Subglottic cysts in preterm infants: superficially located cysts versus deeply buried cysts in the mucosa.

PURPOSE: To analyze the reason for the diversity of the clinical course of subglottic cysts and discuss their pre- and coexistence with subglottic stenosis. METHODS: The medical records of patients who were treated for subglottic cysts between 2003 and 2020 were retrospectively reviewed and direct laryngoscopy videos were analyzed to assess the healing patterns of their disease. RESULTS: Of the 15 patients, 10 had a history of intubation in the neonatal period. In 11 patients, the cysts were transparent and well defined, and no recurrence of subglottic cysts occurred after the initial surgery. In four patients, the cysts were located deep in the mucosa and did not have the typical appearance of a cyst, but rather of a stenotic segment; all of them had a history of intubation and three of them required laryngotracheal reconstruction. CONCLUSION: Transparent, thin-walled superficial subglottic cysts with healthy surrounding mucosa can easily be treated with endoscopic marsupialization; however, the treatment of deep subglottic cysts can be challenging. The coexistence of subglottic cysts and subglottic stenosis is not rare. We point out the need for considering the possibility of a missed deep submucosal cyst in a seemingly refractory case of pediatric subglottic stenosis with atypical endoscopic findings and with a background history of prior intubation.

Massive pulmonary embolism presenting with hemoptysis and S1Q3T3 ECG findings.

BACKGROUND: Venous thromboembolism clinically presenting with a deep vein thrombosis or pulmonary embolism is among the most commonly seen cardiovascular syndromes. The aim of this case presentation is to emphasise the typical electrocardiographic findings that are detected with massive pulmonary embolism along with the electrocardiographic S1Q3 and S1Q3T3 accompanied by T negativity at the D3 derivation based on prevalent T negativity. CASE PRESENTATION: We present the case of an adult male who presented with a massive pulmonary embolism that was associated with tachycardia, haemoptysis and typical S1Q3T3 electrocardiographic findings. Tomographic findings showed filling defects in the two main pulmonary artery lumens, which were found to be compatible with a massive embolism. Intravenous heparin was injected (5000 IU), and low molecule weight heparin (LMWH) treatment was initiated. After two days of observation and treatment in the coronary intensive care unit, the patient was discharged for outpatient care. DISCUSSION: Massive pulmonary embolism is an urgent life-threatening clinical situation that is frequently confused with acute ST elevation myocardial infarction. The definitive diagnosis of massive pulmonary embolism was made with a computed tomography pulmonary angiogram. Electrocardiographic findings and hypoxic hypercarbia in the blood gas analysis are typical. Early diagnosis with laboratory and imaging investigations is vital in the treatment and prognosis of pulmonary embolism. CONCLUSIONS: Ventricular overload signs accompanied by ST segment elevation in electrocardiography and S1Q3 and prevalent T negativity are crucial features in terms of distinguishing between pulmonary embolism and myocardial infarction and selecting effective treatments for patients admitted to the emergency department.

Congenital Mucocele of the Nasal Dorsum: A Case Report.

Congenital nasal dorsum cysts are very rare lesions. Its differential diagnosis lies between gliomas, dermoid cysts and encephaloceles. We present a case of solitary congenital external nasal cyst with no intranasal fistulous tract connection in a newborn. Histopathologic analysis of the mass demonstrated findings consistent with an external mucocele. Total excision with external open approach provided the cure with good cosmetic outcome. This is the first report presenting an external mucocele in a newborn in the literature. External mucoceles should be kept in mind in the differential diagnosis of congenital nasal dorsum masses.

Endonasal choanal atresia repair; evaluating the surgical results of 58 cases.

