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Neurology

A Mass in the Infratemporal Fossa

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Otolaryngology–Head & Neck Surgery

Published Online: March 31, 2022

Clinical Challenge

Article Information and Disclosures

Kevin Tie, MD¹;

Yew Song Cheng, MD²;

James G. Naples, MD¹

Author Affiliations

¹Department of Otolaryngology–Head & Neck Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
²Department of Otolaryngology–Head & Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts

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A 51-year-old woman was referred for evaluation of headache, right-side jaw pain, paresthesia, and trismus. The patient reported that the facial and jaw symptoms had evolved gradually over the past 5 years and that multiple medical therapies had provided only minimal relief of pain. The patient’s medical history included anxiety, depression, emphysema, hyperlipidemia, migraines, and pseudoseizures. She denied prior head trauma and had no pertinent surgical history. On physical examination, the patient had normal body habitus and reported bilateral tenderness of the temporomandibular joints and paresthesia of the right trigeminal nerve in the V2 and V3 distribution with intact masseteric nerve and symmetric facial nerve. Audiometric evaluation showed normal hearing bilaterally. Magnetic resonance imaging (MRI) revealed a cystic mass in the right side of infratemporal fossa (ITF) that was nonenhancing on T1 sequencing with contrast and hyperintense on T2 (Figure 1A).

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A. Encephalocele

The ITF is a difficult-to-access space between the skull base, lateral pharyngeal wall, and ramus of the mandible. It is bounded anteriorly by the posterolateral wall of the maxillary sinus; posteriorly, by the carotid sheath; laterally, by the ramus of the mandible; medially, by the lateral pterygoid plate, tensor veli palatini, and levator veli palatini; superiorly, by the greater wing of the sphenoid; and inferiorly, by the medial pterygoid muscle. The medial border of the infratemporal fossa is continuous with the pterygopalatine fossa.¹

The differential diagnosis of an ITF mass typically includes various tumors, such as juvenile nasopharyngeal angiofibroma, parotid tumors, and schwannoma.² In rare cases, encephaloceles can present in the ITF. Diagnosis of ITF lesions can often be delayed because symptoms are vague, and there are few examination findings that suggest this specific diagnosis.

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Article Information

Corresponding Author: James G. Naples, MD, Division of Otolaryngology–Head & Neck Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (jnaples513@gmail.com).

Published Online: March 31, 2022. doi:10.1001/jamaoto.2022.0175

Conflict of Interest Disclosures: Dr Naples reported receiving honorarium from DeckerMed for serving as editor-in-chief, outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Casale J , Bordoni B . Anatomy, head and neck, infratemporal fossa. In: StatPearls. StatPearls; 2022.

Lisan Q , Leclerc N , Kania R , Guichard JP , Herman P , Verillaud B . Infratemporal fossa tumors: when to suspect a malignant tumor? a retrospective cohort study of 62 cases. Eur Ann Otorhinolaryngol Head Neck Dis. 2018;135(5):311-314. doi:10.1016/j.anorl.2018.06.005 PubMed Google Scholar Crossref

Kato H , Kanematsu M , Mizuta K , et al. “Flow-void” sign at MR imaging: a rare finding of extracranial head and neck schwannomas. J Magn Reson Imaging. 2010;31(3):703-705. doi:10.1002/jmri.22071 PubMed Google Scholar Crossref

Matos Cruz AJ , De Jesus O . Encephalocele. In: StatPearls. StatPearls; 2021.

Alobaid A , Schaeffer T , Virojanapa J , Dehdashti AR . Rare cause of trigeminal neuralgia: Meckel’s cave meningocele. Acta Neurochir (Wien). 2015;157(7):1183-1186. doi:10.1007/s00701-015-2434-4 PubMed Google Scholar Crossref

Gozgec E , Ogul H . Giant cephalocele case mimicking cystic neoplasia in skull base. J Craniofac Surg. 2020;31(6):e530-e532. doi:10.1097/SCS.0000000000006460 PubMed Google Scholar Crossref

AMA CME Accreditation 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.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.