A bump in the neck. Myositis ossificans of the omohyoid muscle: Imaging findings.

Myositis ossificans is a benign ossifying soft-tissue mass that occurs in muscle. In the majority of cases it is related to trauma but rarely observed in the neck. A 54 year-old-man with history of minor trauma and anticoagulant drug assumption for V Leiden mutation, was referred to our institution for a painless mass in the right supraclavicular fossa. On CT plan study a mass with negative attenuation values located in the posterior triangle of the neck, into the inferior belly of the right omohyoid muscle was evident. On MRI the lesion appears as an ovalar mass, with smooth borders, isointense to muscles on T1 images, isointense to fat on T2 images, intensely enhancing after i.v. Gd administration. After surgical removal the pathologist concluded for the nature of myositis ossificans. This is the first case, as far as we know, reported in the literature of a myositis ossificans arising in the inferior belly of the omohyoid muscle in a patient treated with dicumarol.

Moderate hypofractionated helical tomotherapy for prostate cancer in a cohort of older patients: a mono-institutional report of toxicity and clinical outcomes.

PURPOSE OR OBJECTIVE: To evaluate toxicity and outcomes of moderately hypofractionated helical tomotherapy for the curative treatment of a cohort of patients aged ≥ 75 years with localized prostate cancer (PC). MATERIALS AND METHODS: From January 2013 to February 2017, 95 patients with median age 77 years (range 75-88) were treated for PC. 39% were low risk, 33% intermediate risk (IR), 28% high risk (HR). Median iPSA was 9.42 ng/ml (1.6-107). Androgen deprivation was prescribed according to NCCN recommendations. All patients received 70 Gy in 28 fractions to the prostate; 61.6 Gy were delivered to the seminal vesicles for IR; whole pelvis irradiation with a total dose of 50.4 Gy was added in the HR group. Toxicity evaluation was based on CTCAE V4.0 criteria, biochemical failure was defined following Phoenix criteria. Quality of Life was assessed with the EPIC-26 index. Overall survival and biochemical failure-free survival were analysed with Kaplan-Meier method. RESULTS: With a median follow-up of 36 months (range 24-73), acute and late toxicity were acceptable. No correlation between toxicity patterns and clinical or dosimetric parameter was registered. EPIC-26 showed a negligible difference in urinary and bowel function post-treatment that did not reach statistical significance. The 2- and 3-years OS were 93% and 87% with cancer specific survival of 97.9% and 96.2%. CONCLUSION: Moderate hypofractionated RT reported excellent outcomes in our cohort of older patients. Shorter schedules may be proposed regardless of chronological age facilitating the treatment compliance in the older population.

Barotraumatic blowout fracture of the orbit after sneezing: Cone beam CT demonstration.

A 40-year-old man with no history of trauma or previous sinus surgery complained sudden right diplopia after vigorous sneezing. The patient was submitted elsewhere to a MRI study for persisting diplopia, with inconclusive findings. One week later the patient was submitted to a maxillofacial cone beam CT (CBCT) in our Institution. A blowout fracture of the right orbital floor and lateral orbital wall with an intact orbital rim and a ipsilateral maxillary sinus effusion with an air liquid level, were detected at the CBCT study. Our conclusion, confirmed by the clinician, was the patient had a barotraumatic, isolated, pure blowout fracture of the right orbit consequence of the episode of vigorous sneezing. The patient was treated by steroid and antibiotic therapy and diplopia resolved after two weeks. Clinicians and radiologists should be aware that a barotraumatic blowout fracture of the orbit after sneezing should be included among the unusual causes of sudden diplopia.

Physics, Techniques and Review of Neuroradiological Applications of Diffusion Kurtosis Imaging (DKI).

