A Teenager With Dysphagia, Mild Dyspnea, and an Indolent Mass

A 15-year-old male presented with dysphagia to solid foods, and dyspnea when laying on the right side that had progressed during 8 months. What is your diagnosis?

Metastatic renal cell carcinoma to the thyroid with cervicothoracic venous tumor thrombosis

INTRODUCTION

Metastatic renal cell carcinoma (RCC) represents 25%-42% of metastatic thyroid malignancies. Propensity for RCC to demonstrate intravascular extension to the inferior vena cava is well documented. We present an analogous phenomenon of intravascular extension to the internal jugular vein (IJV) from thyroid gland metastasis.

METHODS

A 69-year-old male presented with metastatic RCC of the right thyroid lobe. Imaging demonstrated tumor thrombosis of the ipsilateral IJV, extending inferiorly to the junction of the brachiocephalic, subclavian, and internal jugular veins within the mediastinum.

RESULTS

Surgical excision required control of both the IJV in the neck and mediastinal venous great vessels via sternotomy, prior to subtotal thyroidectomy and venotomy for en bloc resection.

CONCLUSION

This case report describes metastatic RCC to the thyroid gland with cervicothoracic venous tumor thrombosis successfully treated with subtotal thyroidectomy, sternotomy for venotomy and tumor thrombectomy, and preservation of IJV conduit.

Langerhans Cell Histiocytosis of the Head and Neck: Experience at a Rural Tertiary Referral Center

OBJECTIVES

Retrospectively analyze head and neck Langerhans Cell Histiocytosis at a rural tertiary referral center and compare results with previously published data.

METHODS

Electronic health record review was performed from 2003 to 2019. Patients with biopsy proven LCH with primary head and neck involvement were included. Demographics, presentation, imaging characteristics, treatment modality, delay in diagnosis (DD, ≥60 days), and outcomes were analyzed and reported.

RESULTS

Twenty-four patients were included. The most common presenting symptoms were otorrhea (n = 6) and scalp pain or swelling (n = 6). All patients had bony involvement. The most common site was facial or skull lesions (n = 20). Most skull lesions (75%) demonstrated CNS risk. Six patients were treated with primary surgery, 15 with primary chemotherapy, and 3 with surgery plus adjuvant chemotherapy. Nine patients experienced relapse of disease with median time to documented relapse of 11.4 months; all were treated with salvage chemotherapy to achieve complete remission (median follow-up: 72 months). Patients most likely to relapse were those with multisystem disease (5/7, 71.4%), temporal bone lesions (4/7, 57.1%), and DD (7/12, 58.3%). Of the 9 total patients who experienced relapse, 78% had a delay in diagnosis.

CONCLUSIONS

LCH is a complex disease process in which diagnosis can be delayed if not considered in the differential. Within the head and neck, the skull, including isolated temporal bone involvement, is the most common site of involvement. Treatment modality does not appear to have an influence on relapse rates. Relapse was more likely to occur in the first year after treatment and close monitoring is required.

Systemic corticosteroids for orbital complications of pediatric rhinosinusitis: A systematic review

OBJECTIVES

Determine if systemic corticosteroids administration is associated with reduced length of stay, surgical intervention, and abscess formation in pediatric patients with orbital complications of rhinosinusitis.

METHODS

Systematic review and meta-analysis were performed utilizing the PubMed and MEDLINE databases to identify articles published between January 1990 and April 2020. Retrospective cohort study of the same patient population over the same time period at our institution.

RESULTS

Eight studies, 477 individuals, met criteria for inclusion in the systematic review. 144 patients (30.2%) received systemic corticosteroids, while 333 patients (69.8%) did not. Meta-analyses of frequency of surgical intervention and subperiosteal abscess showed no difference between those who did and did not receive systemic steroids ([OR = 1.06; 95% CI: 0.46 to 2.48] and [OR = 1.08; 95% CI: 0.43 to 2.76], respectively). 6 articles evaluated hospital length of stay (LOS). 3 of these reported enough data to perform meta-analysis, which showed patients with orbital complications who received systemic corticosteroids had shorter mean hospital LOS when compared with those who did not receive systemic steroids (SMD = -2.92, 95% CI: 5.65 to -0.19).

CONCLUSION

While available literature was limited, systematic review and meta-analysis suggests systemic corticosteroids decrease length of stay for hospitalized pediatric patients with orbital complications of sinusitis. Further research is needed to more clearly define the role of systemic corticosteroids as an adjunctive treatment.

Gray-Scale Inversion on High Resolution Computed Tomography of the Temporal Bone: An Observational Study

OBJECTIVES

This is a qualitative study to explore the utility of gray-scale inversion or the "invert" function of high-resolution computed tomography (HRCT) scans in the diagnosis of temporal bone anatomy and pathology.

METHODS

This is a case series describing an innovative application of an existing image processing tool to visualize temporal bone anatomy and pathology. Illustrative patients at a tertiary referral center with otologic symptoms and findings leading to HRCT scans of the temporal bone were included. Diagnostic HRCT scans were evaluated utilizing the gray-scale inversion function (invert function).

