Orbital cellulitis as a vfirst sign of ethmoid sinus osteoma in children - case report and short literature review

Introduction: Orbital cellulitis is a rare condition with very dangerous complication of acute sinus infection that could potentially lead to vision loss. It is the most common complication of acute sinusitis, especially in children. On the other hand, osteoma of paranasal sinuses in pediatric patients causing orbital cellulitis is a very rare phenomenon. Case report: A 13-year-old male child was presented to our Clinic with severe frontal headache, large swelling of the upper right eyelid, proptosis, chemosis and impaired vision of the affected eye. Fiberendoscopy showed purulent discharge from both nasal cavums and mucosal inflammation which caused the narrowing of the right ostiomeatal complex as well as sphenoetmoidal recess. Computer tomography of the paranasal sinuses revealed a subperiosteal abscess localized on the superolateral orbital wall with opacified right frontal sinus and huge ethmoid sinus osteoma measuring 2.5x2x1 cm. The tumour was removed endoscopically and great care was taken not to pierce the skull base and simultaneously remove all parts of the tumour. In addition, an outer incision of 1 cm of the upper eyelid was performed. The patient’s symptoms decreased postoperatively, and the patient was released from the Clinic with significant improvement on the sixth postoperative day. Discussion: We present an extremely rare case of ethmoidal osteoma which caused orbital cellulitis in a pediatric patient. Treating such patients is very sensitive and established algorithms do not exist. We examined the available literature on the aforementioned topic. According to Chandler’s classification of orbital cellulitis, the treating of grade III or subperiosteal abscess is still a controversy. However, in our patient’s case, the cause of cellulitis was large osteoma, so surgical intervention was inevitable. An endoscopic approach gives excellent results, but maximal care must be taken in order to avoid damaging the surrounding important structures, especially in pediatric patients who have narrow nasal cavities

Orbital cellulitis as a vfirst sign of ethmoid sinus osteoma in children - case report and short literature review

Introduction: Orbital cellulitis is a rare condition with very dangerous complication of acute sinus infection that could potentially lead to vision loss. It is the most common complication of acute sinusitis, especially in children. On the other hand, osteoma of paranasal sinuses in pediatric patients causing orbital cellulitis is a very rare phenomenon. Case report: A 13-year-old male child was presented to our Clinic with severe frontal headache, large swelling of the upper right eyelid, proptosis, chemosis and impaired vision of the affected eye. Fiberendoscopy showed purulent discharge from both nasal cavums and mucosal inflammation which caused the narrowing of the right ostiomeatal complex as well as sphenoetmoidal recess. Computer tomography of the paranasal sinuses revealed a subperiosteal abscess localized on the superolateral orbital wall with opacified right frontal sinus and huge ethmoid sinus osteoma measuring 2.5x2x1 cm. The tumour was removed endoscopically and great care was taken not to pierce the skull base and simultaneously remove all parts of the tumour. In addition, an outer incision of 1 cm of the upper eyelid was performed. The patient’s symptoms decreased postoperatively, and the patient was released from the Clinic with significant improvement on the sixth postoperative day. Discussion: We present an extremely rare case of ethmoidal osteoma which caused orbital cellulitis in a pediatric patient. Treating such patients is very sensitive and established algorithms do not exist. We examined the available literature on the aforementioned topic. According to Chandler’s classification of orbital cellulitis, the treating of grade III or subperiosteal abscess is still a controversy. However, in our patient’s case, the cause of cellulitis was large osteoma, so surgical intervention was inevitable. An endoscopic approach gives excellent results, but maximal care must be taken in order to avoid damaging the surrounding important structures, especially in pediatric patients who have narrow nasal cavities

