What is Oncocytoma?

Oncocytoma can be described as a tumor that is mainly constituted out of oncocytes. These are actually epithelial cells, containing excessive quantities of mitochondria. This excess leads to a cytoplasm that is acidophilic and granular. It is important to understand that the cells comprising the oncocytoma are benign in nature; however, there are patients in which these cells demonstrate a pre-malignant or malignant state (malignant transformation).

Histopathology

The oncocytes that contribute to the formation of oncocytoma are epithelial cells, as it was already mentioned. The composition of oncocytoma is what places it in the epithelial tumors category. The oncocytes are eosinophilic cells that are large in size, having a small and round nucleus. They nucleus has a benign appearance, being surrounded by nucleoli that are large in size as well. One should keep in mind that the oncocytoma is not restricted to a particular organ; on the contrary, it can arise in more than just one organ.

Renal oncocytoma

Despite being a benign tumor, it is quite difficult for it to be distinguished from the renal cell carcinoma. The renal oncocytoma is one of the primary adult epithelial renal neoplasms that are treated through surgical resection (5% of all the cases). The condition often affects patients who are in their 6th-7th decade of life, with the peak incidence being at approximately 55 years.

The male population is predisposed to developing this condition, with the majority of the patients being asymptomatic. If a large mass occurs in the flank or abdominal area, the patient might start to present symptoms – pain is the most common complaint. Apart from pain, the patient can present blood in the urine (hematuria) or occasional high blood pressure (hypertension). This condition can be found in association with other medical problems, such as the Birt-Hogg-Dubé syndrome or the tuberous sclerosis.

Pathology

The growths that are larger in size present a tan color, which is similar to the one of the renal cortex. In some situations, the macroscopic oncocytoma might appear to be darker in color. A pseudocapsule can be present in some of the growths. It is also possible that macroscopic hemorrhage appears (20% of all the cases). It is not helpful to perform a biopsy on the oncocytoma, hoping to make the differential diagnosis from the renal cell carcinoma (as this contains oncocytic elements as well). Necrosis is not present.

Diagnosis

These are the most common methods used for the diagnosis of the renal oncocytoma:

• Imaging studies
  • Sharp and demarcated lesions of various sizes
  • Difficult to distinguish from renal cell carcinoma (due to the similar appearance)
  • Sharp central stellate scar – helpful sign, characteristic of oncocytoma (only in 1/3 of the cases)
  • May reveal the metastasis or the aggressive infiltration of the adjacent structures (the diagnosis if then of renal cell carcinoma)
  • Both kidneys have to be evaluated – patients can present multiple oncocytomas in both kidneys; moreover, concurrent renal cell carcinomas can be identified
• Intravenous pyelogram
  • Sharp demarcation of the growths
  • Enhancement is noticed during the nephrographic phase
• Ultrasound
  • Well-circumscribed mass
  • Central scar might be visible (not in all patients)
• CT
  • Large and well-demarcated tumors identified
  • Can be made with non-contrast and contrast
• MRI
  • Typical characteristics present, including the central stellate scar
• Angiography
  • Spoke wheel pattern identified – the peripheral vessels are penetrating into the center of the lesion
  • The investigation can also serve to the identification of the microaneurysms in the area.

Based on the available imaging studies, the differential diagnosis can be made with the following conditions: renal cell carcinoma (very difficult to be made, due to the highly similar characteristics), metanephric neoplasms (adenoma or adenofibroma) and renal leiomyoma.

Treatment and prognosis

The surgical resection is often the first line of treatment for the renal oncocytoma, as these lesions cannot be clearly distinguished from the renal cell carcinoma. Renal sparing surgery is performed only in the situation that the diagnosis is confirmed pre-operatively.

Salivary gland oncocytoma

Also known as the oxyphilic adenoma, this is a benign neoplastic growth that occurs at the level of the salivary glands. The tumor is well-circumscribed and it represents approximately 1% of all the tumors affecting this particular part of the body. Upon performing a histopathological analysis, inflamed oncocytes are going to be revealed (the cells contain excessive quantities of mitochondria).

This form of oncocytoma is often encountered in patients of older age (70-80 years). The oncocytoma is more commonly identified at the level of the parotid gland (85-90% of the cases). The growth is firm and painless, growing on a gradual, slow manner. The diameter of the mass is under 4 cm. A bilateral presentation is often encountered with the salivary gland oncocytoma.

Thyroid oncocytoma

The thyroid oncocytoma can appear either a benign (adenoma) or a malignant (carcinoma) growth. In the situation that the growth is benign, it will take the form of an encapsulated and solid nodule. More than one nodule can be present, all of them having a characteristic, brown cut surface. When it comes to the malignant growths, there are not many things that distinguish it from a benign lesion. A trained eye can recognize the invasion of the cancerous cells in the healthy tissue, as well as the development of the vascularization in the area (neo-vascularization). The transcapsular and/or vascular invasion remain the main criteria used for the diagnosis of the malignant thyroid oncocytoma.

The patients who suffer from thyroid oncocytoma generally present a thyroid nodule, with the rest of the thyroid gland functioning normally. When the tumor becomes too large in size, invading the area around the thyroid gland, the patient might experience difficulties swallowing or talking.

In conclusion, the general treatment for oncocytoma is represented by the surgical resection. This guarantees the best outcome for the patient and also the relief from the experienced symptoms, if any. As you have had the opportunity to read, the renal oncocytoma presents the most complex diagnostic difficulties, as it shares many of its characteristics with the renal cell carcinoma.

Definition: What is Hilar adenopathy?

Hilar adenopathy can be defined as the enlargement of the lymph nodes, occurring at the level of the pulmonary hilum. This condition does not appear on its own, always signifying the existence of an underlying pathology. It is possible that both lungs present the enlargement of the lymph nodes.

