M.T. Makada, MD

Case History: A 24-year-old female presented with complaint of pain during chewing with locking of jaw, more on left side, and clicking sound while opening the mouth for two months.

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Case History: 24-year-old female with pain while chewing and locking of jaw.

Jaw Pain While Chewing

Case History: 24-year-old male presented with complaints of right shoulder pain associated with slowly increasing swelling for five years.No complaint of blackening or redness over right shoulder and no complaint of tingling, numbness, or paresthesia.

Case History: 24-year-old male with complaints of shoulder pain, slowly increasing swelling for five years.

Shoulder Pain, Swelling

 A 75-year-old male with complaints of occasional headache for last two years. Laboratory examination, ophthalmic examination and family history were unremarkable. Neurophysician sent patient for routine brain MRI.

 T2WI axial and sagittal images show a small 12x8 mm well-defined, well-circumscribed heterogenous signal intensity lesion to adjacent grey matter with tiny focal area of CSF intensity in left lateral ventricle along inter ventricular septum in the region of foramen of monro (arrow).

 FLAIR axial and coronal images show a small well-defined, well-circumscribed hyperintense signal intensity lesion to adjacent grey matter in left lateral ventricle along inter ventricular septum in the region of foramen of monro (arrow).

 T1W axial image shows isointense signal intensity lesion to adjacent grey matter with focal cystic area in left lateral ventricle along inter ventricular septum in the region of foramen of monro.

 Diffusion weighted axial image shows no restricted diffusion within the lesion (arrow).

 T1 weighted FAT SAT axial imges show minimal to mild enhancement on post contrst study within lesion.

On MRI, a small 12x8 mm well-defined, well-circumscribed lesion was noted in the left lateral ventricle along inter ventricular septum in the region of foramen of monro. It showed heterogenous signal with adjacent grey matter on T2WI (Figure 1) with a tiny focal cystic area, which followed CSF signal, hyperintense signal on FLAIR weighted images (Figure 2) and isointense to white matter on T1WI (Figure 3) and did not show restricted diffusion on diffusion weighted images (Figure 4). No susceptibility artifact was noted. On post contrast study, the lesion showed minimal to mild enhancement (Figure 5). No evidence of obstructive hydrocephalus was seen.

: Subependymoma are uncommon, benign (WHO grade I) tumors, which are slow growing and non-invasive. Subependymoma tend to present in middle-aged to older individuals. There is a slight male predilection (M: F 2.3:1). Typically, patients are asymptomatic and small lesions are discovered incidentally. In some cases, especially when the tumors are larger, presentation is with symptoms of raised intracranial pressure due to obstructive hydrocephalus.


CT shows isodense intraventricular mass compared to adjacent brain, which does not usually enhance. Surrounding vasogenic edema is usually absent. MRI-T1 iso shows hypointense to white matter, T2-heterogenous to adjacent white and grey matter, with susceptibility related signal drop out due to calcifications occasionally seen no adjacent parenchymal edema. On post contrast-T1 fat sat images there is usually no enhancement, although at times may demonstrate mild enhancement


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Articles

Case History: 75-year-old male with complaint of occasional headaches for last two years.

Subependymoma of Lateral Ventricle

 A 75-year-old male presented with complaint of mucus discharge from an external opening on skin at anterior aspect of mid part of neck on left side. No history of trauma or surgery and unremarkable family history. Upon examination, there was an external opening on skin at anterior aspect of mid part of neck on the left side. Naked eye examination of the oropharynx did not reveal any visible opening at posterior to tonsillar pillar.

