bluuebunny/crossref_metadata_2025 huggingface dataset:
602 Using Plastic Surgery Techniques in Abdominal Wall Surgery
Authors: Lee-A-Ping K , Chintapatla S , Chitsabesan P , Lim P , MacLeod T
Published: November 2022

Complex Abdominal Wall Hernias (CAWH) present a huge challenge to surgeons and patients often requiring Abdominal Wall Reconstruction (AWR). AWR aims to restore abdominal wall anatomy, improve function, and reduce the risk of future herniation. Plastic surgery techniques can be used including primary closure, skin grafts, flaps, tissue expansion and small bite, small stitch technique. Below are two cases where some of these techniques were utilised.

Case 1

LC is a 65 y/o female with CAWH. Her gastric band became infected requiring a laparotomy for perforation of gastroesophageal junction. She subsequently had primary open repair of abdominal hernia using Permacol. It became infected requiring 5 debridements and application of a VAC device. Her hernia was a Ventral Hernia Working Group (VHWG) grade 3 at 10cm×16cm. Her CAWH was repaired using a Rives-Stoppa technique and a Surgimend mesh. The epigastric component of her wound was closed using a superiorly based local rhomboid flap and a Prevena VAC dressing.

Case 2

KH is a 37 y/o female with a para-ileal conduit skin granuloma that was painful and refractory to other treatments such as silver nitrate and steroid topical treatments. She had excision of the area of granulation and her wound was closed using a local advancement flap taking account of previous scars raised and a prevena VAC dressing.

Discussion

CAWH requiring AWR is a complex operation benefiting from plastic surgical specialists. Plastic surgical techniques can help with closure of the abdominal wall and reduce complication rates including wound infections and incisional hernia.
609 Metachronous Osteoid Osteoma of the Mid-Diaphysis of the Fibula and Distal Humerus: A Case Report
Authors: Adlan A , Azzopardi C , Davies AM , Botchu R
Published: November 2022

A 7-year-old boy presented with a 4-week history of pain and swelling of the right leg. He had a history of mucoepidermoid carcinoma of the parotid gland, treated by surgical resection without any complication. There was no other significant past medical history. A radiograph of the right leg showed a lytic lesion of the right diaphysis of the fibula with periosteal reaction. An MRI of the right leg showed osteoid osteoma of the fibula with marked cortical thickening with osseous and soft tissue oedema. The patient subsequently had a Jamshidi biopsy and curettage of the lesion, with the histopathological results of the biopsy showing fragments of a typical osteoid osteoma nidus with irregular calcified bony lamellae. His symptoms had significantly improved after the procedure, and he was ambulating without any discomfort or pain. The patient remained asymptomatic until he returned seven years later with right elbow swelling, pain and reduced range of movement over 2–3 months. A radiograph of the elbow joint had shown a large effusion with a sclerotic lesion on the coronoid fossa of the distal humerus in keeping with an osteoid osteoma. The patient had a confirmational biopsy and subsequently radiofrequency ablation of the lesion with complete resolution of pain. To our knowledge, our case is an atypical presentation of osteoid osteoma in two widely separate bones, between the lower and the upper limb separated by seven years disease-free interval.
632 A Rare Case of Genitourinary Tuberculosis Presenting as Occult Compensated Renal Failure
Authors: Shkoukani ZW , Nandakumar A
Published: November 2022

It is acknowledged in the literature that genitourinary TB is a diagnostic challenge due to its rarity and insidious presentation.

We herein report a case of a 64-year-old gentleman originally from Peru with an unremarkable past medical history that attended his GP practice on multiple occasions complaining of recurrent left sided loin pain, headaches, and microscopic haematuria. Abdominal ultrasonography revealed an atrophic left kidney and dilated renal pelvis. This was interpreted to either be a complication of chronic renal calculi, or secondary to malignancy.

Further investigations including CT urogram, MAG3 renogram, cystoscopy and anterograde pyelogram effectively ruled out malignancy, revealing hydronephrosis and loss of cortical thickness. And although this was initially dismissed, further deterioration prompted more robust investigations.

A complication of testicular pain and swelling with an associated lack of response to prolonged courses of antibiotics and associated scrotal abscess on ultrasonography prompted rapid surgical decompression and drainage. Histopathological results reported findings of acute necrotising granulomatous inflammation with positive acid-fast bacilli on Ziehl-Neelsen staining – consistent with tuberculosis. Routine follow up since commencing anti-TB therapy showed marked improvement with no further episodes of haematuria or flank pain, and kidney function remained at baseline.