Hilar Adenopathy Causes

These are the potential causes or etiologies that can lead to the appearance of the hilar adenopathy:

• Inflammatory
  • Sarcoidosis
  • Inorganic dust disease (silicosis, berylliosis)
• Malignant
  • Lymphoma (more often Hodgkin lymphoma, in comparison to non-Hodgkin lymphoma)
  • Metastases
  • Bronchogenic carcinoma (primary hilar tumor)
  • Mediastinal tumors
• Infectious
  • Tuberculosis
  • Histoplasmosis
  • Infectious mononucleosis
  • Fungal infection
  • Mycoplasma
  • Intestinal lipodystrophy (Whipple’s disease)
  • Coccidioidomycosis
  • Viral infection
  • Atypical mycobacterial infection
  • Tularemia
  • Anthrax
• Extrinsic allergic alveolitis – bird fancier’s lung (hypersensitivity pneumonitis)
• Other causes (more rare)
  • Churg-Straus syndrome
  • HIV
  • Still’s disease (adult onset)
  • Reaction to medication.

The following conditions lead to the appearance of unilateral or bilateral, symmetrical hilar adenopathy: primary tuberculosis, fungal infection, atypical mycobacterial infection, viral infection, tularemia, anthrax, bronchogenic carcinoma, lymphoma, sarcoidosis and silicosis. On the other hand, the bilateral symmetrical adenopathy can only be caused by: sarcoidosis (most common), viral infections (adenovirus or mononucleosis).

Diagnosis

One of the most investigations used for the diagnosis of the hilar adenopathy is the plain pulmonary X-ray. However, has to take into consideration that the pulmonary arteries go through the same area. In the situation that these vessels are enlarged, they might be mistaken for hilar adenopathy. In order to make the difference between this condition and the enlarged vessels, you need to analyze their appearance. While the enlarged lymph nodes have a lumpy or bumpy appearance (characteristic opacity on the X-ray), the enlarged pulmonary arteries appear to be smooth (in reference to their contour).

Chest CT can also be used for the confirmation of hilar adenopathy. Depending on the results provided by the imaging studies, the enlargement of the lymph nodes can be classified as unilateral or bilateral. In the situation that the hilar adenopathy is bilateral, it can be further classified into symmetrical or asymmetrical.

Treatment

In order for the hilar adenopathy to disappear, the treatment has to be concentrated on the underlying etiology.

Pictures of Hilar Adenopathy

Take a look at how Hilar Adenopathy looks like:

What is Metaphysis?

The metaphysis can be defined as the wide portion of the long bones. This is commonly found between the two ends of a bone, meaning the epiphysis and the diaphysis. Part of the growth plate, the metaphysis develops during the childhood period, its ossification centers being located close to the ends of the bone.

The growth plate contains an epiphyseal component (cartilaginous), a bony component (metaphysis) and a fibrous component (surrounds the peripheral part of the growth plate). In adults, the main function of the metaphysis is to support the load transfer from the joint surfaces that bear weight to the diaphysis. The metaphysis is adjacent to the epiphyseal disk as well, being considered as a transitional zone.

During the period of growth, it is the job of the metaphysis to support the epiphyseal plate (ensuring thus the longitudinal growth). The metaphysis mainly consists of spongiosa, being often presented in adults as the area located near the diaphysis of the long bones.

In children, the long bones is divided into the following segments: diaphysis, metaphysis, physis and epiphysis. The diaphysis is known as the shaft or the primary ossification center, while the metaphysis is presented as the segment where the bone flares. The physis is represented by the bone plate, whereas the epiphysis is the second ossification center. As opposed to children, the long bones of adults present only the diaphysis, metaphysis and epiphysis.

In children, the epiphysis is constituted mainly of cartilaginous tissue (growth cartilage). The physis or the growth plate ensures the longitudinal growth of the bones. While the physis cannot be assessed on the plain radiologic film, its function can be indirectly assessed with the help of the Harris lines. These are normally present at the level of the metaphysis – if the child is healthy and the function of the physis is good, then these lines actually represent the contour of the physis.

Anatomy Pictures of Metaphysis

Metaphysis Picture 1 – Bone Metaphysis and other regions including Epiphysis, Metaphysis, Diaphysis

Metaphysis Picture 2 – Comparison of Adult and Child’s Metaphysis

Clinical significance

The metaphyses of the long bones are characterized by a rich vascular supply, as well as by the vascular stasis. Because of these characteristics, in children, this part of the bone presents a high risk for the hematogenous spread of conditions such as osteomyelitis. It is also possible that the metaphysis is affected by different types of tumors, such as: osteoid osteoma, non-ossifying fibroma, aneurysmal and simple cysts of the bone, fibrous dysplasia, enchondroma, osteoblastoma, fibrosarcoma, chondrosarcoma and osteosarcoma.

Rickets, a condition that is defined by the defective demineralization of the bones, has a negative effect on the metaphyses. In making the diagnosis for this condition, doctors analyze the state of the metaphyses of the long bones. If these presents signs of cupping or fraying, then the diagnosis is most likely rickets.

Pathology

The condition known as “celery stalk metaphysis” is encountered in the situation that the metaphyses of the long bones present linear sclerosis bands. These changes are identified through imaging studies (most commonly – plain radiologic films). The linear sclerosis bands are longitudinally aligned, being encountered in the following medical conditions: congenital infections (congenital rubella, congenital syphilis, and congenital cytomegalovirus) and osteopathia striata.

Introduction

The Fitz-Hugh-Curtis syndrome can be defined as a rare complication that occurs in patients diagnosed with the pelvic inflammatory disease. This condition bears the name of the doctors who discovered it, meaning Fitz-Hugh and Curtis. One of the most important changes that occurs is related to the inflammation of the liver capsule, followed by the appearance of adhesions in the respective area. The adhesions form between the anterior part of the liver capsule and the anterior abdominal wall.

The complication might also affect the diaphragm, which is the respiratory muscle separating the thorax from the abdomen (in this situation, the adhesions are formed between the same part of the liver capsule and the diaphragm). The symptoms of the syndrome, as you will have the opportunity to read in the paragraphs below, can mimic other medical problems, such as cholecystitis or pyelonephritis.

The prevalence of this complication in women who suffer from the pelvic inflammatory disease is between 4-10%. In the situation that one suffers from genital tuberculosis, the prevalence of the Fitz-Hugh-Curtis syndrome is higher. Women who are in their child-bearing years are most commonly affected by such complications. Adolescents are also affected by this syndrome, as the frequency of the pelvic inflammatory disease is high in that period of life (plus, their immature anatomy is a serious risk factor). In extremely rare situations, this condition has been encountered in men as well.

