Fair Game Cases
Case 051
History: middle-aged man with left eye blurred vision and respiratory symptoms.
Legend:
Axial T2WI shows a hypointense heterogeneous lesion in the medial aspect of the left orbit (arrows) and slightly displacing the globe laterally. The anterior portion of the medial rectus muscle cannot be well identified and all of the retrobulbar fat is edematous.
Differential diagnosis: lymphoma, sarcoidosis, meningioma, Wegener’s granulomatosis of the orbit, orbital pseudotumor. Case 052
History: strange voice after total thyroidectomy in a young woman.
Legends:
A) Enhanced CT scan shows medial deviation of the right aryepiglottic fold (arrow) and enlargement of ipsilateral piriform sinus.
B) Enhanced CT scan shows adduction of the right true vocal cord (arrow) and medialization of the arytenoid.
Differential diagnosis of causes of vocal cord paralysis: above the hyoid- metastases to the jugular foramen, glomus tumors, schwannomas, nasopharyngeal carcinomas, chordomas; below the hyoid- squamous cell carcinoma, thyroid masses, glomus vagale tumors, schwannomas, posttraumatic dissections, pseudoaneurysm, intraoperative injury, lymphadenopathy, also lesions in the parathyroid tissue and esophagus; in the mediastinum- lymphoma, bronchogenic carcinoma, lymphadenopathy, patent ductus arteriosus, mitral stenosis, aneurysms, arterial dissections. Case 053
History: woman presenting with left-sided neck pain and shocks.
Legends:
A) Coronal post gad fat suppressed T1WI shows enhancement of the V cranial nerve branches on its path (arrows) and the pterygoid muscle (p).
B) On this coronal post gad fat suppressed T1WI one can also see the V cranial nerve’s branch enhancement and thickening in the Meckel’s cave region (arrow).
Differential diagnosis: schwannoma, neuroma, perineural spread of neoplasm, neuritis, meningioma. Case 054
History: smoker, drinker middle-aged man presenting with otalgia.
Legend:
Enhanced CT scans (A, B) demonstrate anterolateral extension of a poorly defined hyperdense mass to the base of the tongue (arrows), approaching the left retromolar trigone. Bilateral adenopathy (N) can be seen.
Differential diagnosis: nasopharyngeal carcinoma, tonsil carcinoma, lymphoma, rhabdomyosarcoma of the tongue, synovial sarcoma. Case 055
History: middle-aged man with seizures.
Legend:
A) Coronal T2WI demonstrates a right temporal lesion (arrows) herniating into the sphenoid sinus. Note the presence of cerebro-spinal fluid in the lesion (C).
Differential diagnosis: meningocele, meningoencephalocele, arachnoid cyst of Meckel’s cave, mucocele, lytic skull mass, temporal lobe encephalocele.
Case 056
History: young woman presenting with left-sided hearing loss after car accident.
Legends:
A, B) CT scans show a left horizontal fracture (short arrows) of the temporal bone extending to the middle ear cavity. Note the widened space (separation) between the neck of the malleus and the incus short process (large arrow). Dislocation of the fragments can be also seen in figure B.
C) CT scan shows tracking of air around the carotid canal (large arrow) and along the Eustachian tube (short arrow).
Diagnosis: temporal bone fracture. Case 057
History: elderly man presenting with slowly progressive periorbital swelling, fronto- temporal soft tissue increase and bilateral vision disturbance.
Legends:
A) Coronal T2WI shows a hypointense diffuse infiltrative mass (arrows) affecting both orbits and extra orbital tissues.
B) Enhanced CT scan shows a hyperdense lesion along the medial wall of the right orbit probably infiltrating the medial rectus muscle and causing periorbital swelling. (arrows)
Differential diagnosis: orbital pseudotumor, Wegener’s disease, sarcoidosis, multifocal orbital lymphoma, schwannoma/neurogenic tumor, leiomyoma, metastasis. Case 058
History: young man with a long-term history of atopy and sinonasal obstruction.
Legend:
B) Non- enhanced CT scan shows a slightly hyperdense lesion bilaterally occupying, expanding and thinning (large arrows) the ethmoid and sphenoid sinuses. Erosions of the posterior wall of the sphenoid sinus and clivus can be seen (short arrows).
Differential diagnosis: allergic fungal sinusitis, polyps, mucoceles, cystic fibrosis, inverted papilloma.
Case 059
History: middle-aged left-handed smoker housewife presenting with ataxia and vertigo when cleaning the house.
Legends:
A) Axial 2DTOF MRA raw data shows both carotid arteries and right vertebral artery. Left vertebral artery is not seen (arrow).
B) Contrast enhanced MRA of the great vessels of the neck and head shows stenosis of the proximal left subclavian artey (large arrow) and both vertebral arteries (left vertebral artery demonstrated with arrows). It’s presence on the CEMRA but not on the NC 2D TOF implies retrograde flow. A superior sat pulse is placed on the latter.
