Clinical Case SeriesDentistry

Clinical Case Series: Case #2: What’s this lump?

Thank you guys for the fabulous responses and overall success of our first clinical case scenario. Please feel free to continue making comments and discussion on that article, but if you are looking for something new, read on!

Scenario #2 – What’s this lump? (Diagnosis)

Approx year level 3+

Scenario
A 60 year old man, Mr Ellis, presents at his check-up appointment with you. Upon questioning upon why he is here today, he comments that he is having some trouble swallowing like ‘something is lodged in my throat’. He says he was going to book an appointment with his GP after he got his teeth cleaned.

Mr Ellis upon presentation
 (Ref: American Academy of Family Physicians: Home Page — AAFP)

What can you see in this photograph?
What should you do as apart of your extra oral exam in regards to what is presented in the photograph?
What other anatomical landmarks should you be aware of?
What else might you need to do as apart of Mr Ellis dental exam and why?

Ok I'll have a go. I'm trying to be mindful of using clinically appropriate descriptive language.<br />
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<blockquote>What can you see in this photograph?</blockquote><br />
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A (presumably) unilateral supraclavicular mass (or swelling) located over in the region of the left mid-jugular chain area. <br />
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<blockquote>What should you do as apart of your extra oral exam in regards to what is presented in the photograph?</blockquote><br />
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Gently palpate the mass and it's immediate surroundings, noting size, shape, firmness, mobility, depth and whether it is tender/painful on palpation, movement or swallowing. I'd also want to make particular note of whether it's unusually warm or discoloured or if there are others signs of acute inflammation.<br />
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Then visual and tactile examination of the head and neck with particular attention paid to the supradiaphramatic lymph nodes and suferficial glands. <br />
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<blockquote>What other anatomical landmarks should you be aware of?</blockquote><br />
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In regards to the mass? Or the focused extra oral exam?<br />
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Maybe start at the pre and post auricular nodes, submandibular region inferior to the mandible, and then note the position of the sternocleidomastoid muscle (to identify the cervical chain lymph nodes) down to the clavicles. <br />
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Also submental region down, identify thyroid cartilage and bilaterally palpate (gently) on swallowing. <br />
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<blockquote>What else might you need to do as apart of Mr Ellis dental exam and why?</blockquote><br />
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Intra oral examination, with close inspection of the mucosa, tongue, floor of the mouth, oropharynx (tonsils in particular), posterior pharyngeal wall and pharyngeal pillars. In this patients case I would be particularly vigilant for signs of infection, mucosal/oropharyngeal lesions/masses.<br />
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I think one of the key things would be to determine whether this neck mass is discrete or present in conjunction with other abnormalities of the glands & lymph, including systemic symptoms (fever, weight loss/gain, night sweats, fatigue). If it is mass of lymphoid origin, it could very well be a sign of disease process occuring elsewhere (or vice versa).
    Awesome, thanks for the response!<br />
    <br />
    <blockquote><br />
    In regards to the mass? Or the focused extra oral exam?<br />
    </blockquote><br />
    <br />
    I meant in relation to the mass. So in addition to the jugular vein as you have described, I would be mindful of the deep cervical lymph node chain (possible origin?). Its too inferior and posterior to have much to do with the submandibular glands or parotid. <br />
    <br />
    In regards to the intraoral, I would be mindful of specifically palpating the salivary glands to ensure the swelling is separated from them. Also, the general state of the dentition or any heavily carious or restored teeth which might well be the cause of this swelling (an interesting path of infection, but still). Same applies to periodontal disease, and as you said, any other infections, or lesions which might indicate a systemic disease.
    <blockquote>Ok I'll have a go. I'm trying to be mindful of using clinically appropriate descriptive language.<br />
    <br />
    A (presumably) unilateral supraclavicular mass (or swelling) located over in the region of the left mid-jugular chain area. </blockquote><br />
    <br />
    A single mass can't be described as being <span style="font-style:italic;">both</span> "supraclavicular" and "located over the the jugular chain". One or the other: not both.
      <blockquote>A single mass can't be described as being <span style="font-style:italic;">both</span> "supraclavicular" and "located over the the jugular chain". One or the other: not both.</blockquote><br />
      <br />
      Thanks Chinaski :)<br />
      <br />
      What would be the most concise and appropriate way to describe this location? Either? Or something else?
