Anil Nepali1,2, Satyam Kharga1, Malavika Jayan2,3, Prakriti Adhikari4, Amit Shah1, Vivek Sanker2,5

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A Case of Ulcerative Colitis Complicated by a Simple Appendiceal OpeningXiao Liu1*, Fang Fang2，Qingfeng Luo11 Department of Gastroenterology, Beijing Hospital, National Center of Gerontology；Institute of Geriatric Medicine, Chinese Academy of Medical Sciences，P.R. China2 Department of pathology, Beijing Hospital, National Center of Gerontology；Institute of Geriatric Medicine, Chinese Academy of Medical Sciences，P.R. ChinaEmail: [email protected]

Fusion of a maxillary third molar with a supernumerary fourth molar: a case reportCase ImageA 20-year-old Caucasian male consulted the Department of Dentoalveolar Surgery, School of Dentistry in February 2023 due to intermittent pain in the left side of maxilla and face. Intraoral examination revealed probing pocket depth distally to left maxillary second molar 7mm and bleeding on probing. No health problem arises from medical history. Panoramic radiograph revealed impacted mandibular third molar, mesially angulated, with medium impaction depth, abnormal shape and size in close proximity with maxillary sinus floor (Figure 1).Preoperatively 2gr of Amoxicillin were prescribed. Surgical extraction took place under local anesthesia. Infiltration anesthesia with Lidocaine 2% with 1:80000 epinephrine. A full thickness mucoperiosteal flap was prepared and raised, and then ostectomy was performed using surgical handpiece and sterile saline irrigation. Tooth extraction was performed using straight and Warwick-James elevators. Valsalva maneuver was negative. Extraction socket was flushed with saline and flap was repositioned and sutured. Niflumic acid 250mg was prescribed for 3-5 days. Ex vivo examination of the tooth confirmed “double” tooth diagnosis. In order to obtain as much information as possible regarding dental anatomy, photos of all aspects of the tooth were taken and ex vivo CBCT of the tooth was carried out (Figure 2, Figure 3). Additionally, tooth was submerged in epoxy resin. After setting, three sections of the tooth were cut with a low-speed precision sectioning machine (Isomet 11-1180 Buehler, Lake Bluff, IL, USA) with water cooling. The cut surface of each tooth specimen was ground on a polishing machine (Jean Wirtz TG 250, Dusseldorf, Germany) with 200 rpm under water cooling (50 mL/min) using gradually 600-, 800-, and 1000-grit silicon carbide abrasive papers (Apex S system, Buehler, Lake Bluff, IL, USA) for 20s each. Final tooth sections were <1mm. Tooth specimen was placed between two liner polarization filters. Afterwards flash (Speedlight SB-700, Nikon, Japan) with softbox (Godox, China) was held from one side and DSLR camera (D7200, Nikon, Japan) with macro lens (Micro Nikkor 105mm, Nikon, Japan) from the other side. Filters were crossed in different directions until intended result was obtained (Figure 4, 5, 6). Sutures were removed after one week, healing was unproblematic. Oral examination after six months revealed complete healing of soft tissues.Differential diagnosis between different subcategories of “double” tooth is difficult. The supposition that gemination displays a single root canal and fusion displays several root canals is controversial. Fusion of a normal tooth with supernumeraries will still result in a normal tooth count. Given the presence of features suggestive of both diagnoses, this case, actually, presented a diagnostic dilemma.Fusion of two impacted teeth apparently results in a larger dental structure that makes extraction more invasive and inevitably raises the possibility of complications. Close proximity of maxillary third molar with maxillary sinus floor has to be appreciated. Fracture of maxillary tuberosity may occur in cases with extensive ostectomy.Alterations in tooth size and shape during initial radiographic examination may be a primary sign of dental abnormalities. Utilizing contemporary imaging techniques, including CBCT and dental photography, may showcase such special dental anatomies and complement dentists’ education in this field. Dentists’ awareness will result in a meticulous treatment planning and ensure a successful outcome.Figure legendsFigure 1: Initial panoramic radiograph. White arrow shows impacted third molar with small changes in size and shapeFigure 2: Images of the extracted “double” tooth from different aspectsFigure 3: Images exported from ex vivo CBCT of extracted “double tooth”. Shared pulp canal system is noticed.Figure 4: Image of the first tooth section, using polarization filters, DSLR, macro lens and flashFigure 5: Image of the second tooth section, using polarization filters, DSLR, macro lens and flashFigure 6: Image of the third tooth section, using polarization filters, DSLR, macro lens and flash

