Tuberculosis of the manubriosternal joint and concurrent asymptomatic active pulmonary tuberculosis in a patient presenting with a chest wall mass.

A 62-year-old woman presented to our hospital with an anterior chest wall swelling. Computed tomography (CT) and magnetic resonance imaging showed findings consistent with an infectious arthritis of the manubriosternal joint, and CT images also demonstrated multiple centrilobular nodules in both lungs, suggesting an infectious bronchiolitis. A CT-guided fine needle aspiration of a presternal mass yielded growth of Mycobacterium tuberculosis. Bronchoalveolar lavage confirmed an active pulmonary tuberculosis. Septic arthritis of the manubriosternal joint is exceedingly rare.

Autogenous rib grafts for reconstruction of the manubrium after resection: technical refinements and outcomes.

OBJECTIVE: Sternal reconstruction after resection is essential for restoring the rigidity of the chest cavity. However, no consensus has been reached regarding the most physiologic or efficacious material for this procedure. We present our clinical experience with autogenous rib grafts for reconstruction of the manubrium after resection and discuss the refinements in this procedure. METHODS: Twelve consecutive patients with a confirmed diagnosis of a primary neoplasm in the manubrium between March 2003 and August 2013 were analyzed retrospectively. All patients underwent manubrium resection and immediate reconstruction with autogenous rib grafts. RESULTS: No cases of perioperative mortality were noted. The median operation time was 129 minutes. One patient experienced mild paradoxical movement; the other patients recovered well without any complications. The median follow-up period after surgery was 69 months. Two patients died. One patient with chondrosarcoma died as a result of cardiac disease 26 months after surgery and another patient with non-Hodgkin lymphoma died as a result of local recurrence 6 months after surgery. Computed tomographic scans for the other 10 patients have shown neither dislocation nor abnormality of the transplanted ribs; moreover, no absorption of the grafts or recurrence was noted. None of the patients required prescription analgesics for the pain at the donor site at the 3-month follow-up visit. CONCLUSIONS: This case series demonstrates the successful use of autogenous rib grafts in the reconstruction of the manubrium after resection. We consider that the reconstruction technique is a safe and effective alternative to a complex problem.

Relationship of the Medial Clavicular Head to the Manubrium in Normal and Symptomatic Degenerated Sternoclavicular Joints.

BACKGROUND: Clavicular prominence is common in patients with symptomatic degenerative sternoclavicular arthritis. It is unclear if this is caused by enlargement or subluxation of the clavicle. The aim of this report is to describe a reproducible measurement technique to evaluate the relationship of the medial clavicular head to the manubrium. METHODS: One hundred normal sternoclavicular joints, twenty-five sternoclavicular joints with symptomatic degenerative arthritis, and twenty-five non-symptomatic sternoclavicular joints on the contralateral side were studied with three-dimensional (3D) reconstruction with use of computer modeling. The greatest width (anterior-posterior distance) and height (superior-inferior distance) of the clavicle in the sagittal plane were measured, and the positions of the anterior and superior borders of the medial clavicle and their distances to the frontal and axial planes, respectively, were evaluated. The ratio of the anterior-posterior distance to the anterior-frontal plane distance was measured to evaluate the anterior-posterior position of the clavicle and the ratio of the superior-inferior distance to the superior-axial plane distance was measured to evaluate its superoinferior position. If the ratio was not in the 95% normal range, the clavicle was defined as subluxated. The reproducibility of this technique was evaluated on the basis of the interobserver and intraobserver reliability. RESULTS: This technique showed good interobserver and intraobserver reliability. The mean anterior-posterior and superior-inferior distances were significantly larger in association with symptomatic sternoclavicular arthritis than in the normal sternoclavicular joints (p < 0001). The clavicle was subluxated anteriorly in twenty-two of the twenty-five cases of symptomatic sternoclavicular arthritis, but it was not subluxated superiorly. CONCLUSIONS: The medial clavicular head in patients with degenerative sternoclavicular arthritis is significantly larger than it is in the normal population, and it is usually subluxated anteriorly.

"Hidden" bone metastasis from thyroid carcinoma: a clinical note.

The (131)I-iodide ((131)I) whole-body scan, for thyroid carcinoma is at times difficult to interpret. In a diagnostic whole body (131)I scan of a patient with follicular carcinoma, a posterior skull lesion was partially hidden by overlapping facial structures. On lateral head view, the abnormality was clearly evident. SPECT/CT and MRI showed the lesion originated in the occipital bone and had enlarged into the posterior fossa. The mass was surgically removed and the patient received (131)I therapy for residual tissue. The study demonstrates a pitfall in the reading of two dimensional radioiodine images which can be overcome by SPECT or lateral imaging.