By raising awareness of potential imaging features as well as more subtle clinical presentations, it is hoped that clinicians can consider genitourinary tuberculosis as a differential, if there is no improvement with conventional antimicrobial agents.
662 Bilateral Vocal Cord Paralysis and Cranial Polyneuropathy: A Rare Presentation of Ramsay Hunt Syndrome
Authors: Dhar P , Brimioulle M , Nair D
Published: November 2022

Case Presentation

A 61-year-old gentleman with chronic lymphocytic leukaemia presented with right sided disseminated vesicles, otalgia, hearing loss, facial weakness, dysphagia, hoarseness, breathlessness, and stridor. In the preceding 48 hours he had two A&E presentations with only right otalgia, facial weakness, throat tightness and mild breathlessness. Cranial nerve (CN) examination demonstrated right cheek numbness and absent jaw jerk reflex (CNV), right grade 6 lower motor neuron facial palsy (CNVII), impaired hearing (CNVIII), dysphonia, dysphagia, and asymmetric palate elevation (CNIX and X). Fibreoptic nasendoscopy (FNE) demonstrated bilateral vocal cord palsy. He was diagnosed with Ramsay Hunt syndrome (RHS) and disseminated herpes zoster (HZ) requiring intubation and ventilation, intravenous steroids, aciclovir, antibiotics and a prolonged intensive care admission. He was discharged after three months. Eight months later, he has a long-term tracheostomy, gastrostomy, and live-in carer.

Discussion

This is the only case found in the literature of RHS and associated bilateral vocal cord palsy with cranial polyneuropathy requiring a long-term tracheostomy. It highlights the significant morbidity attached with RHS complications, particularly in a patient with underlying malignancy. Awareness of these rare and potentially life-threatening complications should be raised to avoid investigation and treatment delay. HZ should be considered in patients with CNVII palsy and otalgia, with or without vesicles. Clinicians should perform full CN examination including FNE to assess for cranial polyneuropathy. RHS can present without vesicles, making it indistinguishable from Bell's Palsy. Therefore, we should consider treating Bell's Palsy with aciclovir. Furthermore, multidisciplinary management of disseminated HZ is essential.
666 Rugby Tackle: A Cause of Delayed Onset Laryngeal Oedema
Authors: Dhar P , Brimioulle M , Nair D
Published: November 2022

Case Presentation

A 14-year-old boy presented to the emergency department with facial and neck swelling, hoarseness and dysphagia. The symptom onset was 24 hours after a rugby tackle to the neck and shoulder. Examination found significant bilateral lower facial and neck swelling. Blood results and observations were normal. Fibreoptic nasendoscopy (FNE) revealed diffuse oedema of arytenoids and soft tissue around the larynx. Computed Tomography (CT) neck with contrast demonstrated diffuse inflammatory changes in the submental and submandibular regions extending to the suprasternal notch, the aetiology for this was indeterminate. He responded to medical treatment with regular intravenous dexamethasone, intravenous antibiotics and as required, adrenaline nebulisers. He was discharged after two days and was able to return to school the following week.

Discussion

Laryngeal oedema is an ear, nose and throat emergency which can result in airway obstruction. It is commonly caused by bacterial infection. However, rarely other precipitants including blunt trauma are reported. This is the first case reported in the literature of delayed laryngeal oedema from a common sporting injury. It is important to recognise and consider trauma as a cause in patients with delayed laryngeal oedema, especially when no other obvious underlying cause is present. This case highlights the importance of thorough history taking to detect trauma. After ensuring a secure airway, systemic steroids are effective against trauma-induced laryngeal oedema and prophylactic antibiotics should be considered to avoid oropharyngeal contamination. FNE, CT and a minimum 24-hour observation period with specialist involvement are essential for neck trauma management.
674 A Rare Cause of Dysphagia in an Adult: Laryngeal Cleft, a Case Report from a Tertiary Care Centre
Authors: Mehtani N , Dall'Amico G , Sandhu G
Published: November 2022

Introduction

Laryngeal cleft is a rare congenital anomaly where the laryngotracheal wall fails to fuse posteriorly resulting in a gap. Embryologically, larynx develops from IV and VI branchial arches and is separated from foregut by trachea-esophageal septum, which closes from caudal to cranial end. Symptoms can vary, depending on where these fusion arrests, from none in mild cases to aspiration, recurrent pneumonia, dysphagia, and hoarseness of voice in severe. The condition is almost always detected in childhood and rarely diagnosed in adults.

Method

We present a case of 41-year-old male with dysphagia and choking episodes, having previously been treated for cleft palate and larynx as a child alongside a literature review of such published cases.

Results

A 41-year-old male developed swallowing problems with choking episodes on a background of having had a successful repair of a type 3 cleft in childhood. He underwent video fluoroscopy which demonstrated evidence of aspiration. He subsequently underwent a diagnostic microlaryngoscopy, which disclosed a type III laryngeal cleft. He was treated surgically with open laryngeal cleft repair, following which the postoperative fibreoptic endoscopic evaluation of swallowing demonstrated strong swallow. He was discharged home on successful resumption of his baseline diet.

Conclusion

Laryngeal clefts in adults are very rare and can be successfully treated surgically. The case report showcases the condition can still present in adult life with late failure (breakdown) and the need for awareness about the disorder. A review revealed very few reported adult cases in the current literature.
680 An Incidental Finding of Pneumatosis of the Colon in a Patient with Mesothelioma Being Treated with Nivolumab
Authors: Gopaul S , Lam S
Published: November 2022

A 75-year-old woman attended a large academic teaching hospital for a computed tomography (CT) of the chest for a T3 N0 M0 epithelioid mesothelioma of the right pleura (to assess treatment response). The malignancy was diagnosed one year previously, and the patient was being treated with second line immunotherapy, Nivolumab (a human immunoglobulin G4 monoclonal antibody) with palliative intent. To date, the patient was showing a partial response to this treatment.