BACKGROUND: Choanal atresia is the most common congenital nasal anomaly, with an incidence of 1:5000-1:8000 live births. Atresia can be seen as membraneous, bony or mixed type. When it is bilateral, it is accepted lifethreatening, therefore bilateral atresia necessitates immediate intervention. Diagnosis is confirmed by endoscopic examination and computed tomography. The absolute treatment is surgical, and different approaches have been proposed. METHODS: Herein, we describe our 15-year experience in the treatment of 58 patients of congenital choanal atresia with transnasal endoscopic approach, and we compare the efficacy of placement of an intranasal stent and applying mitomycin while endoscopic microsurgical repair. RESULTS: The study included 41 female patients (71%) and 17 male patients (29%) with congenital CA. The mean age was 3 years ranging from 10 days to 16 years. The atretic plate was bilateral in 24 patients (41%) and unilateral in 34 (59%). The most common atresia type was the mixed type with 29 patients (50%). A total of 17 patients (29%) required postoperative revision(s). Postoperative revisions were more frequent among patients with bilateral CA (50%), and with mixed CA (31%). Stenting was used additionally by surgical correction for 10 patients. After stenting, fibrosis and restenosis was seen in 7 patients (79%). Mitomycin C was applied peroperatively in 8 patients. Restenosis after mitomycin application was seen in 4 patients (50%). CONCLUSIONS: By our experience, endoscopic microsurgical repair of atresia proved to be an effective and safe procedure, results compared with adjuvant treatment modalities like stent or mitomycin C use, was not better. Restenosis was the major problem seen after surgical correction.

The relationship between positivity for COVID-19 RT-PCR and symptoms, clinical findings, and mortality in Turkey.

Introduction: This study aimed to assess the correlation between nucleic acid amplification test (real-time reverse transcription-polymerase chain reaction, RT-PCR) positivity of patients presenting with suspected COVID-19 and pneumonic infiltration consistent with COVID-19-specific pneumonia diagnosis on thoracic computed tomography (CT), with symptoms, laboratory findings, and clinical progression.Methods: The study included 286 patients (female:male 131:155; mean age, 53.3 ± 17.9 years) who were divided into two groups according to their RT-PCR test results. The symptoms, laboratory examinations, clinical findings, and thoracic CT imaging of the patients were evaluated.Results: While the physical examination, comorbidities, and total CT scores were similar between the groups, taste/smell abnormalities were observed more frequently in the PCR-positive group. The use of moxifloxacin, lopinavir/ritonavir, and tocilizumab was higher in the PCR-positive group (p = 0.016, p < 0.001, and p = 0.002, respectively). The duration of hospitalization, intensive care requirement, and mortality rate of the studied groups did not differ between the groups.Conclusions: Among patients presenting with suspected COVID-19 and pneumonic infiltration consistent with COVID-19 on thoracic CT, the symptoms, physical examination, total CT scores, duration of hospitalization, intensive care requirement, and mortality rate were similar between RT-PCR-positive and RT-PCR-negative patients. However, PCR-positive patients appeared to require more specific treatments.

Posttraumatic pseudoaneurysm of the superficial temporal artery: After paintball game.

A 20-year-old man suffered from a swelling with a painless but cosmetic problem in the right temporal region. Pseudoaneurysm of the superficial temporal artery is rare. It typically occurs after blunt trauma to the temporal region and presents as a painless, preauricular and pulsatile mass during the following 2-6 weeks. The diagnosis is made simply by physical examination and ultrasound. Surgery under local anesthesia is a very effective treatment.

Evaluation of Periarticular Soft Tissues in Patients With Juvenile Idiopathic Arthritis by Superb Microvascular Imaging and Shear Wave Elastography.

OBJECTIVES: This study aims to compare the vascularity and elasticity of periarticular soft tissues by superb microvascular imaging (SMI) and power Doppler (PD) ultrasound along with shear wave elastography (SWE) between children with juvenile idiopathic arthritis (JIA) and healthy children. PATIENTS AND METHODS: This prospective single center study, conducted between March 2018 and May 2018, included 22 children with JIA (14 males, 8 females; mean age 11.27±5 years; range, 5 to 17 years) and 24 healthy pediatric volunteers (12 males, 12 females; mean age 13±5.5 years; range, 7 to 17 years). Quadriceps tendon (QT), patellar tendon (PT), infraarticular and supraarticular soft tissue elasticities were calculated via SWE. Supraarticular and infraarticular soft tissue vascularity index (VI) were evaluated via SMI and PD. RESULTS: No significant difference was found among the mean ages of the participants in study and control groups. Mean VI of both supraarticular (8.15%) and infraarticular soft tissues (7.9%) by SMI were significantly higher in study group compared to control group (2.88% vs. 2.57%, respectively). Mean VI of both supraarticular (9.1%) and infraarticular soft tissues (8.12%) by PD were significantly higher in study group compared to control group (3.4% vs. 3.1%, respectively). Highly significant good positive correlation was found between VI values obtained with PD and SMI (r=0.9, p=0.001). There was a significant moderate positive correlation between the mean elasticity of the QT with VI of the supraarticular soft tissues by SMI (r=0.4, p=0.003). There was a significant moderate positive correlation of VI of infraarticular soft tissues by SMI with mean elasiticity of PT (r=0.42, p=0.002). CONCLUSION: Vascularity index by SMI and PD could differentiate patients with JIA from healthy subjects. The SWE examination of tendons and soft tissues did not show any significant difference among patients with JIA and healthy subjects.

