1. Case Presentation
Moderator ā Dr. V. B. Pathak
Ass. Professor
Department of General Surgery
MIMS , Barabanki
Presenter- Dr.Pooja Pandey
PGJR2
Department of General Surgery
MIMS , Barabanki
7/16/2022 1
4. History of Presenting Illness
ā¢ Apparently well 2months back
ā¢ Suddenly noticed a swelling located just below the right jaw .
ā¢ initially the size of a peanut and had been gradually increasing until it
reached the present size of lemon of approx 2x1cm .
ā¢ Swelling was neither increasing or decreasing in size in relation to meal
7/16/2022 4
5. History of Presenting Illness contd..
ā¢ H/o pain from 15 days
ā¢ Dull aching, intermittent , localized to the swelling , no radiation , not
increased or decreased with the food .
ā¢ No aggravating factor , sometimes she has to take pain killers from local
chemist .
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6. History of Presenting Illness contd..
ā¢ No h/o pus discharge from the floor of mouth
ā¢ No h/o drooling of saliva ,skin changes over the swelling
ā¢ No h/o toothache, ear ache
ā¢ No h/o fever, cough and weight loss .
ā¢ No h/o change in voice .
ā¢ No h/o difficulty in swallowing
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7. History of Presenting Illness contd..
ā¢ No h/o Radiation to head and neck
ā¢ No h/o joint pain
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8. Past history
ā¢ No h/o HTN, T2DM, Thyroid disorder and Tuberculosis
ā¢ No h/o any surgical intervention
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9. Family history
ā¢ No h/o HTN, T2DM and TB
ā¢ No h/o autoimmune disease in the family .
ā¢ No h/o malignancy related to head and neck
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10. Menstrual history
ā¢ Age of menarche- 13years
ā¢ LMP-1st July 2022
ā¢ Regular cycles
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11. Drug and allergic history
ā¢ No known h/o allergy to any drug and food
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12. Treatment history
ā¢ She is taking pain killers on-off prescribed by local chemist from past 15
days (no documentation available)
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13. Personal history
ā¢ Mixed diet
ā¢ Appetite normal
ā¢ Normal sleep habit
ā¢ Normal bladder and bowel habit
ā¢ No h/o addiction to smoking and alcohol.
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14. Case summary
ā¢ A 17yr female from Barabanki normotensive ,nondiabetic presented in an
OPD with C/O swelling in the right upper part of neck x2months and pain
x15 days .
ā¢ She suddenly noticed a swelling located just below the right side of jaw
,initially the size of a peanut and had been gradually increasing until it
reached the present size of lemon of approx 2x1cm . Swelling was neither
increasing or decreasing in size in relation to meal. Associated with pain x
15days which was dull aching, intermittent , localized to the swelling , no
radiation , not increased or decreased with the food and gets relieved on
taking pain killers.No h/o skin changes, discharge,toothache ,ear ache , loss
of weight, fever ,cough, drooling of saliva, joint pain and radiation to head
and neck .
7/16/2022 14
15. General Examination
ā¢ Well nourished
ā¢ Conscious and well oriented to time , place and person
ā¢ No pallor ,icterus ,cyanosis , clubbing , oedema and lymphadenopathy
(Except for neck ).
ā¢ Spine is normal
7/16/2022 15
17. Systemic examination
ā¢ Central Nervous System- conscious , oriented
GCS-15/15
ā¢ Cardio Vascular System- S1,S2 heard
No murmur
ā¢ Respiratory System ā Bilateral air entry present
Normovesicular breathing sound .
No added sound
ā¢ Abdominal examination- Soft ,non tender ,no distension
Bowel sound present .
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18. Neck- Local Examination
ļInspection
ā¢ Single ,diffuse swelling with ill-defined borders of approximately 4 Ć 3 cm in
the right submandibular region.