Type V Gastric Ulcer: An Unusual Etiology of Gastrosplenic Fistula Associated with Upper Gastrointestinal BleedingMuhammad Nadeem Yousaf MD1, Riyasha Dahal MBBS2, Subeena Phull MD3, Vinayak Aryal MD4, Karun Neupane MD5, Hamza Ertugrul MD6, Ebubekir Daglilar MD71Department of Medicine, Division of Gastroenterology and HepatologyUniversity of Missouri, Columbia, MO, United States2Department of Medicine, Universal College of Medical Sciences, Bhairahawa, Nepal3Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States4Department of Pathology and Laboratory Medicine, MetroHealth System, Case Western Reserve University, Cleveland, OH, United States5Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States6Department of Medicine, Saint Mary’s Hospital, Waterbury, CT, United States7Department of Medicine, Division of Gastroenterology and HepatologyCharleston Area Medical Center, Charleston, WV, United StatesKeywords: Gastric Ulcers, Gastrosplenic fistula, Gastrointestinal bleeding, NSAIDs, Embolization, Endoscopy.Consent statement: Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.

IntroductionStriae Distensae (SD), a well-recognized phenomenon resulting from dermal scaring, it is usually associated with physiological conditions such as pregnancy, growth spurt, rapid weight loss or gain or iatrogenic causes such as topical or systemic corticosteroid administration1. It is aesthetically troublesome and therapeutically challenging. SD early stages appear as flesh-toned atrophic linear plaques that eventually progress to silvery-whitish atrophic plaques.1,2 Most commonly affect dispensable body areas such as the buttock, lower back, thighs, calves, breast and abdomen.3 Rare secondary changes within SD have been mentioned in the literature, including edema, urticaria, dyspigmentation, ulceration, dehiscence and subcutaneous emphysema. Fluid filling these striae are an unusual finding. Very few cases have been reported discussing this phenomenon.4,5 Upon literature review, it was notable that even in the very few case reports of BSD, almost all the patients were on long-term oral steroids as well as having hypoalbuminemia, except for one patient as demonstrated inTable 1 .4 Herein, we report a case of a 17-year-old girl with nephrotic syndrome who was treated with high dose of corticosteroids presented to the day-care unit with Bullous Striae Distensae.

