Inflammatory Pseudotumor Presenting as a Facial Swelling

We present a case of inflammatory pseudotumor (IPT) presenting as a facial swelling after an accidental hit on a right side of a face. As swelling did not resolve, dental examination and teeth extraction were done by a dentist presuming the swelling was misdiagnosed with infection of dental origin. Swelling grew even bigger and patient was referred to Department of Maxillofacial Surgery. CT scan of the face and FNA of the lesion was ordered. A homogenous tumor mass in the right infraorbital region in front of anterior wall of the maxillary sinus was seen on CT. The result of the FNA was reactive hyperplasia of the lymph node. Since the lesion was easily accessible surgical exploration and complete extirpation was done. Pathohistological analysis indicated a low grade B-cell Non Hodgkin lymphoma. PCR showed policlonality of B cells discarding the diagnosis of lymphoma. Pathohistological review showed diffuse intramuscular, perineural and perivascular infiltration with small lymphocytes without formation of germinative centers. Imunohistochemistry was positive for CD20 and CD3. Taking into account all features the diagnosis of IPT was established. Diagnosis of IPT is a diagnosis by exclusion, combining clinical, radiological and pathohistological characteristics. Lack of clear histologic criteria makes differential diagnosis extremely difficult. Our case is unique regarding localisation of head & neck IPT, no case presenting on the face in infraorbital region has been described in the literature. Although IPT is very rare in general and especially on the face, one should be aware of it when considering differential diagnosis of facial swelling

Employment of Computed Tomography in the Study of Traumata Scored from Two Adults from Croatian Bioarchaeology

Računalnu smo tomografiju (CT) rabili u proučavanju trauma dviju odraslih osoba iz hrvatske bioarheologije – žene iz sekundarnog arheološkog konteksta (Zagajci) i muškarca iz srednjovjekovnog grobnog kompleksa (Zvonimirovo). Ozljede smo razmotrili u odnosu na moguća nasilna djelovanja nasuprot slučajnim nezgodama. Imali smo ukupno dva cilja: izolirani nalaz lubanje iz Zagajaca sa zacijeljenom depresijskom frakturom čeone kosti (slučaj 1) ispitali smo kako bismo dobili uvid u mogući utjecaj ozljede na unutarnju lubanjsku tablu. Izolirani slučaj osobe iz starije zbirke Zvonimirova koja je pokazivala zacijeljene prijelome lijeve lakatne i ključne kosti, te relikt mandibularnog zuba (slučaj 2), ispitali smo kako bismo dobili detaljne radiološke podatke o drugim mogućim traumama (korijena zubā). CT presjeci koje smo dobili u slučaju ženske osobe pokazali su depresijsku frakturu s prodorom u unutarnju tablu upućujući na agresivni udarac u čelo tupo-tvrdim predmetom. CT presjeci koje smo dobili u slučaju muške osobe iznjedrili su nazočnost nezacijeljenih (perimortalnih) prijeloma korijena gornjočeljusnih zubā. Vremenski različite implikacije na koje upućuju zaživotne i perimortalne traume ukazuju na različite scenarije traumatskih događaja u slučaju muškarca: ozljede je mogao zadobiti prilikom (vremenski različitih) nezgoda, budući da nema nazočnih zaživotnih/perimortalnih ozljeda kostiju lubanje; ipak, s obzirom na srednjovjekovni kontekst ne može se isključiti scenario u dvije etape prema kojem ponovljene ozljede na lijevoj strani mogu upućivati na nekoliko epizoda nasilnog djelovanja na sljedeći način: muškarac je prvotno mogao zadobiti udarac u lijevu podlakticu podignutu u samoobrani; prijelom ključne kosti, nastao po svemu sudeći za vrijeme istog događaja, mogao se zbiti prilikom pada koji je uslijedio. Vremenski različit udarac u bradu, pri čemu bi zubi donje čeljusti vrlo snažno udarili o gornjočeljusne zube s učinkom neizravnih (perimortalnih) prijeloma korijena zubā, mogao bi upućivati na posttraumatske implikacije koje su mogle pridonijeti smrti osobe.Computed tomography (CT) was employed in the study of two adults’ traumata from Croatian bioarchaeology – a female from a secondary archaeological context (Zagajci) and male from a medieval burial complex (Zvonimirovo). Injuries were considered in reference to possible violent acts versus accidents. Our aim went two ways: an isolated Zagajci cranium with healed depressed fracture to the frontal bone (case 1), was investigated as to assess insight into a possible impact effect of the injury on the inner table. An isolated case from the early Zvonimirovo collection with healed left ulna/clavicle fractures and the mandibular tooth relic (case 2), was investigated as to obtain detailed radiological data on other possible (root) traumata. The female CT scans showed a depressed fracture penetrating the inner table – suggestive of aggressive blow to the forehead with hard-blunt object. The male CT scans generated unhealed (perimortal) left maxillary root fractures. Different time implications suggested by antemortal/perimortal traumata offer alternative traumatic scenarios for the male: traumata could be sustained in (different time) accidents due to the absence of (antemortal/perimortal) cranial bone traumata; however in terms of the medieval context one cannot exclude the two-step scenario whereby repeated injuries to the left body side could be suggestive of several episodes of violence as follows: firstly a man could sustain a blow to the left forearm raised in defense; possibly co-occurring fractured clavicle might be suggestive of the fall that followed. Different time blow to the chin, whereby the lower teeth could violently hit the upper causing indirect (perimortal) root fractures, might be suggestive of posttraumatic implications accounting for the death of individual