C) Coronal CTA image of the great vessels of the neck shows an intraluminal thrombus (arrow) in the left proximal subclavian artery before the origin of the vertebral artery. Marked calcified plaque is seen distally.
Diagnosis: subclavian steal.
Clinical symptoms: early arm fatigue, ataxia, vertigo, dizziness; worse with arm exercise. Focal sensory or motor loss, dysphasia, and unilateral visual disturbances rarely may occur.
Case 060
History: young woman presenting with right-sided lower neck mass after previous thyroidectomy.
Legends:
A) Enhanced CT scan shows a hyperdense mass in the right thyroid gland (large arrow), involving and posterior displacing the right carotid artery. A lymph node with tiny calcifications can be seen (short arrow).
B) Enhanced CT scan through the upper thorax shows the extension of the hyperdense thyroid mass to the anterior mediastinum, encasing the inominate artery. (arrow)
Differential diagnosis: adenoma, follicular carcinoma, papillary carcinoma, medullary carcinoma of the thyroid gland, lymphoma, parathyroid carcinoma. Case 061
History: middle-aged woman presenting with left-handed weakness after radiotherapy for breast cancer axillary nodes.
Legends:
A, B) Coronal fat suppressed T2WI shows a hyperintense left brachial plexus (arrows). Upper trunks and divisions are bright. Small arrows in B depict the posterior division.
Differential diagnosis of causes of brachial plexopathy: viral, injury secondary to birth trauma and shoulder dystocia, Pancoast tumor, breast cancer radiation, lymphadenopathy from neoplasms, cervical rib, chronic inflammatory demyelinating polyneuropathy.
Case 062
NO IMAGES AVAILABLE.
History: middle-aged woman presenting with headache, galactorrhea and bitemporal hemianopsia.
Differential diagnosis: craniopharyngioma, meningioma, metastases, granulomatous disease, lymphocytic hypophysitis, pituitary adenoma, chordoma, nasopharyngeal carcinoma, plasmacytoma. Case 063
NO IMAGES AVAILABLE.
History: toddler presenting with an asymmetric face due to a left-sided violaceous mass.
Differential diagnosis: venous vascular malformation, capillary hemangioma, schwannoma, neurofibroma, fibromatosis, Sturge-Weber syndrome, Klippel-Trénaunay syndrome. Case 064
History: middle-aged man with dental caries and pain in the right mandible.
Legend:
B) Non-enhanced CT scan shows erosion in the right ramus of the mandible and periosteal reaction (arrows).
Differential diagnosis: radicular cyst, brown tumor, osteomyelitis, dentigerous cyst, keratocyst, osteosarcoma, Ewing’s sarcoma, fracture, SAPHO syndrome. Case 065
History: asymptomatic man undergoing routine scan for dentist appointment.
Legend:
Non- enhanced CT scan shows a lucent slightly expansile lesion (arrow) in the midline incisive canal.
Differential diagnosis: nasopalatine cyst, radicular cyst, globulomaxillary cyst. Case 066
History: toddler with bilateral leukokoria, decreased vision and right ocular pain.
Legend:
Coronal T2WI shows a hypointense mass occupying the majority of the right globe and just a small spot in the left globe (arrows). Unfortunately, MRI cannot discern evidence of calcification.
Differential diagnosis: persistent hyperplastic primary vitreous (PHPV), Coats’ disease, toxocara canis infection, bilateral retinoblastoma, retrolental fibroplasias, Von Hippel Lindau disease, multiple hemangioblastomas, melanoma. Case 067
History: woman presenting with pain referred to the left-sided skull base.
Legends:
A) Axial T2WI demonstrates an isointense skull base mass (arrow) posterior to the carotid artery within the jugular foramen and growing in the jugular vein.
B) Axial post gad fat suppressed T1WI shows enhancement of the lesion (arrow) with flow voids within it (salt and pepper pattern).
Differential diagnosis: meningiomas, metastases from thyroid, renal cell carcinoma, and melanoma, schwannomas, glomus jugulare, chondroid lesions.
Case 068
History: child presenting with sensorineural hearing loss especially for low- frequency sounds.
Legends:
Axial (A) and coronal (B) CT scans show absence of well-formed cochlear turns creating a cystic- inner ear structure (arrows) where the cochlea should be located. The modiolus is insufficient.
Differential diagnosis: Cock’s deformity, Mondini malformation, cochlear aplasia or hypoplasia, large vestibular aqueduct syndrome.
Case 069
NO IMAGES AVAILABLE.
History: one-year-old girl presenting with skin spots, menstruation and right-sided lesion on the head.