Accidental Finding Prior to Rhinoplasty: Rhinolith- A Rare Case ReportKey Clinical MessageThrough this case report, we review a rare radiopacity finding within the nasal cavity and its histopathological findings in order to emphasize the importance of familiarizing oneself with all radiographic findings, regardless of their rarity.Keywords: Rhinoplasty; Nasal Cavity; Nasal Obstruction; RhinolithIntroductionA rhinolith, also known as a nasal calculus, is a densely calcified mass, possibly formed around either external substances such as stones, batteries and plastic, or internal materials including dental epithelium and dried blood clots, within the nasal cavity (1-4). However, its exact etiology remains unknown (2). Typically, it is found either between the maxillary sinus wall and the inferior turbinate or between the nasal septum and inferior turbinate (1). Rhinoliths are generally single, unilateral and have an irregular shape (5). Various sizes and internal structures have been reported based on the nature of the rhinolith’s core, including homogeneous or heterogeneous radiopacities (6). The occurrence of rhinoliths in the oral and maxillofacial structures is rare (1). However, they are more commonly observed in young adults, females, and individuals with a low socioeconomic status (2). Symptoms such as headache, anosmia, nasal obstruction, discharge, swelling, unpleasant nasal odor, halitosis, epistaxis, localized pain, and fever have been reported in approximately 1 out of 10,000 patients visiting ear, nose, and throat (ENT) specialists in relation to rhinoliths, which may persist for months or even years (4, 6). Although rhinoliths are often asymptomatic (7) and may be detected incidentally through routine radiographic imaging (5). Conventional radiographs are useful in differentiating rhinoliths from other lesions and detecting their location, especially in cases where the foreign body has high radiodensity (5, 7). However, computed tomography (CT) is more effective in localizing rhinoliths with lower radiodensity in the core (3).In this case report, we present the incidental detection of a rhinolith through radiographic imaging in a 20-year-old patient who was a candidate for aesthetic rhinoplasty.Case presentationA 20-year-old female came to the outpatient department as a candidate for rhinoplasty. The patient’s general medical history and the head and neck examinations were unremarkable. There were no complaints of nasal obstruction or discharge. On extraoral examination, there was no sensory disturbance and the face was symmetrical except for the nasal septum deviation. Cone beam computed tomography (CBCT) was prescribed to the septum deviation. The CBCT revealed an s-type deviation of the nasal septum, open ostia, and clear maxillary sinus cavity. Additionally, a solitary, densely heterogenic calcified mass measuring 9.3 mm in width, 14.4 mm in height, and 8.7 mm in anteroposterior size was noted in the right nasal fossa between inferior turbinate and nasal septum. The mass was attached to the septum and the superomedial portion of inferior nasal concha and the inferomedial part of the middle nasal concha. The mass was well defined with mix, mostly opaque, and laminated internal view. (fig. 1)Based on the radiographic findings, three differential diagnoses were rhinoliths, paranasal osteoma, and nasal foreign body.The procedure entailed the removal of the lesion under general anesthesia. The lesion, which was attached to the perichondrium, was successfully excised using a nostril approach. Unilateral perforations on the mucosa of the septum and inferior and middle conchae, resulting from the lesion removal, were left unsutured due to their size, allowing them to heal through secondary intention. The excised lesion was sent for histopathological evaluation, and a routine septorhinoplasty was performed. For this purpose, a septal graft was harvested. However, the preserved L-strut proved inadequate in supporting the septal mucosa perforation due to its location and the amount of cartilage graft required. Turbinate outfracture or cauterization were not carried out, although turbinectomy was performed. An internal splint was applied as a routine measure, and follow-up sessions were scheduled for 1 week, 1 month, 3 months, and 6 months after the operation.The histological examination revealed the presence of vascular respiratory epithelium, with subepithelial glands displaying a bland appearance and mild chronic inflammation. Calcified foreign body fragments were also identified. No atypical cells or conclusive evidence of malignancy were detected. The histological findings were consistent with a diagnosis of rhinolith. (fig.2)The patient expressed satisfaction with the results and reported no nasal obstruction. Additionally, the patient noted improved breathing, despite having had no difficulties in breathing prior to the operation. No asymmetry was detected.A CBCT scan was ordered 3 months post-surgery to validate the histopathologic outcomes and confirm the complete removal of the lesion. The CBCT evaluation confirmed the successful and complete excision of the lesion, thus supporting the rhinolith diagnosis. Synechia was found to be limited. (fig.3)DiscussionRhinoliths are uncommon findings, likely caused by the deposition of mineral salts around a nidus, such as a foreign body (8). A high level of suspicion is necessary, and differential causative factors, including osteoma, calcified nasal polyps, and ossifying fibroma should be considered to choose the best treatment approach (9). A variety of symptoms may be reported, depending