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Pathology · patient case with 2 questions

Neck swelling that worsens with meals

Patient: 41-year-old woman.

Chief complaint: A lump in my neck that swells up and hurts when I eat.

History: Three months of intermittent swelling. The swelling and pain build during meals and settle over the following hour. No fever, no weight loss.

Findings: A soft, doughy swelling in the anterior neck. Bimanual palpation of the floor of the mouth elicits tenderness along the course of the left submandibular duct. Scant saliva expressed from the duct orifice.

Question 1

What is the MOST likely diagnosis?

  1. Submandibular space infection
  2. Obstructive submandibular sialadenitis from a sialolith
  3. Thyroglossal duct cyst
  4. Reactive cervical lymphadenopathy
Show answer and explanation

Correct answer: B. Obstructive submandibular sialadenitis from a sialolith

  • A. A space infection presents with fever, trismus, systemic upset and a firm indurated swelling that does not come and go.
  • B. CORRECT. Swelling and pain PROVOKED BY EATING is the defining history of obstructive salivary disease. Meals stimulate flow; an obstructing stone backs saliva up and the gland swells painfully, then settles. The submandibular gland accounts for 80 to 90 percent of salivary calculi because its secretion is mucous and alkaline and Wharton's duct runs uphill.
  • C. A thyroglossal duct cyst sits in the MIDLINE and characteristically moves on swallowing or tongue protrusion. It does not fluctuate with meals.
  • D. A reactive node is a discrete, mobile swelling unrelated to eating.

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Question 2

Which imaging study best confirms the diagnosis?

  1. Periapical radiographs of the mandibular anterior teeth
  2. Panoramic radiograph
  3. Mandibular cross-sectional occlusal radiograph
  4. Serum thyroid function tests
Show answer and explanation

Correct answer: C. Mandibular cross-sectional occlusal radiograph

  • A. Periapical films image teeth and periapical bone, not the duct.
  • B. A panoramic view superimposes the mandible over the floor of the mouth and frequently hides a stone.
  • C. CORRECT. A cross-sectional OCCLUSAL film projects the floor of the mouth clear of the mandible and is the classic view for a radiopaque calculus in Wharton's duct. Roughly 80 to 85 percent of submandibular stones are sufficiently radiopaque to be seen. Where the film is negative but the history is convincing, ultrasound or sialography follows.
  • D. Thyroid function tests would be relevant to a thyroid or thyroglossal lesion, not to an obstructed salivary duct.

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