A case of a ‘swelling’

Dr. Archan Khandekar(PGY3, VSGH)

History A 22 year old female Hindu patient named XYZ coming

from low socioeconomic class residing at Amraiwadi, Ahmedabad came to VSGH on the 22nd of July 2015 with chief complaints of :-

Swelling in right side of neck since the last 2 years. The patient was relatively asymptomatic before 2 yrs;

after which she noticed a single swelling in right side of neck just below the jaw while being in front of the mirror. The growth of the swelling was insidious; gradually increasing in size from being barely noticeable to its current size of that of a lemon.

The swelling was not associated with pain. There was no associated fever. There was no difficulty in breathing, swallowing or change

of voice There were no similar other swellings present at any other

location or in the past. The skin over the swelling wass normal no redness or

blackening of the skin was noticed. There was no restriction in movement of the jaw. There was no history of trauma to the region.

No associated history of loss of body weight was present. There was no history of any episodes of loss of

consciousness. Patient has no past history of any major or minor surgical

procedure. Patient is not a known case of Diabetes Mellitus or

Tuberculosis. There is no past history of any blood transfusion or any

allergic reactions. Patient is on mixed diet with normal bowel and bladder

function with no addictions. The obstetric and gynecological history of the patient has

no findings of any significance.

General examination

I have examined the patient in proper light and exposure. The patient is conscious, cooperative and well oriented with

person place and time. She is fairly built and fairly nourished with no specific decubitus

, gait or attitude. No signs of pallor, icterus, cyanosis, clubbing, edema or

generalized lymphadenopathy present. The Pulse is 88/min in right radial artery with normal force

tension and volume with bilateral symmetry. The is BP is 124/76 mm Hg in the right brachial artery.

There is a single, ovoid swelling 4*3 cm in size, just below the body and anterior to the angle of the mandible in submandibular triangle on the right side.

Surface over the the swelling is smooth with regular well-defined edges.

Skin over the swelling is is normal. No ulcer, scar sinus fistula or venous engorgement seen over the skin.

No impulse on coughing is seen over the swelling and there are no visible pulsations.

Inspection

There is no movement of the swelling with deglutition and there is no movement of the swelling with protrusion of the tongue.

The oral cavity does not show any positive findings on inspection.

The cervical spine of the patient does not have any visible deformity.

Palpation

The skin over the swelling is non warm, non tender. The swelling is 4*3*3 cm in size with its superior border just below

and lateral to body of the mandible and and deep to the platysma made evident by making the muscle taut.

The surface of the swelling is smooth with well defined edges on all aspects except the superomedial side where it merges imperceptibly with the deep structures but can be seperated from the mandible in its entire extent.

The consistency of the swelling is cystic and fluctuation can be illicited with no slip sign.

Some amount of indentation is present in the entire extent of the swelling.

Transillumination is negative with no impulse on coughing present.

It is non reducible and non compressible. The swelling is non pulsatile. It is not fixed to the overlying skin and becomes less

evident on making the platysma taut on the right side signifying its presence deep to it.

The surrounding lymph nodes do not show any enlargement.

The cervical spine is normal. The oral cavity; including the floor of the mouth reveal no

abnormalities on bimanual digital examination of the same.

There are no positive findings on percussion or auscultation.

Diagnosis

The swelling is a Inframylohyoid (cervical) dermoid of the lateral variety.

D/D

Submandibular lymph node.

Submandibular gland swelling.

Plunging ranula.

Branchial cyst.

Investigations

Complete blood hemogram. X-ray (Cervical spine/ local part/ chest) Ultrasonography. CT Scan.

Treatment

The operative procedure for the above swelling would be a complete excision with an incision kept in the langer’s lines in the submandibular region.

CT pictures