In recent years many papers about diagnostic applications of diffusion tensor imaging (DTI) have been published. This is because DTI allows to evaluate in vivo and in a non-invasive way the process of diffusion of water molecules in biological tissues. However, the simplified description of the diffusion process assumed in DTI does not permit to completely map the complex underlying cellular components and structures, which hinder and restrict the diffusion of water molecules. These limitations can be partially overcome by means of diffusion kurtosis imaging (DKI). The aim of this paper is the description of the theory of DKI, a new topic of growing interest in radiology. DKI is a higher order diffusion model that is a straightforward extension of the DTI model. Here, we analyze the physics underlying this method, we report our MRI acquisition protocol with the preprocessing pipeline used and the DKI parametric maps obtained on a 1.5 T scanner, and we review the most relevant clinical applications of this technique in various neurological diseases.

Secondary septal mucocele diagnosed by MRI and CBCT and treated surgically.

OBJECTIVE: Here we report a case of a mucocele of the nasal septum diagnosed by MRI and cone beam CT (CBCT) 23 years after Ogston Luc surgery. METHOD: A 49-year-old man with nasal obstruction was examined by endoscopy, MRI, and CBCT. RESULTS: Endoscopy showed a smooth and soft septum swelling. MRI revealed an ovalar lesion with high-intensity content on both T1 and T2 images, and a peripheral enhancing rim after i.v. administration of contrast medium. CBCT revealed that the lesion was located in the posterior portion of the septum involving the perpendicular plate of the ethmoid, and destroying the anterior ethmoid cells on the left side but sparing the left lamina papyracea. The patient underwent endoscopic marsupialization of the lesion. CONCLUSION: A mucocele of the nasal septum is a rare occurrence. MRI and CBCT are effective and affordable diagnostic tools for this condition, enabling differentiation of mucocele from other sinonasal diseases.

Intratumoral haemorrhage causing an unusual clinical presentation of a vestibular schwannoma.

We present a case of an elderly woman with no history of audiological disease with sudden onset of visual and hearing deficits associated with systemic clinical signs. On examination she had impairment of right CNs from V to X. CT and MR imaging demonstrated a cystic vestibular schwannoma with a rare intralesional fluid-fluid level correlated to a recent bleed. We include high quality MR images to show the acute impairment of the cranial nerves next to the tumour after acute bleeding. Our case report includes a voxel-based morphometry (VMB) analysis of the tumour that, as far as we know, has never been done before for such a tumour. VBM analysis was performed to calculate the hypothesized volume changes after the acute bleed which likely resulted in a sudden increase in the overall size of the tumour resulting in atypical clinical signs and symptoms due to the establishment of a mechanical conflict with the adjacent cranial nerves.

Comparison of iodinated contrast media for the assessment of atherosclerotic plaque attenuation values by CT coronary angiography: observations in an ex vivo model.

OBJECTIVE: To compare the influence of different iodinated contrast media with several dilutions on plaque attenuation in an ex vivo coronary model studied by multislice CT coronary angiography. METHODS: In six ex vivo left anterior descending coronary arteries immersed in oil, CT (slices/collimation 64×0.625 mm, temporal resolution 210 ms, pitch 0.2) was performed after intracoronary injection of a saline solution, and solutions of a dimeric isosmolar contrast medium (Iodixanol 320 mgI ml(-1)) and a monomeric high-iodinated contrast medium (Iomeprol 400 mgI ml(-1)) with dilutions of 1/80 (low concentration), 1/50 (medium concentration), 1/40 (high concentration) and 1/20 (very high concentration). Two radiologists drew regions of interest in the lumen and in calcified and non-calcified plaques for each solution. 29 cross-sections with non-calcified plaques and 32 cross-sections with calcified plaques were evaluated. RESULTS: Both contrast media showed different attenuation values within lumen and plaque (p<0.0001). The correlation between lumen and non-calcified plaque values was good (Iodixanol r=0.793, Iomeprol r=0.647). Clustered medium- and high-concentration solutions showed similar plaque attenuation values, signal-to-noise ratios (SNRs) (non-calcified plaque: medium solution SNR 31.3±15 vs 31.4±20, high solution SNR 39.4±17 vs 37.4±22; calcified plaque: medium solution SNR 305.2±133 vs 298.8±132, high solution SNR 323.9±138 vs 293±123) and derived contrast-to-noise ratios (p>0.05). CONCLUSION: Differently iodinated contrast media have a similar influence on plaque attenuation profiles. ADVANCES IN KNOWLEDGE: Since iodine load affects coronary plaque attenuation linearly, different contrast media may be equally employed for coronary atherosclerotic plaque imaging.

