0:01

This is an older patient who had

0:04

known history of leukemia.

0:06

And as you can see from the initial CT scan,

0:10

there is evidence of sinusitis.

0:13

There's also middle ear cavity abnormality which is

0:18

present bilaterally with partial opacification on

0:21

the right side as well as partial

0:24

opacification on the left side.

0:26

Now, initially because of the presence

0:29

of the sinusitis and the patient

0:33

had tubes placed previously,

0:38

we thought that this was just benign

0:40

disease in the middle ear cavity.

0:42

What we should have picked up is this large erosive

0:46

process which is occurring in the mastoid tip on the

0:50

left side with gross destruction of the

0:54

outer wall of the mastoid bone.

0:57

And then this opacification of the mastoid

0:59

air cells becomes much more worrisome.

1:02

And so an MRI scan was performed.

1:06

You can also see that there is an erosive area just

1:10

along the sigmoid sinus transfer sinus

1:13

junction on the left side.

1:15

So let's look at the MRI scan which quickly followed

1:19

once the clinical team had pointed out that the

1:22

patient's symptoms were on the left

1:23

side and along the mastoid.

1:25

So I'm going to go to the T2-weighted images and

1:30

you note that there is a very large

1:33

mass affecting the mastoid tip.

1:35

It's not bright in signal intensity.

1:37

It's low in signal intensity.

1:40

On T2-weighted scanning on

1:42

ADC maps, you can see that

1:45

this is diffusion-weighted scan.

1:47

You can see that there is intermediate signal

1:50

intensity. And on the ADC map here,

1:55

it has some dark areas within it.

1:57

This is pretty typical of a lymphoma or leukemic

2:00

infiltration in that it's dark in signal intensity,

2:04

usually thought to be secondary

2:05

to the hypercellularity.

2:07

What was a little bit more striking, however,

2:09

was the post gadolinium-enhanced scans.

2:11

So on the post gadolinium-enhanced scans,

2:14

you can see this necrotic mass which is below the

2:17

skull base and ultimately infiltrates the mastoid.

2:20

Here's a portion of the mastoid tip.

2:22

Here's a portion of the occipital region,

2:25

soft tissues. And then going further superiorly,

2:30

we start to get into the actual temporal bone region

2:34

and there is this big honking mass coming out

2:38

through the stylomastoid frame

2:40

along the 7th cranial nerve.

2:42

So this patient did develop a facial nerve palsy

2:47

associated with the descending portion of the facial

2:52

nerve in the intramastoid portion through

2:54

the leukemic infiltration.

2:56

Here was just a little bit of contrast

2:58

enhancing tissue that was associated.

3:00

In the middle ear cavity,

3:01

which at the time that the temporal bone was

3:03

resected, was also leukemic infiltration.

3:06

This, however, could have been very easily a skin cancer.

3:12

The portion that is superficial

3:14

may be relatively minor.

3:16

You can have deep growth of

3:17

those and facial squamous

3:22

carcinomas and skin cancers can have

3:26

perineural spread, all of the types.

3:29

So melanoma can do it,

3:30

basal cell carcinoma can do it,

3:32

and squamous cell carcinoma can do it.

3:34

Most common being squamous cell carcinoma.