Download MBBS Final Year Surgery Case Presentation Parotid_Split Clinical Examination Discussion and Treatment

55 year old male Mr. Saleem coming from Virugambakkam, shopkeeper by occupation, belonging to lower middle class presented with chief complaints of SWELLING BELOW AND BEHIND THE RIGHT EAR FOR PAST 3 WEEKS

HISTORY OF PRESENTING ILLNESS

Patient was apparently normal 3 weeks back after which he developed a swelling behind the right ear

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• duration 3 weeks
• insidious in onset
• initially small in size & gradually increased in size to attain the current size.
• Not associated with pain
• No h/o sudden increase in size of the swelling

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• No h/o difficulty in opening the mouth
• No h/o difficulty in swallowing
• No h/o increase in size or pain during chewing
• No h/o trauma
• No h/o fever

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• No h/o ear discharge, ear pain
• No h/o of drooling of saliva, difficulty in closing eyelid
• No h/o swelling elsewhere in the body
• No h/o loss of weight and appetite

• No h/o dry mouth, dry eye

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• No h/o cough with hemoptysis
• No h/o bone pain

PAST HISTORY :

• No H/o similar complaints in the past
• No H/o TB, asthma, DM, hypertension, epilepsy, jaundice

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• No H/o chronic drug intake
• No H/o previous surgeries/ hospitalisation
• No H/o radiation exposure

PERSONAL HISTORY:

• normal bowel & bladder habits

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• consumes mixed diet
• non smoker & non alcoholic

FAMILY HISTORY : no relevant family history

GENERAL EXAMINATION

– conscious, oriented, moderately built & nourished

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• No pallor,
• icterus,
• cyanosis,
• clubbing,
• pedal edema,

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• generalised lymphadenopathy

Pulse rate : 82 /min, regular in rhythm, normal in volume and character, no vessel wall thickening, no radioradial/radiofemoral delay Felt in all peripheral vessels

Respiratory rate : 16/min, abdominothoracic

Blood pressure: 110/70 mm Hg measured in left upper arm in sitting posture

Patient is afebrile

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LOCAL EXAMINATION

After explaining the procedure and getting consent, examination was done under bright light

INSPECTION

• A single hemispherical swelling of size 3*3 cm below and behind the right ear is seen
• borders well defined

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• extent upper border 3 cm above angle of mandible lower border just above angle of mandible anteriorly 1 cm in front of angle of mandible posteriorly upto mastoid

• Skin over the swelling – normal
• no scars, sinuses, dilated veins, visible pulsation
• lifting of ear lobule is present
• Retromandibular groove obliterated

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• On opening of mouth swelling becomes less prominent
• On clenching of teeth swelling becomes more prominent

PALPATION

• Not warmth & not tender
• Inspectory findings of site, size, shape and extent are confirmed

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• Surface - smooth Skin- pinchable
• Consistency – firm
• Swelling is mobile in both horizontal and vertical direction but not above the zygoma (curtain sign)
• No induration in surrounding area
• On clenching the teeth mobility not restricted

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• No preauricular or postauricular lymphadenopathy

• Bidigital Palpation of stenson duct- saliva oozes out no discharge
• Bimanual palpation of parotid gland – no deep lobe enlargement

• Examination of left parotid region -normal
• Examination of submandibular gland- normal

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• Examination of oral cavity-
  • lips
  • ant and posterior commisure
  • gums/alveolus/floor of mouth
  • buccal mucosa
  • anterior 2/3 of tongue

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  • hard palate
  • uvula in midline
  • tonsil normal not pushed medially
  • Dental formula 2 1 2 3 2 1 2 3
    2 1 2 3 2 1 2 3

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  normal

• EXAMINATION OF OF FACIAL NERVE
• wrinkling of forehead present
• able to close eyelids against resistance

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• nasolabial folds normal
• no deviation of angle of mouth
• able to blow cheek
• anterior 2/3 of tongue taste normal
• corneal reflex -normal

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• conjunctival reflex- normal

• EXAMINATION OF HEAD AND NECK NODES – normal on inspection and palpation

• Respiratory system :

  Normal vesicular breath sounds heard. No added sounds

• Cardiovascular system :

  S1 S2 heard. No murmurs

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• Central nervous system :

  No focal neurological deficit

• Abdomen :

  Soft, non tender, no organomegaly, no free fluid, hernial orifices free, external genitalia normal

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• Spine and cranium : normal

• DIAGNOSIS

  swelling in the right parotid region most probably pleomorphic adenoma without deep lobe or facial nerve involvement

• DIFFERENTIAL DIAGNOSIS:
  • warthin tumour
  • benign oncocytoma

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  • parotid lymph node enlargement

Management :

Baseline Investigation:

• Blood – CBC, TC, DC, ESR, hb %, blood grouping and typing

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• serum -sugar, urea, creatinine
• urine – sugar, albumin, deposits
• ECG & CHEST X-ray
• Serology : HIV, VDRL, HBsAg

• SPECIFIC INVESTIGATIONS
  • USG neck

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  • FNAC
  • CECT neck MRI NECK
• TREATMENT

  SUPERFICIAL PAROTIDECTOMY WITH FACIAL NERVE CONSERVATION ON RIGHT SIDE

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