The role of chest X-ray in coronavirus disease 2019 (COVID-19) infection: findings and correlation with clinical outcome

OBJECTIVE

It is possible to diagnose coronavirus disease 2019 (COVID-19) faster and more accurately with chest X-ray (CXR) and chest computed tomography (CT) than with reverse transcriptase PCR (RT-PCR) tests. The aim of this study was to verify the possibility of reducing the use of CT in diagnosis and follow-up of COVID-19 infection by using CXR.

PATIENTS AND METHODS

A total of 326 COVID-19 patients who were hospitalized in Ankara City Hospital were included in this retrospective study.

RESULTS

A total of 326 patients were RT-PCR positive for COVID-19 infection; 178 were male (54.6%) and 148 were female (45.4%), with a median age of 45. Considering the results, the baseline CXR sensitivity in our experience was approximately 72%. The CXRs of 113 patients with abnormal CT were divided into 2 groups, the CXR normal and abnormal groups, and were then compared. In the 1st group with abnormal CXR, the mean age, the number of patients over 65 years old, and the comorbidity rate were higher. Additionally, it was determined that the number of patients requiring respiratory support and intensive care unit (ICU) admission in this 1st group was higher than in the 2nd group (with normal CXR). Most of the patients who died (91%, 10/11) were in Group 1. In the group with normal CXR, no patients in the critically ill category needed invasive or non-invasive mechanical ventilators.

CONCLUSIONS

CXR can help in detecting clinically moderate and severe cases of COVID-19. CXR can assist clinicians in patient management and treatment planning regarding the clinical course, respiratory support, ICU need, and mortality and can help them prepare for potential negative outcomes.

Evaluation of postoperative pain relief after pulpotomy using different procedures for disinfection and hemostasis in symptomatic irreversible pulpitis

Aim

This study aimed to evaluate postoperative pain scores after sodium hypochlorite (NaOCl) and KTP laser pulpotomies in the permanent teeth with symptomatic irreversible pulpitis retrospectively. Materials and Methods: This study is based on the records of patients treated with pulpotomy using sodium hypochlorite or KTP laser for disinfection and hemostasis at the Department of Endodontics. Sixty patients' molar teeth were treated with either NaOCl or KTP laser. Sodium hypochlorite was used on 31 teeth, and KTP laser was used on another 29 teeth, for disinfection and hemostasis. Initial bleeding control was obtained with saline. 2.5% NaOCl or KTP laser was applied to complete hemostasis. Calcium hydroxide was then placed on the chamber floor to cover the canal orifices. The permanent restoration was completed with composite resin. Pre and postoperative pain scores were recorded with a visual analog scale. The evaluation was performed on the 6^th, 24^th, 48^th, 72^nd hours, and 7^th days depending on the severity of the pain. Results: There was no significant difference between the groups in terms of demographic data and preoperative pain scores (P > 0.05). The postoperative pain score in the KTP laser group was significantly lower at the 24^th hour than in the NaOCl group (P < 0.05). No significant difference was found between the groups at other evaluated time intervals (P > 0.05). The greatest pain score was recorded at the 6^th hour in both groups.

Conclusion

Although the level of pain decreased significantly in both groups in the postoperative period, KTP laser-assisted pulpotomy provided better pain control, especially at the 24^th hour.

Classical fever of unknown origin in 21 countries with different economic development: an international ID-IRI study

Fever of unknown origin (FUO) is a serious challenge for physicians. The aim of the present study was to consider epidemiology and dynamics of FUO in countries with different economic development. The data of FUO patients hospitalized/followed between 1st July 2016 and 1st July 2021 were collected retrospectively and submitted from referral centers in 21 countries through ID-IRI clinical research platform. The countries were categorized into developing (low-income (LI) and lower middle-income (LMI) economies) and developed countries (upper middle-income (UMI) and high-income (HI) economies). This research included 788 patients. FUO diagnoses were as follows: infections (51.6%; n = 407), neoplasms (11.4%, n = 90), collagen vascular disorders (9.3%, n = 73), undiagnosed (20.1%, n = 158), miscellaneous diseases (7.7%, n = 60). The most common infections were tuberculosis (n = 45, 5.7%), brucellosis (n = 39, 4.9%), rickettsiosis (n = 23, 2.9%), HIV infection (n = 20, 2.5%), and typhoid fever (n = 13, 1.6%). Cardiovascular infections (n = 56, 7.1%) were the most common infectious syndromes. Only collagen vascular disorders were reported significantly more from developed countries (RR = 2.00, 95% CI: 1.19-3.38). FUO had similar characteristics in LI/LMI and UMI/HI countries including the portion of undiagnosed cases (OR, 95% CI; 0.87 (0.65-1.15)), death attributed to FUO (RR = 0.87, 95% CI: 0.65-1.15, p-value = 0.3355), and the mean duration until diagnosis (p = 0.9663). Various aspects of FUO cannot be determined by the economic development solely. Other development indices can be considered in future analyses. Physicians in different countries should be equally prepared for FUO patients.