on the localization and size of the lesion, such as unilateral nasal obstruction, epistaxis, headache, anosmia, epiphora, and purulent rhinorrhea (2, 9). However, rhinoliths can also be asymptomatic (6). Therefore, in cases with no symptoms, radiographic scans can lead to a diagnosis of rhinolith (4). A radiopaque lesion with lesser radiopacity in the center, located in either the nasal cavity or maxillary sinus, is a good predictor for rhinolith (5). However, rhinoliths may also appear as a homogeneous radiopaque view due to the presence of a radiopaque nidus (2).In the present case, CBCT evaluations revealed a mixture of radiopaque and radiolucent radiographic findings. Furthermore, in the absence of any symptoms, a histopathological examination was conducted to establish a definitive diagnosis.In cases where there is a coexistence of septal deviation and rhinoliths, the septum is typically deviated towards the opposite side of the rhinolith (2). This is likely due to the influence of the rhinolith on the cartilaginous septum during mass growth (2). This finding is consistent with our case.Although previous studies have reported the concurrent performance of septoplasty or septorhinoplasty and removing rhinolith (2), the specific details of the septoplasty procedures used are unclear. In this case presentation, we have provided a detailed description of the septorhinoplasty procedure to assist surgeons in surgical planning.The defects in the intranasal mucosal lining may be asymptomatic and do not require additional treatment procedures (10). However, the intranasal exposure of the spreader grafts may occur due to the presence of a defect in the mucosa. Therefore, large defects may require covering the grafts using various techniques to protect them from intranasal exposure (11).A variety of surgical interventions have been introduced to manage perforations of the septal mucosa in cases where the underlying septum is also perforated. These procedures are categorized into local flaps only or incorporation of interposition grafts (10). The local flap may be used unilaterally or bilaterally, unipedicled or bipedicled, and with an anterior or posterior base (12). The interposition graft can also be harvested from various sites including temporalis fascia, conchal cartilage, and tragal cartilage (10). In the present case, despite the absence of supporting septal cartilage, the unilateral perforation of septal mucoperichondrial tissue was left unsutured because of the intact contralateral mucoperichondrial tissue of the septum. Moreover, the internasal splint was used to prevent synechia following the unsutured perforation of the mucosa of the septum and inferior and middle conchae. Favorable outcomes revealed the secondary intention was successfully performed.However, there is insufficient evidence regarding the critical limit of septal mucosa perforation that prevents synechiae and ensures secondary intention. This may also be influenced by many other factors, including the cite of the perforation. Therefore, further researches should be conducted in this matter.Based on the favorable outcomes and absence of complications, the introduced procedure may be useful for assisting surgeons in carrying out septorhinoplasty and successfully removing the rhinolith without concerns about synechia.Conflict of interest statementThe authors have no conflict of interest to declare.ConsentWritten informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.References1. Orhan K, Kocyigit D, Kisnisci R, Paksoy CS. Rhinolithiasis: an uncommon entity of the nasal cavity. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2006;101(2):e28-e32.2. Aksakal C. Rhinolith: Examining the clinical, radiological and surgical features of 23 cases. Auris Nasus Larynx. 2019;46(4):542-7.3. Hsiao J-C, Tai C-F, Lee K-W, Ho K-Y, Kou W-R, Wang L-F. Giant rhinolith: a case report. The Kaohsiung journal of medical sciences. 2005;21(12):582-5.4. Ersözlü T, Gültekin E. Rhinolith in the concha bullosa as a rare location: a case report. Journal of International Medical Research. 2020;48(8):0300060520951019.5. Barros CA, Martins RR, Silva JB, Souza JB, Ribeiro-Rotta RF, Batista AC, et al. Rhinolith: a radiographic finding in a dental clinic. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2005;100(4):486-90.6. Maheshwari N, Etikaala B, Syed AZ. Rhinolith: An incidental radiographic finding. Imaging Sci Dent. 2021;51(3):333-6.7. Manzi FR, Peyneau PD, Piassi FP, Machado VdC, Lopes AC. Radiographic and imaging diagnosis of rhinolith in dental clinics: A case report. Revista Odonto Ciência. 2012;27:170-3.8. Seyhun N, Toprak E, Kaya KS, Dizdar SK, Turgut S. Rhinolithiasis, a rare entity: Analysis of 31 cases and literature review. North Clin Istanb. 2021;8(2):172-7.9. Vedasalam S, Sipaul F, Hill A, Porter G. Nasendoscopy for unusual nasal symptoms. BMJ Case Rep. 2010;2010.10. Goh A, Hussain S. Different surgical treatments for nasal septal perforation and their outcomes. The Journal of Laryngology & Otology. 2007;121(5):419-26.11. Toriumi DM. Structure rhinoplasty: lessons learned in 30 years: DMT Solutions; 2019.12. Watson D, Barkdull G. Surgical management of the septal perforation. Otolaryngologic clinics of North America. 2009;42(3):483-93.Figure legends:Fig.1: pre-operative CBCT. (a) sagittal view; (b) coronal aspect; (c) axial section.Fig.2: histopathological micrograph. Note the fragments of calcified foreign bodies.Fig.3: post-operative CBCT. (a) sagittal aspect; (b) coronal view; (c) axial section. Note the limited synechiae in comparison with pre-operative CBCT.