Spontana rinolikvoreja - prikaz slučajeva

Rinolikvoreja nastaje kao rezultat neprirodne komunikacije između subarahnoidalnog prostora i pneumatiziranog mjesta u bazi lubanje koje uključuje paranazalne sinuse ili nosne kavume. Prema etiologiji možemo ju podijeliti na traumatsku i netraumatsku komunikaciju ili fistulu. Traumatske fistule dijelimo na akcidentalne ili slučajne (one čine većinu – oko 80% svih fistula) i na ijatrogene ili poslijeoperacijske (oko 15%). Netraumatske ili spontane fistule uzrok su rinolikvoreje u otprilike 5% svih slučajeva. Spontane fistule možemo podijeliti na one uzrokovane idiopatskom intrakranijalnom hipertenzijom i na fistule s normalnim intrakranijalnim tlakom. Potencijalne komplikacije rinolikvoreje su meningitis, moždani apsces, pneumocefalus, te je zato važno što ranije započeti kirurško liječenje. Izlaganje prikazuje tri najrecentnija slučaja spontane rinolikvoreje na našoj klinici, koje smo odlučili liječiti transnazalnim endoskopskim pristupom, koristeći višeslojnu kompozitnu tehniku zatvaranja fistule. Kod sva tri slučaja (jedan muški bolesnik i dvije ženske bolesnice) radiološkom slikovnom dijagnostikom verificiran je defekt desne lamine cribriformis. Poslijeoperacijski muški bolesnik zahtijevao je sekundarno kirurško liječenje unutar mjesec dana od primarnog operacijskog zahvata, zbog recidiva rinolikvoreje. Godinu i pol dana od završenog kirurškog liječenja na kontrolnom pregledu sva tri bolesnika urednog su lokalnog nalaza i subjektivno bez tegoba. Smatramo da je uzrok recidiva rinolikvoreje kod muškog bolesnika rezultat korištenja tehnike zatvaranja koja nije imala jednako složenu višeslojnu kompozitnu građu koju smo koristili u kirurškom liječenju bolesnica. Spontana rinolikvoreja rijetko je patološko stanje koje zahtijeva brzu dijagnostiku i kirurško liječenje zbog mogućih opasnih komplikacija. Pravilno uzimanje anamneze, multidisciplinarni pristup, precizna prijeoperacijska radiološka lokalizacija i izbor kirurške tehnike bitni su za uspješno liječenje. Transnazalni endoskopski pristup s višeslojnom kompozitnom tehnikom zatvaranja ima visoku stopu uspješnosti s vrlo visokom sigurnošću i vrlo niskom stopom morbiditeta, kako u recentnoj literaturi, tako i u našem iskustvu

Myxoma of the Zygomatic Bone – A Case Report

Myxoma is a benign tumor composed of primitive connective tissue cells and mesenchymal mucousal stroma. Also referred to as, a gelationus or colloidal tumor. Although rare, it can be found in the atrium of the heart, and it is the most common heart tumor. It has also been described in other body sites, one of which is the bone. We report a case of a 57-yearold female patient, with recurrent headaches located in the area of the right half of the face. Radiological analysis (Multislice Computed Tomography of the paranasal sinuses and viscerocranium) was performed, and a formation of irregular contours, destroying the right zygomatic bone, was described, measuring 25x17x20 mm in its widest diameters. Its medial border was adjacent to the lateral wall of the right maxillary sinus and the cortical bone in this segment was thinned, but preserved. A probatory excision was performed in general anesthesia, and the histopathological fi nding showed, starlike tumor cells embedded in mucoid stroma and infi ltrating the bone. After pathohistological confi rmation of myxoma, the tumor was excised in total, using infraorbital surgical approach to the zygomatic bone. During the follow-up, the patient was symptom free, without headaches, and there were no signs of local tumor recurrence. Despite of the fact that myxoma behaves as a benign disease in its nature, it can cause destruction of the tissue in the vicinity of the tumor itself, and thus major health issues for the patient. A timely proper diagnosis and the right choice of a surgical treatment can help avoid more extensive surgery procedures, as shown in our case report

Hereditarni angioedem

Hereditarni angioedem (HAE) je rijedak nasljedni, životno ugrožavajući poremećaj, koji se prezentira nepredvidivim napadajima bolnih ponavljajućih edema. Iako neizlječivo stanje, danas se zahvaljujući lijekovima, može osigurati relativno normalan život njime pogođenih bolesnika. Obilježavaju ga ponavljajući akutni napadaji edema koji zahvaća kožu i mukozne membrane. Edem zahvaća duboki sloj dermisa, za razliku od urtikarije, koja zahvaća površinske slojeve dermisa, te obično nije praćen pruritusom. Ukoliko edem zahvaća dišne putove mogući su, u slučaju neadekvatne terapije, i fatalni ishodi. Najčešće zahvaćena područja su: ekstremiteti (šaka, stopalo), lice, torzo, genitalije, gastrointestinalni trakt, larinks (što može biti i životno ugrožavajuće), no mogu biti zahvaćeni i drugi organi (npr. mozak, mokraćni mjehur, bubrezi). Patofiziologija HAE je manjak ili disfunkcija inhibitora C1 esteraze koja dovodi do okidačem potaknute autoaktivacije C1 i cijele kaskade reakcija koje rezultiraju angioedemom. Glavni medijator je bradikinin. Za terapiju akutnih ataka daju se: • C1 inhibitori za tip 1 i 2 dobar učinak ima koncentrat C1 inhibitora dobiven iz plazme ili rekombinantno, dok se kod tipa 3 ili stečenog angioedema zbog pojačane potrošnje antitijelima mogu očekivati bolji rezultati od lijekova poput antagonista B2 bradikininskih receptora -ikatibant • svježa smrznuta plazma ili deterdžentom obrađena plazma • inhibitori kalikreina (za sada odobreni na američkom tržištu) • ne reagira na klasičnu antišok terapiju! Bolesnici s hereditarnim angioedemom nisu samo zanimljivi slučajevi, već teški bolesnici, koji imaju ograničene mogućnosti biranja zanimanja, kao i ostalih društvenih i sportskih aktivnosti, a čija se kvaliteta života, uz ispravnu dijagnozu i pravovremenu terapiju, ipak može znatno unaprijediti. Stoga je bitno prepoznati ovaj rijedak, potencijalno životno ugrožavajući poremećaj

