2024_07_19 New Orofacial Symptoms... Tangent or Course Correction?

For this post, I meant to revisit papers on neurocysticercosis, correlate examples therein with my imaging, and post side-by-sides with quoted text so as to make my concerns and reasoning crystal clear. (I had an ELISA test done, which came back negative for NCC, but as experts recommend against that test I am left with questions).

However.

New symptoms claimed my attention. I suspect they might relate to a presumedly anomalous incident in the distant past, and I've redirected my radiological explorations accordingly...

A story unfurls obliquely:

This story begins when your hero is just five years old. She is informed by her mother that her cheek is swollen. It doesn't hurt, but she is taken to a hospital where a full-body x-ray is performed and she is chastised for not standing perfectly still. (For the record, her whole attention had been painfully focused on standing still!)

Later under anesthesia a hole is drilled under her chin, and the material swelling her right cheek is suctioned out through a tube. She stays at the hospital a couple days, wearing a funny Smurf hat; then back to life as usual.

Surgical scar from old-school sialendoscopy

Fast-forward ~thirty years. 

The subject has resumed annoying doctors, via an onslaught of symptoms; in the process acquiring a Maxillofacial CT on which she notices a cluster of nodular hyperdensities along the R mandible above the location of her scar. She gets a second opinion review of the CT and mentions that early sialendoscopy. Reviewing neuroradiologist writes: "Calcifications are noted in the expected location of the right submandibular duct on the maxillofacial CT. These are favored to represent sialoliths. These could be further evaluated with MR sialogram as clinically indicated to better characterize the submandibular gland and duct." Also, "There is a slightly prominent 7 mm midline submental lymph node noted on the CT maxillofacial. Correlation with exam findings is suggested to ensure resolution since this 2019 exam. This is of uncertain but doubtful clinical significance."

She asks in a follow-up question whether it makes sense to pursue MR sialogram; after advisement she feels that it's not necessary at this time as findings are asymptomatic.

Submental lymph node mentioned above, presumably.
Full study: https://www.dicomlibrary.com/meddream/?study=1.3.6.1.4.1.44316.6.102.3.20240504181626641.20600546525101990789

Fast-forward ~3.5 years to now. 

Symptoms arise, perhaps related to aforementioned findings. 

There is once again a facial asymmetry, becoming visible over the course of a week or two. The asymmetry is palpable and tender. Her roommate can feel it, though he cannot see it. There has been a recurring sore on the roof of her mouth for over a month, and gum bleeding and soreness. She recalls the bone loss mentioned by the last dentist she saw a couple/few years ago before she became disabled. How she'd gotten a referral to a periodontist, but that fell through when Insurance wouldn't cover the appointment.

She thinks about the enhancing, diffusion-restricted(?) area involving the R buccal fat and superficial soft tissue on a recent MR study. She initially thought it must be artifact. It corresponds roughly with the visible swelling.

R side swelling (black arrow)

Restricted diffusion? Involves R buccal fat and soft tissue?
Full study: https://www.dicomlibrary.com/meddream/?study=1.3.6.1.4.1.44316.6.102.3.2024020619222112.433093631319132013166

In Summary

Areas of interest (to me):

1. floor of mouth (R sublingual salivary gland), 
2. roof of mouth (L pterygopalatine foramen),
3. side of mouth/cheek (R buccal fat, buccinator muscle?) 

I see the most interesting things on:

1. T2 (esp TIRM), 
2. CT, and possibly 
3. T1 w/out contrast.

Studies I wish I had:

1. MR sialogram
2. MR or CT w/ puffed cheek
3. KISS or FIESTA (the FIESTA I got stopped just above what I wanted to see)
4. CT contrast (kind of worried about how many CTs I've gotten though)
5. A better resolution ADC than the ones I have
6. For all of the above: Axial range from the top of the cavernous sinus down to and including C6 (want to know what's up at C5/C6). Coronal range, as far back as the maxillofacial CT is enough. It would also be awesome if I could rotate the axes like on a 3D model, reconfiguring as I go so I can see ALL bilateral structures paired on the same frames instead of having to deal with a lot of them being woefully shifted. I bet that technology exists, but not for my laptop! If only the world could spare a tiny fraction of the resources needed for Bitcoin. Alas.

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Images to include in future blog post: 

• CT salivary stones, neck hyperdensities (are they all in the sublingual duct?) 
• Submental lymph node over time
• Hard palate over time
• Measurements (greatest asymmetries)