Debut clínico de cáncer prostático con metástasis en el manubrio esternal / Clinical debut of a prostatic cancer with metastasis in manubrium sterni

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[A unique reconstructive technique in a young patient after manubrial recestion in grade II chondrosarcoma]. / Egyedi mutéti megoldás fiatal férfi betegen manubriumresectio után Grade II chondrosarcomában.

OBJECTIVE: Approximately 30% of malignant, primary bone tumors are chondrosarcomas, which occur on the anterior chest wall most frequently. Patients who are treated with adequate surgical intervention recover well, 10 years survival rate is 97%. Besides the aesthetic outcome, preservation of breathing and loading are crucial. METHODS: Authors present a case of a 44-year-old male patient who worked as a sport masseur operated on Grade II chondrosarcoma of the manubrium. Concerning the age of the patient, an immediate reconstruction was carried out. The involved part of the sternum was resected with wide margins. The reconstruction was performed with Dual Mesh covered by a pedicled left sided pectoral major muscle. As a unique technique, authors used the tendons of the semitendinous and gracilis muscles to fix both claviculas together to give the proper stability and function for the shoulder girdle. RESULT: After an uneventful postoperative period the patient had a fast recovery. CONCLUSION: There are no data in the literature for such a method of fixation of the anterior chest wall. The method is suggested by the authors.

Estimation of age from human sternum: an autopsy study on a sample from South India.

Age estimation is one of the main parameters in the evaluation of skeletal remains in forensic anthropology casework. The present investigation is an attempt to study the fusion of manubrium and xiphoid process with mesosternum in 118 sterna (67 males and 51 females) of known age obtained during autopsy in South Indian population. The male samples were aged between 25 and 74 years and the females between 20 and 80 years. The fusion is studied to derive standards for the estimation of age from sternum. The results indicate that, with advancing age, the proportion of sternum with fusion of manubrio-mesosternal and mesosterno-xiphisternal junctions increases in males and females. A larger proportion of sterna showed fusion of mesosterno-xiphisternal junction than manubrio-mesosternal junction in different age groups. Fusion of manubrio-mesosternal and mesosterno-xiphisternal junctions was proportionately commoner in males than females. None of the sterna aged below 30 years showed fusion of mesosterno-xiphisternal junction. Nonfusion of mesosterno-xiphisternal junction was reported till the age of 48 years in males and 46 years in females. Manubrio-mesosternal junction was observed to be very variable with regard to fusion status as the joint remained unfused even in the elderly ages. Based on the variability of the fusion of manubrio-mesosternal and mesosterno-xiphisternal junctions observed in the study, it can be concluded that the sternum alone is not reliable for estimation of age in South Indian population.

Manubrial resection and anterior mediastinal tracheostomy: friend or Foe?

OBJECTIVES/HYPOTHESIS: To review our experience with manubrial resection and anterior mediastinal tracheostomy and formulate operative guidelines to improve the surgical outcome. STUDY DESIGN: Retrospective study. METHODS: Between January 1980 and June 2010, we performed 38 manubrial resections. The indications of the procedure, reconstructive methods, and operative outcomes were analyzed. RESULTS: Fourteen patients had tumors of the hypopharynx/cervical esophagus, eight had parastomal recurrences of laryngeal tumor, four had recurrent esophageal tumors, four had postirradiation sarcoma, four suffered from subglottic/upper tracheal tumors, three had thyroid malignancy, and the remaining patient had tumor recurrence at the previous tracheostomy site. The hospital mortality rate was 5.3% due to bleeding from major vessel erosion. The mean length of the tracheal stump was 5.4 cm, of which 81.6% required relocation inferior to the innominate artery for construction of the mediastinal tracheostomy. Among the different reconstructive methods for the pharyngoesophageal defects, the anastomotic leakage rate was 17.6%, the majority of which required exteriorization followed by second stage reconstruction. The long-term tracheostomy stenosis rate was 47.4%, the risk of which was significantly increased by anastomotic leakage and necrosis of distal trachea. The use of a pectoralis major flap was shown to protect against this complication. The overall survival was 80.6% at 1 year and 55.6% at 5 years after surgery. CONCLUSIONS: With attention to operative details, manubrial resection and anterior mediastinal tracheostomy is a safe procedure with acceptable outcome. It should be performed when indicated to facilitate tumor resection in the cervicothoracic region.