The Importance of Anatomical Topography in Nasolacrimal Duct Stenosis

In our previous study the inclination of nasolacrimal canal in relation to Frankfurt horizontal plane has been analysed on 71 anatomically preparated human skulls by introducing the probe through canal. The results of that study showed that the alpha angle in the frontal plane was greater than 91° in 27% of cases, i.e. nasolacrimal canals descend diverging in relation to the median plane and both probes are intersected on glabella. In 55% of cases, the alpha angle was less than 89° and probes diverge on glabella, and in 18% of cases the canals were parallel to the median plane. In this study nasolacrimal ducts in patients were visualised with Omnipaque contrast that was injected with probe through the superior lacrimal punctum. Thereafter radiography was performed. These in vivo results confi rm our previous results obtained on the skulls. Minimal individual variations of values of the angle were observed. These fi ndings are very important in probing of stenosis of nasolacrimal duct in infants, as the operator would not have to forcefully probe with rigid instrument through gentle infant nasolacrimal duct. Diffi cult and serious consequences for infants arise when directing the probe »via falsa« and that often happened in practice. The authors therefore suggest when using this old method of probing, that this »surgical« act should be performed with »soft« probe made of nylon or silver that is very pliable and does not lead to nasal or temporal rupture of the canal

Pyriform turbinoplasty and nasal wall lateralisation - nova tehnika za rješavanje nedostatnog disanja kroz nos uz očuvanu funkciju nosa kao organa

"Pyriform Turbinoplasty" je novi operativni zahvat popularizian od prof. D. Simmena. Pod kontrolom endoskopa proširi se lateralni dio unutarnje nosne valvule. Nakon frakturiranja donje nosne školjke, odnosno lateraliziranja njezine stražnje dvije trećine, prikaže se izbočenje na prednjoj trećini školjke koje čini njezino hvatište. Sluznica se zareže na mjestu toga izbočenja, te se odigne superiorno i inferiorno, kako bi se prikazala kost donje nosne školjke i njezino hvatište za lateralni zid nosne šupljine. Osteotomom se odstrani kost frontalnog procesa maksile i lakrimalne kosti medijalno, od nazolakromalnog kanala, uz očuvanje sluznice samog kanala. Ovim zahvatom smanjuje se otpor protoku zračne struje, ali se ne utječe na ovlaživanje i zagrijavanje zraka kao kod nekih drugih vrsta turbinoplastika. Očuvanjem sluznice izbjegava se suhoća nosa i stvaranje krasti. Resekcija kosti se može proširiti odstranjivanjem lakrimalne kosti iza nazolakrimalnog kanala i uncinatnog nastavaka, same kosti donje nosne školjke i samog ruba maksile na aperturi piriformis. Takav zahvat naziva se "Nasal wall lateralisation". Na našoj klinici zahvat indiciramo kod bolesnika koji su operirali septum nosa i učinili redukciju nosnih školjki, a i dalje su nezadovoljni disanjem kroz nos unatoč medikamentaznoj terapiji, bolesnika s medikamentoznim rinitisom refraktornim na terapiju intranazalnim kortikosteroidima i operacija maksilarnog sinusa koji zahtjevaju široku meatotomiju

