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Clinical Problem Solving: Radiology
October 2009

Radiology Quiz Case 1

Author Affiliations
 

C. DOUGLASPHILLIPSMD

Arch Otolaryngol Head Neck Surg. 2009;135(10):1052-1055. doi:10.1001/archoto.2009.127-a

A 24-year-old man presented with a 2-year history of a painful, gradually enlarging swelling on the upper part of the right side of the neck and a 5-month history of hoarseness. Physical examination revealed a firm, mobile swelling measuring 5 × 4 cm on the right side of the neck and an intraoral bulge pushing against the anterior faucial pillar. Neurologic examination demonstrated weakness of nerves IX through XII on the right side.

Noncontrast-enhanced computed tomographic (CT) sections from the suprahyoid neck area revealed a partially calcified mass (Figure 1). Contrast-enhanced CT scans showed a mildly enhancing mass in the right poststyloid parapharyngeal space encasing the internal carotid artery (ICA) and extending up to the skull base. Minimal intracranial extension was also noted through the jugular foramen, which was widened but not eroded. The results of magnetic resonance imaging (MRI) complemented the CT findings (Figure 2and Figure 3). A mass in the poststyloid compartment was isohypointense on T1-weighted images and demonstrated predominantly low signal intensity on T2-weighted images, with significant contrast enhancement on gadolinium administration. Anterior displacement of the common carotid artery bifurcation, complete encasement of the ICA, and severe compression and partial encasement of the internal jugular vein were evident on the MRIs. Also, the mass was seen extending into the posterior cranial fossa, with widening of the jugular foramen. Although there was circumferential disease around the ICA, there was no significant luminal narrowing.

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