The CT chest incidentally showed locules of gas under the right diaphragm and therefore an urgent CT of the abdomen and pelvis was performed. This scan re-demonstrated a small pneumoperitoneum, but also an incidental finding of pneumatosis involving the hepatic flexure. Prior to Nivolumab treatment, there were no abnormalities noted on the most recent abdominal CT scan.

The patient was admitted to hospital as an emergency under the care of oncology. The patient was entirely asymptomatic with a soft, non-tender abdomen, with both a normal diet and bowel function. Observations including heart rate, temperature, blood pressure and respiratory rate were within normal limits. Blood testing showed a C-reactive protein of 86 mg/L and white cell count of 4.8 10^9. Based on the radiological findings, intravenous fluids and antibiotics were commenced and the patient was restricted to nil intake orally. A surgical review was also requested. Based on surgical advice, the patient was treated conservatively, and was discharged home without complication and no surgical follow up.
709 Two-Layer Biodegradable Temporizing Matrix Reconstruction of Abdominal Wall Dermatofibrosarcoma Protuberans
Authors: Shah R , Kiely A , McKirdy S
Published: November 2022

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive dermal sarcoma. The management is generally surgical, with wide local excision (WLE) forming the mainstay of treatment. Large abdominal wall defects are most aesthetically reconstructed using pedicled or free flaps; however, these require tumour-free surgical margins, and can cause donor site morbidity. We describe an alternative, aesthetic, and low-morbidity technique for abdominal wall reconstruction following WLE of DFSP, using 2 layers of a novel synthetic dermal matrix (NovoSorb® BTM).

25-year-old women presented with a large DFSP involving the right anterior-abdominal wall. After WLE with 3cm margins, BTM was implanted to the large sub-fascial abdominal wall defect. At 6 weeks, after histological confirmation of tumour-free margins, a second layer of BTM was applied to improve the significant contour deformity of the wound bed. After complete integration by 7 weeks, a split-thickness skin graft was harvested from the right thigh and fixed to the new dermis.

At 14-days postoperatively, the skin graft had fully taken, and donor site healed. By 8 weeks, the scar had started to mature with no obvious contour defect or contracture. Overall, the patient was satisfied with the functional and aesthetic outcome.

To our knowledge, a two-layer reconstruction using an artificial dermal matrix has never been described for abdominal wall reconstruction. We found that double-layer BTM is able to restore the inherent thickness and pliability of skin in complex abdominal wall reconstruction following WLE of DFSP and offers improved durability and cosmesis compared to skin grafting or indeed single layer skin substitutes alone.
718 Cryptogenic Stroke in a Patient with Firearm Injury - a Diagnostic Dilemma
Authors: Bhatti HW , Arham M , Shahid R Muhammad N , Zaidi SMJ , Hanif M
Published: November 2022

Introduction

Neurological deficit associated with firearm injury outside the head and neck region is a rare phenomenon. Multiple explanations, including pellet embolization, patent foramen ovale and carotid intimal tear, have been suggested.

Case Report

We present a case of an otherwise healthy 21-year-old male, who was received in the emergency with a firearm injury, unstable vitals, and GCS 14/15. Bullet entry wound was on the back of the chest, 3 cm medial to the spine of left scapula, with no exit wound, but bullet palpable superior to the medial 1/3rd of right clavicle. CT and X-ray imaging confirmed surgical emphysema and left sided haemopneumothorax. Two release incisions were given superior to the medial 1/3rd of both clavicles. Bullet was found below the right release incision and was retrieved. Chest tube was inserted bilaterally, and the patient was placed on mechanical ventilation. On the 5th day, upon resolution of emphysema and haemopneumothorax, the patient was extubated, and the chest tubes were removed. However, examination findings revealed left facial and abducens palsy along with left circumduction gait. MRI brain showed ischaemic changes in the right frontoparietal region. Carotid angiography and echocardiography were normal. Patient was then managed by neurology and neurosurgery.

Conclusion

In cases of firearm injury the physician should always look for neurological deficits, irrespective of the firearm injury pathway through the body. Stroke should be a concern in such cases even if the patient is otherwise healthy and young.
727 Pulmonary Embolism Following Posterior Shoulder Dislocation and Traumatic Brachial Plexus Injury - a Case Report
Authors: Noton T , Khanom S , Abd Wahab EH , Gerakopoulos E , Colegate-Stone T
Published: November 2022

Traumatic brachial plexus injuries are considered to be among the rarest but most debilitating complications of shoulder dislocation. In addition, posterior shoulder dislocations are also rare, accounting for only 2–4% of all shoulder dislocations.

A 40-year-old female patient presented to the emergency department (ED) with a dislocated right shoulder secondary to a mechanical fall. Plain film X-rays demonstrated a posterior dislocation of the humeral head. The shoulder was reduced under procedural sedation. Clinical examination after relocation demonstrated dense flaccid paralysis affecting all dermatomes and myotomes throughout the right upper limb. Urgent magnetic resonance imaging (MRI) of the shoulder showed oedematous thickening and haematoma along the brachial plexus, a large ‘reverse’ Hill-Sachs lesion, greater tuberosity avulsion fracture and glenohumeral capsular tear.