Differential diagnosis: Paget’s disease, neurofibromatosis, nonossifying fibroma, giant cell tumor, osteoblastoma, enchondromatosis, fibrous dysplasia, osteopetrosis.
Case 070
History: middle-aged woman presenting with left-sided decreased visual acuity and pain.
Legends:
A) Coronal T2WI demonstrates high signal intensity in the left optic nerve (arrow). The nerve is slightly swollen.
B) Coronal post gad T1WI shows enhancement of the chiasmatic segment of the left optic nerve (arrow).
Differential diagnosis of causes of optic neuritis: ischemia, vasculitis, sarcoid, systemic lupus erythematosus, syphilis, Lyme disease, viral infection, toxoplasmosis, tuberculosis, chemotherapy, radiation therapy.
Case 071
History: man with AIDS presented with painful lesions around the left ear and facial nerve palsy.
Legends:
Axial (A) and coronal (B) post gad T1WI show enhancement of the left seventh cranial nerve within the internal auditory canal (arrows). This portion should never enhance normally.
Differential diagnosis: viral neuritis, sarcoidosis, radiation therapy, schwannoma, Lyme disease, leukemia, lymphoma, migraine, hemangioma, perineural tumor spread, Guillain- Barré, Bell’s palsy. Case 072
History: young adult with a sticking sensation in the throat on swallowing.
Legend:
Both styloid processes/stylohyoid ligaments are calcified and are indenting the pharyngeal mucosa space (left > right).
Differential diagnosis: tonsilloliths, Eagle syndrome, sialoliths. Case 073
History: infant presenting with strange left ear and hearing loss.
Legend:
A) Axial non-enhanced CT scan shows absence of the left external auditory canal associated with microtia (short arrow). The temporomandibular joint is not formed (arrows). Note also fusion mass of ossicles. Well- aerated middle ear canal.
Differential diagnosis of causes of external auditory canal abnormalities: Treacher Collins, use of thalidomide, rubella infections, Pierre Robin syndrome.
Case 074
History: elderly man, asymptomatic referred by the ophthalmologist to undergo a CT scan because of routine ophthalmoscopy exam showing bilateral papilledema.
Legend:
Axial non-enhanced CT scan shows bilateral punctate calcifications (arrows) at the junction of the nerve and the globe.
Differential diagnosis: retinoblastoma, optic nerve drusen, residua of infection (toxocara), trauma (detachment), foreign bodies. Case 075
NO IMAGES AVAILABLE.
History: child with recurrent right-sided otitis evaluating with pain, high fever, soft tissue edema and a fluctuant mass.
Differential diagnosis: otomastoiditis, cholesteatoma, rhabdomyosarcoma, abscess, lymphoma, coalescent mastoiditis, Langerhans’ cell histiocytosis. Case 076
History: man presenting with right-sided hearing loss and headache pain.
Legend:
C) Axial T1WI shows a bright heterogeneous mass (arrows) in the right petrous apex. Note the normal left petrous apex (P).
Differential diagnosis: mucocele, aneurysm with clot, hemorrhagic metastasis, epidermoid, petrous apicitis, cholesterol granuloma.
Case 077
History: middle-aged woman presenting with neck mass and seizures after laryngectomy and radiation therapy for laryngeal carcinoma.
Legend:
A) Enhanced CT scan shows a narrowed right carotid artery (arrow) antero- medially deviated by a hypodense mass with peripheral enhancement. This mass completely surrounds the carotid sheath. The patient has had a laryngectomy and the neopharynx (arrowhead) is pushed to the left.
Differential diagnosis: radiation necrosis, recurrent carcinoma, carotid encasement, abscess, fasciitis, flap necrosis.
Case 078
History: middle-aged woman undergoing breast cancer treatment presenting with pain and difficulty raising the left eye.
Legend:
Coronal enhanced CT scan shows enlargement of the left superior rectus muscle (arrow). Compare to the normal size on the right side.
Differential diagnosis of superior rectus muscle enlargement: thyroid eye disease, pseudotumor, vascular congestion, lymphoma, sarcoidosis, metastasis, myositis from adjacent sinusitis.
Case 079
NO IMAGES AVAILABLE.
History: young man with asthma, allergic rhinitis and left-sided nasal obstruction.
Differential diagnosis: mucocele, inverted papilloma, cephalocele, fungal polyp, squamous cell carcinoma, lymphoma, adenoid cystic carcinoma, antrochoanal polyp, minor salivary gland neoplasm. Case 080
History: young man with Down syndrome presenting with dysphagia.
Legends:
Axial T1WI (A, B) show the right subclavian artery (arrow) passing behind the trachea (T) and esophagus (E), slightly compressing the latter’s posterior wall.
Differential diagnosis: other vascular loops. Case 081
History: young man with bilateral hearing loss that became worst after head trauma.