Prakriti Adhikari1, Anil Nepali1,2, Amit Shah2, Shailes Paudel2, Prakriti Bhandari2, and Prakash Nepali31 MBBS doctor, Kathmandu University School of Medical Sciences2 MBBS doctor, Patan Academy of Health Sciences3 MBBS doctor, Chitwan Medical CollegeCorresponding AuthorDr. Anil Nepali, Patan Academy of Health [email protected]

A Rare Case of Fanconi Anemia with Mitomycin C sensitivityIntroduction-Fanconi anemia is a rare type of anemia whose incidence in India is 1 in 3,50,000(3). More prevalence is seen in the South African people. The Ashkenazi community is more likely to suffer from this illness. Compared to black South Africans, who have a carrier frequency of one in 40,000, Ashkenazi Jews have a disease carrier frequency of one in 89 (5). It is the most common inherited form of aplastic anemia. It is an autosomal recessive condition. The disease is evident due to chromosomal instability that affects the proteins involved in DNA Repair and regulation of cell cycle. This disorder has clinical manifestations related to skin, skeletal system, hematogical majorly. The management can be supportive and definite.CASE PRESENTATION-A referred case of a 6-year-old boy who was known to have Fanconi anaemia to SSG Hospital on 11/06/23. Six months before the admission, the patient went to Parul Hospital, Vadodara and made three visits ( in January, March and May ) in a span of six months. Every time, he was administered 2 units of 100 ml blood and the hemoglobin came to normal range after infusions. The private hospital then referred it to SSG Hospital, Vadodara. Initially, for five years the patient was asymptomatic and then this year the patient more frequently at night and with an intensifying dry cough, he started to feel unwell, and the patient was transported to a private hospital. The patient’s parents and two siblings remain unaffected. On general examination, the patient had considerable pallor on the tongue, mucosal linings, and nails, as well as generalised swelling in both the upper and lower limbs. He also had Mesomelia, low set ears, multiple hyperpigmented macules, Microcephaly, Micropthalmos, and thumb hypoplasia in both hands. The left kidney could not be felt when the abdomen was palpated, despite the fact that the testicles were bilaterally undescended and the abdomen was soft and non-tender. All developmental milestones have been attained by the patient. He has a history of PCV (Packed Cell Volume) transfusions from last six months.Investigations included differential WBC count and full blood count. The biochemical investigation (Table 1) reveals a normal urea level, normal thyroid function, and elevated C- reactive protein in addition to an aberrant liver profile (with elevated S.AST and S.ALT) and normal electrolytes. Also, the heamatological profile supported the patient’s pancytopenia as he has decreased Red blood cell count, platelet count and total WBC count. Even the patient’s Hb was below normal levels. The Red Cell Distribution Width was also more than normal levels due to premature release of immature cells into the bloodstream(7). A USG was performed, which revealed a right kidney with a somewhat dilated calyceal system and the absence of the left kidney in the left renal or iliac fossa. This is due to congenital agenesis of left kidney. The X-ray, revealed bilateral radial hypoplasia (Fig. 1) , which is a typical feature of Fanconi Anemia.

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Abstract :Background: A noval radiologic sign in patients with renal failure and UE with metabolic acidosis has recently been identified as the lentiform fork sign. On magnetic resonance imaging (MRI), the ”lentiform fork sign” has been described as bilateral symmetrical hyperintensities in the basal ganglia encircled by a hyperintese rim delineating the lentiform nucleus. Changes in uremic solute retention, aberrant blood-brain barrier transport, disorderd vascular reactivity, altered electrolyte and acid-base balance, and altered hormone metabolism are the most likely causes of the condition.Case presentation : 56-year-old man with end-stage renal disease was brought to the emergency room for a progressive change in mental status and involuntary arm movements over the previous five days, which were also accompanied by mild dyspnea.A brain MRI was performed, and it revealed hyperintensity on T2/FLAIR in the white matter surrounding the basal ganglia. The haloperidol was stopped, and there more dialysis sessions were carried out.Conclusion : intensified hemodialysis and glycemic control are the cornerstones of treating DUS with likely reversible clinical symptoms and remission of imaging abnormalities.