The patient was referred to the specialist peripheral nerve injury unit, who advised nerve conduction studies and a magnetic resonance angiogram (MRA) to rule out expanding haematoma. The MRA scan revealed brachial plexus findings consistent with the MRI scan, no active bleeding, however a thrombus in the brachial vein.

Two days after the MRA scan, the patient presented to ED with ongoing flaccid paralysis, severe neuropathic pain, and right-sided chest pain. Blood tests revealed a d-dimer >1000. CT pulmonary angiography confirmed extensive bilateral pulmonary emboli and she was commenced on appropriate anticoagulation.

Association between brachial plexus injury, flaccid paralysis and venous thromboembolism are rare sequelae resulting from posterior shoulder dislocation. Further studies are required to investigate its incidence and establish whether all patients should receive VTE prophylaxis as standard.
736 Endoscopic-Guided Decompression of an Incidental, Massive, Infected Fronto-Ethmoidal Mucocele: Our Experience
Authors: Muhammad U , DeCarpentier J , Noon E
Published: November 2022

A 55-year-old man was referred to neurology with worsening headaches and right-hand numbness. An MRI brain demonstrated a hemangioblastoma but also a large right sided frontoethmoidal mucocele. The only sino-nasal symptom the patient had was unilateral nasal obstruction but felt this was well-controlled with a steroid nasal spray prescribed in primary care. Nasendoscopy showed pus emanating from a smooth mass anterior in the nasal cavity. A CT scan showed features of a large, expansile mass extending across both frontal and ethmoid sinuses, lateralising the septum, with dehiscence of the lamina papyracea. The patient underwent image-guided endoscopic sinus surgery to drain the mucocele which was filled with a considerable amount of pus and was seen to have eroded all sinus lamellae. Sinonasal mucoceles are expansile collections of mucous, lined with epithelium, and are thought to be more common in the third and fourth decades (1). They are usually caused by sinus surgery as a result of an obstructed sinuses but can follow trauma, inflammation or occur spontaneously (2). Once identified, surgery is the standard of care to prevent complications from expansion or infection. In this case report, along with imaging and intraoperative photographs, we further describe our approach and experience in managing a large mucocele.
739 A Primary Thyroid Squamous Cell Carcinoma Presenting as a Left-Sided Neck Lump
Authors: Akbar S
Published: November 2022

The elderly patient presenting with a neck lump often raises concerns regarding a malignany. Thyroid gland malignancies are well-recognised and sub-type characteristics thoroughly researched, whereas rarer types of thyroid carcinoma are reported infrequently and often behave more aggressively.

An 83-year-old female was referred from the GP to ENT due to a 7-month history of an unexplained enlarging left-sided neck swelling. A fine needle aspiration revealed cytology consistent with squamous cell carcinoma (SCC). Staging imaging failed to reveal evidence of a primary foci elsewhere. The definitive diagnosis was that of a primary thyroid SCC: a rare entity with limited citations in the literature. Surgical resection has been found to comprise the optimal treatment for this disease.

Recognition of the possibility of primary thyroid SCC in elderly patients presenting with a neck lump, with prompt referral to a head and neck specialist permits a timely progression to potentially curative surgical management, a more promising prognosis and reduced mortality rates.
741 Paediatric Pigmented Epithelioid Melanocytoma: A Case Report
Authors: Magill H , AlOmran Y , Abela C
Published: November 2022

Background

Pigmented epithelioid melanocytomas (PEMs) pose a challenge in terms of diagnosis and management, this is due to the wide spectrum of disease severity. Not only is management a grey area, but there is controversy over management and follow up, due to their indeterminate malignant potential.

Case

An 11-year-old boy presented with a six-month history of a rapidly changing pigmented naevus on his upper back. He had Fitzpatrick type 1 with no history of significant sun damage or familial history of skin cancer, and no relevant past medical history. Differential diagnoses included spitz naevus, malignant melanoma, or MelTUMP (melanocytic tumour of unknown malignant potential). An excision biopsy showed a benign pigmented epithelioid melanocytoma with local lymphatic involvement. The child was seen two months following the original surgery and no signs of local or regional recurrence was present.

Discussion

This is one of few cases of paediatric PEM reported in literature. This lesion has potential to metastasise through the lymphatics and mortality is very low. The management of PEMs is complicated due to their unknown malignant potential and should be decided by an MDT. Based on the limited literature on PEMs and our knowledge of ‘thin’ melanomas wide local excision is sensible, however a larger cohort if needed to fully understand prognosis. SNB should be considered on a case-by-case basis by an MDT, and regular ultrasound surveillance with clinical examination offers a safe alternative to SNB in some patients.
743 Dermal Fillers and Fibromyalgia Flares: A Case Report
Authors: Magill H , Totty J
Published: November 2022

Background

Minimally invasive treatment with dermal fillers is increasing in popularity in facial plastic surgery. These fillers can be used in the midface to address volume loss associated with ageing, such as loss of malar projection, or deep nasolabial folds. The use of medicinal products has the potential to cause complications, and dermal fillers are no exception, however, reports of these in the literature are uncommon. Selection of a suitable product, patient, and accurate placement of product may avoid some of these complications.

