D. Ossification of the free flap pedicle
A painful neck mass is most worrisome for recurrence during surveillance of head and neck cancer.1,2 Though traumatic neuroma or chronic postoperative pain is possible,3 ossification of the FFF pedicle is the correct diagnosis for the following reasons. First, the lesion was stable over 5 years, with lack of fluorodeoxyglucose avidity on positron emission tomography, making recurrence less likely. Second, despite standard-of-care palliation techniques, her symptoms were recalcitrant. Third, the linear radiopacity located in the submental triangle, where the pedicle often courses, makes ossification more likely than a neuroma.
The FFF is the standard for oromandibular reconstruction because of its high success rate and low donor-site morbidity.2 A rare complication is pedicle ossification. Often asymptomatic, it may present as a firm, tender neck mass with trismus and pain with mastication and ipsilateral neck rotation.4,5 Diagnostic imaging including computed tomography or panoramic radiographs can confirm this finding. Most commonly, pedicle ossification is detected incidentally on surveillance imaging.4 The true incidence is unknown, with reports ranging from 4% to 65%; surprisingly, only 2.5% present symptomatically.4,6 Ossification is more common in younger patients and those not receiving high-dose adjuvant radiotherapy.4