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Case 111330

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Referral category

Disease / syndrome / tumor / condition

Region of interest

Upper left side

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Canaray 111330

History of left hemimaxillectomy

The majority of the left maxilla is absent. The left antral air space is continuous with the oral cavity and the left nasal fossa. The left inferior and middle conchae also appear absent. Two vascular clips are evident in the left retroantral region. These findings are consistent with a history of hemimaxillectomy due to the purported history of squamous cell carcinoma. The contiguous left orbital floor, nasal septum, and what remains of the posterolateral wall of the left maxilla appear intact. The remaining posterolateral wall demonstrates a thickened and sclerotic appearance, which is likely secondary to the reported history of radiation treatment. The soft tissue overlying what remains of the antral cavity appears relatively uniform in thickness, and there is no radiographic evidence of a recurrent growth.

Axial views of the maxillae

These axial cross-sectional images demonstrate that the majority of the left maxilla is absent. The antral cavity is continuous with the left nasal cavity, as well as the oropharynx. The remaining superior-most portion of the posterolateral wall of the left maxilla demonstrates a thickened and sclerotic appearance, which is likely secondary to the reported history of radiation treatment. Vascular clips are evident in the left retroantral region, which is secondary to the history of surgery in this area.

Coronal views of the maxillae

These coronal cross-sectional images demonstrate that the left inferior and middle conchae are absent. The contiguous nasal septum and left orbital floor appear intact.

Sagittal views of the left maxilla

These sagittal cross-sectional images demonstrate that the left antral cavity is continuous with the adjacent oral and nasal cavities. The soft tissue lining the post-surgical antral cavity demonstrates a relatively uniform thickness, and there is no radiographic evidence of recurrence.

1. Severe bone loss on tooth 21

There is extensive periodontal bone loss around the buccal, distal, and palatal aspects of tooth 21, which extends from the alveolar crest to involve its root apex. There is generalized widening of the periodontal ligament space around the root of this tooth, which is likely secondary to the presence of clinical mobility. This tooth demonstrates a poor prognosis, and may be a potential source of the patient's discomfort.

2. Defect on tooth 37L

Tooth 37 is partially captured in this imaging volume. A small defect is evident along the lingual aspect of tooth 37, at the level of the cemento-enamel junction. This could represent caries, external resorption, or an irregular focus of abrasion. This defect is not yet continuous with the pulp canal system of this tooth. Clinical correlation is recommended.

3. Mild mucositis of right maxillary sinus

The right maxillary sinus exhibits mild mucositis, which represents an incidental finding with no clinical significance.

4. Ethmoid sinus mucositis

The anterior ethmoid air cells are partially opacified, which suggests the presence of mucositis.

5. Sphenoid sinus mucositis

Mild mucositis is present in the right loculation of the sphenoid sinus. This is a non-significant incidental finding.

6. Dural calcifications

Linear calcifications are present superior to the temporal petrous ridges bilaterally. This likely represents calcification of the dura of the superior petrosal sinuses, which is a non-significant incidental finding.

7. Physiologic midline intracranial calcification

A midline physiologic calcification is present intracranially, which likely represents calcification of the pineal gland or habenula. This is a common incidental finding with no significance.

8. Mild cervical degenerative joint disease

Small osteophytes and mild subchondral sclerosis are present in the articular regions of the Atlas and dens of the cervical vertebrae. This is a common incidental finding with no clinical significance that is suggestive of mild cervical degenerative joint disease.

9. Calcified stylohyoid ligaments

The stylohyoid ligaments are partially calcified bilaterally. This is an incidental finding with no clinical significance.