Traumatic Pseudoaneurysms of the Head in War Time: Report of Two Unusual Cases.

Either intracranial or extracranial pseudoaneurysms due to penetrating head injuries with gunshot are very rare entities. As the pseudoaneurysms of the superficial temporal artery are represented commonly with a pulsating mass lesion beneath scalp, the intracranial pseudoaneurysms are represented with symptoms including decreased conscious level, seizure, or focal neurological deficits. Here, two patients with combat related pseudoaneurysms are reported; one was in distal cortical branch of anterior cerebral artery and one was in superficial temporal artery. Both of the cases were victims of Libyan war. One was admitted with a swelling in his scalp and a pseudoaneurysms on parietal branch of superficial temporary artery diagnosed with computed tomography; and the other was incidentally diagnosed on distal cortical branch of anterior cerebral artery during operation for removal of an intracranial bullet. Both of the aneurysms treated with surgical excision without any complication.

A dilemma at gray scale thyroid ultrasound: microcalcification or not? Differentiation with Acoustic Radiation Force Impulse Imaging-Virtual Touch Imaging.

AIMS: To evaluate the capacity of virtual touch imaging (VTI) of the acoustic radiation force impulse (ARFI) techniquein the differential diagnosis of micro-echogenicities in thyroid nodules. MATERIAL AND METHODS: The study comprised 28patients. Gray scale and ARFI displacement maps were used during ultrasound examination.In the same session, fine needleaspiration biopsy (FNAB) samples were obtained from the dominant nodule hav-ing micro-echogenicities. Two radiologists blinded to the FNAB results and clinical data of the patients evaluated these images and rated ARFI echogenicities according to the degree of shining points on the displacement maps and classified them as isohypoechogenic, isohyperechogenic, and obvious hyperechogenic. To differentiate between benignancy and malignancy, "a new sign" was defined as follows: in the ARFI maps obtained by VTI, iso-echogenic or hyper-echogenic appearance of micro-echogenic foci was evaluated as benignancy and hypo-echogenic appearance of micro-echogenic foci was evaluated as malignancy. RESULTS: The FNAB results indicated 14 cases and benign nodules in the other 14 cases. Interobserver agreement between the two radiologists was highly significant for the classification of the micro-echogenic foci (Kappa=0.659, p<0.001). When we reclassified the hyperechoic and isohyperechoic foci as "benign" and isohypoechoic foci as "malignant", the interobserver agreement between the two radiologists increased (Kappa=0.772, p<0.001). The evaluation of the first and second radiologists were highly concordant with the gold standard pathology results (Kappa=0.786, p<0.001 and Kappa=0.714, p<0.001, respectively). CONCLUSIONS: ARFI method with specific VTI features could be a very useful tool in the differentiation of malignant microcalcifications in thyroid nodules.

Gamma Knife treatment of low-grade gliomas in children.

BACKGROUND: Low-grade gliomas have good overall survival rates in pediatric patients compared to adults. There are some case series that reported the effectiveness and safety of Gamma Knife radiosurgery, yet they are limited in number of patients. We aimed to review the relevant literature for pediatric low-grade glial tumors treated with stereotactic radiosurgery, specifically Gamma Knife radiosurgery, and to present an exemplary case. CASE DESCRIPTION: A 6-year-old boy was admitted to clinic due to head trauma. He was alert, cooperative, and had no obvious motor or sensorial deficit. A head CT scan depicted a hypodense zone at the right caudate nucleus. The brain magnetic resonance imaging (MRI) depicted a mass lesion at the same location. A stereotactic biopsy was performed. Histopathological diagnosis was low-grade astrocytoma (grade II, World Health Organization (WHO) classification, 2007). Gamma Knife radiosurgery was applied to the tumor bed. Tumor volume was 21.85 cm(3). Fourteen gray was given to 50% isodose segment of the lesion (maximal dose of 28 Gy). The tumor has disappeared totally in 4 months, and the patient was tumor-free 21 months after the initial treatment. DISCUSSION AND CONCLUSION: The presented literature review represents mostly single-center experiences with different patient and treatment characteristics. Accordingly, a mean/median margin dose of 11.3-15 Gy with Gamma Knife radiosurgery (GKRS) is successful in treatment of pediatric and adult low-grade glial tumor patients. However, prospective studies with a large cohort of pediatric patients should be conducted to make a more comprehensive conclusion for effectiveness and safety of GKRS in pediatric low-grade glial tumors.

Oncocytoma of the parotid gland complicated by hypercalcemia: a case report.

