0:05

And what did you think about this when you dictated out? Do you, do you recall?

0:09

Initially I thought because in the history you have given,

0:13

there is no vascularity.

0:15

So you basically rule out the angio fibroma the tumor, right.

0:19

Angio fibroma.

0:21

So I just left with I thinking of whether can you be peripheral the

0:26

nerve? She the sonoma initially I thought,

0:29

can you be Sonoma because it's mainly in the telco for mm-hmm.

0:34

And other than that I thought,

0:36

can you be some survival grand tumor or squam cell carcinoma?

0:41

Yep.

0:42

Yeah. All good thoughts. Um, and I think I gave you my original dictation too.

0:46

I didn't wanna hide anything from you all, but Yeah, exactly right.

0:49

When I first thought I thought it was gonna be juvenile angio fibroma,

0:51

but when I looked at 'em more, there was actually no, no flow voids. There's no,

0:55

um, uh, no flow voids and really not much mass effect on the posterior wall.

1:00

And then it was actually extending, um, into the

1:07

groove for the inferior alveolar nerve, which raises the possibility,

1:10

like you said, of a neurofibroma schwannoma.

1:15

Uh, so then it came back and it turned out it was a, uh, I believe,

1:18

I think the phylo path was a sarcoma, I believe,

1:22

I think it was a spindle cell sarcoma or a,

1:25

I have to remember what the diagnosis was.

1:26

Would you remember what the diagnosis was on the report?

1:30

Spindle cell carcinoma,

1:33

A spindle cell carcinoma. Very, very rare. They sent it out to multiple, um,

1:37

pathologists and I think they sent it to the Mayo Clinic and that's what they

1:40

ended up saying that it was a spindle cell sarcoma that was arising from the

1:44

tego palatine fossa. And, uh, it was, looks like it was growing along. Uh,

1:49

it looks for all the world. It does look like perineural extension, um,

1:54

into the, um, ramus of the mandible. So it's a very unusual case.

1:58

Probably the one, probably one of the toughest cases of this module.

2:02

Any questions on this one or you just glad this case is over?

2:06

So on the, the explanation you say there is,

2:09

there is extension of this mass into the telecom,

2:13

telecom mandibular fisure,

2:14

which is very unlikely for juvenile and geo fibroma.

2:19

Yeah, I think that's true. Yeah.

2:20

The other thing too is notice how it's displacing the superior, the, um,

2:23

lateral oid and the medial oid. See this enhancement right here?

2:27

Yes.

2:28

And that really looks like it's extending along the nerve.

2:31

I'll have to go back and look at exactly what the nerve is.

2:33

The nerve that there are two nerves that actually run through here.

2:35

One's the inferior alveolar nerve and the other one is the lingual nerve.

2:40

Now those tend to join along the medial portion

2:45

of the medial oid muscle

2:50

to form V three. And so normally it's right here to form V three,

2:55

then it goes up through frame oval.

2:56

But what's interesting about this is that it looks, it,

3:00

we can see that it's involving the, the, uh,

3:04

mandibular notch right here. And it's actually growing me, uh, superior me, uh,

3:08

uh, anterior medially. So it looks like it's growing along the nerve.

3:13

I've just gotta figure out what nerve that is.

3:15

I'll have to go back to the anatomy textbooks.

3:19

Yeah. Because inferior,

3:21

inferior al nerve will go to the foren or valley in instead of going to

3:26

Teleco type.

3:28

That's correct. Yeah.

3:29

The main inferior alveolar nerve will go between the medial and the lateral oid,

3:32

join with the lingual nerve, and then grow up to the skull base. In fact,

3:35

we have a, we have a exhibit on that at as S N R this year,

3:40

So I need to find out why is the enough.

3:44

Yeah, exactly. Yeah. Initially

3:46

I thought there is a involvement or inferior,

3:48

but why it goes to the he for site, I,

3:53

I still cannot comprehend.

3:55

Yeah, it's gotta be a branch. It has to be one of those branches. Yes.

3:59

I just have to go back and look it up.

4:01

And then you mentioned that for the young child,

4:03

because of the tibular ator space,

4:06

we need to think of the rap myo saccharide as well.

4:10

Yes, yes, exactly right. That would actually be the number one.

4:14

Okay.

4:16

That would actually be, the number one would be a rhabdomyosarcoma,

4:19

just based on statistics alone.