Case: 56-year-old female underwent cheek augmentation with hyaluronic acid filler. The procedure was uncomplicated, and there were no concerns immediately afterwards. Over the following months however the patient reported flares that occurred when she had a fibromyalgia flare. She had no signs of infection and there was no evidence of a reaction to the filler itself.

This is the first case of its type to be described to our knowledge; literature searching does not retrieve any reports to date of adverse events related to fibromyalgia following the use of cosmetic dermal fillers. Careful consideration of patient suitability, and clear and detailed informed consent is vital in providing cosmetic treatments safely.
749 Bouveret Syndrome: A Challenging Case of Impacted Gallstone Within the Fourth Part of the Duodenum
Authors: Smith E , Zhao S , El-Boghdady M , Sabato-Ceraldi S
Published: November 2022

Aim

Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. In this report, we present a case of Bouveret syndrome in a 68-year-old requiring an atypical approach to surgical retrieval.

Method

The patient presented acutely with abdominal pain and vomiting. This was on a background of recent admission for gallstone ileus managed conservatively. Initially, due to high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), the patient was managed conservatively with nasogastric drainage and total parenteral nutrition. On day 6 of admission, emergency laparotomy was performed after identifying radiological signs of impending perforation related to a large gallstone impacted in the fourth part of the duodenum and a cholecysto-duodenal fistula. Endoscopic management was not available locally.

Unsuccessful attempt was made to milk the stone proximally for retrieval via pyloroplasty. Subsequently, high pressure water flushes were delivered via the gastrostomy which expelled the stone distally. The stone was then retrieved via jejunotomy at the DJ flexure.

Results

The patient required a 2-day high dependency unit admission, and she was discharged 3 weeks post-operatively at her functional baseline. She was clinically well and asymptomatic when reviewed at the four-month post-operative surgical follow up appointment.

Conclusions

This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. Enterolithotomy can be considered in case of large, impacted stone and can be a safe option in patients with multiple co-morbidities.
800 A Rare Cause of Unilateral Facial Palsy in an Adult Presenting to a Tertiary ENT Centre
Authors: Mehtani N , Navaratnam A , Rennie C
Published: November 2022

Introduction

Sinonasal inverted papilloma are benign tumors usually appearing in 5th decade of life. They are characterised by their recurrent nature with extensive local destruction and malignant potential.

Case Report

A 54-year-old male was referred to our tertiary centre for further management of recurring Inverted papillomas. On review in clinic, he was found to have right facial palsy- House Brackman (HB) grade V with extensive disease in nasal passages and external auditory canal (EAC) bilaterally. This was associated with reduced visual acuity (VA)- 6/12 and proptosis of the right eye.

CT Head was suggestive of a lesion involving the right mastoid, external and middle ear, extending into the right middle cranial fossa is likely to account for the right facial nerve palsy. The MRI scan showed multiple enhancing massess in the nasal cavity, the right mastoid and tympanic cavity, the left tympanic cavity with further possible disease in the oropharynx and nasopharynx.

He was admitted to hospital from clinic for surgical management and underwent Endoscopic debulking of nasal tumour + Biopsy of bilateral external auditory canals + biopsy of pharynx. The patient was discharged a day after undergoing the procedure and remained well on ENT follow-up visit. He was further referred to Oncology team once histology results were available which showed Nonkeratinising sinonasal carcinoma and is due to receive his first dose of chemotherapy shortly.

Conclusion

The study showcases the need for awareness in such conditions and potential complications that can arise due to disease progression.
804 Accessory Extensor Digitorum Brevis Manus Muscle Presenting as a Painful Dorsal Hand Swelling - a Case Report
Authors: Noton T , Magill H , Kazzazi F , Lumsdaine W , Bremner-Smith A
Published: November 2022

Hand and wrist pain are common presenting complaints in General Practice, Emergency Departments, and plastic surgery clinics across the UK.

We present the case of a 43-year-old male who initially presented to his General Practitioner with an 18-month history of progressive pain and intermittent swelling to the dorsum of his right hand and wrist. Magnetic resonance imaging (MRI) and ultrasound (US) performed privately, when his symptoms first presented, were inconclusive, demonstrating generalised tenosynovitis. The patient had previously tried local steroid injections and shockwave therapy prior to being referred, neither of which relieved his symptoms.

On examination in clinic, there was subtle fusiform prominence over the radio-dorsal aspect of his right hand, with tenderness on palpation and on extension of the wrist. An up-to-date MRI scan was performed which revealed an accessory extensor digitorum brevis manus (EDBM) muscle at the dorsal aspect of the right hand and wrist.

The patient opted for excision of the accessory EDBM muscle, which was performed without complication under general anaesthetic and regional block. He made an unremarkable recovery.

