 There is a dominant mass centered in the right retromolar trigone with involvement/direct invasion of the right base of tongue. The mass is diffusion restricting, avidly enhancing, and T2 hyperintense, located at the level of the angle of the mandible. It measures approximately 29 x 22 mm (series 1101, image 23) in greatest axial dimensions, previously measuring 23 x 20 mm (CT neck series 3, image 37). This mass abuts and effaces the glossotonsillar sulcus, which is better delineated on CT. The anterior aspect of the mass extends caudally and laterally towards the inferior right parotid gland, with more heterogeneous enhancement, with intervening fat plane remaining. The mass abuts the angle of the mandible (series 1101, image 24) without definite evidence of erosion or enhancing extension into the mandibular canal/foramen. There appears to be involvement of the right pterygoid muscles anteromedially with partial effacement of the right parapharyngeal fat plane. The distal right cervical ICA is partially encased by the base of the tongue/retromolar trigone mass with sparing of the lateral margin. There is an additional enhancing 8 x 6 mm nodule along the left lateral aspect of the base of tongue in the left retromolar trigone, just anterior to the left pterygoid muscles and abutting the left angle of the mandible. This is best seen on 1101/25.There are multiple enlarged or pathologic appearing cervical lymph nodes with reference measurements provided below, and many of which demonstrate hypermetabolism on recent PET/CT:Several right level Ib nodes are rounded in morphology with the larger measuring 9 mm (series 1101, image 18).Right retropharyngeal lymph node is somewhat necrotic and demonstrates partial restricted diffusion. This node measures 10 mm (series 101, image 27) and may correlate with previous questioned right torus tubarius abnormality on PET CT. This node abuts the upper cervical right carotid artery.An additional right level IIb lymph node measures 12 mm in the long axis (series 1101, image 21) and is not enlarged by size anterior, although demonstrates restricted diffusion as well as hypermetabolic activity on an outside PET examination, although described in the EMR as a right posterior cervical triangle node.There is slight prominence of T2 hyperintense signal along the left fossa of Rosenmueller laterally, although without distinct mass. The questioned thickening of the left nasopharyngeal soft tissues appears to correlate with several partially necrotic appearing left retropharyngeal lymph nodes, which measure up to 13 mm (series 101, image 31) and demonstrate hypermetabolism on recent PET/CT. There is abutment of the distal upper cervical left internal carotid artery with slight lateral displacement, with partial encasement by asymmetric enhancing T2 hyperintense tissue caudal to the distinct lymph nodes.Left level 2a necrotic mass which may be a node versus nodal conglomerate measures 20 x 17 mm (series 1101, image 20), previously measuring 21 x 17 mm (CT neck series 3, image 45). This nodal conglomerate has mass effect on the left sternocleidomastoid muscle and adjacent vasculature.Right submandibular glandular tissue is not well visualized. There are no thyroid masses. The right sternocleidomastoid muscle is atrophied.
1.Right base of the tongue/retromolar trigone mass as detailed, likely representing new primary malignancy. Extension to the right mandibular angle without definite cortical involvement. Direct extension into right parapharyngeal space and invasion of right pterygoid muscles.2.Encasement and abutment of the right distal cervical ICA by the right base of the tongue/retromolar trigone mass and abutment by the right retropharyngeal lymph node.3.Small enhancing mass along the left retromolar trigone, perhaps a lymph node. Correlation with direct inspection is recommended to exclude additional primary malignancy, although no overwhelming hypermetabolism is noted on prior PET/CT and there is no significant diffusion restriction.4.Bilateral cervical lymphadenopathy including retropharyngeal in location, with the reference measurements provided. Dominant left level IIa necrotic nodes. 