Investigation of the relation between risk assessment of exposure and nosocomial SARS-CoV-2 transmission in healthcare workers: a prospective single-centre study

OBJECTIVES

Healthcare workers (HCWs) are among the risk groups for COVID-19. Determining transmission routes and risk levels during healthcare is of great importance in preventing nosocomial outbreaks. This study aimed to investigate the frequency of nosocomial transmission and factors affecting the transmission in HCW.

METHODS

HCWs admitted to the infectious diseases outpatient clinic due to contact with a COVID-19 patient and diagnosed with SARS-COV-2 by reverse-transcriptase PCR (RT-PCR) between 20 March 2020 and 30 June 2020 were included in the study.

RESULTS

A total of 822 HCWs with 295 low, 284 intermediate and 243 high-risk exposures were included in the study. 27.1% of the HCWs were male, and the median age was 31.9 years (20-62). 89.5% of these patients were directly in charge of patient care. Of the index cases contacted, 72.6% were HCW, and 27.4% were non-HCW patients. Most of the risky exposure (51.7%) occurred in nurses. The occurrence frequency of high-risk exposure was lower in those assigned to direct patient care when compared with the occurrence frequency of moderate-risk or low-risk exposures (76.5%, 94.7, 95.3, respectively p<0.001). In most high-risk exposures (220/253), the index cases were HCWs (p<0.001). Symptoms were detected in 311 of the HCWs (37.8%) during the follow-up. The median time to perform SARS-CoV-2 RT-PCR was 5.3 days (IQR) after the last risky exposure. In multivariate analysis, SARS-CoV-2 RT-PCR positivity was 5.65 times higher in HCWs not directly involved in patient care than HCWs who are not involved in patient care (95% CI 2.437 to 13.111; p<0.001).

CONCLUSIONS

This study provides particularly useful information on post-exposure COVID-19 follow-up and management of working schedules and procedures of HCWs.

Increasing rates of extended-spectrum B-lactamase-producing Escherichia coli and Klebsiella pneumoniae in uncomplicated and complicated acute pyelonephritis and evaluation of empirical treatments based on culture results

Increasing rates of extended-spectrum beta-lactamase (ESBL) producing E. coli and K. pneumoniae over time made empirical treatment complicated. Knowing local antimicrobial resistance patterns of common pathogens can make it easier to decide on empirical antibiotics. We aimed to investigate the prevalence and risk factors of ESBL positivity of E. coli and K. pneumoniae strains in uncomplicated and complicated pyelonephritis acquired in community and healthcare associations and to evaluate the appropriateness of empirical treatment. Adult patients hospitalized with diagnosis of community-acquired or healthcare-associated uncomplicated/complicated pyelonephritis initiated empirical antimicrobial therapy were included in the study. Appropriateness of empirical treatment at 48-72 h based on culture results and treatment modifications were evaluated. A total of 369 uncomplicated (94) and complicated (275) episodes of pyelonephritis were evaluated. The most common agents were E. coli (71.0%) and K. pneumoniae (17.7%), and the ESBL-production rate was 64.4%, and higher in healthcare-associated pyelonephritis (P 0.013). Being of healthcare-associated infection, previous antibiotic use, and presence of urinary catheters were independent risk factors for ESBL-producing E. coli and K. pneumoniae (P 0.009, < 0.001, and 0.024, respectively). The treatment inappropriateness was mostly associated with use of ceftriaxone (56.3%) (P < 0.001). Treatment has escalated in 41.5% of ceftriaxone-initiated patients, in only 8.8% and 9.5% ertapenem and piperacillin-tazobactam-initiated patients, respectively. ESBL-production rates are quite high even in community-acquired infections. The use of broad-spectrum antibiotics covering ESBL-producing pathogens to increase the appropriateness of empirical treatment and then narrowing treatment based on culture results appears a better and life-saving choice.

