46 show man with dental x-rays showing "left maxillary cyst." Patient is status post left upper molar extraction about one year ago -- since that time swelling in left cheek. Patient appears to be status post left temporal craniectomy and mastoidectomy with a large defect in the tectum of the petrous bone. There is inferior herniation of the temporal lobe through this bony defect to the expected level of the external auditory canal and middle ear. The inner ear structures are visualized and appear grossly normal. Middle ear structures are not visible and the external auditory canal is not visible. There is soft tissue density present in the expected position of the external auditory canal. Correlate with physical examination and medical history and consider evaluation with MRI.The left maxillary sinus is completely opacified and expanded with bony remodeling extending anteriorly into the soft tissues of the left cheek, medially into the left nasal cavity, inferiorly into the left alveolar process of the maxilla and posteriorly into the pterygopalatine fossa. The left ostiomeatal unit is not visible. The bony floor of the left orbit has normal contour and the orbital contents have normal appearance. This lesion is consistent with a mucocele.There is minimal mucosal thickening in the inferior portion of the right maxillary sinus. The right ostiomeatal unit is not clearly seen to be patent on this study. The frontal sinuses, ethmoid air cells, and sphenoid sinuses are normal in appearance. The right orbit is unremarkable. Limited examination of the soft tissues of the face is normal.The right mastoid air cells and middle ear cavity has normal CT appearance. The right external auditory canal is not clearly patent on this study, however, this may be due to soft tissue compression by the InstaTrak device.
1. Expansile lesion in the left maxillary sinus causing extensive bony remodeling. The appearance of this lesion is consistent with a mucocele. 2. Postsurgical changes of left temporal craniectomy and mastoidectomy with absence of middle ear structures and EAC. Inferior herniation of temporal lobe through bony defect and soft tissue at expected position of the external auditory canal. Consider evaluation with MRI.The ordering physician was not available by pager at the time of study interpretation and no additional contact information was available.