Bilateral accessory anterior bellies of the digastric muscle and review of the literature

OBJECTIVE: The aim of our paper is discussing anomalies of the anterior belly of the digastric muscle with presenting our case in light literature. METHODS: During dissection of the submental region of 26 years old Turkish female embedded cadaver, for this educational purpose in 2000, bilateral accessory digastric muscle was observed. RESULTS: The anterior and posterior bellies of the digastric muscle had their normal origin and course and were joined by an intermediate tendon, the accessory anterior bellies originated from the digastric fossa, and inserted to the hyoid bone, with a common fibrous band. The accessory anterior bellies of the digastric muscle were in the same shape and coursed parallel to each other. CONCLUSION: Anatomical variations of the anterior bellies of the digastric muscles can be easily confused with pathological conditions in CT and MR imaging, it is necessary to recognize that muscle variants of the digastric muscle occur to avoid confusion when diagnosing abnormal lesions of the floor of the mouth and submental region. In human body, such as these muscle variations have clinical significance.     

Coexistence of a pseudolesion and a true lesion in the same location: a rare misleading imaging finding

Congenital cholesteatoma and asymmetric fatty marrow are both common masses that appear as imaging "lesions" in the petrous apex, but their treatment modalities are very different. Accurate preoperative recognition by computed tomography and magnetic resonance imaging is, therefore, important for planning appropriate management strategies. We report a case with coexisting congenital cholesteatoma and asymmetric fatty marrow in the same petrous bone. The 2 lesions were indistinguishable on high-resolution computed tomographic images and were only identified on fat-suppressed magnetic resonance imaging sequences. This is the first report of these 2 lesions coexisting, leading to a rare misleading imaging finding.     

Rhabdomyosarcoma of the infratemporal fossa: diagnostic dilemmas and surgical management

We present a rare case of embryonal rhabdomyosarcoma in the infratemporal fossa presenting as an atypical facial pain syndrome. Radiographic imaging of the patient is discussed, and magnetic resonance imaging is recommended as the diagnostic modality of choice when mass lesions of the infratemporal fossa are suspected. Finally, a temporal approach to the infratemporal fossa is described, along with its advantages as an application for tumor resection in this anatomic region.     

Anatomic landmarks for locating parotid lesions in relation to the facial nerve: cross-sectional radiologic study

OBJECTIVES: To determine the accuracy of using surrogate anatomic structures radiologically to predict the relation of parotid lesions to the intraparotid facial nerve. SETTING: Tertiary centre. DESIGN: Retrospective. PATIENTS AND METHODS: All patients with parotid masses over a 5-year period who undertook parotidectomy were considered. A radiologist and an otolaryngologist reviewed the images. Their decision regarding the location of the lesions using four surrogate structures was compared with intraoperative documentation. OUTCOME MEASURE: We determined the sensitivity and the specificity of using the external carotid artery, retromandibular vein, posterior belly of the digastric muscle, and tragal pointer. RESULTS: Thirty films were examined (24 magnetic resonance images [MRIs] and 6 computed tomographic [CT] scans). The sensitivity and the specificity of the retromandibular vein were 0.85 and 0.57, respectively, whereas for the external carotid artery, they were 0.94 and 0.3, respectively. It was too impractical to relate the other two structures to the lesions. CONCLUSIONS: The retromandibular vein is the most accurate surrogate structure to use on MRI or CT for predicting the location of a parotid lesion to the facial nerve. However, the substantial proportion of deep lesions misjudged limits the benefit of performing the imaging.     

Paraganglioma of the external auditory canal: an unusual case

Primary paraganglioma of the external auditory canal is a rare otological finding. To date, only three cases have been reported in the world-wide literature. Such a tumour is now described in a 42-year-old female. The clinical and histopathological features of the case are discussed. The role of immunocytochemistry in defining diagnosis, from a large list of differentials, is illustrated. We present the first magnetic resonance images of this rare tumour and highlight the benefit of intra-operative frozen section in limiting surgery to canal excision.     

