Clinical Problem Solving: Radiology |

Radiology Quiz Case 1

Charles B. Armstrong, MD; Gregory K. Hartig, MD
Arch Otolaryngol Head Neck Surg. 2009;135(2):210-214. doi:10.1001/archoto.2008.533-a.
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A 69-year-old man was referred for otolaryngologic evaluation after a routine panoramic radiograph (Panorex) demonstrated a multilocular lytic lesion surrounding his right third mandibular molar. He had experienced a sense of fullness in the right side of his mandible for several months, but he denied having pain, loosening of teeth, changes in occlusion, or trismus. His medical and family histories were unremarkable, and he had no history of alcohol or tobacco abuse.

Physical examination revealed fullness of the lateral cortex of the mandible, just posterior to the second molar, which was noted to be slightly loose. No tenderness or mucosal abnormalities were noted. The findings of a cranial nerve examination, including testing of mental nerve function, were normal, and the neck examination showed no nodal enlargement. Computed tomography of the neck and mandible revealed a 1.7 × 4.0-cm, expansile, lytic lesion in the right posterior aspect of the mandible, with an apparent interrupted cortex. No definite periosteal reaction or adjacent fat stranding was noted. The right third molar was present and appeared to be surrounded by the lesion (Figures 1, 2, and 3). An axial view demonstrated an intact cortex on the lingual side of the mandible but an irregular and interrupted cortex on the buccal side (Figure 1). The initial examination of the lingual side suggested a benign odontogenic process, but the buccal cortex was indicative of an aggressive process. No cervical lymphadenopathy or lesions were noted within the thyroid gland. Chest radiography revealed no suspicious pulmonary lesions.

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Figure 1.
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Figure 2.
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Figure 3.
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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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