RESULTS

Nine illustrative cases which demonstrate conditions such as persistent stapedial artery, membranous stapes footplate, total ossicular prosthesis migration into the vestibule, third window syndrome such as superior semicircular canal dehiscence (SSCD) and cochlea-facial nerve dehiscence, otosclerosis, and ossicular chain discontinuity are included. The enhanced visualization was confirmed surgically in 3 cases, and 1 had physiological confirmation using cervical vestibular evoked myogenic potentials (cVEMP).

CONCLUSIONS

Gray-scale inversion can be used to improve visualization of temporal bone anatomy and pathologic changes when diagnoses are in doubt. The invert function is a useful adjunct in the armamentarium of both radiologists and otologists when evaluating HRCT of the temporal bone.

Transcanal incision and drainage of a parapharyngeal abscess in a pediatric patient: A novel technique

The disease of parapharyngeal abscess is well known to the otolaryngologist and is commonly managed via transoral, transcervical, or combined incision and drainage. We report a novel approach to an abscess that was drained through the external auditory canal (EAC). An otherwise healthy 2-year-old female presented with a 4-day history of fevers, decreased oral intake, neck stiffness, and voice changes. CT neck with contrast revealed a deep abscess in the left neck extending from the peritonsillar space into the parapharyngeal space in close proximity to the anterior aspect of the EAC. Because the EAC was the closest surface to the abscess collection, we elected to attempt drainage through this route. Successful incision and drainage was performed via transcanal approach. She received intravenous antibiotics and steroids post-operatively and surgical packing was removed. She was discharged home on post-operative day 5 afebrile and tolerating a regular diet and continued to do well at most recent outpatient follow-up.

Comparison of an enzyme-linked immunosorbent assay (ELISA) to gas chromatography (GC)--measurement of polychlorinated biphenyls (PCBs) in selected US fish extracts

The analysis of PCBs in fish tissues by immunoassay methods was evaluated using fish collected from a US monitoring program, the National Contaminant Biomonitoring Program of the US Department of Interior, Fish and Wildlife Service. Selected composite whole fish samples, which represented widely varying concentrations and sources of PCBs, were extracted and subjected to congener PCB analysis by gas chromatography (GC) and total PCB analysis using an ELISA (ePCBs) calibrated against technical Aroclor 1248. PCB congener patterns in these fishes were different from the patterns found in commercial Aroclors or their combinations as demonstrated by principal component analysis of normalized GC congener data. The sum of the PCB congeners measured by GC (total-PCBs) ranged from 37 to 4600 ng/g (wet weight). Concentrations of PCBs as determined by the ELISA method were positively correlated with total-PCBs and the ePCBs/total-PCBs ratios for individual samples ranged from 1 to 6. Ratios of ePCBs/total-PCBs for dilutions of Aroclors 1242, 1254, and 1260 and for matrix spikes range from 0.6 for 1242 to 2.5 for 1254 and 1260. These results suggest that higher chlorinated PCB congeners have higher affinity for the anti-PCB antibodies. Partial least squares with latent variable analysis of GC and ELISA data of selected Aroclors and fish samples also support the conclusion that ELISA derived PCB concentrations are dependent on the degree of chlorination.

Organochlorine contaminants in double-crested cormorants from Green Bay, WI: I. Large-scale extraction and isolation from eggs using semi-permeable membrane dialysis

A 41.3-kg sample of double-crested cormorant (Phalacrocorax auritus) egg contents was extracted, yielding over 2 L of egg lipid. The double-crested cormorant (DCC) egg extract, after clean-up and concentration, was intended for use in egg injection studies to determine the embryotoxicity of the organic contaminants found within the eggs. Large-scale dialysis was used as a preliminary treatment to separate the extracted contaminants from the co-extracted sample lipids. The lipid was dialyzed in 80x5 cm semi-permeable membrane devices (SPMDs) in 50-ml aliquants. After the removal of 87 g of cholesterol by freeze-fractionation, the remaining lipid carryover (56 g) was removed by 100 routine gel permeation chromatography (GPC) operations. A 41,293-g sample was thus extracted and purified to the extent that it could easily be placed at a volume of 5 ml, the volume calculated to be necessary for the egg injection study. Analyses were performed comparing contaminant concentrations in the final purified extract to those present in the original egg material, in the extract after dialysis and cholesterol removal, and in the excluded materials. Recoveries of organochlorine pesticides through dialysis and cholesterol ranged from 96% to 135%. Total polychlorinated biphenyls in the final extract were 96% of those measured in the original egg material. Analysis of excluded lipid and cholesterol indicated that 92% of the polychlorinated dibenzo-dioxins and -furans were separated into the final extract.