Nasal glioma--case report

Benign congenital lesions resulting from the deficient regression of neuroglial tissue in normal embryonic development are called gliomas. They are usually located in the nasofrontal region and are diagnosed in the postnatal period. They are included in the differential diagnosis of nasofrontal midline masses. We present a case of the 9-year-old boy treated in the ENT Department of Wroclaw Medical University with the initial diagnosis of nasal polyposis or tumour which appeared to be glioma in the postoperative histological evaluation. The tumour was removed endoscopically. We present magnetic resonance imaging of the case together with the review of the literature concerning gliomas. We conclude that each doctor has to be aware of possible neoplasm even in the youngest groups of the patients.     

Rare localization of paraganglioma in head and neck

In this paper, we describe the clinical course of a 61-year-old female patient with paraganglioma in the head and neck region. Computed tomographic scan (CT), magnetic resonance imaging (MRI), ultrasound scan (US) and arteriogram findings initially led us to suspect that this tumor originated in the vagal nerve. In particular, a color Doppler US enabled an easy diagnosis of hypervascular tumor. We removed this surgically, but the tumor was easy to peel from the vagal nerve and carotid bifurcation. The distal side of the tumor was under the digastric muscle and running into the hypoglossal nerve. The intraoperative findings were highly suggestive of localization at the hypoglossal nerve, although Xth and XIIth cranial nerve palsies have remained.     

Magnetic resonance imaging in the diagnosis of temporal bone and skull base lesions

Six patients are presented in whom total reliance on magnetic resonance imaging (MRI) interpretations would have resulted in less than ideal treatment. The misleading information on magnetic resonance imaging could be divided into two types; as follow: type I were those in which there was no signal but nonosseous pathology was present, and in type II an abnormal signal was present but misinterpreted. In three of these patients (cases, 2, 3, and 5), information gained from more traditional means (history, physical examination, audiologic and vestibular testing, and computed tomography) led to proper treatment, whereas, in two patients (cases 4 and 6), treatment exceeded that required by the disease process. In one patient (case 1), ideal therapy resulted, despite a negative magnetic resonance imaging study, when a small intracanalicular tumor was found fortuitously during a translabyrinthine vestibular nerve section for vertigo. Although magnetic resonance imaging provides excellent supplemental information to more traditional means of diagnosis, it cannot be used entirely in their place. As gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) becomes more readily available, as the resolution of magnetic resonance imaging improves, and as we gain more familiarity with this diagnostic modality, misleading information from these studies should decrease.     

Parasellar epidermoid cyst rupturing into the nasopharynx

Epidermoid tumours are non-neoplastic inclusion cysts representing up to 1.1 per cent of all intracranial tumours, typically presenting with symptoms related to pressure or intracranial rupture in the fourth or fifth decade of life. The authors present a case of a parasellar epidermoid cyst which has ruptured in to the nasopharynx; to the best of their knowledge, this has not been previously reported. The computed tomography (CT) and magnetic resonance imaging (MRI) are presented. The pathology and radiological features of epidermoid tumours are discussed, particularly in relation to extracranial connections. The differential diagnosis of lesions eroding the central skull base is reviewed.     

Bilateral sternocleidomastoid tumors of infancy

The sternocleidomastoid tumor of infancy (STOI) is a relatively uncommon condition. Typically, it presents as a firm, well circumscribed mass within the sternocleidomastoid muscle (SCM) in infants 1-8 weeks of age and may be associated with torticollis. This condition must be considered in any infant with a lateral neck mass. The diagnosis can often be made clinically, but unusual presentations may present diagnostic challenges. Although bilateral involvement is rare, it does occur. The second reported case, a 2-week old female with bilateral STOIs and torticollis, is reported. Although many of the characteristics of the masses suggested the condition, the bilateral nature added uncertainty to the clinical impression, and magnetic resonance imaging (MRI) was used to confirm the diagnosis. The clinical presentation and management of the STOI are reviewed, and the unusual features of this case are discussed.     

