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Clinical Problem Solving: Radiology
January 2013

Radiology Quiz Case 1

Author Affiliations


JAMA Otolaryngol Head Neck Surg. 2013;139(1):93. doi:10.1001/jamaoto.2013.1150a

A 52-year-old woman presented with a 2-year history of right-sided facial paralysis and pulsatile tinnitus. Cerebral computed tomography (CT) performed when the symptoms began revealed no abnormalities. The findings of clinical examination confirmed a House-Brackmann grade V right-sided facial paralysis. Otoscopy of the right ear revealed an intact tympanic membrane. The results of the rest of the physical and audiological examinations were normal.

Temporal bone CT demonstrated an enlargement of the facial nerve canal, with irregular destruction of the bone of the inferior medial mastoid air cells. The lesion was lateral to the jugular bulb (Figure 1). Magnetic resonance imaging (MRI) showed a lesion focused on the stylomastoid foramen that extended through the facial canal into the deep parotid lobe. T1-weighted MRIs showed that the lesion was isointense (Figure 2) and demonstrated intense heterogeneous enhancement with gadolinium. T2-weighted MRIs showed a hyperintense mass (Figure 3). Two days before the surgery, a selective right external carotid angiogram revealed a hypervascular mass in the right mastoid region (Figure 4) that was fed by branches of the right occipital and stylomastoid arteries and was completely embolized. Tumor resection was performed through a combined transmastoid-parotid approach. A vascular bluish tumor was observed arising from the facial nerve, with no cleavage plane between the tumor and the nerve. The tumor was not attached to the jugular bulb. Eight months after surgery, there was no evidence of recurrence. Facial reconstruction with a temporal muscle elongation has been planned for this patient.

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