A 64-year-old woman with a history of hyperlipidemia, hypertension, HIV infection, coronary artery disease, and squamous cell carcinoma of the left mandible treated with composite resection, left neck dissection, and fibula free flap (FFF) reconstruction followed by postoperative radiotherapy presented with sharp, shooting left neck pain. Beginning 5 months after her reconstruction, the patient reported point tenderness on the left jaw, facial swelling, and electric pain with severity of 7 out of 10 in the left neck that occurred with talking or eating. Her postoperative course was complicated by osteoradionecrosis post-tracheostomy, plate removal, and left segmental mandibulectomy. She received regular physical therapy and lymphedema therapy and was seen by Physical Medicine and Rehabilitation, who treated her with onabotulinum toxin A injections; neither provided significant resolution of her symptoms. Review of a computed tomography scan of the head and neck (Figure 1) performed on follow-up 5 years after initial reconstruction demonstrated a long, hyperdense structure in the left submental, submandibular region with accompanying soft-tissue thickening. On further review of prior imaging, this calcification appeared as a new finding in various scans dating back to 5 months after FFF reconstruction compared with preoperative imaging. There was no fluorodeoxyglucose avidity in the area of question on multiple positron emission tomography scans done during this follow-up window.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Steven B. Cannady, MD, Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Penn Medicine Washington Square, 800 Walnut St, 18th Floor, Philadelphia, PA 19107 (firstname.lastname@example.org).
Published Online: July 29, 2021. doi:10.1001/jamaoto.2021.1685
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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