The Erroneous Appearance of Silver Nitrate on CT Imaging in Patients with Severe Otitis Externa; A Case Series

Introduction Silver nitrate is commonly used within otolaryngology to treat granulation tissue in severe otitis externa. It appears radio-opaque on CT (computed tomography) imaging and therefore can mimic bony fragments and foreign bodies. This is particularly cumbersome when the phenomena correlates to the clinical complaint. Discussion We report two cases of 73-year-old and 75-year-old males who presented with chronic otalgia and discharge. Granulation tissue in the external auditory canal was identified and chemically cauterised with silver nitrate. Subsequent CT petrous bones demonstrated an unidentified foreign body in the canal with extensive soft tissue swelling giving an impression of a wick in situ and “minor bony erosion in the left external acoustic canal” respectively. An additional CT of a 57-year-old female who had been treated with silver nitrate for granulomatous tissue reported “multiple highly radiopaque foci in the external auditory canal, suggestive of foreign body”. Though relatively unknown, this phenomenon has been reported in literature. However, there are few reports of silver nitrate artefacts in CT images of the head no cases in the context of otitis externa. Our patients avoided further imaging or surgery following clarification with the radiologists and symptomatic improvement with long-term intravenous antibiotics. Conclusion Given the prevalence of CT imaging and cauterization in otolaryngology, we recommend contemporaneously documenting the use of silver nitrate and highlighting this on request forms to avoid alarming erroneous reports, unnecessary investigation and surgical procedures. We also recommend, where clinically acceptable, to use silver nitrate prior to imaging.

A Curious Case of PTH Independent Hypercalcemia Secondary to Silicone Injections

Background: Hypercalcemia is a commonly encountered clinical problem with numerous etiologies. Granulomas formed secondary to foreign bodies are a rare but increasingly recognized cause of hypercalcemia. Clinical Case: A 49-year old African American woman, who had received silicone injections for buttock augmentation 15 years ago, was found to have severe hypercalcemia after she presented with complaints of chronic constipation, muscle cramping, polyuria, and mental fog. Her labs on admission showed severe hypercalcemia Ca 17.9mg/dL (normal: 8.4–10.6 mg/dL), with a suppressed PTH 4 pg/mL (normal 14–54 pg/mL). Prior labs from 5 years earlier, had shown an elevated 1,25(OH)2D, therefore differentials including lymphoma and chronic granulomatous diseases, particularly sarcoidosis, were high on the list of possible diagnosis. Additional labs showed a normal PTH-RP 19 pg/mL (normal 14–27 pg/mL), normal ACE levels 64 U/L (normal 9–67 U/L), low 25(OH)D2 1 ng/mL and normal 1,25(OH)2D 62 pg/mL. Her exam was notable for multiple indurated and firm masses palpable over the bilateral gluteal region and lateral thighs. CT abdomen/pelvis showed extensive and markedly confluent infiltration with intervening globules of macroscopic fat throughout the subcutaneous fat layers of the buttocks and lateral hips and speckled linear calcifications consistent with granulomatous reaction. With aggressive fluid hydration and calcitonin, her calcium levels decreased over the following 48 hours, but remained at 12–13 mg/dL. She was started on 30 mg of prednisone daily and her calcium levels dropped to 10.9 mg/dL the following day. She was discharged home on prednisone, her calcium levels remained suppressed, and her prednisone dose was slowly tapered during the following months. She was referred for plastic surgery evaluation and is being evaluated for possible surgical debridement. Conclusion: Hypercalcemia secondary to foreign body granulomas is a rare clinical entity. The diagnosis is usually established through a thorough history and examination. Lab findings may be variable. Treatment of these patients can be challenging, and corticosteroids are the mainstay of treatment in most cases1. Surgical debridement of granulomas has been reported with good results; however, further investigation and longer follow-up is needed2. References: 1.Tachamo, N., Donato, A., Timilsina, B., Nazir, S., Lohani, S., Dhital, R., & Basnet, S. Hypercalcemia associated with cosmetic injections: A systematic review. European Journal of Endocrinology, 2018; 178(4): 425–4302.Edwards, B.J., Saraykar, S., Suna, M., Murphy, W. A., Lin, P., Gagel, R. Resection of granulomatous tissue resolves silicone induced hypercalcemia, Bone Reports, 2016; 5:163–7

Postoperative bronchopleurale Fisteln: Modifizierte Stents als maßgeschneiderte interventionelle Therapieoption