Development and validation of nomogram to predict severe illness requiring intensive care follow up in hospitalized COVID-19 cases

BACKGROUND

Early identification of severe COVID-19 patients who will need intensive care unit (ICU) follow-up and providing rapid, aggressive supportive care may reduce mortality and provide optimal use of medical resources. We aimed to develop and validate a nomogram to predict severe COVID-19 cases that would need ICU follow-up based on available and accessible patient values.

METHODS

Patients hospitalized with laboratory-confirmed COVID-19 between March 15, 2020, and June 15, 2020, were enrolled in this retrospective study with 35 variables obtained upon admission considered. Univariate and multivariable logistic regression models were constructed to select potential predictive parameters using 1000 bootstrap samples. Afterward, a nomogram was developed with 5 variables selected from multivariable analysis. The nomogram model was evaluated by Area Under the Curve (AUC) and bias-corrected Harrell's C-index with 95% confidence interval, Hosmer-Lemeshow Goodness-of-fit test, and calibration curve analysis.

RESULTS

Out of a total of 1022 patients, 686 cases without missing data were used to construct the nomogram. Of the 686, 104 needed ICU follow-up. The final model includes oxygen saturation, CRP, PCT, LDH, troponin as independent factors for the prediction of need for ICU admission. The model has good predictive power with an AUC of 0.93 (0.902-0.950) and a bias-corrected Harrell's C-index of 0.91 (0.899-0.947). Hosmer-Lemeshow test p-value was 0.826 and the model is well-calibrated (p = 0.1703).

CONCLUSION

We developed a simple, accessible, easy-to-use nomogram with good distinctive power for severe illness requiring ICU follow-up. Clinicians can easily predict the course of COVID-19 and decide the procedure and facility of further follow-up by using clinical and laboratory values of patients available upon admission.

Intrathecal and Intraventricular Administration of Antibiotics in Gram-Negative Nosocomial Meningitis in a Research Hospital in Turkey

AIM

To evaluate the gram-negative nosocomial meningitis cases which were treated with intrathecal (IT) / intraventricular (IVT) antibiotics.

MATERIAL AND METHODS

Medical records were reviewed for IT/IVT antibiotherapy. Gram-negative nosocomial meningitis cases treated with IT/IVT antibiotherapy additional to systemic antibiotics were included. All patients? sex, age, SOFA scores, surgical history, cerebrospinal fluid (CSF) culture results, CSF cell counts, systemic and IT/IVT antibiotics, their dosages and duration, CSF culture sterility and sterility time, 28-day mortality due to meningitis, and all other causes were recorded and analyzed.

RESULTS

Thirteen patients were included between 2014 and 2018. Most common microorganism was Acinetobacter baumannii (A.baumannii) (8/13). IT/IVT antibiotics were chosen according to susceptibility. Colistin was used in eight patients, amikacin was used in four, and one patient used amikacin and colistin consecutively. Culture negativity could not be achieved in two patients. Eight patients clinically improved but five patients had no clinical response. 28-day mortality due to infection occured in 2 of 13 patients (15%). 28-day all-cause mortality occured in 3 of 13 patients (23%).

CONCLUSION

In our study, CSF culture negativity rate was high. IT/IVT antibiotic therapy should be considered as an effective and acceptable treatment option, especially in patients who do not respond to standard IV antibiotherapy.

Characteristics of candidemia in COVID-19 patients; increased incidence, earlier occurrence and higher mortality rates compared to non-COVID-19 patients

