Monday, July 28, 2014

Patterns of Lymphatic Drainage of the Paranasal Sinuses

Sinus Lymphatic Drainage
Frontal Submandibular (level IB)
Ethmoid Submandibular (level IB)
Maxillary: Main Lateral retropharyngeal and internal jugular (levels II, III, and IV)
Maxillary: Lateral antrum Submandibular (level IB)
Sphenoid Lateral retropharyngeal


Monday, July 21, 2014

Marjolin Ulcer

The strict definition of a Marjolin ulcer is a carcinoma that transforms from the chronic open wound of a pressure sore or burn scar. It is now used to describe any carcinoma arising from chronic wounds.

Average latency between ulcer formation and documentation of a malignancy is 30 years; however, intervals as short as 18 months have been reported. Between 1 - 2 % of chronic wounds develop malignant degeneration. The risk of developing malignancy in a venous ulcer is higher (about 20%).

These lesions behave aggressively and have a propensity for local recurrence and lymph node metastases.

The typical presentation is a 40- to 70-year-old man with osteomyelitis and a chronic lower extremity wound, who develops squamous cell carcinoma in the draining sinus tract ("warty tumors in cicatrices").

The image above is from a 50-year-old man with a chronic wound on his shin, with a small plaque that appeared about 1 year ago and has increased in size over the last 2-3 months. Biopsy showed squamous cell carcinoma.

Pyogenic granuloma can have a similar appearance on imaging, but is more common on the hands and feet, has a faster onset after injury/wound formation, and has a typical appearance on physical examination.


  • Gilmore A, Kelsberg G, Safranek S. Clinical inquiries. What's the best treatment for pyogenic granuloma? J Fam Pract. 2010 Jan;59(1):40-2.
  • Quitkin HM, Rosenwasser MP, Strauch RJ. The efficacy of silver nitrate cauterization for pyogenic granuloma of the hand. J Hand Surg Am. 2003 May;28(3):435-8.
  • Zaballos P, Llambrich A, Cuéllar F, Puig S, Malvehy J. Dermoscopic findings in pyogenic granuloma. Br J Dermatol. 2006 Jun;154(6):1108-11.
  • Trent JT, Kirsner RS. Wounds and malignancy. Adv Skin Wound Care. 2003 Jan-Feb;16(1):31-4.

Monday, July 14, 2014

"You keep using that word. I do not think it means what you think it means."

This post is futile. Language is an evolving process. Words have been joining, splitting, and changing meaning for as long as we've had language. The advent of printing helped slow down the process by disseminating "correct" definitions, but words will continue to evolve in spite of dictionaries and curmudgeons like me. That's a good thing.

The definitions of the words below will soon change to match their current "incorrect" usage, first as alternative meanings, and then as the accepted definition. This will happen as surely as ask is changing to aks/axe before our eyes, a continuation of the battle between āscian and āxian in Old English and asken and axen in Middle English.

Having said all that, the following is a list of incorrectly used words that you should feel free to ignore:
  • Epicenter: This refers to a point on the Earth's surface directly above the focus of an earthquake or some other rumble down below. We have appropriated the term to replace plain old center. If we were to correctly use the term in radiology, we'd use epicenter to refer to the skin on top of a deep lesion: "The epicenter of the femoral lesion is on the skin of the medial thigh." See also penultimate.

  • Serpiginous: Serpiginous (from serpere-to creep) is the term that is used to describe creeping and advancing skin diseases, such as ringworm or noduloulcerative cutaneous syphilis. This term is incorrectly used to describe snaky (serpentine) things like vessels or borders of bone infarctions. The person who is responsible for introducing serpiginous into the radiology literature in 1967 issued a correction in 1988, begging us to use serpentine instead. But the damage had been done. By then, the error had serpiginously crept its way into our mouths, and now spills out daily into millions of microphones and reports.

  • Shotty: This refers to small lymph nodes that feel like buckshot under the skin. You must have serious palpation skills if you can feel shotty mediastinal or retroperitoneal lymph nodes! Bonus activity: Do a poll of your colleagues and trainees and see how many think (or thought) the word is actually shoddy. Bonus activity 2: Ask them what shotty/shoddy means in the context of lymph nodes.


