Recurrent nasopharyngeal carcinoma treated with CRT completed July 2016 with worsening left mandible pain, left parotid swelling, and skull base findings of nasolaryngoscopy concerning for ORN and/or osteomyelitis. There is a heterogeneously enhancing mass in the left in the upper left post-styloid parapharyngeal space and extending into the hypoglossal canal and jugular foramen, measuring up to approximately 23 mm in axial section, which is not significantly changed. There is no significant intracranial component or tumor and the left pterygopalatine fossa region appears unchanged. There are persistently diminished adjacent sigmoid and internal jugular venous flow voids. There are denervation changes involving the left masticator and tongue muscles, with associated diffuse edema and enhancement. There is unchanged asymmetric effacement of the left lateral nasopharyngeal recess with diffuse mucosal enhancement and surrounding inflammatory changes, but otherwise no evidence of gross tumor in this particular location. There is diffuse central skull base enhancement and diffuse right sphenoid sinus mucosal thickening. There is also abnormal bone marrow signal in the left mandible with an apparent defect in the left mandibular ramus, with surrounding reticular subcutaneous fat enhancement. There also appears to be mild inflammation of the anterior portion of the left parotid gland and what may represent focal dilatation of the left parotid duct near the ampulla, with a punctate central focus of low signal. There is fluid within the left mastoid air cells and middle ear. There is no significant cervical lymphadenopathy. The orbits and imaged brain parenchyma are grossly unremarkable.
1. The treated recurrent tumor in the left in the upper left post-styloid parapharyngeal space and extending into the hypoglossal canal and jugular foramen has not significantly changed, along with denervation effects in the left masticator and tongue muscles.2. Diffuse central skull base bone marrow abnormality may represent treatment effects, including osteonecrosis, and/or osteomyelitis, perhaps related to sphenoid sinusitis.3. Findings compatible with left mandible osteonecrosis, perhaps with superimposed osteomyelitis and cellulitis and an apparent pathological fracture, for which a maxillofacial CT may aid in further delineation.4. Apparent mild inflammatory changes in the anterior left parotid gland, which may be related to extension from adjacent inflammatory process or perhaps related to ductal obstruction from a calculus. CT may be useful for further evaluation of this as well.5. Fluid within the left mastoid air cells and middle ear may be secondary to Eustachian tube obstruction, perhaps with superimposed otomastoiditis. 