The patient was subjected to radiologic investigations. A fistulogram was performed but did not reveal internal opening. Further, on contrast CT, observed an elongated fusiform-shaped approximately 8-10 cm long, well-defined, smoothly marginated thin-walled, peripherally rim enhancing cystic lesion extending from the anterior surface of the mid part of the neck on the left side up to lateral wall of hypopharynx at the hypoid bone level. It had an external opening on the anterior surface of the mid part of the neck on the left side (Figure 1A). It lies anterior to carotid vessels and lateral to thyrohyoid membrane and antero-medial to sternocleidomastoid muscle (Figure 1B). Cranially, it terminated in the lateral wall of left pyriform fossa at hyoid level. It did not open into posterior to tonsillar pillar, so it ruled out second branchial fistula (Figure 2–4). On the basis of these radiological findings, final diagnosis was made of complete fistula of third branchial cleft. The patient was operated on and complete excision of the cord-like fistulous tract was done, which followed up to the lateral wall of left pyriform fossa. The excised tract measured 9 cm in length. It was found to lie over the carotid sheath and was not going up to tonsillar pillar or in between the internal and external carotid arteries, so it ruled out second branchial cleft fistula which is most common in literature (Figure 5).

 Contrast CT axial images at thyroid gland level (A) show external opening of cystic lesion in anterior surface of the mid part of the neck on the left side (small arrow). In B, at thyroid cartilage level, the cystic lesion (large arrow) lies anterior to carotid vessels and lateral to thyrohyoid membrane and antero-medial to sternocleidomastoid muscle.

 Contrast CT axial images of upper neck at hyoid bone level show a well-defined smoothly marginated peripherally rim enhancing cystic lesion (large arrow in A) opens in to lateral wall of left pyriform fossa (B, small arrow). It does not open into posterior to tonsillar pillar, so it ruled out possibility of second branchial cleft fistula.

 Contrast CT sagittal images of the neck show an elongated fusiform-shaped long well-defined smoothly marginated peripherally rim enhancing cystic lesion extending from anterior surface of the middle part of the neck (long arrow in A) and opens in to lateral wall of left pyriform fossa (small arrow in B).

 Contrast CT coronal images of the neck show an elongated fusiform shaped long well-defined smoothly marginated peripherally rim enhancing cystic lesion extending from anterior surface of the middle part of the neck and opens in to lateral wall of left pyriform fossa.

 Postoperative specimen. Complete excision of cord-like tract was performed, which followed up to the lateral wall of left pyriform fossa. The excised tract measured 9 cm in length. It was found to lie over the carotid sheath and was not going up to the tonsillar pillar or in between the internal and external carotid arteries, so it ruled out second branchial cleft fistula which is most common in literature.

: Complete fistula of third branchial cleft

 Third branchial cleft cysts are rare. A third branchial fistula extends from the same skin location as a second branchial fistula; however, a third branchial fistula pierces the thyrohyoid membrane to enter the larynx, terminating on the lateral aspect of the pyriform sinus. Third branchial cleft cysts occur anywhere along that course, but they are characteristically located deep to the sternocleidomastoid muscle. The external opening occurs about two-thirds of the way down the SCM anteriorly, similar to second branchial cleft cysts. The tract ascends along the carotid sheath posteriorly to the internal carotid artery, under the glossopharyngeal nerve, and over the vagus nerve and hypoglossal nerve to open into the pyriform sinus. Second branchial cleft anomalies are most common. The majority of these have an external opening in the neck along the anterior border of sternocleidomastoid at the junction of the upper two-thirds with the lower one-third and the internal opening extends up to the posterior pillar of the tonsil. In our case, the fistulous tract had external opening in the mid part of the neck along the sternocleidomastoid muscle and terminated in the lateral wall of pyriform fossa.

 CT - rounded, sharply circumscribed, fluid density centrally, thin wall. Ultrasound - sharply demarcated, posterior acoustic enhancement, imperceptible walls. MRI-T1 - variable signal dependant on protein content, high protein content; high signal, low protein content: low signal, T2 - usually high signal, T1 C+ (Gd) - no enhancement in uncomplicated lesions.

 Paramedian thyroglossal duct cyst, cystic lymph nodes, necrotic nodal metastases, esp. SCC and papillary thyroid cancer, tuberculous adenitis.


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Case History: 75-year-old male presents with complaint of mucus discharge from external opening on skin at anterior aspect of mid part of neck on the left side.

Author | M.T. Makada, MD

Articles

Jaw Pain While Chewing

Shoulder Pain, Swelling

Subependymoma of Lateral Ventricle

Complete Fistula of Third Branchial Cleft