Legend:
Non- enhanced CT scan shows bilateral enlarged vestibular aqueducts (arrows).
Differential diagnosis of causes of enlarged vestibular aqueduct: CHARGE syndrome, Pendred syndrome, congenital CMV infections, Mondini malformation.
Case 082
History: middle-aged woman presenting with insidious onset of left eye visual loss.
Legends:
B) Coronal T2WI shows a bright mass (arrow) involving the left optic nerve (doughnut sign).
C) Coronal post gad T1WI shows a homogeneous enhancement of the mass (arrow).
Differential diagnosis: pseudotumor, sarcoid, metastatic disease, lymphoma, leukemia, Erdheim-Chester disease, subarachnoid spread of tumor, infection, optic nerve meningioma.
Case 083
History: middle-aged man presenting with a mass in the right neck.
Legend:
A) Axial time of flight raw data image shows a slightly hypointense mass (large arrows) splaying the internal (arrowhead) and external branches (short arrow) of the carotid arteries.
Differential diagnosis: aneurysms, pseudoaneurysms, hypervascular lymph nodes from thyroid, renal cell carcinoma, melanoma, Bailey’s type 3 branchial cleft cysts, carotid body tumor, schwannomas, hemangiomas, angiofibromas, arteriovenous malformations. Case 084
History: middle-aged woman presenting with difficulty in tasting foods and twisted mouth.
Legends:
B) Coronal CT scan shows an isodense mass (arrows) in the topography of the descending intramastoid portion of the right VII nerve expanding and thinning the bone wall.
C) Enhanced Coronal CT reconstruction demonstrates a non-enhancing mass (S) occupying the descending portion of the VII nerve.
Differential diagnosis: perineural spread of malignancy, facial nerve schwannoma, neurofibroma, hemangioma, meningioma.
Case 085
NO IMAGES AVAILABLE.
History: middle-aged man presenting with nasal obstruction, epistaxis and decrease of olfactory function.
Differential diagnosis: squamous cell carcinoma, olfactory neuroblastoma, adenocarcinoma, small cell neuroendocrine tumor, adenoid cystic carcinoma, metastasis, sinonasal undifferentiated carcinoma, lymphoma.
Case 086
History: young man presenting with hallucinations, renal calculi and abdominal pain.
Legends:
A) Axial T2WI shows a bright lesion (arrow) posterior to the right thyroid lobe, in a paraesophageal location.
B) Axial post gad T1WI demonstrates diffuse enhancement of the lesion (arrow).
Differential diagnosis: lymph node, ectopic thyroid nodule, parathyroid adenoma, schwannoma.
Case 087
History: young woman presenting with a small dimple on the top of the nose.
Legend:
A) Enhanced CT scan shows a rounded midline hypodense lesion (arrow) adjacent to the nasal bone.
Differential diagnosis: nasal/extranasal glioma, nasofrontal encephalocele, venous/lymphatic vascular malformation, nasal epidermoid, sebaceous cyst, post- traumatic chronic hematoma. Case 088
History: teenager with ear pain, fever and headaches.
Legend:
B) A ring-enhancing abscess collection (arrow) is seen in the left mastoid air cells. Adjacent meningeal enhancement could be due to reactive change or meningitis. In this location, the transverse sinus and sigmoid sinus are at risk for thrombophlebitis.
Differential diagnosis: coalescent mastoiditis, abscess, Bezold’s abscess. Case 089
History: facial pain in a young adult.
Legends:
A) Note the soft tissue mass (arrows) in the right pterygopalatine fossa with growth medially to the sphenopalatine foramen on this coronal enhanced CT scan. The lesion enhances mildly and infiltrates the pterygoid musculature.
B) Normally the pterygopalatine fossa is filled with fat and little dots of soft tissue from the fifth cranial nerve branches. On the right, the fossa is filled with soft tissue (arrow) leading towards the inferior orbital fissure anterolaterally.
Differential diagnosis: rhabdomyosarcoma, schwannoma. metastasis, nasopharyngeal carcinoma, juvenile nasopharyngeal angiofibroma, perineural spread of tumor, lymphoma.
Case 090
History: middle-aged adult with a one-month history of hoarse voice.
Legends:
B) The bone window on the axial CT scan shows sclerosis of the left arytenoid cartilage (arrow). This is worrisome for cartilaginous infiltration in a patient with a thickened left false cord.
C) An erosion in the anterior aspect of the left thyroid cartilage (arrow) signifies another area of cartilaginous invasion. Adjacent sclerosis adds to the risk of invasion. Note the marked thickening of the left true cord as the tumor spreads in a transglottic fashion.
Differential diagnosis: squamous cell carcinoma, carcinosarcoma, lymphoma, tuberculous laryngitis.
Case 091
History: infant presenting with right-sided hearing loss.
