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Wk 8, Case 5 - Review

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0:05

How do we do on this one, Han?

0:07

This one, I just can notice the fat stranding,

0:12

the injection or the fat in the right masica space. Mm-hmm.

0:17

And I don't really see any definitive abscess, so that,

0:21

that's why it's quite challenging for me. I thought it's just, uh,

0:26

fragment sitis because I used to see a lot of

0:31

abscess subs from the auto autogenic

0:35

origin. Mm-hmm. I don't why, why I, why, why you choose a case.

0:40

Like just a very mild infection. That's why I,

0:44

I take quite long time for this, this test.

0:47

Yeah. Yeah. So you see it now. You see it right here.

0:51

Yes.

0:52

Yeah. It's subtle for

0:53

It's big swollen. Yeah.

0:55

Yeah. And I had a case the other day that um,

0:58

I had a case the other day that actually I thought it was gonna be, um, Nucor.

1:02

Mycosis. And then I showed it to one of my junior partners and he goes,

1:06

isn't there a little abscess right there? I'm like, oh my gosh, you're,

1:08

you're right. So it still could be mucor,

1:11

mycosis 'cause they can still have fluids.

1:13

So I'm curious to see whether it's gonna be, the patient was had,

1:16

was an uncontrolled diabetic. And so I'm,

1:19

I'm waiting to see whether or not this has turned out to be a bacterial abscess

1:24

or whether it was due to Mucor Muco, mucor mycosis.

1:27

'cause the extent of the soft tissue in Theleman was more than I typically see

1:31

with a odontogenic, um, origin. So we'll see how that,

1:36

see what that turns out to be. And here's the other thing too.

1:39

There's some low attenuation right here. See this area right here?

1:45

Yes.

1:46

Yeah, that's probably all subperiosteal abscess.

1:49

Actually it was subperiosteal abscess. I think they drained it,

1:53

but you're right, because it was a bit unusual,

1:55

because normally what you end up seeing is that you end up seeing bone erosion

1:59

or cortical erosion. And on this one there's no cortical erosion.

2:03

Um, and then normally when you have abscess involving the ator space,

2:07

typically they arise from the molar tooth.

2:09

So it's either the second or third molar,

2:12

and then you have the posterior extension. I mean, you can make an argument,

2:15

maybe there's a rotten tooth there. It's kind of,

2:17

I think that's pushing it a little bit.

2:20

Even on the left side. The mono also look car to me. Yes,

2:25

Yes. Right here. Yes, exactly. Exactly. A hundred percent right. Yeah.

Report

Patient History
Right jaw and dental pain for five days.

Findings
Contrast-enhanced CT was performed of the maxillofacial region and neck. Study is abnormal. There is an abnormality involving the right masticator space. There is asymmetric enlargement of the right masticator space with the suggestion of some fluid adjacent to the medial aspect of the right ramus of the mandible with obliteration of the adjacent fat which could represent early abscess. In addition, there is asymmetric enlargement of the right masseter muscle and medial displacement and enlargement of the right pterygoid muscle. No obvious evidence of bone erosion is identified. There is reticulation of the adjacent subcutaneous fat and ipsilateral platysma muscle superficial to the right masticator space extending inferiorly. In addition, there is subtle increased attenuation involving the right parotid gland which could be due to parotid inflammation from the ipsilateral inflammatory masticator space process. There is also subtle enlargement of right Stensen's duct which could also be due to infectious process.

These abnormalities are typically infectious processes due to posterior spread of an odontogenic infection involving the ipsilateral molar teeth and should be correlated with any relevant findings.

No evidence of infections are identified involving the floor of mouth. There is prominence of the adenoidal tissue involving the soft palate and tonsils. There does appear to be asymmetrically enlarged level 1B and level 2 lymph nodes which may be reactive.

The visualized portion of the brain is within normal limits.

Conclusions
1. Diffuse abnormality involving the right masticator space with likely fluid adjacent to the medial cortex of the ramus of the right mandible and probable myositis involving the medial pterygoid and masseter muscles as described above consistent with myositis, possible subtle abscess. These abnormalities are typically infectious processes due to posterior spread of an odontogenic infection involving the ipsilateral molar teeth and should be correlated with any relevant findings. MR with contrast would further evaluate the extent of abnormality and confirm the presence of possible abscess.
2. Prominence of the lymphoid tissue involving the region of Waldeyer's ring.

Case Discussion

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Suresh K Mukherji, MD, FACR, MBA

Clinical Professor, University of Illinois & Rutgers University. Faculty, Michigan State University. Director Head & Neck Radiology, ProScan Imaging

Tags

Neuroradiology

Head and Neck

CT