Case of the Month June 2014, Page 4

Answer:

  • Superficial
  • The deep cervical fascia is divided into 3 layers: superficial, middle, and deep layer.
  • The superficial layer contains the submandibular and parotid salivary gland as well as the muscles of mastication. It surrounds the muscles of expression, trapezius and sternocleidomastoid.

Diagnosis:

  • The patient has Sialadenitis due to an obstructing sialolithiasis. The calculus is in distal course of the left Wharton’s duct. It is large enough that it could obstruct the orifice of the duct and cause proximal dilatation of the left submandibular gland.
  • He was started on antibiotics and advised to maintain oral hydration, place heat on the area, take tart lozenges and avoid anticholinergic medications until resolution of his symptoms.

Discussion:

  • Evaluation of neck masses is a very common medical dilemma and presents a very wide differential to consider.
  • The major three categories to consider are congenital, inflammatory and neoplastic etiologies.
  • The history and presentation as well as the patient’s age will serve to greatly narrow down the acuity of the symptoms and the likely etiologies, but malignancy should always be considered until a benign etiology can be determined.
  • For neck masses that are particularly suspicious or have failed more conservative diagnostic methods, CT examination with contrast is the imaging tool of choice for evaluation of neck masses
  • The goals of imaging should focus on:
    • Distinguishing anatomic position
    • Tissue discrimination
    • Determine adjacent tissue involvement or mass effect
    • Assess enhancement character
    • Evaluate surrounding region for possible primary malignancy and margins

Works Cited:

  • Schwetschenau E, Kelley DJ. The adult neck mass. Department of Otolaryngology and Bronchoesophagology, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA. American Family Physician [2002, 66(5):831-838]
  • Lee, K.J. (2012). Essential Otolaryngology (10 ed.). McGraw Hill. pp. 559–60
  • Uptodate: Evaluation of a neck mass, Differential diagnosis of a neck mass.

 

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