Legends:
CT scans (A, C, D) show the absence of the incus that can be demonstrated on C by the non visualization of the incudostapedial joint (arrow) and D by the non visualization of long process of the incus.
Differential diagnosis: acute otitis media, cholesteatoma, trauma, epidermoid, CHARGE syndrome, vascular necrosis, congenital second branchial arch anomaly. Case 092
History: young adult with tinnitus.
Legend:
Bilateral dehiscence of the posterior walls of the petrous carotid arteries (arrows) is present. On the left side there is a pseudoaneurysm that has formed after a “biopsy procedure gone wrong” through the tympanic membrane.
Differential diagnosis: persistent stapedial artery, glomus tumors, hemangiomas, aberrant internal carotid arteries. Case 093
History: child with pulsatile exophthalmos.
Legend:
Not only is the left sphenoid wing dysplastic (arrow), but one can probably detect an enlarged left optic nerve even on this bone-targeted window to the axial CT scan. Exophthalmos and soft tissue deformity along the left temporal fossa are present.
Differential diagnosis: meningoencephalocele, vanishing bone disease (Gorham’s syndrome), cutaneous neurofibroma with neurofibromatosis type I.
Case 094
History: recurrent sinus squamous cell carcinoma in an elderly man with proptosis
Legend:
The left hard palate has been resected a long time ago. Perineural spread up the greater and lesser palatine canals leading to a mass in the pterygopalatine fossa (arrows) is obvious here. There is spread into the nasal cavity and the infratemporal fossa from the fossa.
Differential diagnosis: adenoid cystic carcinoma, squamous cell carcinoma, lymphoma, and melanoma. Case 095
History: young adult with right facial palsy for 4 weeks.
Legend:
Contrast enhancement of the labyrinthine (pre-ganglionic) portion of the facial nerve (arrow) in the fallopian canal is always abnormal. The more distal tympanic portion enhancement is not abnormal. The enhancement of the labyrinthine portion of the nerve is the most common finding with this entity.
Differential diagnosis: Ramsay Hunt syndrome, facial nerve schwannoma, multiple sclerosis, meningitis, mononeuritis multiplex, Bell’s palsy. Case 096
History: visual loss after globe trauma in a young adult.
Legend:
When the blood collection extends this far anterior along the globe (arrows) the patient is much more likely to have this type of detachment. The other type of detachment is confined by the ora serrata attachment of the epithelium, whereas the choroids can detach more widely, being confined by optociliary arteries and vortex veins.
Differential diagnosis: melanoma, vitreous hemorrhage, vitrectomy, choroidal detachment, retinal detachment.
Case 097
History: hearing loss in a middle-aged adult.
Legend:
There is a soft tissue mass (arrow) at the geniculate ganglion protruding into the middle ear.
Differential diagnosis: schwannoma, hemangioma, meningioma, glomus tumor, cholesterol granuloma, epidermoid.
Case 098
History: macrocephalic young child presenting with headaches and ataxia.
Legend:
A) Sagittal T1-weighted scan shows diffuse bone marrow thickening (arrow) with dark signal associated to small foramen magnum and tonsillar ectopia (short arrow).
Differential diagnosis: pyknodysostosis, osteopetrosis, craniodiaphyseal dysplasia, talassemia, sickle cell anemia, fibrous dysplasia, Paget’s disease. Case 099
History: fever and night sweats in an adolescent male.
Legends:
Necrotic adenopathy in the right posterior triangle can be seen on the enhanced CT scans (A, B). The adjacent soft tissue does not show inflammatory infiltration.
Differential diagnosis: atypical mycobacteria, pyogenic bacteria, metastatic lymphadenopathy, lymphoma, tuberculous mycobacteria, Kikuchi’s disease, Kimura’s disease, post-transplant lymphoproliferative disorder.
Case 100
NO IMAGES AVAILABLE.
History: headaches in a middle-aged adult.
Differential diagnosis: osteomyelitis, fibrous dysplasia, osteoblastic metastasis, SAPHO syndrome, osteosarcoma, meningioma.
Case 101
History: middle-aged man with nasal bleeding, obstruction.
Legends:
A) Axial T1-weighted study shows a soft tissue mass along the lateral right nasal wall (arrows).
B) The mass (arrow) shows gadolinium enhancement in a solid pattern suggestive of a neoplasm. There may be some erosion of the floor of the maxillary antrum.
Differential diagnosis: squamous cell carcinoma, inverted papilloma, adenocarcinoma, adenoid cystic carcinoma, lymphoma. Case 102
History: incidental finding noted on study for orbital lesion.
Legends:
A) Axial CT bone window reveals absence of the horizontal portion of the left internal carotid artery petrous segment (arrow ?).
B) The coronal postcontrast scan is notable for the absence of the cavernous segment of the left internal carotid artery (arrow ?).