Introduction Survival is dismal for the 40-60% of children with MDS who relapse post allogeneic HCT1,2,3. Strategies to decrease relapse risk include use of cytoreduction prior to HCT or maintenance treatment after HCT, data on the utility of these approaches remains limited4-12. Rapid withdrawal of immune suppression or use of donor lymphocyte infusion (DLI) can enhance the graft versus leukemia effect and achieve disease control in some cases13,14. Addition of hypomethylating agents to DLI may provide additional benefit15 and second HCT should be considered16-21. While several novel therapies may alter the future landscape of MDS therapy22-28 (Table 1), the optimal approach to relapsed pediatric MDS remains unclear. We report the management of a child who relapsed less than 70 days after initial HCT. Our approach demonstrates that multimodal therapy may permit prolonged survival with excellent quality of life (QOL) despite lack of long-term cure.

Optic neuritis after mRNA COVID-19 vaccination; A case reportRaghad Tarcha, Afraa Ghazal, Lama Al-Darwish, Hoda Abdoh, Maysoun Kudsi.

Hashimoto Thyroiditis in a lingual thyroid: an interesting case

TITLE PAGEArticle TypeClinical pictureTitlePenile Injury Caused by Neodymium MagnetsAuthorsYuki Akiyama1, Ryo Ichibayashi2Affiliations1. Department of Orthopaedic Surgery, Toho University Medical Center, Sakura Hospital, Chiba, Japan2. Division of Emergency Medicine Department of Internal Medicine, Toho University Medical Center, Sakura Hospital, Chiba, JapanCorresponding AuthorRyo Ichibayashi, MD, PhDORCID iD https://orcid.org/0000-0002-1273-4875Division of Emergency Medicine Department of Internal MedicineToho University Medical Center, Sakura Hospital564-1 ShimosizuSakura-shi, Chiba 285-8741, JapanPhone: +81-43-462-8811Fax: +81-43-462-8835e-mail: [email protected] titleDamage caused by neodymium magnetsKeywordsNeodymium magnet, Penile foreign body, Emergency, TreatmentConflict of interestThe authors have no conflict of interest to disclose.Financial supportThe author(s) received no financial support for this article’s research, authorship, and publication.Patient consentWritten informed consent was obtained from the patient to publish this report by the journal’s patient consent policy.Author contributionYA wrote and drafted the manuscript. RI helped draft the manuscript. All authors read and approved the final manuscript.Data availability statementThe data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical considerations.AcknowledgmentsNone.Key clinical messageMultiple neodymium magnets can pinch tissue and cause barotrauma. Be careful if the tissue of the penis or foreskin is pinched, as this may cause foreskin necrosis or damage to the urethra.Clinical picture11-year-old boy. He has no history of developmental disabilities or mental illness. The boy played with a neodymium magnet attached to his penis in the bathroom out of curiosity. However, the neodymium magnet remained attached to his penis and could not be removed, and he was transported to our hospital by ambulance with the chief complaint of penile pain. Emergency crews tried to remove it, but it was impossible because it was painful, and there were concerns that it might damage the foreskin. Two hours had passed since he was transferred to our hospital because he was refused admission by multiple medical institutions. At the time of his visit, his penis had two circular neodymium magnets, each approximately 1 cm in diameter, placed against the foreskin of his penis (Figure 1A). Although it was difficult to remove it by pulling it in the opposite direction, it was possible to remove it by shifting the ground surface. After the foreskin was released, there was a crushed wound, so ointment was applied（Figure 1B）. After confirming that there was no problem with the color tone of his glasses, he returned home. The next day, he returned to the outpatient clinic and confirmed that the color of his glans was standard and that he could urinate. Neodymium magnets were developed in Japan in 1982 and have become famous worldwide due to their effectiveness. It is said to be the strongest magnet currently in use. Neodymium magnets are used in various fields and children’s toys [1]. For this reason, accidents such as accidental ingestion by children and insertion into the urinary tract or anus due to sexual preference are problems in the medical field. Accidents caused by multiple neodymium magnets, especially when accidentally swallowed or inserted with a foreign object, are dangerous because they adhere to each other and pinch tissue, resulting in pressure necrosis [2]. This case also had a crush injury to the foreskin. A month later, the scar remained on my foreskin. Barotrauma caused by neodymium magnets often involves damage to thin tissues, including the intestinal tract and mucous membranes. The structures of the corpus cavernosum and the corpus cavernosum of the urethra, which form the penis, are spongy and soft tissues. This tissue becomes rigid as it fills with blood. For this reason, if not only the foreskin but also the corpus cavernosum of the penis is pinched, there is a possibility that blood flow to the corpus cavernosum and damage to the urethra may occur. After removing the neodymium magnet, it is necessary to observe the color of the glans and foreskin and the state of urination.References1. Taylor MA, Spanos SP, Fenton SJ, Russell KW. Ball Magnets Clicked Together on the Epiglottis. Cureus . 2020. 12(5): e8181. doi: 10.7759/cureus.81812. Yuksel C, Ankarali S, Aslan Yuksel N. The use of neodymium magnets in healthcare and their effects on health. North Clin Istanb . 2018; 5(3): 268-273. doi:10.14744/nci.2017.00483Figure 1A　Neodymium magnet that pinches the foreskin of the penisB　 Foreskin with a crush injury