        Personally I'd either go with immediately medial to SCM or within the anterior triangle of the neck.
        <blockquote>Thanks Chinaski :)<br />
        <br />
        What would be the most concise and appropriate way to describe this location? Either? Or something else?</blockquote><br />
        <br />
        Jugular chain would be the better of the two (note, obviously, that there are different levels of neck nodes, so you can be as tricky or as simple as you wish in your description). Supraclavicular nodes are found in the supraclav fossa, and represent a different region of lymphatic drainage (hence, you set off a whole different set of differentials in one's head if you describe a supraclav mass).
          <blockquote>Jugular chain would be better. Supraclavicular nodes are found in the supraclav fossa, and represent a different region of lymphatic drainage (hence, you set off a whole different set of differentials in one's head if you describe a supraclav mass).</blockquote><br />
          <br />
          But doesn't jugular chain imply lymph node involvement? From the picture it's possible that there are lymph nodes involved but possible that it's something entirely different. Wouldn't something less influential be more appropriate? I can just imagine that describing location as being on the lymph nodes would potentially mislead another clinician to immediately be blinded to non-lymph-node problems.
          To be fair, the original description was about something being located over the "mid-jugular chain region" - so we're talking more geographically, rather than pathology specifically. But yes, if you wanted to be picky, then using anatomical landmarks may be considered preferable if you don't want to lead your audience.
          That what I was trying to do. I immediately thought "DDx Hodgkins, lump is probably deep cervical chain", but was trying to describe it generally and not jump the gun. Have a little trouble with picking the landmark sometimes :S
          [offtopic]<blockquote>That what I was trying to do. I immediately thought "DDx Hodgkins, lump is probably deep cervical chain", but was trying to describe it generally and not jump the gun. Have a little trouble with picking the landmark sometimes :S</blockquote><br />
          <br />
          Whoa, Nelly. Hodgkins is certainly a possibility, but it probably shouldn't be at the top of your list. Horse, zebra.... [/offtopic]
          Maybe the first step should really just be to describe the location of the lesion in basic terms, as if you were on the phone to a OMS register or pathologist. I am thinking along the lines of ash's comment, slightly anterior to SCM, below angle of mandible, halfway towards midline of neck...etc
          <blockquote>[offtopic]<br />
          <br />
          Whoa, Nelly. Hodgkins is certainly a possibility, but it probably shouldn't be at the top of your list. Horse, zebra.... [/offtopic]</blockquote><br />
          <br />
          Haha understood. Pulling the reins in :)
          History first.<br />
          <br />
          Before exam.<br />
          <br />
          Onset, time to onset, pain or painless lump?<br />
          Associated symptoms? Infectious (fever, chills, lethargy) ... which others will point out, constitutional features may also be 'B' symptoms of lymphoma<br />
          Any dental abscess or caries? Is this related to an oral pathology at all?<br />
          <br />
          Located anterior triangle of the neck. The dental group know anatomy better than I do?
          Glad to see the medical cohort joining in to. You guys are welcome as always. I will try and find the time to continue the scenario soon :)<br />
          <br />
          Oh and if you want to continue what you would do next that's fine, love a but of good discussion!
          Sorry its been a while. Crazy times. Lets move this along!<br />
          <br />
          <span style="font-weight:bold;">Mr Ellis upon presentation</span><br />
          <img src="http://www.aafp.org/afp/2002/0901/afp20020901p831-f3.jpg" alt=" " /> <font size="1">(Ref: American Academy of Family Physicians: <a href="http://www.aafp.org/">Home Page -- AAFP</a>)</font><br />
          <span style="font-style:italic;"><br />
          What can you see in this photograph?</span><br />
          - A swelling just anterior to the SCM and below the angle of the mandible.<br />
          - Several cm in diameter, may extend towards the submandibular region<br />
          - Overlying skin doesnt seem overly inflammed (some redness)<br />
          - Swelling lies over the deep cervical lymph nodes chain (possible origin), it is too far posterior and inferior to be related to the submandibular salivary gland<br />
          <br />
          <span style="font-style:italic;">What should you do as apart of your extra oral exam in regards to what is presented in the photograph?</span><br />
          - Palpation (firm? fluctant? mobile or fixed? tenderness?), any other areas of swelling around the neck<br />
          <br />
          <span style="font-style:italic;">What other anatomical landmarks should you be aware of?</span><br />
          - Submandibular salivary glands<br />
          - Deep cervical lymph node chain<br />
          <br />
          <span style="font-style:italic;">What else might you need to do as apart of Mr Ellis dental exam and why?</span><br />
