Choanal atresia

Findings

There is bony obstruction of the right choana (Figure 1 and Figure 2) with an air fluid level in the meatus. Note the thickening of the vomer (Figure 1) and the hypoplastic right inferior turbinate (Figure 1).


Diagnosis: Choanal atresia


Choanal atresia is a predominately bony occlusion of the posterior choanae (the posterior nasal cavity transition to the nasophayrnx).
Unilateral choanal atresia presents with unilateral purulent rhinorrhea and a mild breathing obstruction. Patients with bilateral choanal atresia present with severe respiratory distress in the immediate newborn period.
Findings of choanal atresia include unilateral or bilateral narrowing of the posterior nasal cavity at the choanae with a membranous-osseous obstruction.

Choanal atresia results secondary to failure of perforation of the oronasal membrane during the seventh week of gestation. Bony choanal atresia (85-90%) is caused by incomplete canalization of the choanae while membranous choanal atresia (10-15%) results secondary to incomplete resorption of epithelial plugs. Unilateral choanal atresia is twice as common as bilateral choanal atresia. Choanal atresia is twice as common in females.

Patients with bilateral choanal atresia present with severe respiratory distress in the immediate newborn period. This respiratory distress is exacerbated because infants are obligate nasal breathers up until 6 months of age. Feeding aggravates the respiratory distress, while crying, which results in increased oral breathing, relieves it. Unilateral choanal atresia (or choanal stenosis) results in purulent unilateral rhinorrhea with mild respiratory obstruction and may present later in childhood. Failure to pass a nasogastric tube is diagnostic. A number of other associated abnormalities may be associated with choanal atresia, including CHARGE syndrome.

Thin-axial section CT of the maxillofacial bones is recommended to make the diagnosis. Narrowing of the posterior choana less then .34 mm in children less than 2 years old is diagnostic. Associated findings include thickening of the vomer and medial bowing of the posterior maxilla. The nasal cavity may be filled with soft tissue or fluid. If the diagnosis is suspected, suctioning of the child before scanning is recommended. A thick or thin obstructing membrane may also be present.

Membranous choanal atresia may be treated with passage of a nasogastric tube which perforates the obstruction. An oral airway should be established immediately upon suspicion of bilateral choanal atresia. Transnasal endoscopic surgical correction of bilateral choanal atresia should be initiated promptly after the diagnosis. Transpalatal resection of the vomer with choanal reconstruction may be required for bilateral bony atresia.

Cerebral Vasculitis- MR Angiogram

We had a young male patient showing characteristically on MRI brain multiple bilateral gray/white matter infarcts were noted in a young patient. They were all supratentorial in distribution, a point further supported by literature. (Radiology 1992;192 :65-72. ). Further evaluation was done with MR angiography There were multiple areas of alternate narrowing and dilatations giving rise to “string of beads” appearance involving the right MCA and ACA.
These are characteristic of vasculitis.

Differential diagnosis considered was -
-Infectious- Bacterial/viral
Tuberculosis is a common cause.
-Non infectious-collagen vascular disorders, neurosarcoidosis, drug abuse, PAN. Other like-GCA, Takasayu, Wegeners.
-Also such appearance can be mimicked by-neoplasm/SAH

- PRIMARY ANGITIS OF THE CNS (PACNS) can be a diagnosis of exclusion

Case submitted by Dr Sumer Sethi, MD, Dr Jaya Shankar, MD

Teleradiology Providers

PACS Vendor versus Blogger's freedom

Whatever anybody might think of Dalai's PACS blog and his somewhat forthright criticism of various products and vendors everybody is dismayed to hear about the process by which one big PACS company allegedly went about forcing him to withdraw his comments.Surely there would have been a more appropriate way to handle this and we all sure have right to criticism.

Check out this Aunt Minnie discussion forum.

And as one of the contributors on this forum says-

"I may not agree with what you say, but I will defend to the death, your right to say it"

The Old Shoeshine Station in Escolta

On one of my lazy afternoon walks around Binondo, I happened to pass by this shoeshine station in an old decrepit corner of the Escolta, where I used to have my shoes shined way back in the 1980s. That was a long time ago, but this shoeshine stand still exists to this day, and has existed even since the 1950s, a remnant of the old times gone by.

Multiple fungal abscesses secondary to blastomycosis dermatitidis

Findings

Figure 1 and Figure 2: Noncontrast axial CT images demonstrate two focal areas of subtle hyperattenuation in the right parietal and left superior temporal lobe with adjacent edema.
T2 (Figure 3 and Figure 4), FLAIR (Figure 5 and Figure 6), and post-gadolinium T1 weighted (Figure 7 and Figure 8) MR images demonstrate two lesions located near the grey white junction with a small surrounding zone of edema and ring enhancement. No additional lesions were seen. There was no evidence of restricted diffusion.
Figure 9: The spectrum from the lesion shows no significant elevation of the choline peak, no depression of the NAA, and no lactate peak.


Diagnosis: Multiple fungal abscesses secondary to blastomycosis dermatitidis


The differential diagnosis for multiple ring enhancing lesions includes
- Metastatic disease
- Primary neoplastic processes
- Infection
- Demyelination

MRI spectroscopy is a powerful tool to help differentiate these entities in cases where the clinical and conventional imaging findings are equivocal.

Blastomycosis is an endemic organism in the southeast region of the United States usually contained within moist soil. Infection results from inhalation of the organisms which then transform to the yeast. Acutely cases may mimic bacterial pneumonia. Chronically, the disease can present in the lungs, urinary tract, skin, and occasionally with CNS involvement. CNS and severe pulmonary infections are treated with Amphotericin B.

Ring enhancing lesions on MRI have a long differential. Some use the mneumonic “Magical Dr” to help remember the etiologies. These include: Metastatic disease, Abscess, Glioblastoma multiforme, Infarction, Contusion, Aids (toxo), Lymphoma, Demyelination, and Radiation. Each of these entities can have similar imaging features on conventional MRI, however, the constellation of findings can help differentiate between the cases. In cases where the findings are equivocal, advanced techniques such as MR spectroscopy and perfusion imaging may help arrange the differential diagnosis appropriately.

MR spectroscopy of a tumor characteristically shows elevation of the choline to creatine ratio, elevation of the choline to NAA ratio, and frequently will have a lactate peak suggesting necrosis. While some inflammatory lesions can have a similar spectra such as multiple sclerosis, the lack of any significant spectral abnormalities in this case suggests a benign process. Very few processes that have post contrast ring enhancement have a relatively normal MR spectrum.

Radiologist Salary versus Medical Practise Profits

SALARIES are on the rise for both interventional and non-interventional diagnostic radiologists,
reflecting a trend seen among medical specialties across the nation. However, many practices are still losing money as a result of the higher costs of doing business. (According to the American Medical Group Association (AMGA) 2006 Medical Compensation and Financial Survey)

Source- RSNA News

Probably this further supports the collabrative model used by Teleradiology Providers, where we offer the preliminary reads by Indian radiologists thereby benefiting the practise by increasing the work output to generate more revenues.

My Kenkoy Desktop

I forced Dodong Flores to tag me into showing my desktop. I haven't forgotten it, and so here it is Mr. Dodong Flores. Honestly, I did not add or delete any icon on my desktop. It's just what it is. I love this page of Kenkoy so much that I made it into my wallpaper. Hope you find it cute, too :)