Severe COVID‐19 patients in ICU are at high risk for candidemia due to exposure to multiple risk factors for candidemia. We aimed to compare the incidence of candidemia in ICU patients with and without COVID‐19, and to investigate epidemiologic and clinical characteristics of candidemia patients and risk factors for mortality in candidemia patients. This retrospective study was conducted in patients followed in the ICUs of Ankara City Hospital for 2 years, divided into pre‐pandemic and pandemic periods. The incidence (event per 1000 patient‐days) and epidemiology of candidemia, clinical and laboratory characteristics of patients were compared in COVID‐19 and non‐COVID‐19 groups. Candidemia incidence was higher in the COVID‐19 group (2.16, 95% CI 1.77–2.60) than the non‐COVID‐19 group (1.06, 95% CI 0.89–0.125) (p < .001). A total of 236 candidemia episodes (105 in COVID‐19 patients and 131 in non‐COVID‐19 patients) were detected during the study periods. COVID‐19 cases had a higher rate of corticosteroid use (63.8% vs. 9.9%, p < .001). Epidemiology of candidemia and antifungal susceptibility were similar. Candidemia developed 2 weeks earlier in COVID‐19 groups and resulted in higher mortality (92.5% vs. 79.4%, p .005). One‐third of candidemia patients died before receiving any antifungal treatment, and this rate was higher in the COVID‐19 group. In multivariate logistic regression analysis, corticosteroid use, presence of sepsis and age older than 65 years were independent risk factors for mortality in candidemia patients. Candidemia with high mortality is a more serious problem for COVID‐19 patients due to its increased incidence, earlier occurrence and a higher rate of mortality.

Ultrastructural evaluation of intramuscular applied botulinum toxin type A in striated muscles of rats

BACKGROUND

Botulinum toxin type A (BTX-A) is clinically utilized for therapeutic and cosmetic purposes in maxillofacial surgery as well as many other medical specialties. There is no sufficient ultrastructural research about BTX and it is controversial whether BTX-A causes muscle degeneration to some extent, in the course of therapy. The aim of this study was to evaluate the histological effects of BTX-A when injected into masseter and gluteal muscles.

MATERIALS AND METHODS

A total of 30 male Sprague-Dawley rats were used and randomly divided into experimental (n =15) and control groups (n =15). Masseter and gluteal muscles were injected with a single dose of BTX-A in normal saline (0.5 U/0.1 ml), or 0.1 ml of normal saline, in the experimental and control groups, respectively. After 12 weeks all the rats were sacrificed. Gluteal, masseter muscles, and the sciatic nerves of the rats were prepared and electron microscopic, and light microscopic evaluation was performed on semi-thin sections cut from Epon embedded tissues and stained with toluidine blue. Quantitative parameters such as muscle fiber thickness and qualitative assessments including sarcosomal (striated muscle mitochondria) deformation, glycogen content, features of the triad structures and the intensity of connective tissue around the muscle fibers, and endoneurial and perineural tissue around nerve fibers were evaluated microscopically. We paired BTX- A (+) and BTX-A (-) samples statistically. Independent Samples t-test was used for the statistical analysis.

RESULTS

Muscle fiber's diameter was significantly decreased in BTX-A (+) group (p <0,001). Atrophic changes in the myofibrils were characterized by a decrease in the myofibrillar diameter and changes in the sarcomere structure, and were prominent in the BTX-A (+) group. Also, some other changes like dilatation in the sarcoplasmic reticulum cisternae, mitochondrial swelling, and clearing of mitochondrial cristae associated with degeneration, were detected. No morphologic difference in the sciatic nerve fibers was detected, and myelin sheaths of axon structures were intact in both groups.

CONCLUSION

BTX-A-induced muscular changes that are predominantly related to atrophy instead of degeneration. Although predominantly related to atrophy, our degeneration related findings suggest that further studies are needed focusing on detecting BTX-A effects on a cellular level. Hippokratia 2016, 20(4): 292-298.

Evaluation of potential salivary acetaldehyde production from ethanol in oral cancer patients and healthy subjects

BACKGROUND

Acetaldehyde has been implicated as a major factor in oral carcinogenesis associated with alcohol consumption. In this study, saliva samples from oral cancer patients and healthy individuals were incubated in vitro with ethanol in order to investigate factors which can influence salivary acetaldehyde production.

MATERIALS AND METHODS

A total of 66 individuals (40 males and 26 females, mean age 52 years) participated in the study. Participants were classified into three groups: Group 1 (oral cancer patients [n = 20]); Group 2 (poor dental health status [n = 25]) and Group 3 (good dental health status [n=21]). Every patient chewed a 1g piece of paraffin chewing gum for 1 minute then saliva samples were collected from all individuals. After in vitro incubation of the samples with ethanol, the levels of salivary acetaldehyde production was measured by head space gas chromatography. Kruskal-Wallis and Mann-Whitney tests and Spearman's Correlations analysis were performed for statistical analyses.