ā¢ The overlying skin is normal and healthy
ā¢ No other swelling on left , right side and in front of neck
ā¢ No visible scars/sinuses
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19. Neck- Local Examination
ļPalpation
ā¢ Swelling of 5x2cm was felt in the right submandibular region
ā¢ no local rise in temperature, tender, firm in consistency, nonfluctuant,
non compressible, mobile, and showed signs of matting .
ā¢ Other lymph nodes were not palpable.
7/16/2022 19
22. Case summary
ā¢ A 17yr female from Barabanki normotensive ,nondiabetic presented in an OPD
with C/O swelling in the right upper part of neck x2months and pain x15 days .
She suddenly noticed a swelling located just below the right side of jaw ,initially
the size of a peanut and had been gradually increasing until it reached the
present size of lemon of approx 2x1cm . Swelling was neither increasing or
decreasing in size in relation to meal. Associated with pain x 15days which was
dull aching, intermittent , localized to the swelling , no radiation , not increased
or decreased with the food and gets relieved on taking pain killers.O/L/E-
Swelling of 5x2cm was felt in the right submandibular region , no local rise in
temperature, tender, firm in consistency, nonfluctuant, non compressible,
mobile, and showed signs of matting . Other lymph nodes were not palpable.
Oral exam-Digital palpation- No stone is palpable in the duct . Odontogenic
involvement due to the swelling was not present.
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23. Differential diagnosis
ā¢ Right submandibular tuberculous lymphadenitis
ā¢ Right submandibular sialadenitis.
ā¢ Lymphoma
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24. Differential diagnosis
Differential diagnosis Points in favor Points in against
Right submandibular tuberculous
lymphadenitis
Swelling and pain
Firm consistency
Mobile
Sign of matting
No fever, weight loss
Right submandibular sialadenitis. Swelling ,pain
Firm in consistency
No h/o increase and decrease in
swelling in association with food
Mobile
Digital palpation ā enlarged gland is
not palpable , no stone felt .
Lymphoma Swelling
Firm in consistency
pain
Sign of matting (late stage)
No h/o loss of weight
7/16/2022 24
26. Investigation
ā¢ A panoramic radiograph was carried out and it did not reveal
odontogenic origin in relation to the swelling .
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27. Investigation
ā¢ A Mantoux test was positive. No abnormality was detected in chest
radiographs .
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28. Investigation
ā¢ A complete hemogram showed
ā¢ Hemoglobin levels to be 8.8 gm%
ā¢ Total white blood cell count was 8,200 cells/cu mm.
ā¢ Erythrocyte sedimentation rate (ESR) was raised 1st hour 75 mm, 2nd hour
105 mm.
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29. USG neck
ā¢ A ultrasound scan of the patientās neck revealed multiple hypoechoic
nodular lesions of varying sizes in the right submandibular region,
abutting and displacing the right submandibular salivary gland. The
largest of the lesions measured 3.4 Ć 2.9 cm and matting was
apparent . There were a number of other similar smaller lesions along
the right jugular vein, which is suggestive of lymphadenopathy. The
ultrasound report was consistent with that of right submandibular
and jugular tuberculous lymphadenopathy.
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30. FNAC
ā¢ Ultrasound-guided fine-needle aspiration biopsy (FNAB) revealed a
cellular aspirate showing plenty of small and large lymphocytes.
Necrotic debris was seen in focal areas, and few epithelioid cells or
giant cells seen.
ā¢ The ultrasound-guided FNAB report was compatible with that of
tuberculous lymphadenitis.
ā¢
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33. Treatment
ā¢ Treatment consisted of anti-TB drugs for a period of 6 months.
ā¢ No complications occurred, and no further surgery was required.
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By comparison, normal range hemoglobin is 12%ā16 gm%, blood cells 4ā5 million/cu mm, and total white blood cells 4000ā11000 cells/cu mm. Erythrocyte sedimentation rate (ESR) was raised 1st hour 75 mm, 2nd hour 105 mm.
