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Radiology Quiz Case 2: Diagnosis

Radiology Quiz Case 2: Diagnosis Diagnosis: Hypoglossal nerve schwannoma of the submandibular space Schwannoma is a benign nerve sheath tumor that is often found in the head and neck. Up to 45% of schwannomas are known to appear in this region, with most occurring intracranially.1,2 In the subset of extracranial head and neck schwannomas, Kragh et al3 found that over 50% occur in the lateral neck. Schwannomas of the hypoglossal nerve are extremely rare, and it is even rarer to see this type of tumor without intracranial involvement.4 There are few case reports of hypoglossal schwannomas occurring exclusively extracranially and even fewer if only those occurring in the submandibular space are included. 4 A pleomorphic adenoma originating from the submandibular gland is the most common diagnosis in this location. Pleomorphic adenomas are the most prevalent salivary gland neoplasms, representing 40% to 50% of tumors of the submandibular gland.5 Typically, these tumors are T2 hyperintense and enhance homogeneously.5 The imaging appearance of pleomorphic adenoma is similar to those of schwannoma and neurofibroma, which are the peripheral nerve sheath tumors. Schwannomas, in particular, are described as well-circumscribed, homogeneous, and sometimes low-density masses on computed tomography.6,7 On MRI, the majority of both benign and malignant schwannomas demonstrate T2 hyperintensity, a finding which may be due to Antoni B configuration.8 Thus, differentiating benign from malignant schwannomas via MRI is difficult, although the definition of the lesion's borders may be helpful.8 Although extremely rare, schwannomas can occur in the submandibular space even in the absence of intracranial involvement. When occurring in the submandibular space, schwannomas have been reported to originate from the hypoglossal nerve, the lingual nerve, as well as from deep parasympathetic nerves within the gland itself.4,9,10 In conclusion, we report a schwannoma of the hypoglossal nerve in the submandibular space. Differential considers include lesions of salivary gland with origin both benign and malignant. Other differential considerations include submucosal presentation of squamous cell carcinoma in the floor of mouth, infection, lymphoma, schwannoma of the fifth cranial nerve, and nodal metastasis.1,4,9 Schwannomas of the submandibular space are well circumscribed, enhance avidly on T2-weighted images, and consist of Antoni A or Antoni B type tissue.4 Return to Quiz Case. Submissions Residents and fellows in otolaryngology are invited to submit quiz cases for this section and to write letters commenting on cases presented. Quiz cases should follow the patterns established. See Instructions for Authors (jamaoto.com). Material for CLINICAL PROBLEM SOLVING: RADIOLOGY should be submitted electronically via the online submission and review system at http://manuscripts.jamaoto.com. Reprints are not available from the authors. References 1. Gooder P, Farrington T. Extracranial neurilemmomata of the head and neck. J Laryngol Otol. 1980;94(2):243-2497373128PubMedGoogle ScholarCrossref 2. Colreavy MP, Lacy PD, Hughes J, et al. Head and neck schwannomas—a 10 year review. J Laryngol Otol. 2000;114(2):119-12410748827PubMedGoogle ScholarCrossref 3. Kragh LV, Soule EH, Masson JK. Benign and malignant neurilemmomas of the head and neck. Surg Gynecol Obstet. 1960;111:211-21814411616PubMedGoogle Scholar 4. Chang KC, Leu YS. Hypoglossal schwannoma in the submandibular space. J Laryngol Otol. 2002;116(1):63-6411860659PubMedGoogle ScholarCrossref 5. Yousem DM, Kraut MA, Chalian AA. Major salivary gland imaging. Radiology. 2000;216(1):19-2910887223PubMedGoogle Scholar 6. Kumar AJ, Kuhajda FP, Martinez CR, Fishman EK, Jezic DV, Siegelman SS. Computed tomography of extracranial nerve sheath tumors with pathological correlation. J Comput Assist Tomogr. 1983;7(5):857-8656411779PubMedGoogle ScholarCrossref 7. Cohen LM, Schwartz AM, Rockoff SD. Benign schwannomas: pathologic basis for CT inhomogeneities. AJR Am J Roentgenol. 1986;147(1):141-1433487205PubMedGoogle ScholarCrossref 8. Li CS, Huang GS, Wu HD, et al. Differentiation of soft tissue benign and malignant peripheral nerve sheath tumors with magnetic resonance imaging. Clin Imaging. 2008;32(2):121-12718313576PubMedGoogle ScholarCrossref 9. Almeyda R, Kothari P, Chau H, Cumberworth V. Submandibular neurilemmoma; a diagnostic dilemma. J Laryngol Otol. 2004;118(2):156-15814979958PubMedGoogle ScholarCrossref 10. Sato K, Shimizu S, Oka H, Nakahara K, Utsuki S, Fujii K. Usefulness of transcervical approach for surgical treatment of hypoglossal schwannoma with paraspinal extension: case report. Surg Neurol. 2006;65(4):397-40116531208PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 2: Diagnosis

JAMA Otolaryngology - Head & Neck Surgery , Volume 139 (5) – May 1, 2013

Radiology Quiz Case 2: Diagnosis

Abstract

Diagnosis: Hypoglossal nerve schwannoma of the submandibular space Schwannoma is a benign nerve sheath tumor that is often found in the head and neck. Up to 45% of schwannomas are known to appear in this region, with most occurring intracranially.1,2 In the subset of extracranial head and neck schwannomas, Kragh et al3 found that over 50% occur in the lateral neck. Schwannomas of the hypoglossal nerve are extremely rare, and it is even rarer to see this type of tumor without intracranial...
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References (10)

Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6181
eISSN
2168-619X
DOI
10.1001/jamaoto.2013.2878b
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: Hypoglossal nerve schwannoma of the submandibular space Schwannoma is a benign nerve sheath tumor that is often found in the head and neck. Up to 45% of schwannomas are known to appear in this region, with most occurring intracranially.1,2 In the subset of extracranial head and neck schwannomas, Kragh et al3 found that over 50% occur in the lateral neck. Schwannomas of the hypoglossal nerve are extremely rare, and it is even rarer to see this type of tumor without intracranial involvement.4 There are few case reports of hypoglossal schwannomas occurring exclusively extracranially and even fewer if only those occurring in the submandibular space are included. 4 A pleomorphic adenoma originating from the submandibular gland is the most common diagnosis in this location. Pleomorphic adenomas are the most prevalent salivary gland neoplasms, representing 40% to 50% of tumors of the submandibular gland.5 Typically, these tumors are T2 hyperintense and enhance homogeneously.5 The imaging appearance of pleomorphic adenoma is similar to those of schwannoma and neurofibroma, which are the peripheral nerve sheath tumors. Schwannomas, in particular, are described as well-circumscribed, homogeneous, and sometimes low-density masses on computed tomography.6,7 On MRI, the majority of both benign and malignant schwannomas demonstrate T2 hyperintensity, a finding which may be due to Antoni B configuration.8 Thus, differentiating benign from malignant schwannomas via MRI is difficult, although the definition of the lesion's borders may be helpful.8 Although extremely rare, schwannomas can occur in the submandibular space even in the absence of intracranial involvement. When occurring in the submandibular space, schwannomas have been reported to originate from the hypoglossal nerve, the lingual nerve, as well as from deep parasympathetic nerves within the gland itself.4,9,10 In conclusion, we report a schwannoma of the hypoglossal nerve in the submandibular space. Differential considers include lesions of salivary gland with origin both benign and malignant. Other differential considerations include submucosal presentation of squamous cell carcinoma in the floor of mouth, infection, lymphoma, schwannoma of the fifth cranial nerve, and nodal metastasis.1,4,9 Schwannomas of the submandibular space are well circumscribed, enhance avidly on T2-weighted images, and consist of Antoni A or Antoni B type tissue.4 Return to Quiz Case. Submissions Residents and fellows in otolaryngology are invited to submit quiz cases for this section and to write letters commenting on cases presented. Quiz cases should follow the patterns established. See Instructions for Authors (jamaoto.com). Material for CLINICAL PROBLEM SOLVING: RADIOLOGY should be submitted electronically via the online submission and review system at http://manuscripts.jamaoto.com. Reprints are not available from the authors. References 1. Gooder P, Farrington T. Extracranial neurilemmomata of the head and neck. J Laryngol Otol. 1980;94(2):243-2497373128PubMedGoogle ScholarCrossref 2. Colreavy MP, Lacy PD, Hughes J, et al. Head and neck schwannomas—a 10 year review. J Laryngol Otol. 2000;114(2):119-12410748827PubMedGoogle ScholarCrossref 3. Kragh LV, Soule EH, Masson JK. Benign and malignant neurilemmomas of the head and neck. Surg Gynecol Obstet. 1960;111:211-21814411616PubMedGoogle Scholar 4. Chang KC, Leu YS. Hypoglossal schwannoma in the submandibular space. J Laryngol Otol. 2002;116(1):63-6411860659PubMedGoogle ScholarCrossref 5. Yousem DM, Kraut MA, Chalian AA. Major salivary gland imaging. Radiology. 2000;216(1):19-2910887223PubMedGoogle Scholar 6. Kumar AJ, Kuhajda FP, Martinez CR, Fishman EK, Jezic DV, Siegelman SS. Computed tomography of extracranial nerve sheath tumors with pathological correlation. J Comput Assist Tomogr. 1983;7(5):857-8656411779PubMedGoogle ScholarCrossref 7. Cohen LM, Schwartz AM, Rockoff SD. Benign schwannomas: pathologic basis for CT inhomogeneities. AJR Am J Roentgenol. 1986;147(1):141-1433487205PubMedGoogle ScholarCrossref 8. Li CS, Huang GS, Wu HD, et al. Differentiation of soft tissue benign and malignant peripheral nerve sheath tumors with magnetic resonance imaging. Clin Imaging. 2008;32(2):121-12718313576PubMedGoogle ScholarCrossref 9. Almeyda R, Kothari P, Chau H, Cumberworth V. Submandibular neurilemmoma; a diagnostic dilemma. J Laryngol Otol. 2004;118(2):156-15814979958PubMedGoogle ScholarCrossref 10. Sato K, Shimizu S, Oka H, Nakahara K, Utsuki S, Fujii K. Usefulness of transcervical approach for surgical treatment of hypoglossal schwannoma with paraspinal extension: case report. Surg Neurol. 2006;65(4):397-40116531208PubMedGoogle ScholarCrossref

Journal

JAMA Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: May 1, 2013

Keywords: diagnostic radiologic examination,radiology specialty

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