A Submandibular Mass in an Elderly Patient

Abstract

The diagnosis of a neck mass can present a challenge. In the adult the most common diagnosis is malignancy, and both primary and metastatic tumors should be considered. Other frequent options are infectious processes. We present the case of an 88-year-old female patient with a submandibular mass with inflammatory signs, unresponsive to antibiotic therapy, with fine needle aspiration biopsy showing an inflammatory lesion. The mass developed over a month with associated anorexia resulting in admission for diagnosis with open biopsy. Following admission, an invasive carcinoma of the right breast was diagnosed, and the Mycobacterial culture of the submandibular mass biopsy was positive for Mycobacterium tuberculosis. Immunosenescence the elderly contributes to vulnerability to cancers but also infections which can present atypically and thus result in delayed diagnosis. The physical characteristics of the mass are also important for differential diagnosis. Solid, hard, or fixed, with irregular limits are suggestive of solid malignancies; multiple soft and rubbery masses suggest lymphoma; masses with inflammatory signs suggest infectious causes [6]. Inflammatory masses can result from inflammation of lymph nodes (cervical adenitis), which are usually self-limited and resolve spontaneously [2]. Chronic inflammation of submandibular or parotid glands with chronic sialadenitis is also possible [2]. Infectious causes can be viral, bacterial or fungal in nature [2,6]. Viral infections such as Cytomegalovirus (CMV), Epstein-Barrvirus (EBV), measles, Adenovirus, Echovirus, Rhinovirus and Respiratory Syncitial Virus (RSV) [2,6] usually present with multiple lymph nodes with cervical adenitis. Bacterial infections can cause necrosis, with abscess formation, spontaneous drainage and even chronic fistula formation [2]. Other agents should also be considered namely mycobacterial [2,6], cat-scratch disease by Bartonella [6,7], actinomycosis [2,6], Toxoplasma gondii [8]. Other less frequent causes are gout [9], inflammatory pseudotumor [10], Kimura’s disease [11], Castleman’s disease [12] and sarcoidosis [13]. Diagnosis is usually made by fine needle aspiration cytology, which is a rapid and sensitive method [1,6]. If the diagnosis remains unclear, an open biopsy may be necessary [1,6]. Laboratory tests vary with presentation, but should include inflammatory parameters including CASe RePoRt