Neck circumference to thyromental distance ratio: a new predictor of difficult intubation in obese patients.

BACKGROUND: This study was performed to assess whether intubation is more difficult in obese patients and to assess the ability of a new index: the ratio of the neck circumference to thyromental distance (NC/TM), to predict difficult intubation in obese patients. METHODS: The incidence of difficult tracheal intubation in 123 obese (BMI≥27.5 kg m(-2)) and 125 non-obese patients was compared. Difficult intubation was determined using the intubation difficulty scale (IDS≥5). The NC/TM ratio was calculated and its ability to predict difficult intubation in obese patients was compared with that of established predictors including high BMI, the Mallampati score, the Wilson score, NC, width of mouth opening, sternomental distance, TM, and a previous history of difficult intubation. RESULTS: Difficult intubation was more frequent in obese patients than in non-obese patients (13.8% vs 4.8%; P=0.016). Multivariate analysis revealed that the Mallampati score, the Wilson score, and NC/TM independently predicted difficult intubation in obese patients. Among these three indices, NC/TM showed the highest sensitivity and a negative predictive value, and largest area under the curve on an ROC curve. CONCLUSIONS: Difficult intubation was more common in obese patients and the NC/TM was a better method for predicting difficult intubation than other established indices.

Resection and reconstruction for primary sternal tumors.

Radical resection can offer a definitive cure of primary malignant sternal tumors, but the surgical management may be difficult because of the local aggressiveness of these tumors and a high recurrence rate. This article describes improvements in reconstruction techniques with musculocutaneous flaps that have made coverage of wide sternal defects reliable. A rigid reinforcement of the sternum can now be achieved with titanium bars and clips after a total sternectomy. Large sternal defects are safely reconstructed with a musculocutaneous flap. The completeness of the resection and the histologic grade of the tumors are the strongest survival predictors.

Multiple imaging findings in SAPHO syndrome.

SAPHO syndrome is an acronym for a clinical entity characterized by synovitis, acne, palmoplantar pustulosis, hyperostosis, and osteitis. The association of sterile inflammatory bone lesions and neutrophilic skin eruptions is indicative of this syndrome, even though not all components always coexist. We report a case of a 62-year-old female presenting with a lytic manubrial lesion. Diagnoses of metastasis or infection were initially entertained but excluded on open biopsy, and SAPHO syndrome was confirmed on additional investigation and follow-up. Striking imaging findings included intense uptake on bone scintigraphy, photopenia on white blood cell imaging, and dramatically elevated lumbar spine bone density on dual energy x-ray absorptiometry (DXA).

Medial tongue cleft associated with intraoral hamartoma--case report and review of literature.

A newborn female was referred with the following clinical symptoms: median tongue cleft, palate cleft, ankyloglosson, sublingual intraoral hamartoma and palatal intraoral hamartoma. Magnetic resonance imaging showed a subcutaneous cyst overlying the manubrium sterni. Genetic investigation (chromosome analysis) showed no aberrations and/or variations. The quick growth of the intraoral hamartoma required an excision at the age of 3 months. Under general anaesthesia the intraoral hamartoma was excised and the median tongue cleft was closed. Median tongue clefts are reported to be only associated with orofacial digital syndromes type I, II, IV and VI. If the clinical appearance is described without any association to an orofacial syndrome, the Tessier 30 cleft definition could be used as the best explanation of the symptoms. This is the first description of a combination of tongue cleft, palate cleft, intraoral hamartoma and subcutaneous cyst overlying the manubrium sterni. The clinical symptoms of this patient can be described best as a mild form of an orofacial digital syndrome type II or variation of a Tessier cleft No. 30.

[Distant metastases on acinic cell carcinoma of the parotid gland after 12 years symptom-free interval]. / Fernmetastasierung eines Azinuszellkarzinoms der Parotis nach 12-jährigem krankheitsfreien Intervall.

Acinic cell carcinoma of parotid gland as cause of distant metastases are rare. The patient was a 60-year-old woman who had in 1993 a acinic cell carcinoma of right parotid gland. Tumour can be resected through total parotidectomy with facial nerve anastomosis and modified radical neck dissection (T (3) N (2b) M (0)). Since the operation the patient has remained symptom-free without any sign of tumour recurrence. After 12 years the patient noted swelling in the region of sternum and biopsy was necessary. Histologically and immunohistochemically the diagnosis of distant metastase on acinic carcinoma of the parotid gland was confirmed.