Heat-soaked PCR: an efficient method for DNA amplification with applications to forensic analysis

Heat-soaked PCR (HS-PCR) is a method for enhancing amplification performed by heating the DNA sample at 94 degrees C in 90 microliters 1.1 x buffer for 30 min. A 10-microliters bolus of concentrated (10x) deoxynucleotides, Taq DNA polymerase and primers prepared without buffer is then added just prior to thermal cycling. We have investigated the application of this method in a variety of forensically important DNA samples and compared it with regular PCR (R-PCR). DNA samples extracted from bone, postmortem tissues, bloodstains and hair contained low concentrations of human DNA or were contaminated with either non- human DNA or hemoglobin degradation products. Optimal conditions for HS-PCR were determined for the 3' ApoB VNTR locus and applied to a centromeric repeat element and to a single-copy locus. HS-PCR consistently and reproducibly enhanced product yield and specificity over R-PCR at all three loci in the entire set of DNA samples. HS-PCR was also effective in overcoming the inhibitory effect of hemoglobin at concentrations that fully impeded R-PCR.

Characterization of deoxyribonucleic acid (DNA) obtained from teeth subjected to various environmental conditions

This study was designed to determine the effects of various environmental factors on the deoxyribonucleic acid (DNA) obtained from dental pulp. Extracted teeth were subjected to the following conditions: varying pH (3,7,10); temperature (4 degrees C, 25 degrees C, 37 degrees C, incineration); humidity (20%, 66%, 98%); various types of soil (sand, potting soil, garden soil); seawater; burying the teeth outdoors, and aging (one week to six months). In addition, teeth that had been extracted and held at room temperature for 16 and 19 years were also examined. Following isolation of DNA, the samples were analyzed on yield gels to determine the concentration and integrity of the recovered DNA. Restriction digestion with Pst I was followed by electrophoresis of the generated fragments, Southern transfer to nylon membranes, and hybridization to both human and bacterial probes. It was determined that, aside from soil, the environmental conditions examined did not affect the ability to obtain high-molecular-weight human DNA from dental pulp. Restriction fragment length polymorphic (RFLP) analysis of selected samples was performed. Dental pulp patterns were compared with bloodstain exemplars, revealing matching patterns, although an increase in band-shifting was observed with extended exposure to elevated temperatures.

Determination of monocyclic and polycyclic aromatic hydrocarbons in fish tissue

An analytical method is presented in which fish tissue is analyzed for neutral monocyclic and polycyclic aromatic hydrocarbons (AHs) and aromatic sulfur heterocycles (ASHs) by capillary column gas chromatography (CGC) with photoionization detection. The sample enrichment procedure includes saponification with aqueous KOH, acidification of the digestates, and extraction of the aromatic compounds into cyclopentane-dichloromethane. Adsorption chromatography on tandem segments of potassium silicate and silica gel removes 99% of the coextracted lipid. Final enrichment by gel permeation chromatography eliminates residual biogenic material and potentially interfering alkanes. Relatively volatile monoaromatics are included among the analytes by virtue of the efficiency of the complementary enrichment steps, the use of small quantities of only low-boiling solvents, and the selectivity of the detector. Most targeted compounds (AHs ranging in size from C3-alkylbenzenes through benzo[g,h,l]perylene and ASHs within the same size range) can be determined in 5 g (wet weight) samples of fish tissue at concentrations as low as 20 ng/g. Comparisons are made of recoveries of selected AHs under ordinary and gold fluorescent lighting conditions.

Sixty-day infusions of somatotropin-releasing factor stimulate milk production in dairy cows

Twenty-four Holstein cows were infused intravenously with sterile water (placebo) or 1,3, or 12 mg of recombinant bovine somatotropin-releasing factor 1-45-homoserine lactone/d for 60 d. Relative to placebo (22.8 kg/d), 3 and 12 mg of somatotropin-releasing factor increased yield of milk to 28.8 and 33.3 kg/d during infusion. At 1 mg of somatotropin-releasing factor, milk averaged 27.5 kg/d during infusion but was increased above placebo only through 39 d. After infusion of 12 mg somatotropin-releasing factor ended, milk (26.4 kg/d) remained above placebo amounts (20.6 kg/d) for 15 d. Three and 12 mg of somatotropin-releasing factor increased serum somatotropin from .7 (placebo) to 8.2 and 10.3 ng/ml when averaged across 1, 30, and 59 d, whereas 1 mg increased somatotropin to 5.8 ng/ml after 1 d but had no effect at 30 or 59 d. Within 17 h of cessation of somatotropin-releasing factor infusion, serum concentrations of somatotropin were similar across all groups. On d 59, 3 and 12 mg infusions increased insulin-like growth factor I from 115.8 (placebo) to 204.7 and 261.4 ng/ml of serum. We conclude that somatotropin-releasing factor increased serum concentrations of somatotropin and milk yield in a dose-dependent manner for at least 60 d. Also galactopoietic effects of somatotropin-releasing factor persisted for 15 d independent of increased concentrations of somatotropin in serum following withdrawal of somatotropin-releasing factor.