Signs and Symptoms of Fitz-Hugh-Curtis Syndrome

These are the most common signs and symptoms that are present in patients suffering from such complications:

• Pain
  • Acute onset
  • Location – abdomen (right quadrant)
  • The pain is aggravated by breathing, coughing or laughing (this is because these movements increase the intra-abdominal pressure)
  • May radiate to the right shoulder
  • Pleuritic chest pain can also be present among the symptoms
• Tenderness in the right upper abdomen upon palpation
• The tenderness can be elicited through the percussion of the lower ribs (as these protect the liver)
• Systemic symptoms
  • Fever and/or chills
  • Headaches
  • Nausea, vomiting
  • Night sweats
  • State of general malaise
• Other symptoms
  • Hiccups
  • Features of acute salpingitis (not common)

It is important to mention that the patient might present little or even no pain in the pelvic area. There is no vaginal discharge and no tenderness related to the cervical motion, the lack of such symptoms often guiding the diagnosis in the wrong direction. It is believed that these changes are not present due to the bacteria bypassing the structures of the pelvis, before reaching the capsule of the liver and causing the inflammation in the area.

If the patient suffers from a chronic form of this complication, the pain might be dull in persistent, affecting mainly the right upper quadrant. In other patients, suffering as well from the chronic form, the pain subsides.

Pathophysiology

Women are clearly affected by this condition. The most common causes that lead to the appearance of such complications include: gonorrhea (this type is also known as the acute gonococcal perihepatitis) and chlamydia (bacterial infection as well). The latter causes the cervical mucus to become thinner, which in turn allows for the bacteria to travel from the vagina to the uterus and other adjacent structures (oviducts). The infectious organisms is responsible for the inflammation and it may also lead to the formation of scar tissue on the liver capsule. The latter is known as Glisson’s capsule, being a thin layer of connective tissue that surrounds the liver.

Chlamydia trachomatis is the most common bacterial agent involved in the appearance of this syndrome, followed by Neisseria gonorrhoeae. Other infectious agents that may cause such health problems in rare cases include: E. coli, Gardnerella and streptococcus.

Basically, in the Fitz-Hugh-Curtis syndrome, the infection is spread intraperitoneal, from the initial pelvic area (localized infection) to the perihepatic region. Recent studies have demonstrated that the spread of the infection from the pelvis to the liver area is due to the fluid circulating along the paracolic gutter. The infection might be transmitted through the lymphatic system or directly through the bloodstream.

Diagnosis

These are the most common methods used for the diagnosis of the Fitz-Hugh-Curtis syndrome:

Ultrasound

• Performed at the level of the abdomen
• Does not reveal any specific changes
• Incidental discovery of fat on the liver or gallstones
• Useful for the exclusion diagnosis (renal or biliary stones)
• Identification of changes such as the violin strings or excess fluid in the abdomen (ascites)

Blood testing

• Liver function tests
  • Normal or unchanged
  • The infection does not penetrate into the structure of the liver (hence the normal values of the liver enzymes)
• FBC
  • Elevated white count
  • Increased ESR (erythrocyte sedimentation rate)

Abdominal CT (with IV contrast)

• Subtle enhancement of the liver capsule
• May also show the inflammatory process that has occurred at the level of the pelvis
• A tubo-ovarian abscess can be identified
• In the perihepatic area, the following additional changes can be identified:
  • Inflammation and fluid collection at the level of the paracolic gutter
  • Thickening of the gallbladder wall
  • Transient perfusion abnormalities

Cervical samples

• Identification of infectious organisms (chlamydia, gonorrhea)
• Taking cervical samples is considered to be a more faithful investigation of the infectious organisms, in comparison to the urine analysis

Antibody testing

• Rarely required
• Recommended in the situation when the suspicion for this diagnostic is high (and other tests do not provide the desired information)

Laparoscopy

• Rarely required as well
• Performed when diagnosis is uncertain
• May reveal adhesions of the parietal peritoneum to the liver (characteristic aspect – violin strings)

Urine analysis

• Microscopy and culture
• Can be used in conjunction with other investigations for the confirmation of the infectious agent

CXR

• Useful for excluding the diagnosis of pneumonia or the pulmonary embolism.

The diagnosis of the Fitz-Hugh-Curtis syndrome can also be identified by taking samples from the peritoneal fluid. This will most likely contain the infectious microorganisms, such as chlamydia trachomatis or Neisseria gonorrhoeae. Other infectious microorganisms, such as trichomonas vaginalis, ureaplasma urealyticum or mycoplasma hominis can be identified in the fluid from the peritoneal cavity (in rare cases). As it was already mentioned, the syndrome can be found in association with the genital tuberculosis. In this situation, the infection is caused by mycobacterium tuberculosis (endemic areas of developing countries).

Based on the finding provides by the imaging studies, the differential diagnosis of this syndrome can be made with the following conditions: peritoneal carcinomatosis and appendicitis. The first has a different clinical presentation, with more nodules at the level of the peritoneum and a clear malignancy involving the ovaries. As for appendicitis, this can also be discussed as a further complication of the Fitz-Hugh-Curtis syndrome. Other conditions with which the differential diagnosis can be made are: ectopic pregnancy, viral hepatitis, pulmonary embolism and renal colic.

Treatment

These are the common courses of treatment taken for the patients suffering from the Fitz-Hugh-Curtis syndrome:

• Antibiotics
  • Elimination of the infection and improvement of the symptoms experienced by the patient
  • Recommended choices – ceftriaxone, azithromycin
• Anti-inflammatory medication
  • Purpose – reduction of inflammation and pain relief
  • Recommended choice – acetaminophen; codeine (in more severe cases)
• Laparoscopy
  • Performed on the adhesions, improving the refractory pain.

It is important to understand that the appearance of such complications can impair the fertility and also increase the risk for ectopic pregnancies in the future. When treating this syndrome, it is essential to treat the pelvic inflammatory disease as well (not just in the respective patient but also in all of the sexual partners that person has).

Prognosis

The prognosis of the Fitz-Hugh-Curtis syndrome is the same as for the pelvic inflammatory disease. Some patients might be asymptomatic, with the condition being discovered incidentally upon performing investigation for other health problems (for example, when trying to identify the reasons behind infertility).

Prevention

The Fitz-Hugh-Curtis syndrome, as well as the pelvic inflammatory disease, can be prevented by using protection when engaging in sexual intercourse. Maintaining excellent hygiene is essential, in order to reduce the risk of bacterial infections. Avoiding using public restrooms that are not clean is also a good idea, as it reduces the risk of catching a bacterial infection that can lead to such complications.

