A 17-year-old female patient reported to the Department of Oral Medicine and Radiology at Sri Sai College of Dental Surgery in Vikarabad, complaining of a painful swelling in her right submandibular region that had been present for two months and was originally noticed on June 13th 2009. The swelling was initially the size of a peanut and had been gradually increasing until it reached the present size. (Figure 1)
On general examination the patient was thin and malnourished. There were no fever, cough, or weight loss symptoms present. Past medical history and family history was not significant.
On extraoral examination, inspection showed a single diffuse swelling with ill-defined borders of approximately 4 x 3 cm in the right submandibular region. The overlying skin was the same as surrounding skin. On palpation a mass was felt in the right submandibular region, which was firm in consistency, tender, nonfluctuant, noncompressible, mobile, and showed signs of matting (Figure 2). On intraoral examination, odontogenic involvement due to the swelling was not present. Other lymph nodes were not palpable.
A clinical diagnosis of right submandibular tuberculous lymphadenitis was considered. Differential diagnosis of right submandibular sialadenitis, right submandibular gland calcification was considered.
A panoramic radiograph was carried out and it did not reveal odontogenic origin in relation to the swelling (Figure 3). A Mantoux test was positive. No abnormality was detected in chest radiographs (Figure 4). A complete hemogram showed hemoglobin levels to be 8.8 gm%, The red blood cell reading was 3.3 million/cu mm, and the total white blood cell count was 8,200 cells/cu mm. By comparison, normal range hemoglobin is 12%-16 gm%, blood cells 4-5 million/cu mm, and total white blood cells 4000-11000 cells/cu mm. Erythrocyte sedimentation rate (ESR) was raised 1st hour 75 mm, 2nd hour 105 mm.
A ultrasound scan of the patient's neck revealed multiple hypoechoic nodular lesions of varying sizes in the right submandibular region, abutting and displacing the right submandibular salivary gland. The largest of the lesions measured 3.4 x 2.9 cm and matting was apparent (Figure 5). There were a number of other similar smaller lesions along the right jugular vein, which is suggestive of lymphadenopathy. The ultrasound report was consistent with that of right submandibular and jugular tuberculous lymphadenopathy.
Ultrasound-guided fine-needle aspiration biopsy (FNAB) revealed a cellular aspirate showing plenty of small and large lymphocytes. Necrotic debris was seen in focal areas, and few epithelioid cells or giant cells seen (Figures 6 and 7). The ultrasound-guided FNAB report was compatible with that of tuberculous lymphadenitis.
Regarding the clinical presentation of the case and the investigation reports a final diagnosis of right submandibular tuberculous lymphadenitis was arrived at. The patient was referred to the TB hospital for further treatment. Treatment consisted of anti-TB drugs for a period of 6 months. No complications occurred, and no further surgery was required.