Pediatric sialolithiasis distinctive characteristic in radiological imaging.

AIM: Aim of the present paper was to investigate the imaging and related clinical characteristics of sialolithiasis in Italian pediatric population trying to determine the difference between pediatric and adult. METHODS: Twenty-nine pediatric patients (age range 1-17 years) with pain and postprandial swelling and/or purulent discharge in the salivary gland areas were referred to radiology department after pediatric ear, nose and throat (ENT) evaluation. They all were submitted to ultrasound examination of the main salivary glands. Multidetector computed tomography (MDCT) only was performed in 2/6 patients, in 2/6 patients both sialography and MDCT were performed due to inconclusive MDCT features, 2/6 only sialography was performed. Sialoliths were classified on their location and size. RESULTS: In 6 out of 29 patients (4 males, 2 females, age range 1-17 years) salivary stones were detected. Sialoliths were detected in 5/6 patients in the submandibular gland and 1/6 in the parotid gland. All sialoliths, excepted for a case of multiple sialoliths, were located in the distal part of the main salivary ducts. CONCLUSION: Imaging characteristics of sialolith in pediatric group are similar than in adult population in few aspects. In fact sialoliths are smaller in size and located more frequently in the distal part of the main salivary duct, than in adult, making sialography cannulation more complex and requiring short thickness in MDCT.

Sialographic findings in Wharton duct evagination.

Ductal evagination is a rare condition affecting the Wharton duct. The aim of this study was to establish the incidence, imaging features and clinical significance of ductal evagination in patients undergoing submandibular gland sialography. The sialographic findings and reports of 322 patients undergoing submandibular gland sialography during the period 1998-2007 were retrospectively reviewed. Ductal evagination was identified on sialograms as a unique diverticulum, filled with contrast medium, of the Wharton duct, with a narrow neck and a blind end. A ductal evagination was found in 5/322 patients with swelling and pain in the submandibular gland. It was always located in the middle tract of the Wharton duct. Other findings were: in 5/5 patients, an enlargement of the primary and secondary ducts due to sialodochitis; in 3/5 patients, salivary stones; in 1/5 patients, a sinuous distal tract of the Wharton duct; in 2/5 patients, a stenosis of the proximal tract of the Wharton duct. In our series, the incidence of wharton duct evagination was 1.6% incidence. It may represent a form of duct wall weakness although its cause is uncertain. It is, however, a condition that needs to be highlighted on sialograms for eventual inflammatory consequences or in guiding sialoendoscopy to avoid eventual ductal perforation.

Morbidity of salivary gland digital sialography using a non-ionic dimeric contrast medium.

AIM: Sialography is considered a low invasive procedure, due to cannulation of salivary duct orifice. The aim of this study was to evaluate the morbidity of sialography using a nonionic dimeric contrast medium. METHODS: A questionnaire was proposed to 90 patients who underwent parotid and submandibular sialography to reveal related symptoms as: pain, swelling, impairment to daily activities and taste alteration. Pain and swelling intensity was assessed using a visual analogue scale (VAS). RESULTS: Fifty-two out of ninety questionnaires were returned. Sialography was performed in 30/52 patients in the submandibular gland, 22/52 in the parotid gland. Pain during sialography was complained by 28/52 patients with a 2.4 mean VAS score. Pain after sialography, was reported by 17/52 patients with a 1.3 mean VAS score. Swelling was reported by 25/52 patients with a 2.4 mean VAS score; 48/52 patients returned immediately to daily activities; 8/52 complained different taste alterations. CONCLUSION: Main related symptoms for submandibular and parotid sialography are pain and swelling, spontaneously resolving after 24-48 hours in most of cases. The statistical analysis also demonstrated in patients who underwent submandibular sialography the onset of pain during the procedure is significantly related to an increase of pain after the examination. Thus in patients, who referred severe pain during sialography, antiinflammatory drugs are recommended to control the onset of pain after sialography.