<b>Background:</b> Bronchopleural fistula is a rare but life-threatening event with limited therapeutic options. We aimed to investigate the efficacy and safety of the modified silicone stent in patients with post-surgical bronchopleural fistula. <b>Methods:</b> Between March 2016 and April 2020, we retrospectively reviewed the records of 17 patients with bronchopleural fistula and who underwent bronchoscopic placement of the Y-shaped silicone stent. The rate of initial success, clinical success and clinical cure, and complications were analyzed. <b>Results:</b> Stent placement was successful in 16 patients in the first attempt (initial success rate: 94.1%). The median follow-up time was 107 (range, 5–431) days. All patients achieved amelioration of respiratory symptoms. The clinical success rate was 76.5%. Of the 14 patients with empyema, the daily drainage was progressively decreased in 11 patients, and empyema completely disappeared in six patients. Seven stents were removed during follow-up: four (26.7%) for the cure of fistula, two for severe proliferation of granulomatous tissue and one for stent dislocation. No severe adverse events (i.e. massive hemoptysis, suture dehiscence) took place. Seven patients died (due to progression of malignancy, uncontrolled infection, myocardial infarction and left heart failure). <b>Conclusions:</b> The modified silicone stent may be an effective and safe option for patients with post-surgical bronchopleural fistula patients in whom conventional therapy is contraindicated.

Renal artery embolization post subtotal nephrectomy for xanthogranulomatous pyelonephritis: A case report

Xanthogranulomatous pyelonephritis (XGPN) is a rare, chronic disease characterized by the destruction of renal parenchyma and replacement with granulomatous tissue and is associated with long-term obstructive uropathy, chronic renal parenchymal infection, and nephrolithiasis. A 57-year-old patient with XGPN was unable to undergo total nephrectomy. Renal artery embolization (RAE) was performed post subtotal nephrectomy as adjunct therapy to prevent urine formation and decrease the risk of post-operative infection. Our case report demonstrates that RAE can be performed safely and effectively without evident complications and underscores the utility of cone-beam computed tomography in cases of altered post-surgical anatomy. To the author’s knowledge, this is the second case in the literature demonstrating perioperative management of XGPN with RAE.

Modified silicone stent for the treatment of post-surgical bronchopleural fistula: a clinical observation of 17 cases

Background Bronchopleural fistula is a rare but life-threatening event with limited therapeutic options. We aimed to investigate the efficacy and safety of the modified silicone stent in patients with post-surgical bronchopleural fistula. Methods Between March 2016 and April 2020, we retrospectively reviewed the records of 17 patients with bronchopleural fistula and who underwent bronchoscopic placement of the Y-shaped silicone stent. The rate of initial success, clinical success and clinical cure, and complications were analyzed. Results Stent placement was successful in 16 patients in the first attempt (initial success rate: 94.1%). The median follow-up time was 107 (range, 5–431) days. All patients achieved amelioration of respiratory symptoms. The clinical success rate was 76.5%. Of the 14 patients with empyema, the daily drainage was progressively decreased in 11 patients, and empyema completely disappeared in six patients. Seven stents were removed during follow-up: four (26.7%) for the cure of fistula, two for severe proliferation of granulomatous tissue and one for stent dislocation. No severe adverse events (i.e. massive hemoptysis, suture dehiscence) took place. Seven patients died (due to progression of malignancy, uncontrolled infection, myocardial infarction and left heart failure). Conclusions The modified silicone stent may be an effective and safe option for patients with post-surgical bronchopleural fistula patients in whom conventional therapy is contraindicated.

Cirurgia do periápice para remoção de lesões granulomatosas: relato de caso

Periapical granuloma is a histological term that refers to the formation of a mass of granulomatous tissue around the apex of a tooth resulting from inflammation and necrosis of the pulp tissue. It consists of an infiltrate of inflammatory cells such as macrophages, plasmocytes and lymphocytes, as well as fibroblasts, collagen fibers and capillaries. Periapical surgery is an alternative for preserving the tooth in the oral cavity in cases where periapical inflammation is persistent even after treatment of root canals. The objective of this study was to report a clinical case in which the surgical technique was used to remove granulomatous lesions from a patient, female, with a history of recurrent periapical abscess without painful symptomatology in the region of the anterior 11,12 and 13 teeth. The histopathological exam demonstrated the presence of a granulomatous tissue with intense inflammatory infiltrate mixed, permeated with lymphocytes and high number of plasmocytes, confirming the diagnosis of periapical granuloma. The treatment was considered successful since the patient remained asymptomatic and there was incorporation of the inorganic bovine bone graft and initiation of bone neoformation in the periapical region.