RESULTS

The salivary acetaldehyde production was significantly higher (p <0.0001) in both group 1 and group 2 when compared to group 3. However, there was no significant difference between group 1 and group 2. Poor dental health status, infrequent oral hygiene habits and dental visits, smoking and presence of a dental prosthesis were significant parameters for increased levels of salivary acetaldehyde production from alcohol. The evaluation of salivary acetaldehyde production after in vitro incubation with ethanol may be useful for early detection of oral cancer.

CONCLUSION

According to the results of this study, the significantly higher levels of salivary acetaldehyde production in oral cancer patients and individuals with poor dental health status may suggest a possible link between increased salivary acetaldehyde production and oral cancer. Improved oral hygiene can effectively decrease the level of salivary acetaldehyde production in oral cavity. Hippokratia 2014; 18 (3): 269-274.

The use of nail enfolded flaps for reconstruction of full-thickness ala nasi defects: an early report of experience

The most common etiology of nasal defects that require reconstruction is basal cell carcinoma, as well as squamous cell carcinoma and melanoma. In reconstructing full-thickness ala nasi defects following excision of basal cell carcinomas, we present our technique of the nail enfolded local flaps which involves the harvesting of the nail plate and placing it to serve as a supporting component. In four patients, the nail plate grafts are inserted into various local flaps, and used for reconstruction of full-thickness ala nasi defects. Lining deficiencies of the alar lobule were resurfaced with skin grafts. None of the cases experienced skin graft loss or nail plate exposure. The nail graft prevented alar collapse by supporting the nasal airway. This technique discards the need for a second operation.

Gold weight with single hole versus multiple holes--experimental study in rabbits

Lagophtalmia can be a serious complication of facial paralysis. Gold weight application to the upper eyelid is one of the most popular and practical conventional techniques. However, displacement or extrusion are commonly encountered complications. In order to minimize these complications, we modified the original design of the gold weight. Our hypothesis is that gold weight with multiple holes resists displacement and resultant extrusion via extensive fibrous tissue formation through the holes. Twelve New Zealand rabbits were used for this experiment. 2 x 1 cm and 1.8 g ellipsoid golden weights with single and multiple holes were compared. They were placed subcutaneously, to the dorsal surface of the rabbit ears and no suturing was performed. Golden weights with single holes were introduced to the left ear while the golden weights with multiple holes were placed to the right ear. The rates and degree of extrusion and displacement were evaluated in the second and third weeks macroscopically and microscopically. Results were compared by Chi-square and Mann-Whitney U tests. Statistically better outcomes were achieved by golden weights with multiple holes versus single hole (p<0.0034).

A primitive neuroectodermal tumor on the face: case report

In 1918, Stout defined the lesion in which small round cells originating from the ulnar nerve formed a rosette as neuroepithelioma. It was claimed that this tumor originated from neuroectodermis and was different from the classical neuroblastoma. The term primitive neuroectodermal tumor (PNET) involves a group of tumors of the soft tissue originating from neural crest and resulting from the brain, spinal cord and branches of the sympathetic nervous system. Extracranial primitive neuroectodermal tumors originate from neural crest cells outside the sympathetic and central nervous system. PNET also has some distinctive histological, immunohistochemical and ultrastructural features. It is usually encountered in children and young adults; most frequently located in thoracopulmonary region (Askin's tumor). The second most commonly involved body part is the extremities. It is very rarely located on the face. PNET is an aggressive tumor. In fact, the disease has a rapid progression, causes local or distant metastases and 50% of the patients die within two years of the presentation. It is treated with aggressive surgery as well as chemotherapy and radiotherapy. In this report, we presented a case of PNET located on the right cheek with multiple distant metastases. Clinicians should be on alert when treating facial tumors, not to skip PNET, which is a very aggressive one.

In silico evaluation of two mass spectrometry-based approaches for the identification of novel human leukocyte cell-surface proteins

The identification and quantitation of cell-surface proteins expressed by leukocytes currently use the wide availability of monoclonal antibodies (mAb) in immunohistochemical and flow cytometric assays. Presently, approximately 400 such proteins have been characterized; however, analysis of the completed human genome sequence indicates that it may contain several thousand as-yet unidentified molecules, which may be expressed on the leukocyte cell surface. Recent advances in protein isolation and analysis using mass spectrometry illustrate that it is now feasible to identify the protein composition of a complex sample such as a plasma membrane extract. Such an approach may be useful for the identification of the cell-surface proteins that have not been identified using mAb techniques. Here, we detail the results of an in silico evaluation of the peptides isolated using two methods used to label plasma membrane proteins to determine whether these methods are suitable for the identification of known leukocyte cell-surface proteins by mass spectrometry. The labeling of cell-surface proteins before isolation and characterization is a valuable means of differentiating between plasma membrane and internal membrane proteins The results indicate that although the majority of cell-surface proteins can be identified using either of the approaches, others known to be important diagnostically and/or therapeutically would not be identified using either approach. The implication of this for the use of these techniques in the discovery of new leukocyte cell-surface proteins is discussed.