In regard to the sexual transmission, it is very important to talk to your partner about such problems the moment you have received the diagnosis. As it was already mentioned, the treatment of such problems does not concern only you but also all of the sexual partners you have had recently. Left untreated, the infection can be transmitted to other people. All sexual partners have to be treated for the infection and men in particular, as they can transmit the infection to other women (who present the risk of developing complications such as the Fitz-Hugh-Curtis syndrome).

In the recent years, there was a debate whether this syndrome should be presented as a problem related to the gynecologic area or the hepatic one. The latest studies have decided that this health problem belongs to the hepatic area, due to the more extensive affectation of the liver capsule.

Definition

Foramen lacerum is a hole that is found at the base of the skull, with a characteristic triangular shape. These are the elements that surround the foramen lacerum and practically contribute to its formation: sphenoid bone (anterior border), petrous temporal bone (more exactly, its apex) and the occipital bone (specifically, the basilar part). It is known that foramen lacerum is located anteriorly and medially from the carotid canal. The hole is covered by cartilage (connective tissue) in the postnatal period. In general, the foramen lacerum has a length of 9 mm and a breadth of 7 mm. The foramen lacerum is found on each side of the skull base, at a close distance from the pharyngeal tubercle of the occipital bone.

Function of Foramen Lacerum

The internal carotid artery appears at a superior point from the foramen lacerum, after having passed from the carotid canal into the base of the skull. Even though it exists the carotid canal, the internal carotid artery is not going to pass through the foramen lacerum. However, because it is located at a close distance, the part that is found above the foramen lacerum is also known as the lacerum segment. These are the elements that pass through the foramen lacerum: venous drainage, nerve and artery of the pterygoid canal.

The foramen lacerum is also transited by the greater petrosal nerve. This will eventually become a part of the nerve of the pterygoid canal (this also contains the deep petrosal nerve). This nerve contains both sympathetic and parasympathetic fibers, covering the innervation for the blood vessels in the area, as well as for the mucous membranes, salivary and lacrimal glands.

A terminal branch of the ascending pharyngeal artery also passes through the foramen lacerum, as well as emissary veins. The latter are responsible for connecting the intracranial cavernous sinus with the extracranial pterygoid plexus; unfortunately, due to this connection, there is also a high risk for an infection traveling from one point to the other. Also, the foramen lacerum offers the invasive nasopharyngeal carcinoma with the perfect access point into the cavernous sinus. It is because of this connection that the cranial nerves are affected in the spread of the nasopharyngeal carcinoma.

Studies performed on cadavers have demonstrated that the foramen lacerum is not a true foramen. Scientists have based this affirmation on the fact that no significant structures go above the fibrous tissue that covers it. It was suggested that this is rather an extension of the lacerum portion of the carotid canal and not a foramen per say.

In conclusion, the structures that pass at the whole length of the foramen lacerum are the meningeal branch of the ascending pharyngeal artery and the emissary veins. The other structures that traverse the foramen lacerum only partially include the internal carotid artery and the greater petrosal nerve.

Pictures

Foramen Lacerum Picture 1 : Floor of the cranial cavity showing various parts including the Foramen lacerum, Optic foramen, Foramen rotundum, Foramen ovale, Internal auditory meatus, Jugular foramen, Foramen magnum, Occipital bone, Parietal bone, Petrous portion of temporal bone, Sella turcica, Temporal bone, Sphenoid bone, Frontal bone, Cribriform plate (Ethmoid bone) and Crista galli.

Foramen lacerum syndrome

This condition is actually represented by the aneurysm of the internal carotid artery. A congenital condition, it generally involves the intradural portion of the respective artery. Among the symptoms that patients present, there are: inflammation of the meninges, orbital headache and migraines.

What is Mesenteric Panniculitis?

Mesenteric panniculitis can be described as a rare condition, in which the adipose tissue of the bowel mesentery suffers from a chronic, non-specific inflammatory process. It is important to understand that this fibrosing inflammatory disease is benign. The condition was described for the first time in 1924, being presented as retractile mesenteritis. It was re-named mesenteric panniculitis in the 1960s and, today, it is also known as mesenteric sclerosis, mesenteric Weber-Christian disease and liposclerotic mesenteritis.

There are three main changes that occur with this diagnosis, meaning fibrosis, necrosis of the adipose tissue and chronic, non-specific inflammation. This condition will retain the name of mesenteric panniculitis, in the situation that the inflammation and the necrosis of the fat predominate over the fibrosis. On the other hand, if the fibrosis and retraction are the ones predominating, it will be more commonly presented as retractile mesenteritis. The term “sclerosing mesenteritis” might also be used in the situation that there is some degree of fibrosis present.

This condition is more often encountered in men and especially in Caucasians. The incidence of the mesenteric panniculitis increases with age – it is extremely rare encountered in children, perhaps due to the reduced amount of mesenteric fat in comparison to adults.

Causes

The exact cause of the mesenteric panniculitis has yet to be identified. Among the potential reasons that have been incriminated in the appearance of this condition, there are: autoimmune response (caused by an unknown source), mesenteric ischemia. The condition is often found in association with different types of cancer, such as lymphoma but this is not considered a cause.

More than 80% of the patients have reported a history of trauma or surgery at the level of the abdomen. Other potential risk factors for the appearance of this condition include: thrombosis of the mesentery, taking certain medication, thermal/chemical burns, vitamin deficiencies, retained suture materials, pancreatitis, leakage of the bile, bacterial infections. The presence of gallstones, coronary disease and cirrhosis have also been found in association with the mesenteric panniculitis.

Symptoms

These are the symptoms that can appear in patients who suffer from mesenteric panniculitis:

• Pain in the right side of the abdomen (moderate intensity, can last for a long time)
• Nausea
• Vomiting
• Syncope (few seconds duration)

Diagnosis

The diagnosis of mesenteric panniculitis is often made with the help of imaging studies, such as the CT scan (often performed with IV contrast, as it allows for better visualization). However, the final confirmation of the diagnosis is confirmed through the surgical biopsy.

