Vascular anomalies, extracranial and intracranial arteriovenous malformations as well as glomus jugulare tumour are well known causes of pulsatile tinnitus. Of late, benign intracranial hypertension has been stated to be a more common cause. However, tinnitus arising from and within the internal jugular vein has been reported only infrequently. Previously known as cephalic bruit and essential objective tinnitus, the venous hum tinnitus presents as pulse synchronous unilateral objective tinnitus. Ligation of the internal jugular vein appears to be a successful treatment. Two cases are presented.

Background: Laparoscopic cholecystectomy has become the gold standard treatment for symptomatic gallstones. However, a conversion to open surgery may be required to complete the procedure safely. The aim of this study is to identify the predictive factors of conversion from laparoscopic to open cholecystectomy in elective setting.Methods: A retrospective review of all patients underwent laparoscopic cholecystectomy electively for symptomatic gallstones from January 2016 to December 2017 was performed. Data considered for analysis were: demographic data, preoperative laboratory values of liver function tests, gall bladder wall thickness on ultrasound, preoperative ERCP, indication for surgery, history of acute cholecystitis, presence of intraoperative adhesions and frozen Calot's triangle. Conversion to open cholecystectomy was chosen as the dependent variable for both, univariate and multivariate analysis.Results: 546 patients underwent laparoscopic cholecystectomy. 333 were females (60.9%) and 213 (39.1%) males, with a mean age of 44.6 years. The most common indication for surgery was symptomatic cholelithiasis. Conversion to open cholecystectomy occurred in 48 cases (8.8%) and the most common reason for conversion was inability to define the Calot’s triangle anatomy due to inflammation/adhesions. Univariate and multivariate analyses of various variables demonstrated that male gender, gall bladder wall thickness >5 mm and presence of previous documented acute cholecystitis had statistically significant co-relation with higher rates of conversion (p<0.001).Conclusions: Presence of acute cholecystitis, gall bladder wall thickness >5mm on preoperative ultrasound and male gender were independent predictor factors for conversion from laparoscopic to open cholecystectomy. Such patients should be properly counselled about the increased risk for conversion and should be operated by surgeons experienced in laparoscopic procedures to reduce the rate of conversion and operative complications.

Biliary cystadenoma is a very rare cystic neoplasm of the liver that usually occurs almost exclusively in middle-aged women. These are slowly progressive tumours and cannot be safely differentiated from cystadenocarcinomas on preoperative imaging and hence should always be considered for resection. Historically these cystic tumors have been treated by a variety of techniques including aspiration, fenestration, internal drainage, partial resection resulting in high rates of recurrence. In addition biliary cystadenoma is a premalignant lesion and only surgical excision can differentiate it from its malignant counterpart, biliary cystadenocarcinoma.

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