Clinical and radiological evaluation of cherubism: A rare case report.

Cherubism is a rare, non-neoplastic, genetic disorder, characterized by painless bilateral swelling of the jaws. A 5-year-old girl presented with a painless, bilateral symmetrical swelling of both mandible and maxilla. Intraoral examination revealed malocclusion with displacement of teeth and expansion of the alveolar ridges. There was a bilateral expansion of the jaws. In conclusion, cherubism is a genetic disorder that has non-neoplastic bone lesions that affect the jaws. If there is a functional or esthetic problem, it should be treated surgically. The surgical treatment is usually delayed until after puberty.

Unilateral Alar Ligament Injury: Diagnostic, Clinical, and Biomechanical Features.

BACKGROUND: Isolated unilateral alar ligament injury (ALI) is a very rarely diagnosed condition, with only 9 cases reported in the literature. The purpose of this study is to determine clinical, diagnostic, and biomechanical features of unilateral ALI. METHODS: A total of 6 patients diagnosed with ALI were included in this series. The hospital records and radiologic imaging of admission and follow-ups were investigated retrospectively. RESULTS: Rotation of the neck and/or hyperflexion was always present as a mechanism of injury. The patients were neurologically intact. All patients presented with mild neck pain aggravated by head rotation. On computed tomography (CT) scans, the dens was observed to be displaced to the opposite side. Magnetic resonance imaging (MRI) showed a widened lateral dens-atlas space with high signal intensity. All patients underwent lateral flexion-extension CTs for the confirmation of craniovertebral junction (CVJ) stability. The patients were treated with hard collars. The follow-up MRI of 3 patients obtained at the third month showed normal lateral dens-atlas interval and recovered ligaments. All patients were pain free after 6 months. CONCLUSIONS: Unilateral ALI appears to be more common but misdiagnosed than previously thought. Trauma mechanism consists of hyperflexion and contralateral rotation. Neck pain aggravated with rotation is the most significant clinical finding. Dens lateralization is the most important finding in CT scans. An MRI focusing on the CVJ is essential for the diagnosis. The stability of CVJ must be checked with a flexion-extension CT scan. Unilateral ALI is a stable condition and responds to conservative treatment.

Nasopharyngeal Glial Heterotopia with Intracranial Extension: A Case Report.

Nasopharyngeal glial heterotopia is a mass composed of mature neural tissue occurring outside the central nervous system and is extremely rare. The preoperative diagnosis of such a mass in the head and neck region is challenging. In this study, we report a case of a 16-month-old patient presenting with respiratory distress and snoring caused by nasopharyngeal glial heterotopia. Radiologic imaging and histopathology are obligatory for the definitive diagnosis of glial heterotopia. Preoperative evaluation of an intracranial connection is one of the most essential issues in the presence of pediatric nasopharyngeal masses. The gold standard of treatment is surgical excision. Early recognition and early surgical excision by endoscopic or external approach are crucial to relieve respiratory distress and to maintain healthy growth and development.

Magnetic resonance imaging characteristics of cardiac hydatid cyst.

PURPOSE: The purpose of this article is to describe the magnetic resonance imaging (MRI) features of cardiac hydatid disease and show the specific findings in the diagnosis of hydatic cysts. MATERIALS AND METHODS: A retrospective review of cardiac MRI records between 2015 and 2017, 7 patients (3 males, 4 females; age range: 14-74) were identified with the histologic diagnosis of cardiac hydatid disease. Cardiac MRI examinations were performed in order to investigate the cardiac cystic-solid lesion obtained via previous echocardiography (ECG) and thorax computed tomography. 1.5 Tesla magnetic field power generation capacity was used and the images were acquired with ECG trigger. RESULTS: There is variation in signal characteristics of cysts on T1-weighted and T2-weighted images. Early contrast enhancement was not observed in the any of lesions on contrast-enhanced series. In all lesions examined, peripheral contrast enhancement was observed in the late contrast enhanced series, independent from the internal structure and signal intensity. CONCLUSIONS: MRI reveals the exact anatomic location and nature of the cyst structures. Peripheral enhancement of non-enhancing lesion is very valuable for diagnosis of cardiac hydatids on MRI.