Whilst accessory extensor muscles in the hand are not unheard-of, variant EDBM muscles only account for around 1% of these, and only a handful have been documented in literature. When patients present with a painful swelling in the dorsum of the hand or wrist, which is exacerbated with repetitive use, a diagnosis of an accessory EDBM muscle should be considered a differential.
808 A Fascinating Case of Anosmia in an Adult: Benign Peripheral Nerve Sheath Tumour Managed at a Tertiary NHS Centre
Authors: Mehtani N , Acharya V , Rennie C
Published: November 2022

Introduction

A nerve sheath tumour is slow growing lesion in the myelinated connective tissue surrounding the nerve fibres. Paranasal schawannomas are rare and often clinically misdiagnosed.

Case Report

An 80-year-old male referred to us with suspected olfactory neuroblastoma. He initially presented to his local unit with anosmia, nasal blockage, and epistaxis. There was history of right temple skin cancer 20 years ago and he is being currently being treated for hypertension. The biopsy results from local hospital were S100 and CD56 positive and preliminarily suggestive of olfactory neuroblastoma or ancient schwannoma.

On review in clinic, he had a large left sided anterior sinonasal lesion obstructing the cavity. The patient was planned for elective endoscopic or open resection and underwent further imaging to aid surgical planning. The CT Head was suggestive of a large left anterior sinonasal tumour, abutting the cribriform plate which is thinned and possibly focally dehiscent. Abutment of the left lamina papyracea which is bowed and thinned.

The patient underwent Endoscopic resection of left sinonasal tumour and skull base repair with fat, fascia lata and septal flip flop flap. The patient recovered well postoperatively and was discharged home 5 days after his procedure. The histology confirmed benign peripheral nerve sheath tumour.

Conclusion

Peripheral nerve sheath tumours can present with various unusual symptoms and may prove difficult to diagnose. Hence a multidisciplinary approach is beneficial to guide management in such complex cases.
811 Dermal Fillers and Delayed Hypersensitivity Following Influenza Vaccine: A Case Report
Authors: Magill H , Ioannidi L , Collier J
Published: November 2022

Background

Dermal fillers can be used to improve cosmetic appearance of facial soft tissue in patients with Human Immunodeficiency Virus (HIV) associated lipodystrophy. There are documented cases of delayed hypersensitivity reaction to dermal fillers following influenza-like illness, and similarly following coronavirus vaccination, however none following the influenza vaccine.

Case

A 52-year-old female was treated with dermal filler injections to her zygomatic and buccal regions for lipoatrophy secondary to HIV treatment. Her HIV was well controlled with a low viral load. Six months following dermal filler treatment she presented with periorbital and zygomatic arch swellings one week after vaccination for influenza. The swelling was initially treated as periorbital cellulitis with antibiotics; however, it did not resolve. The swelling was in the same distribution as her filler and as it did not appear to be an infection but rather a delayed hypersensitivity reaction, it was treated with prednisolone for one week. There was further reduction in nodules following intralesional triamcinolone injections and following weaning of prednisolone there was no recurrence of swelling.

Discussion

To our knowledge this is the first case of its type to be described; literature searching does not retrieve any reports to date of adverse events related to the influenza vaccine following the use of dermal fillers. This is an important consideration in terms of the risks posed by this treatment in immunocompromised patients, and detailed informed consent is an important component of treatment.
827 Unusual Presentation of Missed Appendicitis
Authors: Khitab N
Published: November 2022

I present the case of old age man, who presented with pain right side of the abdomen with huge anterior abdominal wall swelling, along with loose motion in one of the hospitals in an Asian country. His inflammatory markers were unremarkable, and his ultrasound showed fluid-filled bowel loops, with no ascitic fluid. The appendix could not be visualised. On examination, he had tender and distended abdomen and bowel sounds were exaggerated. Laparotomy was performed and it came out to be missed appendicitis which buried into the abdominal wall and caused the pus track down anteriorly to appear as anterior abdominal wall abscess as one of its rare complications. Appendectomy was done alongside abdominal wall exploration. Pus was drained. The patient improved and went home in the second post-operative week.
883 Clinical Case Report: Recurrent Non-Tuberculous Psoas Abscess with Associated Discitis
Authors: Palepa A , Morrison TEM , Suresh S , Arulampalam T
Published: November 2022

Introduction

Following the discovery of modern anti-tuberculosis treatments, psoas abscesses secondary to Pott's disease of the spine rarely occur in developed countries. We present a case of a recurrent non-tuberculous psoas abscess communicating with the spine and pleural cavity, presenting as an abdominal mass.

Case

A 72-year-old man presented with a left upper quadrant mass, pain, abdominal distension and raised inflammatory markers. Cross-sectional imaging with CT and MRI revealed a large left-sided psoas abscess with a pleural effusion tracking to the retroperitoneum and associated recurrent discitis. The patient was commenced on intra-venous antibiotics and the collection was accessed via a radiologically placed drain to the retroperitoneum.

Discussion

Spinal infections may present with a lump below the inguinal ligament due to pus tracking down the psoas tendon sheath. Irritation of the psoas muscle may also present with pain on hip extension due to muscular spasm. The most common causative agent of primary psoas abscesses is Staphylococcus Aureus. Discitis is more common in men and shows a bimodal age distribution in presentation, predominantly affecting children and then those in the 6th-7th decade of life.