The physical examination of the patient does not reveal any specific changes for this condition. The patient might present moderate abdominal tenderness upon palpation, especially in the right quadrant. An ill-defined mass can also be felt through the palpation of the abdomen. The medical history of the patient will reveal the chronic abdominal discomfort, as well as other long-term symptoms.

Treatment

The treatment of the mesenteric panniculitis is empiric and it often consists of medication. Corticosteroids, such as prednisone, are often chosen as a line of treatment. This treatment guarantees a reduction in the intensity of pain experienced by the patient, as well as an improvement in the other symptoms. The mesenteric mass, if any, is also going to decrease upon receiving this treatment. Colchicine is administered as an alternative to corticosteroids, as it does not have so many side-effects. Among the most uncomfortable side-effects of the corticosteroids, there are: peripheral neuropathy and increased levels of glucose (hyperglycemia).

Depending on the seriousness of the cases, the surgical resection might be attempted as a form of definitive therapy. However, it must be mentioned that the surgical approach has a rather limited effect.

What is Chorda tympani?

Chorda tympani is one of the branches that belongs to the facial nerve, its origin being represented by the taste buds that are located in the anterior part of the tongue. After it leaves its origin, it travels along the middle ear and reaches the brain with information related to the taste sensation. At the level of the facial canal, it joins the facial nerve (also known as the 7th cranial nerve). This union takes place at the point where the facial nerve actually leaves the skull, meaning through the petrotympanic fissure.

There are three cranial nerves that are involved in the taste sensation, the chorda tympani being one of them. All of the three nerves function in perfect synchronization, with each of the nerves working to make sure that the signals of the other nerves are inhibited. The influence of the chorda tympani over the other taste nerves is quite strong; the nerve also influences that pain fibers that are found throughout the tongue. In the situation that the chorda tympani suffers from damage, the inhibitory signals are going to be altered – this means that the other nerves are not going to be so inhibited by the chorda tympani anymore.

It is possible that the chorda tympani nerve varies from one person to the other. There are patients in which the nerve starts at the proximal part of the facial nerve, sometimes quite at a close distance from the geniculate ganglion. Its length can also vary – it can be between 3 and 14 mm. The posterior canaliculus is absent in 10% of the individuals or it may be replaced by a grove.

When it comes to fetuses and small infants, the chorda tympani will separate from the facial nerve outside the skull. However, as the mastoid process begins to grow and develop, it will reach a more anterior position. The growth of the facial canal stimulates the divergence of the chorda tympani from the facial nerve when children reach the age of one year.

Anatomy

The internal acoustic meatus is the point that is used by the chorda tympani in order to leave the cranial cavity, along with the facial nerve. Once it exits the cranial cavity, the chorda tympani is going to run through the middle ear, along the tympanic membrane (from posterior to anterior). Upon its journey, the nerve travels between the incus and the malleus.

It continues through the petrotympanic fissure, reaching the infratemporal fossa. Soon, it will follow the same pathway as the larger lingual nerve, which is actually a branch of the mandibular nerve. Both the chorda tympani and the lingual nerve will travel all the way to the submandibular ganglion. Upon reaching the ganglion, the preganglionic fibers will connect with the postganglionic ones and go on to innervate the salivary glands in the area (submandibular and sublingual). The chorda tympani also has special sensory fibers (for taste) that travel to the anterior part of the tongue (along the lingual nerve).

The chorda tympani also contains fibers that come from two of the brain stem nuclei, meaning the superior salivatory nucleus and the nucleus of tractus solitaris. In the first nucleus, there are the cell bodies that belong to the secretomotor preganglionic parasympathetic neurons. As for the nucleus of tractus solitaris, it is its superior portion that contributes to the chorda tympani. The connections of the chorda tympani at the level of the facial canal include the sensory branch of the facial nerve and the nervus intermedius of Wrisberg.

What is the Function of Chorda Tympani?

The functions of the chorda tympani are given by the nerve fibers that it contains. On one hand, it has special sensory fibers, covering the taste sensation for the anterior part of the tongue. On the other hand, it is the nerve that provides the secretomotor innervation for the above-mentioned salivary glands; apart from these glands, however, the chorda tympani also influences the activity of the blood vessels in the area. For example, if stimulated, it can lead to the dilation of the respective blood vessels (this is because it supplies efferent vasodilator fibers to the tongue).

In the situation that the chorda tympani nerve suffers an injury, the person might experience either the loss or distortion of the taste sensation. If the damage to the nerve has been extensive, it is possible that a person might not be able to differentiate certain tastes from one another. On the other hand, if a part of the tongue is affected (meaning one of the chorda tympani nerve), it has been discovered that the taste intensity on the other part of the tongue is heightened (as a form of compensation).

Pictures of Chorda Tympani

Chorda Tympani Picture 1 : Diagrammatic representation of Chorda Tympani and other parts including Tegman tympani, Malleus, Aditus to mastoid antrum, Incus, Mastoid process, Epitympanic recess, Tensor tympani, Tympanic membrane, Pharyngotympanic tube, Tympanic cavity, Facial nerve (CN VII), Internal jugular vein, Internal carotid artery, and Carotid sheath.

Chorda Tympani Picture 2 : Picture showing the Facial nerve and the Chorda Tympani nerve.

Chorda Tympani and Taste

Many studies have tried to identify the relationship between chorda tympani and taste. Diverse sweeteners have been used in studies that involved mice, rats and primates – based on this research, it was discovered that the sweet taste is detected by the sensory fibers of chorda tympani only in mice and primates (not in rates). Other studies have revealed that the sensory fibers are sensitive to substances such as sodium chloride. The response to quinine has been identified at low levels and, when it comes to hydrochloride, the findings are non-specific. A comparison has also been made between the sensory fibers of chorda tympani and the greater superficial petrosal nerve – it was discovered that the first has a lower response rate to substances such as sucrose.

Resection

A study has demonstrated that, upon the chorda tympani being resected at a young age, the taste buds that are innervated by it are not going to grow back at what should be the full strength. Another study performed on mice showed that the preference for sodium chloride increases upon both the chorda tympani being resected. It is also known that the innervation of the fungiform papillae on the tongue is handled by the chorda tympani. Interestingly enough, if the chorda tympani is resected, these papillae are going to undergo what can be described as a structural change (from fungiform to filiform).

What is Leptomeningitis?

