PMC8164024_01
Non contrast axial CT initial scan in the emergency room demonstrated no significant intracranial pathology. However the soft tissue windows demonstrated loss of fat planes in the right parapharyngeal space (blue arrow) and masticator space (red arrow). (For interpretation of the references to colour in this Figure legend, the reader is referred to the web version of this article).
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Radiological assessment with CT head (Fig. 1) demonstrated thickening of the external auditory canal and middle ear with an ill-defined soft tissue mass pacifying the right mastoid air cells cavity.
Axial STIR MRI sequence demonstrates hyperintensity (oedema) in multiple neck spaces including masticator space adjacent to the lateral pterygoid muscle (blue arrow). There is mucosal congestion within the nasopharynx (red arrow) with high signal noted posteriorly in the longus capitis muscle (green arrow) suggestive of extension through the retropharyngeal space. Note fluid secretions within the right mastoid air cells (yellow arrow). (For interpretation of the references to colour in this Figure legend, the reader is referred to the web version of this article).
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Subsequent MRI (Fig. 2 and Fig. 3) showed an extensive diffuse multi-compartmental enhancement with bone involvement suggestive of osteomyelitis.
Axial FDG PET-CT demonstrates mild increased avidity in the right deep neck spaces including carotid and masticator spaces (arrow). The "low grade" nature of the tracer uptake suggests infective cause rather than malignant.
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In the view of disease progression while on treatment, PET -CT (Fig. 4) was arranged to rule out potential underlying neoplasms; but was furthermore supportive of an underlying infectious process.