Factors Determining the Outcome in Trigeminal Neuralgia Treated With Percutaneous Balloon Compression.

OBJECTIVE: To analyze 3T magnetic resonance imaging (MRI) findings and clinical features of patients with trigeminal neuralgia (TN) who underwent percutaneous balloon compression and to determine whether these findings had an impact on prognosis of TN. METHODS: A retrospective review of patients with TN who underwent percutaneous balloon compression in the Neurosurgery Department at Istanbul Faculty of Medicine between January 1, 2007, and January 1, 2016, was undertaken. Of 105 patients who underwent percutaneous balloon compression, 27 patients who received surgical treatment for the first time for typical TN were included in the study. Follow-up data, clinical features, and 3T MRI findings were analyzed retrospectively. MRI findings and clinical features of patients with and without recurrence of TN were compared. The correlation between fractional anisotropy (FA) values and recurrence was investigated. RESULTS: During follow-up, 9 (33%) patients had recurrence. The patients with recurrence had longer duration of symptoms (P = 0.032), higher FA difference (P = 0.042), and higher FA difference rate (P = 0.023). A trend toward early recurrence was found in patients with higher FA difference rate, although this was not significant (P = 0.051, R = 0.319). CONCLUSIONS: Symptom duration was longer and microstructural changes were more apparent in patients with recurrence. In addition to age, comorbidities, and other clinical and radiographic features, symptom duration and FA values obtained with 3T MRI might be valuable information in surgical decision making.

Ectopic intrathyroidal thymus in children: Prevalence, imaging findings and evolution.

Erol OB, Sahin D, Bayramoglu Z, Yilmaz R, Akpinar YE, Ünal ÖF, Yekeler E. Ectopic intrathyroidal thymus in children: Prevalence, imaging findings and evolution. Turk J Pediatr 2017; 59: 387-394. The aim of this study was to evaluate the ultrasound (US) features of intrathyroidal ectopic thymus (IET) and demonstrate the alterations after follow-up. This study included 36 lesions of 32 patients (mean age 95 ± 58 months) diagnosed with IET. The patients underwent follow-up US examination at least 22-months without a medication or surgical intervention. A total of 36 IETs with an incidence of 0.91% were detected among 3914 thyroid ultrasound (US) examinations. The mean of anteroposterior (ap), transverse (tr), and craniocaudal (cc) diameters in the initial US examinations were 3.1±1.19 mm, 4.89±1.86 mm, and 6.45±3.92 mm respectively. All of the lesions were well-demarcated, hypoechoic to the thyroid gland, and contained uniformly distributed punctate echogenic foci. Follow-up US examinations were performed after 684±85 days. The alterations between the initial and follow-up diameters for ap and cc direction were not statistically significant. However, a significant difference (p=0.007) was found for transverse diameters and the IETs were found to be smaller at follow-up US than in the initial US. Most of the IETs were located in the left lobe (64%), middle portion (83%), and extended to a border of thyroid gland (69%) and nonspherical in shape (89%). The descriptive findings of IETs are uniform distribution of punctate echogenic foci, absence of a rim, and the presence of vessels traversing through the lesion without parenchymal displacement. Given our findings, healthcare professionals should be aware of the diagnosis of IET. Patients with an IET could be safely managed with follow-up US and any surgical treatment would not be required.

Clinical Course of Non-Traumatic Non-Aneurysmal Subarachnoid Hemorrhage: A Single Institution Experience over 10 Years and Review of the Contemporary Literature.