Leptomeningitis can be defined as a medical condition, characterized by the inflammation of the subarachnoid space. Also known as meningitis, this condition affects both the arachnoid and the pia mater. Both infectious and non-infectious causes can be found behind the appearance of this health problem. However, it is important to remember that the infectious leptomeningitis is more common than the one caused by non-infectious causes. Bacterial infections can lead to the inflammation of the meninges, which is the protective membrane of the brain and spinal cord.

The infection can reach the protective membrane from other sites, such as the sinuses, middle ear or nose. Those who are between 30 and 50 years of age present the highest risk for developing leptomeningitis. In children, tuberculosis is the most common reason that leads to the appearance of such health problems.

What are the causes of leptomeningitis?

One of the most common types of leptomeningitis is the pyogenic one. In the elderly population, this condition is caused by the following infectious agents: streptococcus pneumoniae, listeria monocytogenes, neisseria meningitides and gram negative bacilli. The same form of leptomeningitis is caused by these particular infectious agents in adults, such as: streptococcus pneumoniae, neisseria meningitidis and group B streptococcus. In children, the main infectious agent is represented by neisseria meningitides. Both streptococcus pneumoniae and neisseria meningitides are responsible for the appearance of leptomeningitis in infants, while in neonates the following infectious agents are responsible: group B streptococcus, E. coli and listeria monocytogenes.

On the other hand, the viral meningitis is caused by enteroviruses. It is also possible to suffer from mycobacterial leptomeningitis, this form being caused by mycobacterium tuberculosis (tuberculous meningitis and tuberculous pachymeningitis). The fungal meningitis is caused either by cryptococcus neoformans (AIDS patients) and coccidioides immitis.

The aseptic leptomeningitis is caused by the following: leptomeningeal carcinomatosis, rheumatoid arthritis and sarcoidosis. Iatrogenic aseptic meningitis is encountered in the postoperative stage (regardless of the surgical intervention) and also in the situation of a hydrogel-coated aneurysm coils.

Pathophysiology

There are different factors that influence the localization, the extensiveness and the changes that occur at the level of the meninges. If the leptomeningitis has a middle-ear infection as cause, the lesion is going to be unilateral and most likely concentrated on the temporo-sphenoidal lobe. On the other hand, if the condition is caused by pneumonia or endocarditis, the meningitis is going to be bilateral and located at the level of the cortex. The exudate can be fibrinous, purulent or hemorrhagic. In children, it is characteristic for the ventricles to dilate. A turbulent fluid might also be present at the level of the meninges.

Leptomeningitis can also appear due to the hematogenous spread of a primary infection that is found at the level of the lungs. The infection can be acquired during birth – microorganisms in the birth canal. The aspiration of contaminated amniotic fluid can lead to leptomeningitis in newborns as well.

Symptoms of leptomeningitis

These are the most common symptoms of leptomeningitis:

• Headaches – severe and protracted
• Rigidity at the level of the neck
• Fever/chills – suggestive of the suppurative process
• Nausea and vomiting
• Intolerance to sound
• Delirium, followed by coma
• Slow pulse (it is only rapid in children)
• Affectation of the cranial nerves
  • Strabismus
  • Ptosis
  • Facial paralysis
  • Trophic changes (involvement of the 5th nerve)
• Convulsions – especially in children who present a nervous temperament

Pictures of Leptomeningitis

Leptomeningitis Picture 1 : Diagram showing the different parts of the Brain including Meninges, Cerebrum, Ventricles (fluid filled spaces), Skull, Cerebellum, Brain stem and Spinal cord.

Diagnosis

These are the most common methods used for the diagnosis of leptomeningitis:

• Medical history of the patient
  • Known infections and their causes
  • Previous treatments and/or surgical interventions
• Imaging studies
  • CT
    • No changes might be present on the scans
    • Liquid accumulation (subtle hydrocephalus)
    • The basal cisterns might present areas of hyperdensity around them
    • The leptomeningeal area might be enhanced
  • MRI
    • Leptomeningeal enhancement
  • MR angiography
    • The narrowing or occlusion of arteries can be identified.

Complications

These are the complications that can occur in patients suffering from leptomeningitis: thrombosis of the dural sinus, inflammation of the cerebral ventricles, accumulation of excess cerebrospinal fluid (hydrocephalus), infarction and abscess. Other complications include: edema, increased intracranial pressure, cranial nerve palsies and seizures.

Treatment

The measures of treatment are similar to the ones taken for other forms of meningitis.

Prognosis

Even though this is a serious condition, with the right treatment, it is not fatal.

Introduction

The cholesterol granuloma can be defined as a granulation tissue that is found at the level of the middle ear. The tissue is well-known for being prone to bleeding, which makes it a frequent cause of haemotympanum. In fact, we are talking about a rare condition, characterized by the presence of non-cancerous cysts at the level of the middle ear (in particular at the tip of the petrous apex). As you will have the opportunity to find out, these cysts are actually comprised out of fluid, lipids and crystal of cholesterol, all of them being surrounded by a fibrous lining (the cyst is often presented as an expanding mass).

Even though it is said that granulomas in general are not dangerous, the cholesterol granuloma presents a series of risks due to the fact that it is located at a close distance from the ear and some pretty important nerves. If the condition is left untreated and the cholesterol granuloma continues to expand, the following complications can occur: permanent hearing loss, damage to the nerves or destruction of the bone.

Epidemiology

In general, the cholesterol granuloma is identified in individuals who have reached middle-age. The patient’s history of chronic otitis media comes to complete the picture. So far, no gender or race predilections have been identified for the cholesterol granuloma.

Pathophysiology

It is important to understand that the cholesterol granuloma can develop in any aerated portion of the temporal bone. The most common area in which the cholesterol granuloma develops is presented by the mastoid cells. This tissue is also found at the level of the petrous apex, being one of the most often encountered cystic lesions in the respective area.

There are two major theories incriminated when it comes to the appearance of the cholesterol granuloma. The obstruction-vacuum theory considers that the dysfunction of the Eustachian tube is mainly responsible for the problem. If the Eustachian tube does not function properly, this leads to the edema of the mucosa and repeated bleeding episodes. The second is known as the exposed marrow theory – the proposers of this theory suggest that the bone is invaded by the mucosa, which results in the exposure of bone marrow and the repeated bleeding.