Silastic sheet integrated polymethylmetacrylate splint in addition to surgery for commissure contractures complicated with hypertrophic scar

Numerous appliances or methods have been used to manage perioral deep burns and resultant contractures, however, until now, no particular technique is considered to be the "ideal technique". In this article, a new modified design of an extraoral appliance, composed of polymethylmetacrylate and silicon sheet is introduced. Two female and one male patient of a mean age of 33 were included in the study. They had a common history of facial thermal injury and hypertrophic scar formation. All three had a history of failed preceding operations to release commissure contractures. The appliance was placed within 14 days following the operation and stretched continuously for 6 months. During 14 months of follow-up period, no recurrence was encountered and a relatively symmetrical and satisfactory mouth opening was obtained. Owing to the effect of the silicon sheet, a more smooth, flattened scar surface and pliable commissure was achieved. No ulcerations, or tissue breakdown was observed. Extraoral appliances composed of polymethylmetacrylate silicon sheet were considered to be practical, convenient and efficient for the postsurgical treatment of the oral commissure contractures complicated with hypertrophic scar formation.

Multiple atrophies following tooth extraction

Following a molar tooth extraction, the patient developed a depression and atrophy of the right ear, the right half of the mentum, and the tongue. These atrophy deformities were successfully corrected with dermografts.

Use of beta blockers for increasing survival of free fat grafts

Fat tissue is abundant in the body and preferred in soft tissue augmentation. Since resorption is its greatest disadvantage, many agents have been tried in an attempt to increase fat graft survival in various studies. Yet selective beta1 blocker had not been used before. The effect of selective beta1 blockers on resorption following auto-transplantation of free fat graft was examined in rats. The effect of selective beta1 blockers was compared with those of insulin and saline solution as a control. For this comparison, the weight of fat grafts was measured both during and nine months after operation using the "liquid overflow method" in which obtained material was put into 5 cc syringe filled with saline solution and the increase in liquid level was recorded as graft volume. Histological examination of grafts and statistical analyses of the results were also made. Our in vivo study demonstrated that selective beta1 blocker significantly increased free fat graft survival. It is our conclusion that selective beta1 blocker is a promising agent for decreasing fat graft resorption.

Cartilage shaping using the Er:YAG laser: preliminary report

Cartilage grafts have been widely used for reconstruction of congenital or acquired deformities. Reshaping and preserving the new shape of the cartilage grafts have been a problem. In this in vitro experimental study the authors studied the effect of the Er:YAG laser on cartilage reshaping in comparison with scalpel stripping and suture holding. The study consisted four groups (n = 9): group I, untouched cartilage; group II, the short edges of the cartilage were sutured to each other; group III, cartilage was incised using a scalpel; and group IV, Er:YAG laser stripping was applied to the cartilage. Changes in the shape of cartilage were evaluated at 15 minutes, and days 1, 4, and 10. The majority of cartilage in the scalpel-stripped group returned to the initial shape by day 10, whereas the laser-stripped cartilage showed progressive warping day by day, and almost all cartilage formed a circle by day 10. The Er:YAG laser enhanced cartilage warping by a mechanical effect of stripping and a thermal effect of laser radiation resulting in ultrastructural changes.

Ectopic submandibular thyroid tissue

We reported a case of a 66 year-old male patient with a mass located in the right submandibular region. Surgical excision of the mass was performed and histologic examination revealed that the tumor was ectopic thyroid tissue. Additionally, imaging studies confirmed that the thyroid gland was found in its normal location and the patient had normal thyroid function testing. In reviewing the literature, we found submandibular thyroid tissue to be a rare entity with only 4 cases described. We discussed embryologic development of the normal thyroid gland and some explanations as to the origins of several forms of ectopic thyroid tissue, including that found in the submandibular region.