AIM: To report our experience with a relatively large series of patients with non-traumatic non-aneurysmal subarachnoid hemorrhage (NNSAH) to identify the prognosis associated with different bleeding patterns as well as a further diagnostic work-up to determine the underlying cause. MATERIAL AND METHODS: Between January 2004 and December 2014, 81 patients with angiography-negative non-traumatic subarachnoid hemorrhage (SAH) were treated at our institution. Diagnosis was confirmed with a typical history of spontaneous SAH and cranial computed tomography (CT) scan or lumbar puncture (LP). The patients were grouped according to the bleeding pattern on the CT scan: Group 1: Perimesencephalic (PM) SAH (n=33, 40.7%); Group 2: Non-perimesencephalic (nPM) SAH (n=41, 50.6%); and Group 3: CT-negative NNSAH (n=7, 8.6%). The clinical course, hospitalization period, and complications were noted. All patients underwent an initial four-vessel digital subtraction angiography (DSA). Cranial magnetic resonance imaging (MRI), repeat DSA investigations and spinal MRI were performed in all patients. RESULTS: The mean hospital stays were 6.3, 14.7 and 10.1 days for patient groups 1, 2, and 3, respectively. The mortality rate was 1.2% (1 patient) in our series. Repeat DSA investigations were positive in two patients (2.5%), both from Group 2 (4.9%). Cranial MRI revealed 100% negative results. Spinal MRI revealed positive results in three patients from Group 2 (7.3%). CONCLUSION: We suggest our diagnostic work-up for patients with nPM-SAH, namely repeat DSA and spinal MRI, until an evidence-based guideline is established for the patient management.

Memantine and Q-VD-OPh Treatments in Experimental Spinal Cord Injury: Combined Inhibition of Necrosis and Apoptosis.

AIM: To evaluate the effects of NMDA receptor antagonist memantine and pancaspase inhibitor Q-VD-Oph in combination or alone in experimental spinal cord injury. MATERIAL AND METHODS: 45 male Sprague-Dawley rats were divided into five groups. Spinal cord injury was created with the clip compression technique. The drugs were administered either alone of in combination to the subjects according to their groups. Motor function was assessed with Tarlov's motor grading scale and the inclined plane technique. The subjects were sacrificed at the fifth postoperative day. Histopathological examination was done with the use of hematoxylin eosin and TUNEL staining. RESULTS: The results for TUNEL staining and apoptotic cell counts revealed statistically significant differences in Q-VD-Oph and combined treatment groups. Tarlov motor grading scale and inclined plane test results were also found significantly better in these two groups. CONCLUSION: Combined use of memantine and Q-VD-OPh provides better histological and clinical results. The combined inhibition of the two major pathways, necrosis and apoptosis, needs to be further assessed with in-vivo or in-vitro studies.

Tracheostomy in Pediatric Intensive Care Unit: When and Where?

BACKGROUND: Tracheostomy was first observed in Egyptian drawings in 3600 BC and performed frequently during the 1800's diphtheria epidemic. OBJECTIVES: The aim of this study was to elucidate the indications, complications, mortality rate, and the effect of pediatric tracheostomy on length of PICU or hospital stay. MATERIALS AND METHODS: Demographic characteristics, diagnosis at admission, duration of ventilation of 152 patients were analyzed retrospectively. RESULTS: The most common tracheostomy indication was prolonged intubation. The mean duration of mechanical ventilation before tracheostomy was 23.8 days. Forty five percent of the tracheostomy procedures were performed at bedside. Neither the place nor the age had any effect on the development of complications (P = 0.701, P = 0.622). The procedure enabled 62% of the patients to be discharged from hospital. CONCLUSIONS: Tracheostomy facilitates discharge and weaning of mechanical ventilation. Although the timing of tracheostomy has to be determined for each individual patient, three weeks of ventilation seems to be a suitable period for tracheostomy. Tracheostomy can be performed at bedside safely but patient selection should be made carefully.

Nasopharyngeal Mass Diagnosed as Transsphenoidal Encephalocele in an Adult Patient.

Transsphenoidal encephalocele, a rare congenital malformation, is generally diagnosed during childhood when investigating the reason for complaints such as nasal obstruction and recurring cerebrospinal fluid fistula. In this adult patient, the authors identified an asymptomatic transsphenoidal encephalocele after requested monitoring of a pedunculated mass detected in the nasopharynx during nasal endoscopy. After evaluation, the authors decided to follow the patient. Few cases of transsphenoidal encephalocele have been reported, and even fewer have been reported in older patients, with no other anomaly or symptoms. The success of surgical treatment for these masses is debatable. The authors did not consider surgery for this asymptomatic case. With this case presentation, the authors wish to emphasize that without making radiologic assessments of any masses identified in a nasopharyngeal examination, it would be inappropriate to perform a biopsy or any intervention.