Regardless of the proposed theory, it is important to remember that the blood will undergo a process of degeneration (upon being trapped), leading to a chronic inflammatory response (infection might also be presented). The histopathological analysis of the cholesterol granulomas reveals the following consistence: cholesterol crystals, giant cells, red blood cells and hemosiderin. The fluid is surrounded by fibrous connective tissue; plus, the blood vessels in the area are quite fragile and prone to rupture (because of such changes, the resolution is more difficult).

Pictures of Cholesterol Granuloma

Cholesterol granuloma Picture : Diagram showing the fibrous tissue, mastoid trabecula, cholesterol granuloma and small remnant of air.

Diagnosis

These are the most common methods used for the diagnosis of the cholesterol granuloma:

• Medical history of the patient
• Physical examination
  • The doctor will examine the ears using an otoscope
    • Bluish color of the eardrum
    • Identification of protrusion behind the eardrum (brownish tinge)
• Audiogram
  • Investigation performed to assess the hearing (whether or not hearing loss has occurred; if yes, to what extent)
• Imaging studies
  • CT
    • Lesion with demarcated margins
    • The overlying bone appears to be thinned
    • Peripheral enhancement (post-contrast)
    • Location – deciding factor on the appearance of the lesion
      • Petrous apex – aggressive appearance, bony erosion, the lesion can extend to the carotid canal or to the cerebellopontine angle
      • Middle ear – rare associated erosion
  • MRI
    • Thinned adjacent bone
    • High signal – cholesterol component
    • Hemosiderin identified as well.

The differential diagnosis can be made with the following conditions: middle ear effusion, cholesteatoma, base of skull tumor (metastasis, chondrosarcoma), pneumatization or normal asymmetry of fatty marrow. Other medical problems that present a similar appearance include the hydrated mucocele and the thrombosed ICA aneurysm.

Symptoms of Cholesterol Granuloma

The symptoms of the cholesterol granuloma depend on the location.

If present at the level of the middle-ear, the patient will experience the following:

• Vertigo
• Conductive hearing loss
• Dysfunction of the cranial nerves (VII)

When found at the level of the petrous apex, these are the most common symptoms:

• Conductive hearing loss (middle ear effusion)
• Ringing sound in the affected ear (tinnitus)
• Dysfunction of the cranial nerves (VI)
• It is also possible that the patient does not present any symptoms.

In the situation that it is located at the level of the mastoid cells, the patient might suffer from headaches or even by asymptomatic. Other symptoms of the cholesterol granuloma include the facial twitching and/or facial numbness.

Treatment and Prognosis

In the situation that the cholesterol granuloma leads to the appearance of the above-mentioned symptoms or it is too large in size (causing destruction in the area), the surgical excision should be considered as the first line of treatment. The removal of the cyst wall should be performed at the same time. The surgical approach is considered in relation to the location of the cholesterol granuloma. In deciding upon a particular approach, the surgeon will also consider the amount of hearing loss that has occurred. Some patients can benefit from mastoidectomy as a form of treatment. Unfortunately, the recurrence rate for the cholesterol granuloma is quite high.

One of the most common forms of surgical intervention for the cholesterol granuloma is the endoscopic endonasal approach. This has the advantage of being minimally-invasive, with the nasal cavities being used to access what would otherwise have been an inoperable cyst. Among the benefits of this procedure, there are: better and faster recovery, no nasty scars or incisions that take time healing. And, what is more important, this intervention preserves hearing. Other approaches for the surgical intervention include the infralabyrinthine or infracochlear ones; these guarantee the preservation of hearing as well. There is one more approach – the translabyrinthine one – but this is rarely used nowadays. This approach is recommended in the patients who are already experiencing severe hearing loss, as it can lead to complete hearing loss. No matter the approach, be sure to remember that the treatment has to guarantee both the drainage and the ventilation of the cholesterol granuloma.

What is Bronchopneumonia?

Bronchopneumonia can be defined as a medical condition, in which the walls of the bronchioles suffer from an acute inflammatory process. This condition is also known as bronchial pneumonia or bronchogenic pneumonia and it should not be confused with lobar pneumonia. This type of pneumonia can affect more than one pulmonary lobules, having often a bacterial infection as underlying cause.

As opposed to the lobar pneumonia, bronchopneumonia is less likely to be found in association with the streptococcus. On the other hand, it is often found in association with the hospital-acquired pneumonia and the specific bacterial organisms that are behind it – meaning the staphylococcus aureus, E.coli, Klebsiella or pseudomonas.

Pneumonia, in general, is considered to be one of the most common causes of death due to a bacterial infection. The incidence is of 11.6 for each 1000 people each year, only in the United States. Children and older people present the highest risk for developing bronchopneumonia (especially in hospital-setting).

Pathophysiology

In the situation that a person suffers from bronchopneumonia of bacterial cause, the lung parenchyma is practically invaded by the bacteria. In response, the immune inflammatory response is triggered. Because of this response, the alveolar sacs are filled with exudate. When the air space is replaced by the exudate (fluid), this process is known as consolidation. In patients suffering from bronchopneumonia, there are multiple, isolated areas of consolidation, affecting different pulmonary lobes.

It is important to understand that lobular bronchopneumonia can lead to lobar pneumonia, this being suggestive of a progressive bacterial infection. The most common area in which the exudate starts to buildup is in the basal lobes. The affectation is bilateral in the majority of the cases. The diameter of these lesions varies between 2 and 4 cm; the lesions are yellow or grey in color, dry and centered on a bronchiole. Apart from that, their delimitation is not clear and there is a tendency for the lesions to become united (particularly in children).

When there is an inflammatory process in the bronchioles and suppurative exudate starts to gather, neutrophils (leukocytes) arrive in the area and try to clear the infection. The more bronchioles suffer from inflammation, the more extensive the congestion experienced by the patient is going to be. The parenchyma between the areas of consolidation remains, however, normal (aerated).

One has to remember that bronchopneumonia is most commonly precipitated by the inhalation or the hematogenous spread (rarely) of bacteria (infectious organism). The breach of the bacteria leads to the suppurative peribronchiolar inflammation. This can spread further into the lung bronchiole, leading to the consolidation process and the above-mentioned changes. The extensive congestion is almost always accompanied by the dilatation of the blood vessels in the respective area.

