Onodi Cell-Mistaken as ICA Aneurysm

Onodi cell (sphenoethmoid air cell)

Case Submitted by Dr MGK Murthy, Mr Hari Om, Mr Venkat.

Edited by -Sumer Sethi, MD

·         Defined as ethmoidal air cell that lies posterior and sometimes superior to sphenoid sinus

·         Incidence in western world is usually 8 to 13%, though some studies give larger cadaveric incidence up to 60%

·         Optic nerve and Internal Carotid Artery  become closer than normal to  ethmoid air cells –point of concern to endoscopic sinus  surgeons

·         At places the bone separating them  is measured as mean 0.08mm. Infection may lead to mucocele

·         Occasionally could be mistaken for ICA aneurysm in view of the proximity to the loop and flow void nature on MRI. CT is usually adequate  to differentiate by presence of air density

Bifid Thumb-Plain Film

10 yr old child with history of injury , on X ray of the left hand shows an oblique   opacity in continuity with the 1^st Metacarpal with no separate epiphysis and suggestion of abnormal soft tisues in the region with stippled opacity at base of proximal phalanx. X ray of  the other hand shows  only soft tissue abnormality with no bony component. This possibly representative of Bifid Thumb (pre axial polydactyly) type of congenital hand anomalies.

Teaching points  by Dr MGK Murthy, Dr Sumer Sethi.

Duplication or polydactyly is common. Can be complete or partial

Bifid thumb occurs in  about 1 in 3000 births

Usually unilateral , but bilaterality is known. Cause is not known

Hand develops from Apical Ectodermal Ridge(AER)  around 3 to 8 weeks of gestation

Wassel classified the highly complex  hand anomalies as type I(Failure of formation),II(failure of differentiation),III(duplication), IV( overgrowth), Type V(undergrowth),type 6 (constriction band syndromes) and type 7(generalized anomalies and syndromes )

Can be 

·         just extra soft tissue not adherent to skeleton, devoid of bone, cartilage, joints or tendons (as in the non injured hand in our case )

·         digits may show duplication with components like bifid metacarpal (like our  case injured hand )or

·         there may be a complete digits formation with its own metacarpal.

Ellis van creveld syndrome is associated with bifid thumb

 Treatment is usually surgical and involves resection to avoid restriction of movements apart from cosmetic effect. Early surgery is defined as under 2 years and late is defined beyond that . Most surgeons prefer 2^nd year for surgery with good results 

Allow Breast Feeding After MRI-Contrast

According to an article by Jack Newman in Canadian Family Physician April 2007 vol. 53 no. 4 630-631- "Evidence indicates unequivocally that the contrast media used for both magnetic resonance imaging and computed tomography scans are excreted into breast milk in such small quantities that there is no concern at all for nursing babies. The contrast medium used for magnetic resonance imaging (MRI) scans is gadopentetate. It is excreted into breast milk in extremely small amounts.  Considering that we do MRI scans of small babies, concern about continuing breastfeeding after MRI makes no sense at all."

Tendoachilles Calcification-Plain Film

Two views always help for evaluation of any X-ray finding and localize to the site  of problem

Tendoachilles is the largest tendon in the body , spanning two joints and is subject to stress in daily activities (reaching upto 900kg in fast running at times ). Intense short use or prolonged overuse could result in degenerative changes of focal or diffuse variety leading to calcium deposition and is usually susceptible for rupture and degeneration 2-6 cms from site of insertion

Teaching points by Dr MGK Murthy. 

Morris etal classified calcification in to 3 types for management techniques

ü  type I-localised to tendon insertion and  posterosuperior aspect of calcaneum

ü  Type II-localised distal 1-3 cms of tendon

ü  Type III-Intratendinous and involves most of it(IIIA) and all of it (IIIB)

Excision before  other  complications like rupture and ulcerations and bone infection etc would be  preferred

X-ray true lateral  is ideal with MR playing complementary role in evaluating other soft tissue structures. Presurgical doppler  of  the posterior tibial  vessel is recommended 

Robotic Teleultrasound-Not Science Fiction

"Partners in the European MARTE (Mobile And Robotised Teleechography) project, in collaboration with ROBOSOFT have carried out the world's first robotised teleultrasound examination via satellite. This demonstration was accomplished with an ESTELE robot entirely controlled by robuBOX."

Femoral Neck-Aneurysmal Bone Cyst

22 year old male with history of fall and pain right hip. X-ray shows expansile lucent predominantly intramedullary, femoral neck lesion with normal hip joint. MR shows grossly expansile septated, predominantly fluid signal intensity space occupying lesion with cortical breaches, bleed, soft tissue edema in the vicinity – Features are suggestive of aneurysmal bone cyst.

Teaching Points by Dr MGK Murthy, contributors-Mr Hariom Sharma

ABC is non-neoplastic expansile lesion consisting of blood filled spaces separated by connective tissue septa containing bone or osteoid and osteoclast giant cells 

Etiology unknown 

May be primary or secondary ( in about 30 % of associated bone tumors).

CT suggests 20 HU as approximate density with presence of blood and fluid levels.

Double density fluid levels on MR are suggested as quite specific to ABC.

Differential diagnosis includes Simple Bone cyst (Centrally located with no expansion / cortical breach), GCT (more than 20 years of age, no significant expansion and predominantly epiphyseal lesion),  Osteoblastoma (usually diaphyseal, no fluid / fluid levels or cortical breach), Telengiectatic osteosarcoma / Angiosarcoma (difficult to differentiate from agressive ABC).

Escolta After Dark

Escolta, that old ephemeral street of Manila, has been one of my favorite hang-outs since I was a young Manila student in the early 1980s. Back then, I used to frequent this little boulevard to buy my long-playing discs in Syvel's (now closed), or to have my shoes cleaned by one of those ubiquitous shoeshine boys who lined the street sidewalks. Or perhaps just to hang-around in one of its old little cafés. I still visit the Escolta almost everyday, and every time, that wonderful and a little painful feeling of nostalgia is evoked in me.

I took the following photographs while on a solitary late-night walk along the old Escolta. I took these pictures just as souvenirs or perhaps to just record the scenes I have seen at a given time.

Evening newspapers. You can decide if they bear good news or bad.

Plaza Moraga

Night students

The old La Estrella del Norte building

Antique money seller

Pedestrians

Gone was the tranvia but the calesa still plies the Escolta

Posters and cables

Sidewalk-dwellers