Salivary gland tumors are rare head and neck tumors. The majority of these tumors are benign and include pleomorphic adenoma, monomorphic adenoma, oncocytoma, and papillary cystadenoma lymphomatosum. Oncocytoma is a rare benign salivary gland tumor. In this article, we report a 69-year-old female case of oncocytoma of the right parotid gland in whom fine needle aspiration cytology result was reported as a Warthin's tumor.

Typical MDCT Angiography Findings of an Unusual Cutaneous Neoplasia; Masson Tumor.

BACKGROUND: Intravascular papillary endothelial hyperplasia (IPEH), also known as masson tumour, is a lesion composed of proliferating endothelial cells. CASE REPORT: In this article we explained clinical, histological and radiological features of IPEH involving the scalp, localized on the left side of the skull and in the periauricular region. CONCLUSIONS: Radiologically, intravascular papillary endothelial hyperplasia could be misdiagnosed as malignant or benign vascular tumour. On cross-sectional imaging it is useful demonstrating the extremely vascular component of IPEH. But IPEH has no specific radiologic features that we can use to differentiate from the aforementioned lesions. Due to that, histopathological examinations are needed to diagnose IPEH.

The value of ultrasound elastography-guided fine-needle aspiration biopsy of thyroid nodules in reducing nondiagnostic results.

Fine-needle aspiration biopsy (FNAB) is an important tool for diagnosing thyroid nodules; however, nondiagnostic results are a problem with FNAB. We evaluated the optimal targeting area of thyroid nodules for FNAB by using ultrasound elastography (USE) to reduce nondiagnostic results. Between December 2008 and November 2010, 96 consecutive prospective subjects scheduled to undergo FNAB were included in the study. Initially, the dominant nodule was evaluated with ultrasound, after which USE was performed. FNABs were performed from both the red (hard foci) and the green (soft foci) color-coded areas using the same technique according to the USE maps. The cellularity of all the specimens was evaluated cytopathologically. Nondiagnostic results from the red and green color-coded areas were compared by Chi-square test. In the red color-coded regions on USE images, the diagnostic rate was 76.0 % and the nondiagnostic rate was 24.0 %. In the green color-coded regions on USE images, the diagnostic rate was 53.1 % and the nondiagnostic rate was 46.9 %. Seven nodules were malignant and 89 were benign. Nondiagnostic results were significantly fewer in red color-coded regions (P = 0.0001). USE can help to enhance the cellularity of biopsy of thyroid nodules to reduce the nondiagnostic results if the red color-coded (less elastic or hard) areas are preferred.

Ultrasound elastography for the differential diagnosis of nipple retraction.

PURPOSE: Nipple retraction is difficult to diagnose radiologically and extremely worrisome for patients. It occurs most commonly due to pathologies such as previous mastitis or an infiltrative malignancy. With this in mind, the goal of this study was to differentiate benign from malignant lesions of nipple retraction, using the differential characteristics of retroareolar area stiffness, observed by means of the new technological modality of ultrasound elastography (USE). MATERIALS AND METHODS: Nineteen unilateral nipple retraction cases, including five cases of mammary ductal carcinoma posteriorly infiltrated the areola, two cases of Paget disease, and 12 cases of mastitis, were investigated. Imaging findings [gray-scale ultrasound (US) and USE analyses of the breasts' nipple-areolar complex], pathological evaluation, and the results of 4 years of follow-up treatment were obtained. The recorded images were evaluated by two different radiologists, and all data were analyzed statistically. RESULTS: Statistical analysis showed that there was a strong correlation between the two radiologists' evaluations. The US images were not diagnostic for either the malignant or benign conditions. The correlation between the diagnosis using US and the final diagnosis was calculated as 0.436 (p = 0.006). However, the USE images were more informative since the correlation ratio between the USE results and the final diagnosis was found to be 0.723 (p < 0.001). While the area under the concentration curve (AUC) values that were used for the diagnostic determination of the US results were inconclusive at 0.274 (p < 0.021), the AUC values for USE were significant, with a diagnostic value of 0.866 for all cases (p < 0.01). CONCLUSION: The USE modality, which is not commonly used in routine practice, has the potential to solve the problem of differentiation of nipple retraction etiologies in the near future.

Preliminary study on durability of nail as xenograft.

