Sk Bhargava

Pictorial essay: Salivary gland imaging.

Salivary glands are the first organs of digestion secreting their digestive juices into the oral cavity. Parotid, submandibular, and sublingual glands are the major paired salivary glands in the decreasing order of their size. In addition, multiple small minor salivary glands are noted randomly distributed in the upper aerodigestive tract, including paranasal sinuses and parapharyngeal spaces. The imaging is directed to the major salivary glands. Commonly used imaging methods include plain radiography and conventional sialography. Recently, high-resolution ultrasonography (HRUS) is being increasingly used for targeted salivary gland imaging. However, the advent of cross-sectional imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) have revolutionized the imaging of salivary glands. This article illustrates the role of imaging in evaluating the variegated disease pattern of the major salivary glands.

Pachydermoperiostosis or primary hypertrophic osteoarthropathy: A rare clinicoradiologic case

Pachydermoperiostosis (PDP) or primary hypertrophic osteoarthropathy is a rare syndrome with diverse radiological and clinical features. Though the diagnosis can be made on the basis of the classic clinical and radiological features, it is often missed due to variable presentations. A case of PDP that presented with dental complaints and had almost all the clinical and radiological features described in literature is reported. We also discuss the differential diagnosis.

Spontaneous transmural migration of retained surgical textile into both small and large bowel: a rare cause of intestinal obstruction

Retained surgical textile is an infrequent but serious complication of abdominal surgery. Diagnosis is often delayed owing to non-specific clinical symptoms and inconclusive imaging features. Medicolegal implications further complicate the issue. We report a case of a 30-year-old woman who had previously undergone caesarean section and who presented with pain and features of intestinal obstruction. Contrast-enhanced CT revealed a heterogeneous ill-defined mass with mottled air densities lying within both the large and the small bowel. Barium study beautifully demonstrated the intraluminal mass in the transverse colon extending into the jejunum, with a fistulous communication between the two loops. To the best of our knowledge, this is the first reported case in which the gauze migrated simultaneously into the large and small bowel, and where the exact site of migration was clearly mapped out on pre-operative imaging studies.

Mature ovarian dermoid cyst invading the urinary bladder

Mature ovarian dermoid cysts are common lesions, accounting for up to 10–25% of all ovarian neoplasms. Uncomplicated dermoid cysts are often asymptomatic and are relatively easy to diagnose on imaging and to treat. Symptoms develop once complications set in and these may cause diagnostic dilemmas. Torsion (16%) is the most common complication, while rupture, suppuration and malignant transformation are relatively uncommon. Of all these complications, spontaneous rupture into the urinary bladder is least common. The diagnosis of this condition has been through the use of cystoscopy or laparotomy in all cases reported so far. We report a case of a 30‐year‐old patient with pyuria and dysuria, where ultrasound examination clearly demonstrated an ovarian dermoid cyst invading the urinary bladder. A clear‐cut imaging diagnosis helped to allow planning of surgery in advance and a mucosa‐sparing partial bladder resection could be performed. Copyright

Effect of Low Level Lasers in de Quervains Tenosynovitis: Prospective study with ultrasonographic assessment

Summary Low level laser is one of the relatively new therapeutic modalities being used in physical medicine. However, its efficacy as a therapeutic tool is controversial. The purpose of this study was to observe the effect of low level laser therapy using ultrasonography for assessment in de Quervains tenosynovitis. A double-blind placebo-controlled trial was conducted on 30 limbs (28 patients) with de Quervains tenosynovitis. Fifteen limbs received the placebo treatment and 15 received a maximum of ten laser applications. The area to be treated was divided into a grid of approximately 1 cm squares, and a dosage of 2–4 joules/cm 2 with continuous output of 100% was given. The placebo group followed the same protocol but with the laser switched off. Pre- and post-treatment grip strength, pinch strength, ultrasonographic measurement of antero-posterior and medio-lateral diameters of the abductor pollicis longus and extensor pollicis brevis within the sheath in transverse section were measured. The placebo group showed no improvement. A significant increase in grip (p Laser therapy may prove to be a useful modality in the treatment of de Quervains tenosynovitis.