  • Di Chiro G, Doppman J, Ommaya AK. Selective arteriography of arteriovenous aneurysms of spinal cord. Radiology. 1967 Jun;88(6):1065-77.
  • Di Chiro G. Serpentine (not serpiginous) vessels in spinal arteriovenous malformations. Radiology. 1988 Jan;166(1 Pt 1):286.

Monday, July 7, 2014

Vagus Nerve Neurofibroma

Vagus nerve neurofibromas are very rare. They can be located in cervical or mediastinal positions. They are slowly growing and typically asymptomatic.

While the vagus nerve itself can be hard to see, knowledge of the anatomy can be helpful in localization. The vagus nerve travels from the jugular foramen in the carotid sheath between the internal jugular vein (IJ) and internal carotid artery above C4 and between the IJ and common carotid artery (CC) to the root of neck.

The case above shows a T2-hyperintense structure between the IJ and CC at the base of the neck. In this patient with neurofibromatosis, the primary consideration is a vagus nerve neurofibroma.


  • Gilmer-Hill HS, Kline DG. Neurogenic tumors of the cervical vagus nerve: report of four cases and review of the literature. Neurosurgery. 2000 Jun;46(6):1498-503.
  • Kanzaki R, Inoue M, Minami M, Sawabata N, Shintani Y, Nakagiri T, Okumura M. Bilateral mediastinal neurofibroma of the vagus nerves in a patient with neurofibromatosis type 1. Ann Thorac Cardiovasc Surg. 2013;19(4):293-6.
  • Matejcik V, Steno J, Haviarova Z, Mravec B. Neurofibroma of the vagus nerve in the cervical portion. Bratisl Lek Listy. 2008;109(10):455-8.
  • Sesenna E, Magri AS, Corradi D, Ferri T, Ferri A. Malignant peripheral nerve sheath tumor of the vagus nerve in a teenager with the neurofibromatosis 1 gene mutation: a case report. J Pediatr Surg. 2011 Aug;46(8):e9-12.
  • Shintani Y, Ohta M, Hazama K, Minami M, Okumura M, Hirabayashi H, Matsuda H. Bilateral cervicomediastinal neurofibroma originating from the vagal nerve in a patient with von Recklinghausen's disease: report of a case. Surg Today. 2002;32(12):1068-71.

Saturday, July 5, 2014

Hypertrophic Osteoarthropathy

Hypertrophic osteoarthropathy (HO), formerly and incorrectly referred to as hypertrophic pulmonary osteoarthropathy, has primary and secondary forms. The primary form (pachydermoperiostosis) is often familial and is more commonly seen in males.

The secondary form can be seen in a variety of pulmonary and hepatic conditions, including:
  • Lung cancer
  • Mesothelioma
  • Carcinomas of liver and gut
  • Inflammatory bowel disease
  • Liver cirrhosis
  • Congenital cyanotic heart disease
  • Pulmonary fibrosis
  • Empyema
  • Graves disease
  • Thalassemia

Patients can present with clubbing of fingers, periostosis of distal long bones, thickening of skin over face and ankles, gynecomastia, and arthritis and synovitis. The synovitis is accompanied by a viscous, non-inflammatory effusion.

Various etiologies have been proposed, but the most recent thought is that it is due to arteriovenous shunting (e.g., in the liver, lung, or various tumors). The idea is that unfragmented megakaryocytes get delivered to distal sites in systemic circulation instead of being filtered in the lungs. This leads to production of growth factors (PDGF and VEGF), which lead to angiogenesis, endothelial hyperplasia. In certain lung tumors, there is de novo production of these growth factors by tumor, which makes it to the peripheral circulation.

A neurogenic role has also been proposed. This is supported by the fact that pain and deformity resolve with peripheral vagotomy in both primary and secondary forms, even with the primary tumor intact.

Differential diagnosis for Multifocal Periostitis in Adults and children were covered earlier.


Armstrong DJ, et al. Hypertrophic pulmonary osteoarthropathy (HPOA) (Pierre Marie-Bamberger syndrome): two cases presenting as acute inflammatory arthritis. Description and review of the literature. Rheumatol Int. 2007 Feb;27(4):399-402.