

Investigation of temporal bone asymmetry in cases with unilateral tinnitus: morphometric and multicentric clinical study.

The aim of this multicentric study was to compare the anatomical structures of temporal bone in patients with unilateral tinnitus with their healthy ears. We also aimed at evaluating whether age and gender-related asymmetrical changes occur in temporal bones or not. Fifty two ears of 26 patients who had unilateral tinnitus were included into the retrospective study. The patients who had subjective nonpulsatile tinnitus and who previously had temporal computed tomography according to their file records were accepted to study. Temporal CT scans and audiometric results of patients were examined retrospectively. Middle ear volume, diameter of internal acoustic meats and diameter of jugular bulb were evaluated by both anatomist and radiologist, interobserverly. Internal acoustic meats and jugular bulb were found larger in the ears that had tinnitus than healthy ears; however, there was no statistically significance. The stereological morphometrical study of temporal bone asymmetry in humans correlate with sex is of importance for both otolarygologs and anatomists. These results will contribute to data on middle ear volume, internal acustic meats and jugular bulb sizes.

Cystic lymphangiomatosis with severe intra-abdominal bleeding in a newborn: case report.

We report the case of a newborn girl with intestinal cystic lymphangiomatosis who presented with abdominal distension and intra-abdominal bleeding following a prenatal ultrasound diagnosis of intestinal anomaly. Postnatal abdominal ultrasound revealed disseminated submucosal and intramural cystic dilatations of various sizes in the bowel and intestinal lymphangiomatosis was diagnosed. The presence of severe bleeding diathesis and widespread disease led to conservative treatment. The patient died on postnatal day 7 and postmortem examination confirmed cystic lymphangiomatosis. Detection of intestinal hyperechogenicity and/or dilatation in prenatal ultrasonography and the persistence of these findings during pregnancy are suggestive for pathologies such as meconium ileus, meconium peritonitis, and intestinal atresia. Although rare, intestinal lymphangiomatosis should be kept in mind in patients whose prenatal sonographic findings persist until birth.

A case of von Hippel-Lindau disease with juxtapapillary retinal capillary hemangioma and nutcracker phenomenon.

The aim of this study was to evaluate a patient with von Hippel-Lindau (VHL) syndrome and to discuss the clinical manifestations. A 25-year-old woman presented to our clinic with blurred vision for 2 months. Best corrected visual acuity in right eye was 20/50, and fundoscopic examination revealed juxtapapillary endophytic retinal capillary hemangioma. Examination findings on left eye were normal. On optical coherence tomography, exudation was prominent on macula. History revealed cerebellar operation because of cerebellar hemangioblastoma. On abdominal ultrasonography, liver hemangiomas and pancreatic cysts were seen, confirmed by abdominal computerized tomography (CT). Abdominal CT imaging also revealed nutcracker phenomenon. Transthoracic echocardiography showed atrial septal aneurysm without shunt. The patient refused ocular treatment. At 3-month control, ophthalmic findings were the same. To our knowledge, this is the first case of VHL disease reported to be associated with nutcracker phenomenon and atrial septal aneurysm. Systemic evaluation and regular follow-up should be recommended to subjects with VHL disease.

Role of surrogate markers of atherosclerosis in clinical and subclinical thyroidism.

Background. Data on the relationship between homocysteine, plasminogen activator inhibitor 1, hs-CRP, fibrinogen, and carotid intima media thickness (CA-IMT) is plenty but contradicting and the majority of the studies investigated this issue in only specific thyroidism groups. The aim of this paper was to investigate these relations in patients with subclinical and clinical hypo- and hyperthyroidism. Methods. In this cross-sectional study, 16 patients from each thyroidism group and 20 healthy cases were enrolled. Fibrinogen levels and plasminogen activator inhibitor 1 (PAI-1) activity were assessed. CA-IMT was determined by gray-scale high-resolution color Doppler ultrasound. Results. Serum homocysteine levels were higher in hypothyroidic patients compared to the control (P = 0.003). Fibrinogen levels were higher in patients with subclinical hypothyroidism compared to other groups (P < 0.05). There was no difference between groups regarding PAI-1. Whereas total cholesterol, homocysteine, and LDL were correlated with CAIMT, hs-CRP, PAI-1, and fibrinogen were not. In the clinical hypothyroidism group, the correlation of homocysteine with CA-IMT was derived from the correlation between CA-IMT and homocysteine. Conclusions. Homocysteine and fibrinogen levels are higher in patients with clinical and subclinical hypothyroidism, respectively. Homocysteine level is associated with CA-IMTonly in patients with clinical hypothyroidism.

Spontaneous splenic rupture with hematoma in a patient with brucellosis.

Brucellosis is one of the most common zoonotic diseases worldwide with a variable frequency in European countries. Brucellosis is usually transmitted after direct contact with or consumption of dairy products from an infected animal. Initially, our patient, a 65 year-old man, had nonspecific manifestations of fever, malaise, headache, anorexia and arthralgia which are the classic symptoms of this disease. After the diagnosis of brucellosis had been confirmed by blood culture and serology, progressive thrombocytopenia developed in spite of appropriate antibiotic administration. Radiological investigation revealed imaging findings consistent with splenic rupture. The complete recovery was observed after administration of antibiotic therapy and platelet transfusion. Spontaneous rupture of the spleen with subcapsular hematoma is an extremely rare condition in brucellosis. We want to remind clinicians of this rare complication.

Metastatic basal cell carcinoma presenting as a neck mass.

Neck masses are common in physicians' daily practice; however, there is a small possibility that the origin of the neck mass is a basal cell carcinoma (BCC). We present a BCC of the scalp that metastasizes to the neck without any lymphoid involvement. We also reviewed possible risk factors for metastasis of the BCC, which is a probable cause of neck mass.