In reconstructive surgery, many autograft/allograft/xenograft and synthetic materials are being used for repairing congenital or acquired tissue and skeletal deformities. Compatibility of the graft or the material to the tissue, the risk or rejection, toxicity, and morbidity affect the preference. With the aim of searching the usability of human cadaver nail being used as xenograft instead of cartilage graft on small and composite defects, 60 rats were separated into 3 groups, each of which was composed of 20 rats. One hundred twenty nail samples of 1 × 1-cm size, whose epithelium tissue was shaved 2-sided, were prepared for the purpose of placing 2 of them into the back of rats. They were placed under the dorsal skin of rats as naked in the first group, as fascia-wrapped in the second group, and as amnion membrane-wrapped in the third group. It has been stated as a result of the pathologic surveys performed in 2, 4, 12, and 24 weeks from rats in all groups that all the nails were available; acute and chronic inflammatory signs that were observed in early stages regressed, and in late stages, histopathologic signs of all groups were similar. Nail has some advantages such as being cost-effective, being easy to obtain, and having less rejection risk for being composed of dead cells. Application of nail xenograft eroded 2-sided can be taken into account instead of cartilage graft in small-size areas needing support tissue.

Laryngeal reconstruction with porous high-density polyethylene.

OBJECTIVE: This study was undertaken to evaluate the use of the Medpor (Porex Surgical, College Park, GA) implant in laryngeal reconstruction and to discuss potential indications of this material in head and neck surgeries. METHOD: Twelve rabbits were used in this particular study. Laryngoplasties were performed by extracting 5 x 10-mm thyroid cartilage and replacing it with Medpor implant. Animals were sacrificed in the 1st, 2nd, and 4th weeks and 2, 6, and 9 months after implantation. The degree of fibrous capsule formation, histiocytic reaction, foreign body giant cell reaction, lymphocytic and neutrophilic reactions, vocal fold changes, and hyaline cartilage formation in the implant bed were evaluated. RESULTS: Fibrous capsule was formed around the implant in 2 weeks. Four weeks after the implantation cellular reaction in the implant bed decreased significantly. Foreign body giant cell reaction was detected only the first 2 weeks after the implantation. CONCLUSION: According to the results of this study, the Medpor implant can be safely used in laryngeal reconstruction.

Combined use of histopathology with touch smear cytology in biopsies of the larynx.

The aim of this prospective study is to evaluate the effectiveness of combined use of histopathology with cytology in biopsies of the larynx. Biopsies taken for this purpose are studied by using two different methods and the results are evaluated. One hundred and thirty-five patients with suspected malignant laryngeal lesions were examined by direct microlaryngoscopy for primary diagnosis. Each lesion was biopsied first. Subsequently touch smear cytology was obtained from the biopsies. In all cases, cytologic slides (one or two per biopsy) were screened and compared to corresponding biopsies. Lesions were categorized as benign, laryngeal intraepithelial neoplasia and malignant. Results obtained were compared with surgical samples obtained from patients who have undergone surgery. In other cases, where surgery was not applied, results of the follow-up were evaluated. In larynx biopsies the results for histopathology were as follows: sensitivity 93.9%, specificity 100% and accuracy 96.3%. The results for cytology were as follows: sensitivity 82.5%, specificity 94.5% and accuracy 87.4%. A comparison of cytologic evaluation versus histopathologic evaluation in laryngeal biopsies reveals that histopathology is superior. According to the study results, in 88.9% (120/135) of the cases the agreement between cytological and histopathological results was found. In two other cases (1.5%) cytologic evaluation contributed to the histopathologic diagnosis.

Soft tissue response of the larynx to silicone, Gore-Tex, and irradiated cartilage implants.

OBJECTIVE: The aim of the study is to compare the efficiency of three different materials (Silicone, Gore-Tex, and irradiated cartilage) used in medialization laryngoplasty. Local tissue reaction to implants in laryngeal skeleton has been examined for this purpose. STUDY DESIGN AND METHODS: In this prospective study, New Zealand rabbits were used. Different materials have been implanted in the paraglottic space of both sides of the larynx to enable a better comparison of the different materials used. Limited medialization was applied. Special care has been taken not to narrow the airway and cause breathing problems. The reaction of the tissue in this region against the materials used has been studied. Each material was implanted 14 times in total. The rabbits were killed 6 months after the implementation to study their larynx. For each material, the fibrous capsule formation, histiocyte infiltration, foreign body giant cell infiltration, eosinophil infiltration, neutrophil infiltration, and lymphoplasmacytic infiltration levels were investigated histologically. RESULTS: Best fibrous capsule formation has been observed around silicone. Allergic reactions and inflammatory responses were minimal for this material. Fibrous capsule formation was more limited with Gore-Tex. Some degree of chronic inflammatory response (in few cases) has been observed against this material. Severe allergic response was observed against irradiated cartilage, and the implant material was resorbed completely in most cases. CONCLUSION: According to histopathologic results of this study (tissue compatibility of three materials), silicone is the most suited material among the study materials for medialization. Gore-Tex can also be used for this purpose. Irradiated cartilage, on the other hand, appears not to be a suitable material for medialization laryngoplasty.