Modified silicone stent for the treatment of post-surgical bronchopleural fistula: A clinical observation of 17 cases

Background: Bronchopleural fistula is a rare but life-threatening event with limited therapeutic options. We aimed to investigate the efficacy and safety of the modified silicone stent in patients with post-surgical bronchopleural fistula.Methods: Between March 2016 and April 2020, we retrospectively reviewed the records of 17 patients with bronchopleural fistula and who underwent bronchoscopic placement of the Y-shaped silicone stent. The rate of initial success, clinical success and clinical cure, and complications were analyzed.Results: Stent placement was successful in 16 patients in the first attempt (initial success rate: 94.1%). The median follow-up time was 107 (range, 5-431) days. All patients achieved amelioration of respiratory symptoms. The clinical success rate was 76.5%. Of the 14 patients with empyema, the daily drainage was progressively decreased in 11 patients, and empyema completely disappeared in six patients. Seven stents were removed during follow-up: four (26.7%) for the cure of fistula, two for severe proliferation of granulomatous tissue and one for stent dislocation. No severe adverse events (i.e. massive hemoptysis, suture dehiscence) took place. Seven patients died (due to progression of malignancy, uncontrolled infection, myocardial infarction and left heart failure).Conclusions: The modified silicone stent may be an effective and safe option for patients with post-surgical bronchopleural fistula patients in whom conventional therapy is contraindicated.

Therapeutic Vaccination with Cationic Liposomes Formulated with Dioctadecyldimethylammonium and Trehalose Dibehenate (CAF01) and Peptide P10 Is Protective in Mice Infected with Paracoccidioides brasiliensis

The peptide P10 is a vaccine candidate for Paracoccidioidomycosis, a systemic mycosis caused by fungal species of the genus Paracoccidioides spp. We have previously shown that peptide P10 vaccination, in the presence of several different adjuvants, induced a protective cellular immune response mediated by CD4+ Th1 lymphocytes that was associated with the increased production of IFN-γ in mice challenged with a virulent isolate of Paracoccidoides brasiliensis. Cationic liposomes formulated with dioctadecyldimethylammonium and trehalose dibehenate (DDA/TDB, termed also CAF01–cationic adjuvant formulation) have been developed for safe administration in humans and CAF01 liposomes are utilized as an adjuvant for modulating a robust Th1/Th17 cellular response. We evaluated the efficacy of the adsorption of peptide P10 to CAF01 cationic liposomes and used the generated liposomes to vaccinate C57Bl/6 mice infected with P. brasiliensis. Our results showed that P10 was efficiently adsorbed onto CAF01 liposomes. The vaccination of infected mice with cationic liposomes formulated with DDA/TDB 250/50 µg/mL and 20 µg of P10 induced an effective cellular immune response with increased levels of Th17 cytokines, which correlated with significant decreases in the fungal burdens in lungs and protective granulomatous tissue responses. Hence, cationic liposomes of DDA/TDB 250/50 µg/mL with 20 µg of P10 are a promising therapeutic for safely and effectively improving the treatment of paracoccidioidomycosis.

Modified silicone stent for the treatment of post-surgical bronchopleural fistula: A clinical observation of 17 cases

Background: Bronchopleural fistula is a rare but life-threatening event with limited therapeutic options. We aimed to investigate the efficacy and safety of the modified silicone stent in patients with post-surgical bronchopleural fistula.Methods: Between March 2016 and April 2020, we retrospectively reviewed the records of 17 patients with bronchopleural fistula and who underwent bronchoscopic placement of the Y-shaped silicone stent. The rate of initial success, clinical success and clinical cure, and complications were analyzed. Results: Stent placement was successful in 16 patients in the first attempt (initial success rate: 94.1%). The median follow-up time was 107 (range, 5-431) days. All patients achieved amelioration of respiratory symptoms. The clinical success rate was 76.5%. Of the 14 patients with empyema, the daily drainage was progressively decreased in 11 patients, and empyema completely disappeared in six patients. Seven stents were removed during follow-up: four (26.7%) for the cure of fistula, two for severe proliferation of granulomatous tissue and one for stent dislocation. No severe adverse events (i.e. massive hemoptysis, suture dehiscence) took place. Seven patients died (due to progression of malignancy, uncontrolled infection, myocardial infarction and left heart failure).Conclusions: The modified silicone stent may be an effective and safe option for patients with post-surgical bronchopleural fistula patients in whom conventional therapy is contraindicated.