Atypical forms of pneumonia are known to be caused by viral and rickettsial infections. In infants, the most common pathological agent that leads to the appearance of bronchopneumonia is the respiratory syncytial virus.

Risk factors

These are some of the most common factors that can increase a person’s chances of developing bronchopneumonia (risk factors):

• Age – bronchopneumonia typically affects small children (under 2 years) or the elderly (over 65 years)
• Lung disease – cystic fibrosis, asthma, chronic obstructive pulmonary disease
• HIV/AIDS
• Other chronic disease – heart disease, diabetes
• Reduced immunity – chemotherapy, immunosuppressive drugs
• Assisted breathing (ventilator)
• Smoking
• Alcohol abuse
• Difficulties coughing or swallowing
• Malnourishment

Pictures of Bronchopneumonia

Bronchopneumonia Picture 1 : Diagram showing the differences between bronchopneumonia, Lobar pneumonia and Interstitial pneumonia

Symptoms

From the start, it should be mentioned that the presentation of bronchopneumonia depends on several factors, such as: how serious the bacterial infection is, what are the host factors and how many complications have appeared along the way.

In general, these are the most common symptoms that patients diagnosed with bronchopneumonia present:

• Productive cough (mucus)
• Difficulties breathing or shortness of breath (dyspnea)
• Pyrexia/fever
• Rigor
• State of general malaise
• Pleuritic pain
• Hemoptysis (coughing up blood; not in all patients)
• Chest pain
• Rapid breathing
• Sweating or chills
• Headaches
• Muscle aches
• Fatigue
• Confusion or delirium (more often encountered in the elderly population).

Diagnosis

These are the most common methods used for the diagnosis of bronchopneumonia:

Physical examination

• Temperature check (fever)
• Lung auscultation (stethoscope)
  • Identification of bubbling or wheezing sounds
  • Areas where the breathing is fainter (affected by the bronchopneumonia)

Laboratory testing

• Complete blood count (CBC) – white blood cell analysis (elevated – bacterial infection)
• Bacterial cultures – identification of the infectious organism
• Sputum culture – sample of mucus (infection cause)

Imaging studies

• X-ray
  • Multiple small nodular or reticulonodular opacities
  • The opacities are patchy and/or confluent
  • Opacity – area of inflammation
  • Normal lung parenchyma can be noticed between the patches of inflammation.
• CT
  • Multiple opacities (lobular pattern)
  • Tree-in-bud appearance
  • Consolidation areas can overlap, leading a bigger area of consolidation (patchwork quilt appearance)
• Bronchoscopy
  • A small camera is guided through the bronchioles, thus allowing for the visualization of the infection area
  • Can be done to exclude other causes, besides the bacterial infection
• Pulse oximetry
  • A sensor is placed on the finger, being used to measure the amount of oxygen in the blood
  • Can be used to determine how extensive the bacterial infection actually is (whether it has affected the blood’s capacity to transport oxygen or not).

Treatment

These are the regular treatment approaches taken for patients with bronchopneumonia:

Antibiotics

• These can administered orally or intravenously, depending on the seriousness of the infection
• The entire course of antibiotics should be taken, otherwise the infection will return (with the bacteria having developed resistance to the said antibiotic)
• Probiotics are administered at the same time with the antibiotic treatment, so as to protect and maintain a healthy intestinal flora
• Recommended choices of antibiotics – amoxicillin, erythromycin

Symptomatic treatment

• Medication to reduce fever
• Cough medication

Home remedies

• Rest
• Drinking warm fluids (chicken soup, tea)
• Humidifying the air in the room (makes breathing easier)
• Drinking water

Hospital treatment (in serious cases)

• Intravenous antibiotics
• Oxygen therapy (recommended as a supportive care measure in the situation that the blood oxygen levels are low)
• Clearing the bronchioles of the secretions (improved breathing)
• The hospital admission is more recommended in patients who are older in age, with rapid breathing and a drop in the blood pressure
• It is also indicated in those who present confusion or delirium, not to mention those who require breathing assistance.

Prognosis

In the situation that there are no complications and that the patient follows the exact treatment prescribed by the doctor, the symptoms of bronchopneumonia should disappear somewhere between 4 and 6 weeks. Severe infections might take longer to heal, especially if the patient is a child or an elderly person. The pre-existing conditions can delay the healing period, as well as a compromised immune system. Even though one will start to feel better after three or four days since the beginning of the treatment, it is important to complete it as advised. Otherwise, the bacteria can develop resistance to the antibiotics and return, causing a more serious form of bronchopneumonia.

Complications

These are the complications that can occur in patients diagnosed with bronchopneumonia:

• Pleural effusion
• Emphysema
• Lung abscess
• Peripheral thrombophlebitis
• Respiratory failure
• Congestive heart failure

Prevention

The easiest way to prevent bronchopneumonia is through vaccination. At the moment, there are vaccines available against a wide range of bacterial and viral organisms, such as: bordetella pertussis, chickenpox, bacillus anthracis, diphtheria, haemophilus influenza, streptococcus pneumonia, rubella, measles, and adenoviruses.

The annual flu shot is the best way to prevent pneumonia caused by viral organisms. The vaccines are especially recommended for small children and also for the older population. For children, the vaccines have an additional purpose and that is to protect them against community-acquired infections (kindergarten, school).

There are also simple measures that can be taken in order to protect yourself from a potential infection. You should wash the hands on a regular basis, using antibacterial soap. Smoking and alcohol abuse should be avoided, as they can reduce the strength of the immune system. Avoiding contact with sick individuals is a good measure of prevention as well. Apart from that, you can build a strong immune system by taking good care of yourself – you need to maintain a healthy diet (with fresh fruits and vegetables), exercise and get plenty of rest. Getting enough hours of sleep is essential, as this is one of the main factors that contribute to a strong immune system.

In conclusion, this is a serious medical problem and it should be treated as such. Both children and the elderly should be taken to the doctor as soon as the symptoms of pneumonia become obvious, as they present a serious risk for complications (including those that are potentially life-threatening). Hospitalization remains a must for anyone who experiences difficulties breathing, suffering at the same time from confusion or delirium. The admission to the hospital is also recommended for those who suffer from other health problems – the supportive care measures that are offered within the hospital setting can reduce the risk for complications and guarantee the best road to a full recovery.