Descriptive and functional definition of nucleolus – a pathway to cancer therapy

Očekuje se da moderna terapija tumora djeluje ciljano i sveobuhvatno. U novim kliničkim ispitivanjima terapije raka primjenjuju se mali molekularni inhibitori transkripcije ribosomalnih gena i aktivatori apoptoze. Model terapije prikazan ovdje je aktivacija supresora tumora koji djeluju u domeni jezgrice. Stanice tumora pokazuju poremećaj regulacije proteina i mutaciju P53 gena koji suprimira rast. Razvoj bolesti definira terapiju. Moderna se definicija bolesti temelji na etiopatogenezi staničnog stresa u kojem sudjeluju brojne organele, uključujući jezgricu. Jezgra i jezgrica su mikroskopski oblici. Ovaj prikaz daje sažet opis onoga što se vidi kada se kaže „jezgrica”. Nadalje su opisani kiseli nehistonski proteini koji se okupljaju oko transkripcijskog ustroja RNK polimeraze I te je istaknut značaj njihove vizualizacije za promjenu definicije jezgrice. Osim što je tjelešce u nukleoplazmi i subnuklearna organela, jezgrica se može vizualizirati pomoću njezinih funkcionalnih struktura – AgNOR-a. AgNOR proteini imaju ulogu u nukleolarnom stresu. Svrha ovoga teksta je raspraviti nukleolarni stres.Modern tumour therapy should be target specific and comprehensive. Recent clinical trials test small molecular inhibitors of transcription of ribosomal genes and activators of apoptosis. We treatise on models of activation of the suppressors of tumour growth acting in the nucleolar domain. Tumour cells demonstrate a disordered protein regulation and mutation of P53 gene which codes for a suppressor of growth. Therapy is guided by pathogenesis. Modern disease definition is based on etiopathogenesis of cell stress, wherein participate numerous organelles, including the nucleolus. Nucleus and nucleolus are forms seen on light microscopy. This presentation focuses on the description of the visible correlate of the notion of “nucleolus”. Further to this, acid non-histone proteins which gather around the transcriptional machinery of RNA polymerase I are described, and the significance of their visualisation towards the alteration of the definition of nucleolus is pointed out. Besides being a particle within the nucleoplasm and a subnuclear organelle, the nucleolus is visualized through its functional structures – the AgNORs. The AgNOR proteins have a role in nucleolar stress. The aim of this article is to discuss the nucleolar stress

Post-otoplasty Ear Keloid

Uvod: Odstojeća uška predstavlja jedan od najčešćih estetskih deformiteta ušne školjke. Idealno vrijeme za liječenje je predškolska dob. Pristup svakom bolesniku je individualan i uključuje detaljan pregled i uzimanje anamnestičkih podataka. Kirurško liječenje uvijek čini kombinacija nekoliko kirurških pristupa (Mustard, Converse, Bear, Pitanguy, Šercer, Stenström...). Komplikacije zahvata su rijetke, a kao jedna od mogućih izdvaja se pojava keloida ili prekomjernog ožiljka. Prikaz slučaja: U desetogodišnje djevojčice zbog odstojećih uški učinjena je otoplastika po Bearu. Osam mjeseci poslije operacije pojavio se manji keloid u području poslijeoperacijskog ožiljka. Promjenu smo liječili flavonoidom u vidu gela. Dvije godine poslije operacijskog zahvata kod bolesnice je ustanovljen velik grozdasti keloid na obje uške. U liječenju smo koristili kiruršku eksciziju, intralezijske kortikosteroide i terapiju argon laserom. Rasprava: Keloid je česta kožna lezija koja se teško liječi i ima visoku učestalost recidiviranja. Do sada nije osmišljen jedinstven terapijski pristup keloidu. On uključuje primjenu okluzivnog zavoja, intralezijske injekcije kortikosteroida, kriokirurgiju, kiruršku eksciziju, radioterapiju, lasersku terapiju, terapiju interferonom, 5 % imiquimod kremom, 5- FU (fluorouracilom) i drugu manje poznatu terapiju usmjerenu na sintezu kolagena. Zaključak: U našem slučaju koristili smo se pristupom koji se sastojao od kirurške ekscizije keloida te poslijeoperacijske uporabe intralezijskih injekcija kortikosteroida i primjene argon lasera. S obzirom na to da se radi o dječjoj dobi, uočili smo nedostatak literature o primjeni intralezijskih kortikosteroida. Nadamo se da će naš rad pridonijeti spoznajama o mogućnostima liječenja keloida nakon otoplastike u dječjoj dobi.Aim: Prominent ear represents one of the most common aesthetic deformations of the auricle. The ideal time for its treatment is the pre-school age. The approach to each patient is individual and includes a detailed examination and thorough medical history. Surgical treatment always uses a combination of several techniques, including those after Mustard, Converse, Bear, Pitanguy, Šercer, Stenström et al. It is very rarely followed by some complications, one of them being keloid or excessive scar. Case: An otoplasty after Bear was carried out on the protruding ears of the ten year girl. Eight months after the operation, a minor keloid appeared in view of a post-operative scar which was treated by gel flavonoid. Two years after the operation a large grapelike keloid was found at both auricles. The treatment included excision, intralesional corticosteroids and argon laser therapy. Discussion: Keloids are skin lesions difficult to treat and are highly recidive. So far, no common therapy for keloid treatment has been established. It includes the application of occlusive bandage, intralesional corticosteroid injections, surgery, excision, radiotherapy, laser therapy, interferon therapy, therapy by 5% imiquimod cream, by 5 FU (fluorouracil) and other less utilised therapy aimed at collagen synthesis. Conclusion: The authors used the combined techniques of keloid excision followed by post-operative intralesional corticosteroid injections and the application of argon laser. Additionally, we observed a lack of resources dealing with intralesional corticosteroid applications in children. Therefore, our paper should encourage further research of keloid treatment, following otoplasty in childhood