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Clinical Problem Solving: Radiology |

Radiology Quiz Case 1

Chia-Jui Du, MD; Chia-Hsiang Fu, MD; Shu-Hang Ng, MD; Kai-Ping Chang, MD, PhD
Arch Otolaryngol Head Neck Surg. 2012;138(2):197. doi:10.1001/archoto.2011.1161a.
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A 68-year-old woman presented with a 2-week history of a painless right preauricular mass. She had no discomfort except for slight trismus. She denied symptoms of fever, facial palsy, or weight loss. In addition to well-controlled hypertension, she had a medical history of a cerebral infarction that had occurred 10 years earlier without any residual neurologic deficits.

Physical examination revealed a 3 × 2-cm, nontender, firm, right preauricular bulging mass. The covering skin was intact, without erythematous change. Laboratory tests showed a normal leukocyte count of 6100/μL (to convert to ×109/L, multiply by 0.001) and an elevated C-reactive protein level (20.6 mg/L [to convert to nanomoles per liter, multiply by 9.524]) and erythrocyte sedimentation rate (59 mm/h). Computed tomography (CT) showed rim-enhancing fluid collections in the right posterior masticator space, within the lateral pterygoid and masseter muscles, as well as osteolytic destruction of the right mandible condylar head, with surrounding dense, amorphous calcifications (Figure 1 and Figure 2). Subsequently, a gallium 67 scan revealed a focal area of increased uptake in the right temporomandibular joint (TMJ). Ultrasonography demonstrated an infiltrative and ill-defined lesion with internal heterogeneous echogenicity and scattered vascularity. Fine-needle aspiration was performed simultaneously. Cytologic examination of the aspirate showed necrotic debris with some neutrophils and lymphocytes, while smear examination and bacterial culture failed to demonstrate acid-fast staining or other microorganisms.

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