Endoscopic Endonasal Surgery for a Pterygopalatine Fossa Hydatid Cyst.

Background: Cystic echinococcosis is a manifestation of a zoonosis caused by larvae of the tapeworm Echinococcus granulosus sensu lato and pterygopalatine fossa cases are extremely rare. Clinical Presentation and Findings: A 45-year-old Caucasian female with a history of repeated surgeries for HC was referred to our center for treatment of a cystic mass of the pterygopalatine fossa. Multiorgan dissemination was noted on preoperative imaging. Interventions: An endonasal endoscopic procedure was carried over under general anesthesia and the CE completely removed. Etiology was confirmed by molecular diagnostics. Three weeks after the skull base procedure, the patient underwent a combined abdominal/urological procedure for treatment of other cysts. Conclusion: This case shows that the pterygopalatine fossa HC are amenable to surgical treatment using the endonasal endoscopic approach. Extensive preoperative workup is essential to assess the extent of the disease.

Pneumatized Crista Galli: A Histopathologic Study.

OBJECTIVE: This is the first histopathologic study that investigates the incidence of the pneumatized crista galli. STUDY DESIGN: A prospective histopathologic study. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: A total of 109 specimens of crista galli were obtained postmortem during 2018 from randomly chosen patients who died at the University Hospital Centre Zagreb and had an autopsy at our Department of Pathology and Cytology. Specimens were surgically resected during the autopsy and then fixed, decalcinated, dehydrated, and embedded in paraffin. All slides were cut into 5-µm-thin sections and stained with a standard method (hematoxylin and eosin) for light microscope analysis. Specimens were histopathologically analyzed for the existence of pneumatization inside crista galli. The criterion to declare a specimen pneumatized was the presence of mucosa inside the cavity. RESULTS: Pneumatized crista galli was found in 5 of 109 specimens (4.59%). In 5 of 5 cases (100%) of pneumatized crista galli, there was evidence of chronic inflammation. CONCLUSION: We found that the incidence of pneumatized crista galli is significantly lower in our histopathologic study in comparison with the majority of previous radiologic studies. Our study also found that all 5 specimens with pneumatized crista galli had chronic inflammation in the mucosa, which is a considerably higher incidence than in the previous studies (7.7%-44%). Due to the emerging evidence of pneumatized crista galli being of clinical importance, we suggest that a larger study be conducted before the results are generalized to the general population.

Metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma.

OBJECTIVE: To investigate possible metastasis predictors for neck sublevel IIb in papillary thyroid carcinoma (PTC) with lateral neck metastasis and to determine the reliability of preoperative ultrasound-guided fine-needle aspiration biopsy (FNAB) as a method of detecting positive lymph nodes in sublevel IIa in comparison with the finding of definitive pathohistological analysis. DESIGN: Prospective study with patients with proven lateral neck metastases from PTC at the time of initial diagnosis. All patients had total thyroidectomy, central neck dissection (level VI) and selective neck dissection (levels II-V). Potential predictive factors for the occurrence of metastasis in sublevel IIb were analysed. Sensitivity and specificity tests were used to determine the reliability of preoperative ultrasound-guided FNAB. Patients were monitored for recurrence for at least ten years. SETTING: Single-centre study. PARTICIPANTS: Study included 53 patients with proven lateral neck metastases from PTC at the time of initial diagnosis. RESULTS: Predictive factors for the occurrence of metastasis in sublevel IIb that have reached statistical significance are positive sublevel IIa, number of positive lymph nodes and positive levels IIa + III + IV + V. None of the patients who fulfilled predefined criterion for minimum 10-year follow-up had local recurrence in operated lateral levels. CONCLUSION: Highest clinical significance has positivity of sublevel IIa. Therefore, it is necessary to prove or exclude metastasis in sublevel IIa, preoperatively or intraoperatively, to decide whether to include sublevel IIb in dissection. Preoperative ultrasound-guided FNAB is a reliable method for the detection of positive lymph nodes in sublevel IIa in comparison with the definitive histopathological analysis.

Role of matrix metalloproteinases and their inhibitors in the development of cervical metastases in papillary thyroid cancer.

OBJECTIVE: To investigate the role of matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) in the development of cervical metastases in papillary thyroid cancer. Our hypothesis is that level of expression of MMPs and TIMPs is associated with the development of cervical metastases and the pattern of metastatic process in papillary thyroid cancer. DESIGN: This research retrospectively investigates the expression of MMP-1, -2 and -9 as well as TIMP-1 and -2 in papillary thyroid carcinoma tissue. Tissue specimens were immunohistochemically treated with primary monoclonal antibodies against MMP-1, MMP-2, MMP-9, TIMP-1 and TIMP-2. SETTING: Single-centre study. PARTICIPANTS: In total, samples of 159 patients were analysed. In all patients, total thyroidectomy was performed, whereas 102 patients underwent selective neck dissection of either central (level VI) or lateral neck (level II-V). Subjects were divided into four groups. MAIN OUTCOME MEASURES: Matrix metalloproteinases and TIMPs expression values were analysed in each group, and groups were compared to each other. RESULTS: Total number of patients was 159, of which 125 were women and 34 men. Comparing expression levels of MMPs and TIMPs in metastatic (study groups) and non-metastatic (control group), papillary thyroid carcinomas yielded significant differences in MMP-1 and TIMP-1 expression levels, where the highest expression values were found in the group with metastasis in lateral neck. Expression levels of MMP-2, MMP-9 and TIMP-2 did not differ statistically significant among the groups. CONCLUSION: Elevated expression of MMP-1 and TIMP-1 in tumour tissue can be considered a predictive factor for the development of metastases.

Spontaneous Resolution of Fourth Branchial Fistula Following Thyroid Surgery: Case Report.

Fourth branchial pouch anomalies represent one of the rarest types of all branchial apparatus anomalies. They appear in the first lifedecade in a form of recurrent left-sided neck masses which demands surgical treatment. Accidental finding, appearance later in life and spontaneous resolving are really rare. We present a case of a 43-year-old man with accidental finding of asymptomatic fourth pouch cyst and fistula following follicular thyroid cancer surgery. The day after the surgery, suction bottle was filled with little white crumbs and the wound started to suppurate. Barium swallow revealed the presence of a fistulous canal that arose from the left pyriform sinus. Meanwhile, the pathologist confirmed the presence of a lateral neck cyst within this thyroid lobe. The patient was operated on but fistulous canal was not visualized. In the meantime, wound discharge ceased spontaneously. At 1-year follow up, the patient was still well and free from any symptoms. These anomalies may manifest not only in childhood but may stay asymptomatic for a long time. It seems that the fistula can resolve spontaneously and that conservative approach is an alternative to multiple surgical procedures.

Transoral removal of a large parapharyngeal space neurofibroma with the Harmonic Scalpel.

We report the case of a 19-year-old man with neurofibromatosis type 1 who presented for evaluation of odynophagia, left-sided hemiparesis, multiple café au lait spots all over his body, and numerous subcutaneous and cutaneous neurofibromas. Imaging revealed the presence of two large neurofibromas-a 60 × 50 × 35-mm tumor in the left parapharyngeal space and an intradural tumor measuring 25 mm in diameter. We removed the larger tumor via a transoral route with the Harmonic Scalpel. The size of this tumor far exceeded the size of any other reported tumor removed in this manner. Various approaches to the parapharyngeal space have been described in the literature. To the best of our knowledge, this case represents the first report of a transoral removal of a huge parapharyngeal space neurofibroma with a Harmonic Scalpel.