What's in a fungus ball? Report of a case with submucosal invasion and tissue eosinophilia.

Fungus balls are tangled mats of hyphae that are often found in the maxillary sinus. In approximately half of affected patients, radiologic evaluation will reveal areas of hyperdensity within soft-tissue masses. Histopathologic examination will reveal no invasion of the mucosa and no granulomatous reactions. Surgical removal is sufficient because fungus balls are not known to recur. We describe an interesting case of a sinonasal fungus ball that resembled dental filling material on radiologic imaging because of its extraordinary radiopacity. Histopathologic examination detected eosinophilic infiltration, hyphae in the submucosal tissues, and tissue necrosis.

p21, p53, and p27 Kip1 alterations in benign and malignant tumors of sinonasal epithelium.

OBJECTIVE: The goal of this study was to investigate alterations of cell cycle-related molecules, including p27, p21, and p53, in inverted papillomas (IPs) and squamous cell carcinomas (SCCs) of the sinonasal epithelium. Study design Sixteen IPs and 6 SCCs of the sinonasal epithelium, surgically resected at Istanbul Faculty of Medicine, Department of Otorhinolaryngology, from 1992 to 2000 were immunohistochemically investigated (p27, p21, and p53). RESULTS: A significant decrease in p27 nuclear staining was observed for SCCs of paranasal sinus compared with inverted papillomas (P = 0.0072). In SCCs there was no association between p27 expression and the presence of keratinization and tumor grade. p21 and p53 expressions were not associated with IPs (dysplastic and nondysplastic) and SCCs. CONCLUSION: Reduced levels of p27 expression correlate with increased cell proliferation in tumors of sinonasal region. Our findings indicate that p27 immunohistochemistry can be recommended to analyze the dysregulation of cell kinetics in these tumors.

Use of polyethylene terephthalate and expanded-polytetrafluoroethylene in medialization laryngoplasty.

Various materials have been used up to the present time in vocal fold augmentation. Although silicon has been the most frequently employed, the surgical difficulties encountered in shaping, positioning and placing this material have led to a search for a more easily applicable material. In our study, we investigated the local tissue reaction to implants in the laryngeal skeleton of 10 New Zealand rabbits in which we performed medialization laryngoplasty employing polyethylene terephthalate (PETP=Dacron) and expanded polytetrafluoroethylene (e-PTFE=Gore-Tex). When the local host tissue reaction to PETP and e-PTFE were compared, PETP was found to cause significant foreign body giant cell and histiocyte infiltration localized around fibres of the implant. The greater irregularity of the fibrous capsule formed in response to PETP and the density of foreign body giant cells around the PETP fibres suggested that resorption of the implant with time would decrease the degree of medialization.

Expression of the the cyclin-kinase inhibitors p21(WAF1) and p27(Kip1) and the p53 tumor suppressor genes in adult-onset laryngeal papillomas.

Different types of human papilloma virus are known to be closely associated with laryngeal papillomas. On the other hand, the proliferation of epithelial cells is associated with various abnormalities in the mechanisms of cellular regulation. In this study, we detected the expressions of p53, p21 and p27 proteins in adult-onset laryngeal papillomas by immunohistochemical techniques. The objective of this study is to evaluate the expression of these factors in adult-onset laryngeal papillomas and to determine whether such expression is correlated with the existence of dysplastic epithelium covering the papillomas. Eighteen patients with adult-onset papillomas who were surgically treated at the Department of Otolaryngology at the University of Istanbul between January 1994 and December 1999 were included in this study. Anti-p21, -p27 and -p53 antibodies were used to perform immunostaining. Positive nuclear staining for p21 was detected in 14 of the 18 (78%) cases, especially in the parabasal layer. Also, in 78% of the cases, weak to strong immunoreactivity was observed for p27. In all cases, negative immunoreactivity was observed for p53 throughout the epithelium except for the basal and parabasal cells. A negative correlation was observed between the existence of dysplastic epithelium and p21 expression (P=0.02). In conclusion, variable p21 and p27 expression was detected by immunohistochemistry in our series of 18 cases of adult-onset laryngeal papillomatosis, and a statistically significant inverse correlation was detected between p21 expression and the existence of dysplastic epithelium covering the papillomas. Further prospective studies are warranted to determine the prognostic values of these variables and to evaluate their role in the pathogenesis of adult-onset laryngeal papillomas.