Macroscopic and CT Diagnostic Approach in Interpreting a Non-traumatic Calvarial Lesion in a Medieval Man from Northern Croatia

Na kaloti mlađe odrasle muške osobe koja potječe iz ranosrednjovjekovnoga grobnog kompleksa Zvonimirovo (sjeverna Hrvatska) prikazala se remodelirana lezija koja zahvaća liniju sagitalnog šava u blizini bregme. Mali udubljeni anteroposteriorno (AP) izduženi − ovalni defekt u središnjoj liniji vanjskog svoda kalote, s rubnim odlaganjem kortikalne kosti, upućivao je na razvitak nekadašnje mekotkivne (cistične) tvorbe. Nisu se prikazali pokazatelji – traumatski ili patološki, koji bi upućivali na drukčiju vrstu lezije, ili varijaciju. Pored makroskopskog pristupa u tumačenju netraumatske koštane lezije, imali smo za cilj koristiti podršku pomoću računalne tomografije (CT). Na CT presjecima prikazala se dobro razgraničena nepravilna i u AP smjeru izdužena litička lezija (u obliku erozije) vanjske table s osteosklerotičnim rubovima koja se protezala do diploë, tj. s izostankom zahvaćenosti površine unutarnjeg svoda lubanje (unutarnje table). Diferencijalna dijagnoza u ovom radu uključuje procjenu prisutnosti dermalne nasuprot epidermalnoj inkluzijskoj cisti, varijante sinus pericranii povezanog s defektom na kaloti i ateroma popraćenog upalnim procesom. Najizglednija dijagnoza koštane lezije koja se, po svemu sudeći, temelji na kožnoj leziji jest varijanta površinske kongenitalne dermalne inkluzijske ciste s lokalizacijom u (nekadašnjem) skalpu. Na to upućuju sveukupan izgled, smještaj u središnjoj liniji, pojavljivanje u mlađoj dobi i tendencija manje invazivnosti u usporedbi s epidermoidom. Na pojavljivanje nekadašnje mekotkivne tvorbe u skalpu, umjesto dublje u kaloti, upućuju erozija vanjskog svoda kalote (koja završava u diploë), te izostanak zahvaćenosti površine unutarnjeg svoda kalote. Popratno odlaganje kortikalne kosti uokrug koštane litičke lezije moglo bi upućivati na nekadašnji rubni upalni proces povezan s mekotkivnom tvorbom. Moguću prisutnost varijante sinus pericranii isključili smo na osnovi iznjedrenih CT presjeka, dok smo prisutnost ateroma isključili na temelju smještaja lezije i dobi osobe.The calvaria of a young adult male from the early medieval burial complex Zvonimirovo (northern Croatia) exhibited the presence of a remodelled solitary lesion embracing the course of the sagittal suture line near the bregma. The small concave antero-posteriorly (AP) elongated – ovoid defect in the midline of the calvarial vault, with marginal cortical bone deposition, was indicative of a once soft-tissue lesion (cystic) development. There were no indicators – neither traumatic nor pathological, which would suggest a different type of lesion or variation. Beside the macroscopic approach, we aimed to use computed tomography (CT) support in interpreting the present non-traumatic dry bone lesion. The CT scans generated well-demarcated irregular and AP elongated lythic lesion (erosion) of the outer table, with osteosclerotic borders, ending up in the diploë, i.e. lacking the involvement of the inner calvarial vault surface (inner table). In this study, the differential diagnosis involved dermal versus epidermal inclusion cyst, sinus pericranii variant in association with the calvarial defect and inflamed atheroma evaluation. The most probable diagnosis of the present, apparently, skin-based dry bone lesion was a variant of a superficial congenital dermal inclusion cyst which was located in the (onetime) scalp. This was suggested by its gross morphology, midline localization, the appearance in early age and the tendency of minor invasiveness when compared to epidermoid. The once soft-tissue feature occurrence in the scalp instead of deeper in the calvaria was suggested by the erosion of the external calvarial vault (ending up slightly in the diploë), i.e. the absence of the inner calvarial vault surface involvement. The accompanying cortical bone deposition surrounding dry bone lythic lesion was suggestive of the past marginal inflammation associated with once soft-tissue feature. The possible presence of a sinus pericranii variant was excluded by the generated CT scans, while atheroma was ruled out due to the lesion localization and the age of the individual