A rare case of pedunculated bronchial hemangioma.

We describe a rare case of pedunculated endobronchial hemangioma observed in a 60-years-old patient complaining of chronic productive cough and accessional dyspnea which had been progressively worsening over 20 years. The lesion was first noticed at fiberoptic bronchoscopy; then computed tomography scan was performed and integrated with tridimensional reconstruction techniques. Pathology showed the picture of a vascular neoplasm, compatible with capillary hemangioma. The lesion was submitted to laser-assisted endoscopic removal in order to relieve the obstruction, leading to remission of symptoms.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ): run dental management designs and issues in diagnosis.

Recently, jawbone osteonecrosis has been largely reported as a potential adverse effect of bisphosphonate (BP) administration. Because of the peculiar pharmacokinetic and pharmacodynamic features of the BF (mainly for i.v. administration), their efficacy and large use, some major issues have to be taken into account extendedly both by oncologists and by dentists: 1) therapeutic dental protocol for patients with diagnosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ); 2) dental strategies for patients in former or current i.v. BF treatment and in absence of BRONJ signs; 3) strategies for patients before i.v. BF treatment. Clinical features and guidelines for the management of this condition have been investigated and reported, sometimes with unclear indications; hence, on the basis of the literature and our clinical experience, major end points of this paper are providing our run protocols for the issues above described and, finally, focusing on a crucial, but not extensively investigated point: the early and correct diagnosis of BRONJ versus metastatic jaw lesions in cancer patients.

Sialodochoplasty in the treatment of salivary-duct stricture in chronic sialoadenitis: technique and results.

PURPOSE: This study was undertaken to investigate peroral balloon angioplasty of salivary-duct strictures (sialodochoplasty) in chronic sialadenitis, analysing the technique, results and limitations. MATERIALS AND METHODS: Nine patients underwent sialodochoplasty: seven for Stensen's-duct strictures and two for Wharton's-duct strictures. One patient had a double stricture of Stensen's duct and another a salivary stone associated with a Wharton's-duct stricture. All patients were subjected to preliminary sialography to evaluate stricture site, length and grade. Sialodochoplasty was performed after local anaesthesia and progressive dilation of the salivary-duct orifice. RESULTS: The stricture was successfully dilated in 7/9 patients. The stricture was unchanged after dilatation in one patient, and in another, it recurred after 13 months. In the patient with a double stricture of Stensen's duct, one was resolved and the other was only partially dilated, with significant symptom improvement. One patient developed a new episode of sialadenitis after 3 months, which resolved with medical therapy. Five out of seven patients were asymptomatic at follow-up. CONCLUSIONS: Sialodochoplasty is an effective procedure in the treatment of salivary-duct strictures, improving symptoms in the majority of patients. The procedure is repeatable and can be proposed as a first-line treatment for symptomatic salivary-duct stricture.

MRI findings in lingual venous malformations.

