Presentation
Known case of pathologically proven squamous cell carcinoma at the left cheek managed with partial left maxillectomy, mandibulectomy, internal fixation and reconstruction of the left mandibular ramus. Left neck dissection was also performed with missing left sternocleidomastoid muscle, left submandibular salivary gland and left internal jugular vein.
Patient Data
There is diffuse soft tissue bulkiness involving the surgical bed and anatomical site of the left masticator space, left side of the neck and the left cheek. However, there is an irregular enhancing component related to the left cheek fat (buccomasseteric fat) reaching about 1.5 cm in size.
Two small peripherally enhancing lesions are noted related to the lateral side of the left hemi-tongue as well as the left side of the soft palate averaging 1 cm each. Enhancing necrotic lymph node is noted at the left parotid region, measuring about 1 cm. The remaining left side of the mandible showed mild periosteal reaction.
Atrophy of the left trapezius muscle suggestive of chronic cranial nerve XI denervation.
High position of the left diaphragmatic dome with mild subsegmental collapse involving the lower lobe of the left lung. The left hemidiaphragm showed diffuse thinned muscle thickness as compared to the right one with diffuse relaxation and elevation.
Case Discussion
Elevation of the hemidiaphragm is a radiologic finding seen in conditions such as diaphragmatic eventration, lobar lung collapse, subphrenic mass or abscess and phrenic nerve paralysis. In diaphragmatic paralysis, the entire hemidiaphragm is typically affected. The atrophic changes of the left hemidiaphragm, combined with the history of ipsilateral radical neck dissection strongly suggests phrenic nerve paralysis.
Phrenic nerve palsy occurs in about 10% of neck dissection cases. Symptoms include dyspnea, cough, chest pain and an increased risk of atelectasis. Phrenic nerve arises from the ventral rami of the C3, C4 and C5 nerve roots, part of the cervical plexus. It descends on the anterior surface of the anterior scalene muscle, so it can be affected in neck dissection.
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