Neuronavigation-assisted percutaneous balloon compression for the treatment of trigeminal neuralgia: The technique and short-term clinical results.

BACKGROUND: Percutaneous balloon compression (PBC) has been widely used in the treatment of trigeminal neuralgia. However, this technique has a steep learning curve and significant complications were reported that were related to foramen ovale puncturing. The aim of this study was to evaluate the clinical results of a small patient group who underwent neuronavigation-assisted PBC. METHODS: An intraoperative computed tomography (CT) device (CereTom, Neurologica, Danvers, MA/USA) was used to obtain CT scans with 2-mm slice thicknesses. The data were transferred to a neuronavigation system planning station (BrainLab, Feldkirchen, Germany). A soft touch registration system was used for image registration. With the image guidance, a trajectory was defined and the foramen ovale was cannulated using neuronavigation and Hartel's landmarks. RESULTS: Sixteen procedures were performed on 13 patients (4 female and 9 male) without complications. The total length of the procedure was not more than 57 min in all instances. CONCLUSIONS: We believe that image-guided neuronavigation is useful for neurosurgeons who are at the beginning of their PBC learning curve. It may also be an alternative for particular patients with significant anatomic variations that result in an unsuccessful foramen ovale puncture.

The relationship between the fistula tract and the facial nerve in type II first branchial cleft anomalies.

OBJECTIVE: To share our experience involving seven patients with type II first branchial cleft anomalies (hereafter, type II anomalies), to determine whether the location of the external fistula openings of the anomalies are associated with the location of the facial nerve tract, and elucidate the relationship between the location of the fistula opening and the facial nerve. METHODS: The medical records of seven patients who underwent surgery from 2005 to 2013 for type II anomalies were retrospectively examined. The relationship between the fistula opening and the facial nerve was evaluated in each patient with respect to whether the fistula opening was superior or inferior to the mandibular angle. All patients underwent partial parotidectomy, facial nerve exposure, and total excision of the mass together with connection of a small cuff of the external auditory canal skin to the fistula tract. RESULTS: The fistula tracts were located medially to the facial nerve in two patients, and both fistulae had openings inferior to the mandibular angle. The fistula tracts were located laterally to the facial nerve in the remaining five patients: one patient had no external opening, one had an opening inferior to the mandibular angle, and the remaining three had openings superior to the mandibular angle. CONCLUSION: Because type II anomalies are rare, their diagnosis is difficult. Surgery of such lesions is challenging and associated with a high risk due to their proximity to the facial nerve. We believe that the location of the fistula opening may help to identify the relationship between the anomalous lesion and facial nerve. Studies involving larger series of cases are needed to confirm our hypothesis; however, because of the rarity of this specific anomaly, it will not be easy to compile a large number of cases. We believe that our study will encourage further investigation on this subject.

Intraoperative ultrasonography is useful in surgical management of neck metastases in differentiated thyroid cancers.

Differentiated thyroid carcinomas are the most common malignancies of endocrine organs. Metastases to cervical lymph nodes occur in 20-50% of cases. Recurrence and survival rates are closely related to the type of surgery performed. High-resolution ultrasonography (USG) is a sensitive imaging method used to detect occult lymph node metastases in patients with thyroid cancer. We evaluated how intraoperative USG affected surgical success. This was a retrospective study comparing two groups of patients with thyroid carcinoma who underwent cervical lymph node dissection. A total of 101 patients (33 males and 68 females) were included. Group 1 included 53 patients who underwent surgery with intraoperative USG guidance. Group 2 included 48 patients who underwent surgery without the use of USG. All patients were followed up (mean 23 months; range 5-44 months) with thyroglobulin measurements and USG evaluations. Group 1 (intraoperative USG) had a residual/recurrent tumor rate of 1.9% (1/53 patients). Group 2 had a residual/recurrent tumor rate of 12.5% (6/48 patients). A statistically significant difference appeared between the residual/recurrent tumor rates in Groups 1 and 2 (p<0.05). In addition to its classical use in diagnosis and follow-up, intraoperative use of high-resolution USG can improve surgical success and may decrease the number of residual/recurrent tumors encountered during follow-up.