Giant dermoid cyst of the neck can mimic a cystic hygroma: using MRI to differentiate cystic neck lesions

OBJECTIVE: To describe differential features of giant cervical dermoid cysts and other cystic lesions of the head and neck. METHODS: Case report including magnetic resonance imaging, surgical excision, pathologic examination and correlation. RESULTS: We report the case of a 15-year-old boy who presented for evaluation of a slowly enlarging doughy submental mass. Ultrasound showed some features consistent with a cystic hygroma and both sclerotherapy and surgical excision were discussed with the family. However, an unusual solid component on magnetic resonance imaging (MRI) mitigated toward surgical excision. At surgery, the cystic mass was excised and measured 9.5 cm x 5.5 cm x 4.0cm. Histology showed a giant dermoid cyst similar to those seen in the ovary. The solid component was a smooth spherical collection of inspissated sebum. CONCLUSIONS: The unique MRI characteristics of giant dermoid cysts can help to separate these rare lesions from more common cystic hygromas. Fine needle aspiration should be considered for questionable lesions before treatment with OK 432 or similar agents.     

Spiral CT versus MRI in neonatal airway evaluation

Magnetic resonance imaging has become the standard means of imaging pediatric airway obstruction due to vascular anomalies. However, magnetic resonance imaging requires a long acquisition time and is prone to motion artifacts. The development of spiral or helical computed tomography provides an alternative imaging modality for evaluating pediatric airway obstruction. We present the case of a neonate with a double aortic arch which initially was not identified on magnetic resonance imaging but was visualized with spiral computed tomography. If suspicion of an intra-thoracic abnormality is high, spiral computed tomography may be a useful adjunct or replacement to magnetic resonance imaging.     

Thyroid-stimulating hormone-secreting ectopic pituitary adenoma of the nasopharynx

Thyroid-stimulating hormone-secreting ectopic pituitary adenoma of the nasopharynx is highly unusual, with only three reported cases in the world literature. We describe the clinical presentation and radiologic findings in one patient with such rare lesions. A 46-year-old male with typical symptoms of Grave's disease was found to have a mass on magnetic resonance imaging. An otolaryngologic examination revealed a nasopharyngeal mass lesion, which was endoscopically resected. The results of immunohistochemical staining for thyroid-stimulating hormone were positive. After the resection, the patient's TSH was within normal limits. The clinical significance of the case and a brief literature review are presented.     

Primary cholesteatoma of the middle ear and petrosal bone

Petrosal cholesteatomas are rare lesions, which may be primary or acquired in nature. We report a case of primary cholesteatoma in petrous bone occurring in 51-year old woman who presented with a unilateral facial nerve palsy and conductive hearing loss, despite normal tympanic membrane appearance. Early diagnosis was facilitated by computed tomography scanning and magnetic resonance imaging. Complete cholesteatoma removal was accomplished using a transtemporal supralabyrinthine approach, which allowed hearing preservation. Facial nerve function is the main complication of these lesion. We suggest that use of CT scanning and MRI in unilateral conductive hearing loss may allow the earlier detection of the most cases of petrosal cholesteatomas.     

Magnetic resonance imaging of facial nerve neuromas

Facial nerve neuromas are uncommon tumors often confused with other tumors of the temporal bone and cerebellopontine angle. Radiologically, it may be impossible to differentiate an intracanalicu-lar facial nerve neuroma from an acoustic neuroma. We present three case reports of facial nerve neuromas arising within the internal auditory canal to show the important magnetic resonance imaging features of these tumors. One tumor extended into the cerebellopontine angle, middle cranial fossa, and middle ear. Another filled the internal auditory canal and extended through the cerebellopontine angle to the brain stem. The third occurred in a patient who had neurofibromatosis as well as numerous other intracranial tumors. We feel that gadolinium-enhanced magnetic resonance imaging provides the most useful information in the preoperative assessment of this disorder.     

Neuroendocrine carcinoma of the ethmoid sinuses treated with radiotherapy alone

Objective: We present the first report of a case of neuroendocrine carcinoma of the paranasal sinuses treated successfully with radiotherapy alone. Method: A case report and literature review are presented. Results: Fewer than 50 cases of paranasal sinus neuroendocrine carcinoma have been reported. We present an 82-year-old man referred with recurrent epistaxis. He was investigated by biopsy, computed tomography and magnetic resonance imaging, and was found to have a rare neuroendocrine carcinoma. He declined any surgery or chemotherapy but consented to radiotherapy. Thirty months later, he remained clinically free from cancer. Conclusion: There is no consensus for the management of paranasal sinus neuroendocrine carcinoma. Most cases are treated with surgery with or without chemoradiotherapy. This case shows that radiotherapy alone may be a viable treatment option for some cases.     

