Wk 2, Case 5 - Review

Patient History
Localized swelling. Mass in right neck.

Findings
Pre- and postcontrast MR was performed of the neck. The study is abnormal. There is a large mass involving the right palatine tonsil which could be submucosal and medially displaced in the right tonsil. The lesion extends laterally and involves the right parapharyngeal space. The lesion extends deeply and is in close proximity to the right paraspinal musculature. The superior aspect of the tumor extends submucosally to the level of the right nasopharynx with extension into the region of the right torus tubarius. No definite evidence of skull base involvement is seen, although it does extend in close proximity to the inferior skull base. Inferiorly, the lesion extends into the soft tissues of the neck and extends inferiorly to the level of the right pharyngoepiglottic fold. There is anterior displacement of the right submandibular gland with asymmetric enhancement which could be due to adjacent sialadenitis.

There is some edema and enhancement right paraspinal musculature adjacent to the mass which could be due to deep muscle involvement. However, these findings should be correlated with clinical signs of fixation for accurate staging.

There are some enlarged likely metastatic lymph nodes involving right level 2. However, on the MR, this appears to be a conglomerate mass that involves the right tonsil and extends laterally with direct extension into the right neck. Given the patient's age, this likely represents squamous cell carcinoma involving the right tonsil (likely HPV positive) versus lymphoma. Other mesenchymal malignant neoplasms are less likely. CT of the neck may be helpful to better define the lesion and assess for lymph node involvement.

Conclusions
1. Large mass involving the right visceral space extending laterally into the parapharyngeal space and right neck which is likely due to squamous cell carcinoma of the tonsil (likely HPV positive) versus lymphoma.
2. There is some edema and enhancement directly adjacent to the right paraspinal musculature suggesting deep muscle involvement. These findings should be correlated with clinical signs of fixation.