Toothache with a twist: Incidental inferior alveolar nerve sheath tumor on cone beam computed tomography

An incidental mandibular canal lesion was identified in a 26-year-old male on routine cone beam computed tomography done for dental caries workup. Imaging revealed a well-defined lytic lesion with focal expansion of the right mandibular canal and cortical thinning. Subsequent magnetic resonance imaging demonstrated a T2/short tau inversion recovery hyperintense lesion with a characteristic “target sign” and homogeneous post-contrast enhancement along the course of the inferior alveolar nerve. These features favored a peripheral nerve sheath tumor. Such lesions are rare and often asymptomatic, detected incidentally on imaging done for other head and neck pathologies. Recognition of canal-centered morphology and characteristic features is critical, as imaging can lead to a sufficiently confident provisional diagnosis and guide management.