Mastoid Trepanation in a Deceased from Medieval Croatia: A Case Report

We present a rare case of infratentorial mastoid trepanation, by drilling, from medieval Croatia. An artifi cial antemortal opening was found in a male skeleton from the 11th century cemetery Zvonimirovo. It was placed roughly at the intersection of the Frankfurt’s plane and the midline of the right mastoid. The right posterior parietal of the deceased also exhibited a callus-like formation consistent with the linear cranial fracture. Our aim was to investigate by computed tomography (CT) a possible presence of otopathology – a chronic middle ear infection – MEI/mastoiditis or cholesteatoma. On the other hand, both standard radiography and CT were employed in a cranial fracture diagnostic agreement. The generated CT scans confi rmed the presence of an artifi cial hole running into a well defi ned trepanne canal connected with the antrum. The presence of otopathology was not established. The radiography and CT substantiated the presence of a linear posterior parietal discontinuity – without displacement, in front of the right lambdoid suture. From the medical point of view, it would be unusual to perform infratentorial – mastoid trepanation for reasons of treating supratentorial trauma, i.e. possible posttraumatic acute subdural hematoma (PTASDH). However, since there was a lack of CT evidence of osteolysis in ME, there is a possibility of medieval trepanation procedure performed for reasons of posttraumatic treatment. To our best knowledge, usually, ancient trepanations described in Croatian bioarchaeology and all over the world are supratentorial and do not always reveal such sophisticated surgical techniques

Procjena cerebrovaskularne bolesti magnetskom rezonancijom mozga i magnetskom angiografijom