OBJECTIVES: To describe the plain and enhanced MRI findings of lingual venous malformations and to discuss the importance of contrast medium in the differential diagnosis of high intensity lesions of the tongue on T(2) weighted images. METHODS: The clinical records and MR images of eight patients affected by a lingual venous malformation were retrospectively reviewed. Patients presented with a palpable submucosal bluish-red soft mass in the tongue. MRI examinations were performed on a 0.5 T superconducting unit. Plain and enhanced SE (spin echo) T(1) weighted and FSE (fast spin echo) T(2) weighted images were acquired in axial, sagittal and coronal planes. Axial SPGR (spoiled gradient recalled echo) T(1) weighted images were also obtained before and after intravenous (i.v.) injection of paramagnetic contrast medium. RESULTS: Five of eight venous malformations were located at the tip of the tongue. The other three involved the whole tongue and had an extralingual extent; two extended into the submandibular space and one into the glossoepiglottic valleculae. The largest diameter ranged from 2.5 cm to 8 cm. All lingual venous malformations presented as lobulated masses that were slightly hyperintense or isointense on T(1) weighted images and highly hyperintense on T(2) weighted images with respect to normal tongue and/or surrounding muscles. They showed a slow and homogeneous filling following iv injection of contrast medium. Millimetre-sized hypointense foci and linear hypointense strands were sometimes noticed, which were owing to phleboliths, flow void or septation. CONCLUSION: Knowledge of MRI findings of lingual venous malformations is useful for differential diagnosis with other high intensity lingual lesions on T(2) weighted images. This discrimination is achievable using iv paramagnetic contrast medium.

Isolated hydatid disease of the spleen: CT findings in 4 patients and differential diagnosis.

AIM: To report our experience with four cases of isolated hydatid disease of the spleen studied by spiral Computed Tomography (CT) and to review the literature with special attention to the differential diagnosis with other focal lesions of the spleen. MATERIALS AND METHODS: The spiral CT images and clinical records of four patients (1 man, 3 women; age range 26-45 yrs) affected by isolated hydatid disease of the spleen were retrospectively evaluated. None of the patients had a history of hydatid disease. All the patients were evaluated by plain and enhanced spiral CT of the abdomen. All patients underwent preoperative chest X-ray and surgery; all surgical specimens were studied by histology. RESULTS: Spiral CT depicted all the hydatid lesions of the spleen. It showed the location, size, low density of their content without enhancement after iv contrast medium injection, the possible presence of daughter cysts, the appearance of the wall with calcifications, and excluded the presence of complications. The preoperative chest X-ray was negative for focal pulmonary lesions in all cases. Pathology confirmed the diagnosis of hydatid disease in all cases. CONCLUSIONS: According to our results and to the literature, spiral CT plays an important role in the pre-surgical evaluation of patients with hydatid disease of the spleen, and provides useful information for differentiating the disease from other isolated cyst-like lesions of the spleen.

Intra-articular osteoid osteoma: diagnostic imaging in three cases.

PURPOSE: To report our experience pertaining to three cases of intra-articular osteoid osteoma assessed by means of integrated imaging and review of literature. MATERIALS AND METHODS: Medical records, radiologic and nuclear medicine findings pertaining to three cases of intra-articular osteoid osteoma were retrospectively evaluated and compared with those of surgery. All the patients (2 males, one female; age range 8-38 ys) affected by intra-articular osteoid osteoma respectively of the elbow, tibio-talar joint and hip were evaluated by means of radiographic examination and Magnetic Resonance Imaging (MRI). SE T1-w and T2-w, GRE T2*-w, GRE 3D T1-w and STIR pulse sequences were used and axial, coronal and sagittal images were acquired. Two patients underwent CT scan. One patient underwent skeletal scintigraphy. All the patients underwent surgery. RESULTS: In 2 out of 3 cases plain radiography allowed the radiologist to suspect the presence of the lesion. In the remaining one, plain radiography failed to detect both the nidus and the perilesional osteosclerosis; nevertheless, a small osteochondral erosion of the humeral condyle suggested the presence of joint inflammation, thus leading to further investigation. CT scan well depicted the presence of the nidus and, in one case, the presence of joint effusion. MRI was always able to detect the nidus, which presented as lesion of low to intermediate signal in T1-w images, low signal in the T2-w images in one patient and high signal in the remaining two; in these latter STIR images showed high intensity nidus and edema of neighbouring cancellous bone. Furthermore, in all patients MRI clearly depicted joint effusion. Skeletal scintigraphy demonstrated both the lesion and the inflammatory involvement of neighbouring soft tissue. In all patients histologic specimen confirmed the diagnosis of osteoid osteoma with joint inflammation and synovitis. CONCLUSIONS: According to our results and literature data the pre-surgical diagnosis of osteoid osteoma is very difficult to achieve. Indeed, only the combination of clinical information and radiologic and nuclear medicine findings enables the radiologist to make the right diagnosis.