Isolated pancreatic hypoplasia: A rare but significant radiological finding

Pancreatic hypoplasia refers to underdevelopment of pancreatic parenchyma which arises from either the ventral or dorsal anlage. Pancreatic hypoplasia secondary to agenesis of the dorsal pancreas is a rare congenital anomaly, with less than 20 cases reported till date.[1,2] Though the majority of these patients present with abdominal pain (which is either nonspecific or typical of pancreatitis) or diabetes mellitus, the disorder may rarely remain quiescent and be detected only incidentally.[2] Agenesis of the dorsal pancreas is usually associated with various anomalies, such as polysplenia syndrome, wandering spleen, interruption of the inferior vena cava, hemiazygos and azygos continuation, symmetrical liver, anomalous hepatic fissure or lobe, left-sided inferior vena cava, median gall bladder, inverted gallbladder and stomach, and intestinal malrotation; there may also be a combination of multiple visceral anomalies.[3] In this article, the authors report a rare case of hypoplasia of the pancreas that was detected incidentally on imaging; there was no other coexisting anomaly or complication. The case is reported because of its rarity. The emphasis is on the differential diagnosis, coexisting anomalies, and complications. A 45-year-old alcoholic, nondiabetic male patient with clinical hepatomegaly and an unremarkable past medical history came for ultrasonography of the abdomen. Laboratory tests, including blood glucose levels, HbAlc levels, liver function tests, and kidney function test were within normal limits. Ultrasonography revealed mild hepatomegaly with grade I fatty infiltration. The pancreas body and tail were not optimally visualized; however, the head of the pancreas appeared normal. The main pancreatic duct was not dilated. Contrast-enhanced computed tomography (CT) of the abdomen revealed complete absence of the neck, body, and tail of the pancreas [Figure 1]. The head of the pancreas, though normal in attenuation and pattern of enhancement, appeared flattened and truncated at the anterosuperior part [Figure 2]. Mild hepatomegaly was also noted. The other intra-abdominal structures, including the spleen, gall bladder, and inferior vena cava appeared unremarkable. Figure 1 Axial contrast-enhanced CT image shows absence of neck, body, and tail of the pancreas; there is a truncated head (black arrow) Figure 2 Axial contrast-enhanced CT image shows a normalappearing truncated head with a normal-appearing uncinate process (black arrow) Based on the clinical and CT findings, we arrived at the diagnosis of isolated, uncomplicated, agenesis of the dorsal pancreas or hypoplasia of the pancreas secondary to agenesis of the dorsal pancreas. Pancreatic hypoplasia refers to congenital underdevelopment of pancreas and is often referred to as partial agenesis of the pancreas; this agenesis can involve the ventral or dorsal anlage. Figure 3 shows the ventral and dorsal buds from which the head; and neck, body and tail of the pancreas, respectively, develop. When the dorsal bud fails to develop, agenesis of the dorsal pancreas results. Agenesis of the dorsal pancreas is more common than ventral agenesis. Complete agenesis of the pancreas is extremely rare and is incompatible with life.[1] Severe hypoplasia of the pancreas can be associated with mutations involving the HNF1β gene. Figure 3 Schematic figure shows embryonic development of pancreas from the ventral and dorsal buds arising from either side of the duodenum The common clinical presentation is abdominal pain, which may be nonspecific or secondary to pancreatitis. Recurrent pancreatitis is quite common.[2] Many patients present with diabetes mellitus.[4] Sometimes, the patient may present with steatorrhea or other signs of exocrine insufficiency.[5] Imaging in a case of agenesis of the dorsal pancreas reveals a short and truncated head of pancreas, with absence of the neck, body, and tail of the organ. Based on endoscopic retrograde cholangiopancreatography (ERCP), absence of the dorsal anlage is categorized as complete (when the duct of Santorini and the minor duodenal papilla are absent) and partial (when they are remnant).[1] ERCP and magnetic resonance cholangiopancreatography will show a short ductal system in the ventral pancreas, with absence of any ductal system in the body and tail region.[5] Important differential diagnoses are carcinoma of head of pancreas with secondary atrophy of the distal body and tail of pancreas, pancreatic lipomatosis (fatty replacement of pancreatic parenchyma), and pancreatic divisum. All can be differentiated easily by imaging. Treatment is not required in asymptomatic patients.[5]

Femoral neck anteversion: A comprehensive Indian study

Background: The femoral neck anteversion has important implications. Since these values are not documented for our population, we undertook this study to define this for Indian population. Methods: FNA was calculated on 300 dry femora by the Kingsley Olmsted method, and prospectively on otherwise normal living adults by CT method (n=72 hips), by biplanar radiography (n=138 hips) and clinically (n=138 hips). Results: The mean FNA by CT was 7.4° (SD 4.6°) and more than 75% of cases were between 3.4° and 11.4°. The mean FNA by X-ray method was 11.5° (SD 5.4°) and more than 71% of cases were between 6.5° and 16.5°. The mean, clinically, was 13.1° (SD 4.6°) and almost 75% of cases were between 9.1° to 17.1°. The mean FNA on dry femora has been calculated as 8.1° (SD 6.6°) and almost 62% of cases were between 3.1° to 13.1°. The mean FNA on right side was statistically significantly 1.7° less than on the left side. Statistically significant difference between the sexes was found only by the dry bone method (F>M = 3°). Conclusions: Considering CT to be most accurate on living subjects, FNA in our study has been found to be 7.4° (SD 4.6°). It is 4 -12° lower than most of the western studies by all these methods. Readings are 4.1° higher by the X-ray method and 5.7° by the clinical method. Correlation and regression equations have also been formed between the various methods and the clinical method correlates better than the X-ray method to the CT method.

Radiography and sonography of clubfoot: A comparative study.

Background: Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot. Materials and Methods: Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades. Results: MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity. Conclusion: All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.

Esophagobronchial fistula - A rare complication of aluminum phosphide poisoning

Aluminum phosphide is a systemic lethal poison. Fistulous communication between esophagus and airway tract (esophagorespiratory fistula) has rarely been reported in the survivors of aluminum phosphide poisoning. We report a case of benign esophagobronchial fistula secondary to aluminum phosphide poisoning, which to best of our knowledge has not been reported in the medical literature.

Pancreatic laceration and portal vein thrombosis in blunt trauma abdomen.

Injuries to the pancreas by blunt trauma are uncommon. The association of pancreatic injury with acute portal vein thrombosis secondary to blunt trauma abdomen is furthermore rare. The early diagnosis of the pancreas with injury to the portal vein is challenging and difficult. These injuries are associated with high morbidity and mortality, particularly if the diagnosis is delayed. Accurate and early diagnosis is therefore imperative and computed tomography plays a key role in detection. We present a case of child with a rare combination of pancreatic laceration and acute portal vein thrombosis following a blunt trauma to the abdomen. With extensive literature search we found no such cases has been described previously.