Presentation
10 day history of facial pain, purulent rhinorrhea, and poor PO intake.
Patient Data
Non-contrast CT head showed no acute intracranial abnormality. However, there is near complete opacification of the left maxillary sinus with soft tissue extension into the premaxillary and retromaxillary space. There is also subtle abnormal fat stranding in the left superior parapharyngeal and masticator space around the pterygoid muscles. Invasive infectious process was suspected and an urgent MRI sinus with contrast and ENT consult were recommended.
There is extensive T2 hyperintense edema and enhancement involving the soft tissues of the left deep face including the infratemporal fossa and pterygopalatine fossa. The left maxilla alveolus is expanded, with abnormal T1 dark marrow signal and lack of normal enhancement. The adjacent hard palate mucosa is swollen and edematous. There was also lack of normal enhancement of the left inferior turbinate.
Case Discussion
The lack of normal enhancement of the left maxilla and inferior turbinate seen on imaging was initially concerning for invasive infection with mucosal/ bone necrosis. The patient was taken to surgery. Endoscopic nasal exam revealed severe edema and granulation tissue in the left nasal cavity and maxillary sinus. The surgical team debrided necrotic bone of the left maxilla and left inferior nasal turbinate. Surgical specimen was negative for hyphae and culture was negative for fungus.
Further clinical history revealed bisphosphonate use. This, along with the patient's relatively stable clinical course and pathology findings, is in keeping with bisphosphonate-related osteonecrosis of the jaw (BRONJ).
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