Magnetic resonance imaging (MRI) is an important imaging technique for evaluation of cerebral ischemic changes. Using magnetic resonance angiography (MRA), both large and medium sized intracranial arteries and veins can be visualized by selecting appropriate imaging parameters. The aim of this retrospective study was to evaluate our own results in the diagnosis of cerebrovascular diseases with MRI and MRA, and to compare them with literature data. Data on 278 patients with cerebrovascular symptomatology (158 female and 120 male, mean age 45-54 years), examined between April 2001 and November 2002, were analyzed. MRA was performed in all 278 and both MRA and MRI in 231 patients. On MRA, 90 pathologic alterations of intracranial arteries (69 aneurysms and 21 vascular malformations), 13Rintracranial arterial occlusions, 19 intracranial arterial stenoses, and 14 cases of intracranial arteriosclerotic changes were identified. On MRI, 114 strokes (73 brain infarctions, 22 cerebral hemorrhages and 19 sub-arachnoid hemorrhages), 14 vascular malformations and 14 cases of small vessel disease were detected. MRI was found to be a powerful tool to detect ischemic lesions immediately upon stroke onset. MRA is highly sensitive for the detection of occlusive disease in large intracranial arteries. For cerebral venous and sinus thrombosis, MRI and MRA are first line studies. MRA of extracranial and intracranial vessels alone or in combination with transcranial color-coded duplex sonography (TCCD) as well as computed tomography angiography (CTA) may eliminate the need of intra-arterial digital subtraction angiography (DSA) in most patients studied for occlusive cerebrovascular disease. DSA may be reserved for those patients in whom there is a disagreement among the results obtained by use of noninvasive techniques, and for the diagnosis of arteriovenous malformations, whereas MRA can prove useful on follow-up examinations.Magnetska rezonancija (MR) mozga je važna tehnika prikazivanja u procjeni ishemijskih promjena moždanoga parenhima. Magnetskom angiografijom (MRA) se birajući odgovarajuće parametre prikaza mogu pokazati i velike i male intrakranijske arterije i vene. Cilj ove retrospektivne studije bila je procjena vlastitih rezultata u dijagnostici cerebrovaskularnih bolesti pomoću MR mozga i MRA, te njihova usporedba s literaturnim podacima. Analizirani su podaci 278 bolesnika (158 žena i 120 muškaraca srednje životne dobi od 45,54 godine), koji su bili pregledani u razdoblju od travnja 2001. do studenoga 2002. Učinjeno je 278 postupaka MRA, a u 231 bolesnika učinjena je i MR mozga. MRA je otkrila 88 patološki promijenjenih intrakranijskih krvnih žila (69 aneurizma i 21 vaskularnu malformaciju), 13 okluzija intrakranijskih arterija, 19 stenoza intrakranijskih arterija, te 14 slučajeva arteriosklerotskih promjena intrakranijskih arterija. MR mozga otkrila je 114 cerebrovaskularnih inzulta (73 cerebralne ishemije, 22 intracerebralne hemoragije i 19 subarahnoidnih hemoragija), 14 vaskularnih malformacija, te 14 slučajeva "patologije malih krvnih žila". MR mozga je moćno sredstvo u otkrivanju ishemijskih promjena neposredno nakon nastupa moždanog inzulta. RMRA ima visoku osjetljivost za otkrivanje okluzivne bolesti velikih intrakranijskih arterija. MR mozga i MRA su osnovne pretrage za dijagnozu tromboze moždanih vena i sinusa. Samo se pomoću MRA ekstrakranijskih i intrakranijskih krvnih žila ili u kombinaciji s obojenom dupleks sonografijom krvnih žila glave i vrata (TCCD) te kompjutoriziranom tomografijskom angiografijom (CTA) može isključiti potreba za intraarterijskom digitalnom subtrakcijskom angiografijom (DSA) u većine bolesnika pregledanih zbog okluzivne cerebrovaskularne bolesti. DSA može biti rezervirana za one bolesnike kod kojih postoji neslaganje između nalaza neinvazivnih metoda pregleda, te za dijagnozu arteriovenskih malformacija, dok se MRA može rabiti za daljnje praćenje

Etiology of Deafness in Children Cochlear Implant Candidates in Croatia

The aim of this study was to provide more information on the causes of sensorineural hearing loss (SNHL) in children cochlear implant candidates in Croatia. The retrospective study included 270 children candidates for cochlear implantation between January 1997 and January 2005 at our institution. The medical assessment of the candidates included the history, physical examination, radiologic evaluation of the temporal bone and audiologic assessment. A family history of SNHL had 82 (30.4 %) candidates. The prematurity and/or complicated perinatal course was found in 35 (12.9%) of candidates. Computerized tomography (CT) scan analysis identified 44 (16.3%) candidates presenting with an inner ear malformation. Overall, a definite or probable cause of SNHL was identified in 58.9% of candidates and 41.1% had no obvious cause. The results of the study might give us better insight into the potential causes of SNHL and allow more timely intervention, allowing children with SNHL to reach their potential