Title : Synovial Sarcoma of the Maxilla: A Challenging Diagnostic Case Report and Literature ReviewAbstract : Synovial sarcoma, a malignant mesenchymal tumor, is primarily associated with the extremities. Nevertheless, its appearance within the head and neck region, particularly in the maxillary area, is remarkably rare. This rarity underscores the significance of each case in unraveling the complexities of its behavior and management strategies. The core focus of this research is a detailed case report involving a 6-year-old female patient who presented with a conspicuous swelling in the left posterior maxilla. Subsequent incisional biopsy led to microscopic identification of malignant spindle cell proliferation, marked by dysplastic changes and abundant mitoses. Immunohistochemical analysis demonstrated negative reactivity for neural and muscular markers, while positive expression of Vimentin, Bcl-2, and TLE1. These morphological and immunohistochemical findings coalesced to definitively diagnose synovial sarcoma, substantiated by a notable 40% Ki67 proliferative index. The chosen treatment strategy encompassed surgery and radiotherapy, which yielded successful outcomes, with no recurrence observed during the one-year follow-up period. Beyond the specific case, this article undertakes a review of existing literature, meticulously analyzing nine similar cases reported in scholarly sources.Keywords : Case report, Head and neck, Maxilla, Synovial sarcoma

IntroductionInternational continence society defined mixed urinary incontinence (MUI) as “complaint of involuntary loss of urine associated with urgency and also with effort or physical exertion or on sneezing or coughing”., which include both urgency urinary incontinence (UUI) and stress urinary incontinence (SUI) complaints. Urinary incontinence affects social behaviors, financial burden such as using class of drugs, rehabilitation floor muscles, and psychological suffering such as dissatisfaction in sexual activity. Diagnosis of urinary incontinence is based on history, physical examinations and supplemental evaluations like dye test, cystoscopy, urodynamic study, urine analysis, urine culture, and imaging technics. (1)At the first, conservative treatments are performed for patient such as biofeedback, pelvic floor muscle exercise, electrical stimulation and drug treatment. In the second step of treatment, surgery is considered. The surgery is usually used to address the failure of normal anatomic support of the bladder neck and proximal urethra, and intrinsic sphincter deficiency, meanwhile its implementation should be approached with caution for carefully. In some cases, surgery intervention also failed and other novel interventions should be considered. (2)Platelet rich fibrin glue, stem cells, butolonium toxins and TVT separately applied for treatment of patients, but this is the first time that these mixed modalities were used for the treatment of mixed urinary incontinence which did not respond to pharmaceutical and surgical treatment.