Invasive cerebrospinal fluid cysts and cephaloceles of the petrous apex.

OBJECTIVE: To describe the presentation, diagnostic evaluation, and surgical management of petrous apex cerebrospinal fluid (CSF) cysts and cephaloceles. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Six patients with symptomatic CSF cysts or cephaloceles. INTERVENTION(S): All patients underwent operative intervention. MAIN OUTCOME MEASURE(S): Presentation, imaging characteristics, operative findings, surgical approach, resolution of symptoms, and complications. RESULTS: Six patients presented with various neurotologic symptoms including vertigo, otalgia, diplopia, meningitis, hearing loss, and retroorbital headaches. Four lesions were centered within the anterior petrous apex and were classified as a cephalocele originating from Meckel's cave. The remaining two lesions were arachnoid cysts that involved the posterior petrous apex. Cysts and cephaloceles both demonstrated bone erosion on computed tomography and were hyperintense on T2-weighted magnetic resonance imaging and isointense or hypointense on T1-weighted magnetic resonance imaging. A variety of surgical approaches was used to treat these lesions. Preoperative symptoms were improved in five of six cases. One patient developed a postoperative CSF leak that resolved with conservative measures. CONCLUSION: Petrous apex CSF cysts and cephaloceles may present with a variety of neurotologic symptoms. Imaging often helps narrow the differential diagnosis, but these lesions can still be confused with other erosive skull base lesions such as cholesterol granulomas, epidermoids, or tumors. Optimal treatment of symptomatic posterior petrous apex CSF cysts is marsupialization via a posterior fossa approach (i.e., retrosigmoid or retrolabyrinthine). A middle fossa approach with obliteration of the anterior petrous apex may be used to treat symptomatic CSF cephaloceles arising from Meckel's cave.     

An unusual neck lump: intramuscular haemangioma of the sternocleidomastoid muscle

Neck lumps can often present a diagnostic dilemma, with a wide pre-operative differential diagnosis. We present an unusual case of an intramuscular haemangioma arising in the sternocleidomastoid muscle. Pre operative diagnosis is often difficult, as these lesions are extremely rare in the head and neck region and only few sporadic cases have been reported in the literature. We report the presentation diagnosis and management of intramuscular haemangiomas of the sternocleidomastoid muscle.     

Magnetic resonance imaging in the diagnosis of innominate artery compression of the trachea

In the past, the diagnosis of tracheal compression by intrathoracic arterial structures has been made by using bronchoscopy alone or in combination with one of a variety of imaging techniques, including barium contrast esophagography and cineangiography. However, all of these imaging techniques involve exposure of patients to ionizing radiation and, in the case of angiography, an invasive procedure. The use of magnetic resonance imaging in the diagnosis of thoracic arterial disease is well documented and, more specifically, has been found to be useful in the diagnosis of innominate artery compression of the trachea and congenital vascular rings. This report documents the use of magnetic resonance imaging at the Children's Hospital Medical Center, Cincinnati, Ohio, in the diagnosis of innominate artery compression of the trachea. In addition, the radiographic appearance of this entity is contrasted with other compressive lesions of the trachea.     

Myofibrosarcoma of the nasal bone

Myofibrosarcoma is a recently recognized rare tumor that mainly occurs in adults. These tumors are composed of a collagenous stroma and pleomorphic stellate to spindle-shaped cells that resemble smooth muscle cells with eosinophilic cytoplasm and tapered nuclei. We present a case of myofibrosarcoma of the nasal bones in a 4-year-old girl who showed rapid enlargement of a painless glabellar swelling. Computed tomography and magnetic resonance imaging revealed an expanding solid mass with erosion of the surrounding nasal bones. After excision and histopathological examination, this tumor was identified as a myofibrosarcoma. This is the first report of such a tumor localized to the glabellar region. This case report contributes to better awareness of an extremely rare type of glabellar lesion in children.