          - Intraoral examination (submandibular glands appear normal? State of dentition? Possible cause of any abscesses? eg carious tooth or advanced perio)<br />
          - Medical history check<br />
          - Questioning about history of swelling (pain? sudden appearance?)<br />
          <br />
          Feel free to add stuff guys, I am just writing what I can think of.
          So as above, here is some more information...<br />
          <br />
          You have palpated the swelling and surrounding tissue:<br />
          - Lesion approx. 8cm x 6cm<br />
          - Feels firm, possibly slightly fluctuate<br />
          - It is mobile and not fixed to overlying skin or deeper structures<br />
          - No tenderness to palpation<br />
          - No other swellings<br />
          <br />
          Intraoral exam<br />
          - Submandibular glands sppear symmertrical, mobile and are not attached to the swelling<br />
          - Patients mouth has had extensive restorative work, and does not to be overly stable (some carious lesions are present)<br />
          - Generalised ~3-4mm pocketing with no mobility<br />
          - Lower left molar has lost of large restoration and has had secondary decay developing previously<br />
          - No soft tissue swellings or draining sinus, with no tenderness to palpation around the lower left molar, also no TTP<br />
          <br />
          <span style="font-style:italic;">What are some of the differential diagnoses?<br />
          <br />
          What investigation(s) would you perform related to the swelling?</span>
[OFFTOPIC]This is actually really interesting, can't wait to join in when the time comes :p[/OFFTOPIC]
    I can't wait either! You should be able to have a read and contribute to the first clinical case discussion Raiden! (Go have a look)<br />
    <br />
    But anyway, cmon guys! I dont want to answer myself!
      How long has the lump been there / when did the patient first start noticing foreign-body sensation on swallowing?<br />
      Is there a history of trauma or surgery to the head/neck region? Hx of recent or reoccuring systemic symptoms (fever, malaise, anorexia, sweating, chills etc).<br />
      <br />
      The timeline of the presenting complaint will be important in the DDx and next steps.<br />
      <br />
      However, absent other information perhaps the following for consideration and revising:<br />
      - Sebaceous cyst<br />
      - Paraganglioma (e.g. carotid body tumour, maybe glomus vagale)<br />
      - Brachial cleft cyst<br />
      - Squamous cell carcinoma met or other met<br />
      - Lipoma<br />
      - Lymphoma<br />
      - Hodgkins disease<br />
      <br />
      also aneurysm should be considered.<br />
      <br />
      Absent other information, perhaps referral for contrast CT, FNB and examination of upper aerodigestive tract
        C'mon dent peeps (who may or may not be in the middle of exams :))
          From any medlings chiming in you also want to know<br />
          <br />
          - if there is a bruit on auscultation, does it sound vascular?<br />
          - the degree of obstruction - pemberton's sign<br />
          - is it true dysphagia, or is it odynophagia. Is it for solids and fluids? Or is one easier then the other? Are they able to eat at all? Does it sound mechanical? or is something else going on?<br />
          - in addition to signs, and symptoms of Lymphoma, you also want the same for other head, neck cancers - specifically drinking, smoking and reflux<br />
          - mumps vaccination<br />
          - and of course since this is a dent question :p you definitely want to know if they have something interesting in there past history which would concern you somewhat - aka a prosthesis of some kind, such as a metallic heart valve<br />
          <br />
          My ddx at this stage includes<br />
          <br />
          Infection; reactive lymphadenitis - EBV and CMV, lymphadenitis, parotitis <br />
          AV malformation<br />
          Neoplastic; lymphoma, or mets from elsewhere eg. oral, oseophageal <br />
          Lipoma<br />
          <br />
          In light of the extensive dental work such development of recent infectious looking stuff - I'd be leaning towards infection. <br />
          <br />
          Bloods; FBC, UECs, LFTs, EBV/CMV serology, swab of the infectious tooth<br />
          <br />
          If some/all of neoplastic signs were becoming evident, I'd be considering a biopsy +/- further investigations for the likely primary eg. endoscopy<br />
          <br />
          If the patient was leaning towards the more unstable side of things - eg airway compromise/unable to tolerate solids and fluids I'd potentially be looking at a referral to the ED
          <blockquote>C'mon dent peeps (who may or may not be in the middle of exams :))</blockquote><br />
          I wish I could but I know nothing about diagnosis yet! Just about to finish up with Head and Neck anat so past being able to say where that lump is I wouldn't be of much use haha. :( Maybe next sem/year!
          Thanks season for chipping in. I k ow this is aimed at dent students but obviously it will have medical relevance as well! Join in guys!!
          <blockquote>Thanks season for chipping in. I k ow this is aimed at dent students but obviously it will have medical relevance as well! Join in guys!!</blockquote>Wish i could, but all i have done is embryology and reproductive systems. So unless that person is actually a girl and its an ectopic pregnancy...im gone.Give me a few years haha :)
C