Differential diagnosis: aberrant ICA, absent internal carotid artery, persistent stapedial artery.
Case 103
History: right eye visual loss in a young adult.
Differential diagnosis: axial myopia (congenital and acquired), neurofibromatosis type 1, Proteus syndrome, Sturge Weber syndrome, Lowe’s syndrome, Marfan’s syndrome, homocystinuria, glaucoma, staphyloma, coloboma.
Case 104
History: middle-aged man with chronic sinusitis.
Legend:
B) Note the calcification (arrow) within the secretions in the left maxillary antrum.
Differential diagnosis: sinolith, fungus ball, fungus sinusitis, osteoma, fibrous dysplasia, fracture fragment, inverted papilloma, olfactory neuroblastoma, calcification in the sinus, osteosarcoma.
Case 105
NO IMAGES AVAILABLE.
History: young adult with pain in the left temporomandibular joint.
Differential diagnosis: chondroblastoma, chondrosarcoma, osteochondroma, fibrous dysplasia, chondromyxoid fibroma.
Case 106
NO IMAGES AVAILABLE.
History: elderly man with proptosis and skull base pain.
Differential diagnosis: metastasis, lymphoma, atypical meningioma, plasmacytoma, rhabdomyosarcoma, sinus squamous cell carcinoma.
Case 107
History: elderly man with lower neck mass, pain.
Legend:
Axial postcontrast CT scan reveals a right thyroid mass that is seen eroding the lateral wall of the cricoid cartilage, narrowing the airway (arrow).
Differential diagnosis: anaplastic, papillary, follicular, and medullary carcinoma of the thyroid gland, parathyroid carcinoma, nodal infiltration, sarcoma, lymphoma, laryngeal carcinoma growing outward. Case 108
History: young adult with fever. Chills, painful neck fullness.
Legend:
A) Note the low density fluid collection anterior to the thyroid cartilage deep to the strap muscles as well as superficially in the subcutaneous tissues (arrows).
Differential diagnosis: thyroglossal duct cyst, epidermoids, phlegmon, abscess.
Case 109
NO IMAGES AVAILABLE.
History: adult man with sinonasal obstruction.
Differential diagnosis: squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, lymphoma, olfactory neuroblastoma, small cell neuroendocrine tumor.
Case 110
History: elderly man with palpable neck mass.
Legend:
Mixed density lesion is seen in the tail of the right parotid gland protruding superficially.
Differential diagnosis: pleomorphic adenoma, monomorphic adenoma, lymphoepithelial, lesion, lymph node, low grade mucoepidermoid tumor, Warthin’s tumor. Case 111
History: young adult with right-sided recurrent serous otitis.
Legend:
B) The introducer 18 gauge needle is seen (big arrow) placed through the coronoid notch of the mandible. Through this the aspiration 22 gauge quincke needle (small arrows) has been placed.
Differential diagnosis: lymphoma, minor salivary gland tumor, rhabdomyosarcoma, sarcoma, nasopharyngeal carcinoma.
Case 112
History: middle-aged man with a floor of mouth submucosal mass.
Legends:
B) Postcontrast axial fat suppressed MR image shows a hypointense lesion (arrows) in the right side of the floor of the mouth. There is no enhancement and infiltration of the adjacent planes.
C) Postcontrast coronal fat suppressed MR image shows the perforated edge of the left mylohyoid (arrow) muscle by a cystic mass. The absence of enhancement of the mass implies its cystic nature.
Differential diagnosis: dermoid cyst, lymphatic malformation, thyroglossal duct cyst, epidermoid, ranula.
Case 113
History: young adult with left jaw pain.
Legend:
A) The CT scan shows a mass that presents with new bone growth (arrowhead) as well as a soft tissue mass (arrows).
Differential diagnosis: Ewing’s sarcoma, lymphoma, osteosarcoma, metastasis. Case 114
NO IMAGES AVAILABLE.
History: middle-aged man with abdominal pain, hematuria and skeletal pain.
Differential diagnosis: Paget’s disease, lytic metastases, myeloma, histiocytosis, chronic renal failure of the skull.
Case 115
History: infant with difficulty breathing.
Legend:
A) Not only are the posterior choanal passageways narrowed (arrows) but the posterior vomer is also markedly thickened, contributing to the narrowing.
Differential diagnosis: piriform aperture stenosis, fibrous dysplasia, choanal atresia. Case 116
NO IMAGES AVAILABLE.
History: child with facial dysmorphism (micrognathia).
Differential diagnosis: Treacher Collins, Goldenhar syndrome, Miller syndrome, Pierre Robin syndrome, Stickler syndrome, pyknodysostosis, Trisomy 13, Trisomy 18, Turner syndrome.
Case 117
History: neck pain in a young adult.
