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Radiology Quiz Case 1

Radiology Quiz Case 1 A 50-year-old woman presented with an 8-month history of unilateral left-sided otalgia and tinnitus. The findings of her ear, nose, and throat examination were remarkable only for a House-Brackmann grade II lower motor neuron facial palsy on the left side. Her audiogram confirmed normal hearing in both ears. Magnetic resonance imaging of the internal auditory meatus was performed to investigate her unilateral tinnitus. The findings were reported to be normal, but it was later found that a subtle soft tissue signal was present in the left mastoid complex instead of the absence of signal that would be expected. The facial palsy was treated with prednisolone (initally at 60 mg/d, with gradual reduction of dosage thereafter). The patient made a complete recovery and was subsequently discharged. She presented again 1 year later with a painful swelling above her left ear. She gave no history of otorrhea or hearing loss. Physical examination revealed a fluctuant, tender swelling, measuring approximately 3×2 cm, above and behind her left ear. She had a normal tympanic membrane on both sides, and findings of the rest of the ear, nose, and throat examination were normal. A provisional diagnosis of a subcutaneous abscess was made, and the patient underwent incision and drainage of the postauricular swelling. Surgery revealed increased soft tissue deep to the skin that bled profusely, but there was no pus. The results of microbiologic examination of a swab were negative, and histologic analysis of a biopsy specimen demonstrated inflammatory tissue. The wound failed to heal despite a course of oral and topical antibiotics. Magnetic resonance imaging was performed to exclude an underlying vascular lesion. The T2-weighted images (Figure 1) showed a relatively low-intensity signal within the left temporal bone in comparison to the opposite temporal bone. The patient was readmitted for intravenous antibiotic therapy, but her wound remained unchanged, although her pain improved. Her white blood cell count was 11 900/μL; erythrocyte sedimentation rate, 8 mm/h; and C-reactive protein, 2.1 mg/L (20.0 nmol/L). Examination of the wound, with the patient under anesthesia, revealed loss of cortical bone deep to the wound and a cavity extending into the petrous temporal bone. A myringotomy showed no fluid in the middle ear, suggesting that there was no active middle ear disease. Biopsy specimens were subsequently obtained for histologic and microbiologic analysis, and computed tomography of the temporal bones (Figure 2) showed a large lytic lesion of the left temporal bone, particularly in the squamous part. The middle and inner ear structures demonstrated no abnormalities. Histologic analysis showed inflammatory debris, bone fragments, and cartilage of questionable viability. There were 2 tiny areas of very cellular fibrous tissue and blue spindle cells, but the findings of the biopsy were considered nondiagnostic. Serologic tests were negative for antinuclear, antineutrophil cytoplasmic, antimitochondrial, anti–smooth muscle, and rheumatoid factor antibodies. Figure 1. View LargeDownload Figure 2. View LargeDownload What is your diagnosis? http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 1

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Radiology Quiz Case 1

Abstract

A 50-year-old woman presented with an 8-month history of unilateral left-sided otalgia and tinnitus. The findings of her ear, nose, and throat examination were remarkable only for a House-Brackmann grade II lower motor neuron facial palsy on the left side. Her audiogram confirmed normal hearing in both ears. Magnetic resonance imaging of the internal auditory meatus was performed to investigate her unilateral tinnitus. The findings were reported to be normal, but it was later found that a...
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Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archoto.2007.31-a
Publisher site
See Article on Publisher Site

Abstract

A 50-year-old woman presented with an 8-month history of unilateral left-sided otalgia and tinnitus. The findings of her ear, nose, and throat examination were remarkable only for a House-Brackmann grade II lower motor neuron facial palsy on the left side. Her audiogram confirmed normal hearing in both ears. Magnetic resonance imaging of the internal auditory meatus was performed to investigate her unilateral tinnitus. The findings were reported to be normal, but it was later found that a subtle soft tissue signal was present in the left mastoid complex instead of the absence of signal that would be expected. The facial palsy was treated with prednisolone (initally at 60 mg/d, with gradual reduction of dosage thereafter). The patient made a complete recovery and was subsequently discharged. She presented again 1 year later with a painful swelling above her left ear. She gave no history of otorrhea or hearing loss. Physical examination revealed a fluctuant, tender swelling, measuring approximately 3×2 cm, above and behind her left ear. She had a normal tympanic membrane on both sides, and findings of the rest of the ear, nose, and throat examination were normal. A provisional diagnosis of a subcutaneous abscess was made, and the patient underwent incision and drainage of the postauricular swelling. Surgery revealed increased soft tissue deep to the skin that bled profusely, but there was no pus. The results of microbiologic examination of a swab were negative, and histologic analysis of a biopsy specimen demonstrated inflammatory tissue. The wound failed to heal despite a course of oral and topical antibiotics. Magnetic resonance imaging was performed to exclude an underlying vascular lesion. The T2-weighted images (Figure 1) showed a relatively low-intensity signal within the left temporal bone in comparison to the opposite temporal bone. The patient was readmitted for intravenous antibiotic therapy, but her wound remained unchanged, although her pain improved. Her white blood cell count was 11 900/μL; erythrocyte sedimentation rate, 8 mm/h; and C-reactive protein, 2.1 mg/L (20.0 nmol/L). Examination of the wound, with the patient under anesthesia, revealed loss of cortical bone deep to the wound and a cavity extending into the petrous temporal bone. A myringotomy showed no fluid in the middle ear, suggesting that there was no active middle ear disease. Biopsy specimens were subsequently obtained for histologic and microbiologic analysis, and computed tomography of the temporal bones (Figure 2) showed a large lytic lesion of the left temporal bone, particularly in the squamous part. The middle and inner ear structures demonstrated no abnormalities. Histologic analysis showed inflammatory debris, bone fragments, and cartilage of questionable viability. There were 2 tiny areas of very cellular fibrous tissue and blue spindle cells, but the findings of the biopsy were considered nondiagnostic. Serologic tests were negative for antinuclear, antineutrophil cytoplasmic, antimitochondrial, anti–smooth muscle, and rheumatoid factor antibodies. Figure 1. View LargeDownload Figure 2. View LargeDownload What is your diagnosis?

Journal

Archives of Otolaryngology - Head & Neck Surgery – American Medical Association

Published: Feb 1, 2008

Keywords: diagnostic radiologic examination,radiology specialty

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