Learning points

Retroperitoneal disease should be considered in a patient who presents with an abdominal mass. In patients who present with a psoas abscess or an empyema communicating with the retroperitoneum, a spinal source should be considered. Crohn's disease is a common cause of secondary psoas abscesses and should also be considered. Cultures for mycobacteria should be obtained to exclude Tuberculosis as an underlying cause.
915 Duodenojejunal Intussusception Caused by a Solitary Peutz-Jeghers-Type Polyp
Authors: Nazir S , Merchant A , Borscheid R , Wedgwood K
Published: November 2022

A solitary Peutz-Jeghers (SPJ) type polyp is a rare hamartomatous polyp that shares similar histological features to polyps found in typical Peutz-Jeghers syndrome (PJS), without the associated mucocutaneous pigmentation or family history. Intussusception is rare in adults and of the six previous reports of intussusception caused by a SPJ type polyp, only two occurred in adults.

A 59-year-old female presented with recurrent episodes of colicky abdominal pain lasting a few hours. These episodes were followed by abdominal bloating and belching, but no vomiting. A CT scan of the abdomen and pelvis suggested intussusception of the fourth part of duodenum (D4) into the jejunum and a small bowel mass with D4 involvement. Physical examination did not reveal the associated signs of PJS.

Multi-disciplinary team (MDT) recommendation was to resect the area in question. An exploratory laparotomy found a small bowel intussusception. Enterectomy of D4 and proximal jejunum was performed, with primary side to end anastomosis. Macroscopically, the specimen showed intussusception of the distal duodenum into the proximal jejunum, associated with a large duodenal polyp measuring 5×3 x 2 cm. microscopic examination revealed hamartomatous changes suggestive of a Peutz-Jeghers polyp. The resection margin showed normal small bowel tissue with no evidence of dysplasia. A colonoscopy to rule out additional polyps was negative, and the patient recovered well from surgery.

This rare case highlights the non-specific presentation of intussusception, shows the need for methodical evaluation of the patient's history, examination, and investigations, and queries the requirement for surveillance and screening.
934 Chemical Burns and the Use of High-Strength Topical Lidocaine Cream in Tattooing - a Case Report
Authors: Noton T , Burke-Smith A , Jones I
Published: November 2022

Topical anaesthetics have long been used for their ease of use and short duration to provide local anaesthetic prior to procedures such as cannulation and tattooing.

We present the case of a 26-year-old tattoo artist sustaining a chemical burn and resulting infection from a high-strength topical lidocaine cream. The patient presented to the emergency department 5-days following application of the cream. The topical preparation was sourced online, came in a nondescript white tube, and was marketed as having a 50% lidocaine content with no information regarding its constitution. For comparison, EMLA cream (lidocaine/prilocaine) commonly used in hospitals, is a 5% preparation. Following application, the patient proceeded to self-tattoo his left lower leg, in a ‘blackout’ style.

On presentation, a 2.5% TBSA area was blistered, with areas of denuded skin, in keeping with a deep dermal burn. Much of the lower leg was actively discharging yellow-stained serous fluid. In addition, there was tracking erythema around the demarcated area, and the left foot was grossly oedematous. Blood tests revealed CRP of 103 and WCC of 11.4.

The patient was commenced on intravenous flucloxacillin. Wound swab results showed significant growth of Pseudomonas aeruginosa. Following stepdown to oral antibiotics and careful wound management with dressings such as Flaminal and then honey-based dressings, the patient made a full recovery, avoiding the requirement for surgical intervention.

This case highlights the difficulty when assessing burns in heavily tattooed skin. Additionally, unregulated topical anaesthetics must be avoided by the public, due to infection risk and unknown ingredients.
954 Sarcoidosis Mimicking Progression of Melanoma: A Case Report
Authors: Quigley A , Al-Khattab M , Kennedy S , Kelly J
Published: November 2022

A 78-year-old lady with a history of malignant melanoma on the dorsal aspect of her left foot, presented with a new fluorodeoxyglucose positron emission tomography (FDG-PET) avid lesion in her left fibular head.

The patient had been diagnosed eight months previously with a 5.1mm Breslow thickness invasive melanoma. Following initial diagnosis, she underwent a wide local excision and sentinel lymph node biopsy (SLN). The melanoma was completely excised and SLN was negative for malignancy.

Postoperatively, she underwent radiological staging with computed tomography scans (CT) of her thorax, abdomen, and pelvis. This showed scattered pulmonary nodules, and multiple indeterminate liver lesions. A PET scan was then performed, which showed an expansile, FDG-avid, lytic lesion in the left fibular head, suspicious for bone metastasis. Following discussion at the multidisciplinary team meeting, the patient underwent an open biopsy of the fibular head. Histology revealed non-necrotising epitheloid granulomata without evidence of malignancy. Ziehl-Neelsen and periodic acid Schiff stains were negative. The findings were suggestive of sarcoidosis.

The patient revealed she had a previous diagnosis of pulmonary sarcoidosis 25 years prior, however, had no known extrapulmonary disease and was not attending a specialist. The pulmonary findings on CT were consistent with sarcoidosis.