Legend:
A) Axial T1-weighted scan with fat suppression (poorly applied) shows a crescentic area of hyperintensity along the lumen of the right vertebral artery.
Differential diagnosis of causes of those imaging findings: trauma, fibromuscular dysplasia, Marfan’s syndrome, chiropractic manipulation, Ehlers- Danlos syndrome, homocystinuria. Case 118
History: young adult with a flail limb after a recent motorcycle accident.
Legend:
B) While the anterior nerve root (black arrow) is seen on the right, it is missing on the left and the thecal sac enlarges (white arrow) on the same side.
Differential diagnosis: dural ectasia, pseudomeningocele, nerve root avulsion, arachnoid cyst. Case 119
History: elderly man with headache, ear pain and drainage.
Legends:
A) Axial CT scan image shows soft tissue in the right external auditory canal with erosion of the anterior wall of the canal.
E) Postcontrast T1-weighted MR shows soft tissue enhancement along the right skull base extending into the parapharyngeal space.
Differential diagnosis: nasopharyngeal carcinoma, skull base osteomyelitis, malignant otitis externa, lymphoma.
Case 120
History: bilateral temporomandibular joint pain and restriction of movement.
Legend:
T2- weighted scan (A) and post-gadolinium scan (B) show inflammation of the thickened synovium of both temporomandibular joints, left greater than right.
Differential diagnosis: gout, pseudogout, rheumatoid arthritis, septic arthritis, mixed connective tissue disease, hemarthrosis.
Case 121
NO IMAGES AVAILABLE.
History: middle-aged woman with headaches, right visual blurring.
Differential diagnosis: dural metastasis, cavernous sinus meningioma, lymphoma, sarcoidosis, plasmacytoma, pituitary adenoma.
Case 122
NO IMAGES AVAILABLE.
History: young adult with left jaw pain.
Differential diagnosis: ranula, epidermoid, lymphatic malformation, dental abscess.
Case 123
NO IMAGES AVAILABLE.
History: young adult with sinusitis, congestion, nasal discomfort.
Differential diagnosis: Wegener’s granulomatosis, lymphoma, rhinoscleroma, cocaine usage, sarcoidosis. Case 124
History: young female with jaw pain, limited motion.
Legends:
A) Sagittal T1-weighted closed mouth view shows anterior meniscus displacement (arrow) in front of the mandibular condyle.
B) Sagittal T1- weighted open mouth view shows persistence of anterior displacement of the meniscus. This defines anterior displacement without recapture.
Differential diagnosis: meniscal perforation, stuck disk. Case 125
NO IMAGES AVAILABLE.
History: infant with esotropia.
Differential diagnosis: cavernous sinus aneurysm, meningioma, schwannoma, dural vascular malformation, hemangiopericytoma. Case 126
NO IMAGES AVAILABLE.
History: young adult presenting with adenopathy, headaches, visual blurring.
Differential diagnosis: varieties of nasopharyngeal carcinoma including squamous, non- keratinizing undifferentiated, lymphoepiteliomatous carcinoma, lymphoma, rhabdomyosarcoma, spread of infection. Case 127
NO IMAGES AVAILABLE.
History: young adult with chronic ear drainage.
Differential diagnosis: chronic otitis media, fungal infection, spread of squamous cell carcinoma, acquired cholesteatoma with tympanosclerosis.
Case 128
NO IMAGES AVAILABLE.
History: young adult with left facial malar region mass and headaches.
Differential diagnosis: fibrous dysplasia, cherubism, aneurysmal bone cyst, myxoma, ossifying fibroma.
Case 129
History: middle-aged man with multiple cranial nerve palsies.
Legends:
A) Orbicularis oris (arrow) and pterygoid (arrowhead) muscular atrophy is present on the CT scan.
B) Note the atrophic left side of the tongue (T).
C) Note atrophy of sternocleidomastoid muscle (arrowheads) and trapezius (arrow) on the left.
D) The platysma on the right (long arrow) is seen but not on the left.
Differential diagnosis: neoplastic, post-traumatic, iatrogenic, denervation atrophy, post- therapy. Case 130
NO IMAGES AVAILABLE.
History: elderly man after resection for base of tongue cancer.
Differential diagnosis: pectoralis major myocutaneous flap, denervation atrophy, lipoma. Case 131
NO IMAGES AVAILABLE.
History: young adult with right forehead pain.
Differential diagnosis: metastasis, plasmacytoma, epidermoid of bone, multiple myeloma, langerhans cell histiocytosis, lymphoma. Case 132
History: adult with history of squamous cell carcinoma of the sinonasal cavity.
Legend:
There are hot areas of uptake on the PET scans (black arrows) which correspond to intranasal uptake on the CT (white arrow).
Differential diagnosis: sinusitis, osteomyelitis, cancer, metastasis.
Case 133
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History: young adult with epistaxis.
