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Clinical Problem Solving: Radiology |

Radiology Quiz Case 2

George Garas, BSc(Hons), MBBS(Dist), MRCS(Eng), DOHNS; Gitta Madani, BDS, MBBS, MRCS(Eng), FRCR; Neil Tolley, MD, FRCS(Eng and Ed), DLO
Arch Otolaryngol Head Neck Surg. 2012;138(4):424. doi:10.1001/archoto.2012.193a.
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A 3-year-old boy presented with a 2-year history of snoring and mouth breathing. His symptoms had gradually worsened, and he had an increasing frequency of prolonged apneic episodes during sleep, which were associated with cyanosis. He also had daytime somnolence, and his growth rate was suboptimal for his age.

On clinical examination, the palatine tonsils were not enlarged. However, a large mass prolapsed from the posterior wall of the oropharynx and obstructed the airway. Magnetic resonance imaging, which was performed with the patient under general anesthesia, revealed a well-circumcised mass in the prevertebral space, extending on both sides of the midline but extending further laterally to the left. The 5.5 × 2.5 × 4.5-cm mass was situated deep to the left longus coli muscle, which stretched over it and passed behind the left carotid sheath (Figure 1 and Figure 2). It spanned from the skull base superiorly to the level of the oropharynx inferiorly and contained fine internal septations and a prominent vessel, manifesting as a flow void on the pregadolinium sequences. With the exception of this vessel, the mass exhibited no postgadolinium enhancement. It demonstrated high signal intensity on T1- and T2-weighted images and signal dropout on the postgadolinium fat-saturated sequences (Figure 3). After multidisciplinary team discussion and parental consent, surgery was performed. The patient was intubated via the nasotracheal route, and the mass was excised transorally. His symptoms completely resolved after surgery.

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Figure 1.

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