Interventional treatment of sialoliths in main salivary glands.

PURPOSE: The aim of our study was to demonstrate the effectiveness of interventional radiology in the treatment of sialolithiasis, as the first-choice treatment for the removal of stones located in the middle and proximal tracts of the main salivary ducts, and to assess its limitations and contraindications. MATERIAL AND METHODS: Between February 1998 and May 2001 eleven interventional removals of sialoliths were performed for recurrent obstruction of the main salivary duct associated with chronic sialadenitis. Patients were selected on the basis of a preliminary sialogram, designed to determine the location and size of the stone. Exclusion criteria were location of the stone in the gland hilum or intraglandular stone, maximum stone diameter >20% of the duct calibre, signs of adherence of the stone to the duct wall. Stone removal, performed after obtaining informed consent, involved administering antibiotic therapy and local anaesthesia, and dilatating the duct ostium to enable introduction of the basket catheter. The basket was then advanced along the duct under fluoroscopic guidance and suitably manoeuvred so as to capture and extract the stone. On completing the procedure a sialogram was taken to ensure the complete patency of the duct. Patients were prescribed a short course of antibiotics and were followed up at 1, 3 and 6 months. RESULTS: In 10/11 patients the stone was located in Wharton's duct and in 1/11 in Stensen's duct. Removal of the calculus was successful in 10/11 patients; in 2 of these it was necessary to reintroduce the basket after extraction of the stone, in order to eliminate small stone fragments and salivary sand; in 1 patient a preliminary balloon-catheter sialoplasty was performed prior to the procedure to dilatate a distal stenosis caused by chronic sialadenitis; in 3 patients it was necessary to make a small incision in the orifice to introduce the dilator. Removal of the sialolith was unsuccessful in 1/11 of the patients treated, as it proved impossible to capture the calculus, even after repeated attempts. 8/11 patients reported pain during the procedure and swelling in the gland region immediately after the procedure, which resolved spontaneously within 24-48 hours. 9/11 patients remained asymptomatic in the follow-up; only 1/11 patients experienced a recurrence of sialadenitis after a short time, with pus secretion, which resolved with antibiotic treatment. CONCLUSIONS: The interventional removal of sialoliths in the salivary glands is an effective alternative to the conventional treatment of obstructive diseases of the glandular ducts.

Analysis of radioactive pollution in the Gulf of Palermo.

PURPOSE: Sea water represents more than three quarters of the whole world. The radioactive fall out caused by nuclear experiments, radioactive drosses from nuclear power plants and other pollution sources, are able to contaminate the world ecosystems, and especially the sea water. The aim of this work is the evaluation of a possible radioactive pollution in the Gulf of Palermo. MATERIAL AND METHODS: The Gulf of Palermo was divided into 5 homogeneous hydrological parts, in which fish and water were collected. The dosage of 131I e del 137Cs was mainly assessed because they have a long half-life and their presence in the water can be due to nuclear accidents but also to a wrong removal of the waste materials of nuclear medicine procedures; the other radioisotopes assessed (144Ce, 106Rh, 140La) are due only to nuclear fall-out. Gamma spectrometry technique was used for the evaluation of the radioisotopes' concentration after an adequate treatment of the samples. RESULTS AND CONCLUSIONS: The concentration of the examined radionuclides was below the instrumental capability apart from the 137Cs, whose dose was increased, and can be due to nuclear accidents and explosions. The radionuclide levels detected do not determine a higher risk than normal for the population's health even regard the eatablity of ittical species.