A 9-year-old girl presented to the Outpatient Otolaryngology Department with swelling under the right jaw that had slowly increased in size for the past two years. There was no associated fever, pain, voice changes, breathing difficulty, dysphagia, odynophagia, weight loss, and/or history of exposure to tuberculosis. There was a history of exposure to cats. Exposure to cats with the onset of symptoms in the patient led to cat scratch disease and fungal infections being included in the differential diagnosis. These were ruled out with a negative cat scratch titer and negative toxoplasma IgG.
Physical exam showed the presence of two distinct swellings in the submental and right submandibular (SM) area. The swelling in the right SM area was about 2 x 2 inches and the submental area swelling measured approximately 1.5 x 1.5 inches. The swellings felt firm and nodular and were not freely mobile. The remaining of the ear, nose, and throat and general physical exam was normal. Laboratory tests were negative.
Ultrasound (US) of the neck showed the presence of two calcified masses with heterogeneous echotexture. A computerized tomography (CT) scan of the head and neck area with contrast was obtained. A nonenhancing, multilobulated mass with peripheral rim calcification was noted in the SM region mostly on the right side but crossing the midline. The peripheral rim calcifications could signify precursor to bone development within the mass or local necrosis due to mass effect. It measured 4.88 x 3.55 cm (Figure 1). The right SM gland was distinct from the swelling. The remaining salivary glands were normal. The cervical vascular structures were also normal. CT scan characterization of the mass was suggestive of a benign mesenchymal lesion. Other possible differentials included calcified lymph node, calcified plunging ranula without any intraoral component, or liposarcoma.
Surgical excision of the mass was performed through a routine right SM approach. The entire mass was removed along with a surrounding cuff of normal tissue. Since the right submandibular gland was distinct from the swelling and did not seem to be involved at the time of surgery, it was not removed. The mass was a well circumscribed and encapsulated soft tissue lesion with adipose tissue, fibrosis, smooth and skeletal muscle, cartilage, and bone fragments. A thin outer rim was calcified, but the rest of the cut surface was mostly yellowish white with a whorled pattern. The findings were consistent with those of a benign mesenchymoma. The child did well at one- and 6-month follow-up periods without any recurrence of the lesion.