Sarcoidosis is a systemic inflammatory disease characterised by the development of non-caseating granulomata which typically affect the lungs and lymph nodes but can affect multiple organ systems. This case highlights the diagnostic uncertainty of an FDG-avid lesion on PET, necessitating diagnostic biopsy. Sarcoidosis is an uncommon but possible differential in this setting.
961 Surgery for Stage IVA Metastatic Thymoma Found Incidentally Post-COVID-19
Authors: Ajdarpasic D , Weaver H , Hawari M
Published: November 2022

Background

Thymic epithelial tumours (TET) are rare thoracic cancers with reported annual incidence of 1.3–3.2 per million. TETs are histologically classified as thymomas or thymic carcinomas. Thymomas are slow-growing tumours that comprise the majority of lesions found in the anterior mediastinum. They can be associated with autoimmune disorders such as Myasthenia Gravis.

Contrast CT is the standard for diagnosis. Surgery is treatment of choice depending on resectability of the tumour. The Masaoka-Koga staging system is correlated with overall survival and is utilised post-surgical resection to guide adjuvant treatment.

Case Presentation

A 50-year-old male presented with cough, shortness of breath, myalgia, sore throat, and reduced sense of smell that was diagnosed as COVID-19. CT chest and abdomen showed a large heterogeneous mediastinal mass (11cm) invading the innominate vein and left upper lobe with two left pleural deposits, and diaphragmatic disease. CT biopsy confirmed thymoma. MDT recommended surgery due to patient age and resectability of tumour with post-operative chemotherapy. The sites of disease necessitated a left thoracotomy and median sternotomy. The pleural and diaphragmatic deposits were resected, followed by left upper lobe anatomical dissection enbloc with invaded pericardium, phrenic and vagus nerve, followed by median sternotomy to resect the thymic mass along with the innominate vein. Final staging was stage IVA thymoma (B2 and B3) (T3N0M1aR0). A CT scan at 1 year showed no recurrence despite patient declining adjuvant chemotherapy.

Conclusion

Surgical resection is a viable treatment option for patients with stage IVA thymoma who present with resectable primary and metastatic disease.
982 Embolisation of Iatrogenic Lumbar Artery Bleed Causing Psoas Haematoma Following Elective Lumbar Puncture
Authors: Oladeji E , Rati K , Rakhimova K , Day N
Published: November 2022

The case of a 59-year-old female patient presenting as a surgical emergency with abdominal pain and a positive Obraztsova's sign. Seven days prior to the presentation, she had attended her General Practice (GP) complaining of sudden onset severe occipital headache associated with photophobia, vertigo, and paraesthesia. Due to a family history of cerebral aneurysms, her GP urgently transferred her to an emergency department, where she was subsequently admitted under the acute medical team. A lumbar puncture (LP) had been performed to exclude a subarachnoid haemorrhage. The patient was investigated with a Computerised Tomography abdomen and pelvis with contrast and was subsequently found to have an acute lumbar arterial bleed causing haemodynamic instability and a psoas haematoma. An emergency lumbar artery embolisation procedure was performed by the interventional radiology department in order to stabilise the bleed. The patient made a full recovery prior to discharge. This rare case exemplifies the value of obtaining adequate history in arriving at a diagnosis. In the appropriate clinical context, a contrast-enhanced CT scan of the abdomen and pelvis should be obtained to exclude this treatable condition. Also, measures to minimize the risk of complications and make lumbar puncture safer should be incorporated into guidelines, including methods to ensure that the correct position of L3/L4 or L4/L5 is found prior to performing the procedure, use of atraumatic spinal needles and performing the procedure under ultrasound guidance.
1021 Spontaneous Rupture of Haemorrhagic Pancreatic Pseduocyst – Case Report
Authors: Lakshmipathy G
Published: November 2022

Case Study

A 67-year-old male presented to the emergency department with sudden onset of diffuse abdominal pain, nausea, and vomiting.

Relevant surgical history

He has a history of choledocholithiasis, and he was treated for an episode of acute gallstone related pancreatitis twelve months ago. He underwent ERCP in the admission. He subsequently developed a pancreatic pseudocyst which was managed conservatively through watchful waiting.

Examination

He was particularly tender in the epigastric region. He was mildly tachycardic and normotensive.

Imaging

CT Abdomen and Pelvis demonstrated a significantly enlarged pseudocyst which is closely applied to multiple branches of the coeliac axis. Haematoma within the left upper quadrant was compatible with recent haemorrhage.

Management

The patient was initially managed with IV fluids, broad spectrum IV antibiotics, analgesia, and anti-emetics. He needed emergency surgery for definitive management. Central pancreatectomy and peritoneal toilet were carried out. Pancreatic bed drains were left in-situ for two weeks. Patients need to spend one day in Intensive care. He was fed through TPN initially before switching to nasogastric feeding. Patient was discharged two weeks post-op with Octreotide and fortisips.

Discussion

Pancreatic pseudocyst is a common complication of pancreatitis. Spontaneous rupture of a pseudocyst is rare occurrence as a result it appears sporadically in the medical literature. However, it can be a potentially serious leading to severe peritonitis and needs emergency surgical exploration as highlighted in this case. Prompt surgery combined with extensive lavage was life saving for this patient.