Differential diagnosis: squamous cell carcinoma, hemangioma/venous vascular malformation, amyloidoma, juvenile nasopharyngeal angiofibroma. Case 134
History: young adult with rhinorhea.
Legend:
A) T2-weighted coronal scan shows herniation of meninges through the left cribriform plate (arrow) on the side of the CSF leak. Bilateral frontal encephalomalacia is present.
Differential diagnosis: meningocele, arachnoid cyst, nasal glioma, CSF leak after trauma. Case 135
History: middle-aged adult with fever, sinusitis.
Legend:
A) Note the low density collection (arrow) medial to the right medial rectus muscle.
Differential diagnosis: resolving hematoma, epidermoid, sinusitis with subperiosteal abscess, phlegmon. Case 136
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History: elderly woman with history of retromolar trigone cancer treated previously.
Differential diagnosis: radiation necrosis of bone, sarcoma, recurrent cancer. Case 137
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History: elderly man with calcium dysmetabolism, neck mass.
Differential diagnosis: medullary carcinoma, follicular adenoma, papillary carcinoma, follicular carcinoma, functioning adenoma of the thyroid gland, Hurthle cell adenoma, nodular goiter.
Case 138
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History: young adult with tongue fullness.
Differential diagnosis: thyroglossal duct cyst, ranula, mucous retention cyst, lymphatic/vascular malformation, abscess, dermoid of the tongue. Case 139
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History: young adult with left-sided neck mass.
Differential diagnosis: necrotic lymph node, lymphangioma, abscess, branchial cleft cyst, seroma, jugular lymphatic sac. Case 140
History: young adult with vocal cord paralysis.
Legend:
A) A mass (S) is seen between the left jugular vein (long arrow) and carotid artery (small arrow).
Differential diagnosis: lymph node, vagus schwannoma, carotid body tumor. Case 141
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History: teenage boy with throat fullness, dysphagia.
Differential diagnosis: hemangioma, amyloidoma, lingual thyroid tissue, lymphoma, lymphoid hyperplasia. Case 142
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History: middle-aged adult with lacrimal fossa fullness.
Differential diagnosis: pleomorphic adenoma, adenocarcinoma, mucoepidermoid carcinoma, adenosquamous carcinoma, lymphoma, sarcoidosis, adenoid cystic carcinoma, Wegener’s granulomatosis. Case 143
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History: young adult with a neck mass.
Differential diagnosis: pathologic adenopathy from melanoma, thyroid carcinoma, branchial cleft cyst, hematoma, lymphatic malformation (cystic hygroma). Case 144
History: young adult with throat and neck pain and stiffness.
Legend:
Peripherally enhancing low density center mass is seen in the retropharyngeal space on the left (arrow).
Differential diagnosis: necrotic adenopathy from squamous cell carcinoma, papillary thyroid cancer, branchial cleft cyst (Bailey’s 4 type II BCC), necrotizing adenitis.
Case 145
History: young adult with acute neck pain after a gymnastics competition.
Legend:
A) High signal is seen instead of flow voids in both carotid arteries (arrows).
Differential diagnosis: flow related enhancement, jugular thrombosis, bilateral carotid artery dissections, inappropriately applied saturation pulses. Case 146
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History: young adult with chronic sinusitis, right eye pain.
Differential diagnosis: bacterial infection with orbital extension, lymphoma, leukemia, mucormycosis of the paranasal sinuses invading the orbit. Case 147
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History: long term smoker with recent voice change.
Differential diagnosis: lymphoma, carcinosarcoma, sarcoma, squamous cell carcinoma.
Case 148
History: young adult with facial cellulitis complicated by acute eye pain.
Legends:
B) MR shows inflammation (arrows) of the masticator space with effacement of parapharyngeal fat and infiltration of the pterygoid musculature.
C) Note the peripheral enhancement of the left ophthalmic vein (arrow).
D) Spread of the inflammation in the masticator space (arrow) along the foramen ovale into the trigeminal ganglion and cavernous sinus region (arrowhead) may suggest the means of spread to the superior ophthalmic vein.
Differential diagnosis: perineural spread of neoplasm (adenoid cystic carcinoma), lymphoma, sarcoidosis, superior ophthalmic vein thrombosis. Case 149
History: middle-aged woman with left sided tinnitus.
Legend:
Non- enhanced CT scan shows an erosive process in the left jugular bulb (arrows).
Differential diagnosis: meningiomas, metastases from thyroid, renal cell carcinoma, and melanoma, schwannomas, glomus jugulare, chondroid lesions, nasopharyngeal carcinoma.
Case 150
History: visual loss in a very tall adult.
Legend:
Not only are the globes very myopic and elongated but the left lens has been dislocated.
Differential diagnosis: trauma, homocystinuria, Marfan’s disease, post-operative complication.