A 12-year-old female patient came with her parent to the morning consultation clinic of our institute suffering from a diffuse swelling of the cheek and lower jaw on the left side with dull pain and discomfort aggravated by swallowing. The symptoms developed and gradually worsened over 8 months and was associated with weight loss and generalized weakness that had been subjectively attributed to the decreased nutrition and appetite. Initially, the patient suffered from a painful intraoral swelling involved the left side of the lower jaw. Management was sought at a local dental clinic, where extraction of a carious deciduous tooth in the area was performed. Later as the symptoms progressed, she was referred to the maxillofacial surgery unit of a local hospital. Two biopsies were taken separately from the region, only yielding inconclusive findings of inflammatory cells and fibrosis.
The patient was referred to our institute for further investigations and management. On examination, there was a slightly tender firm left-sided swelling involving the cheek, not crossing the lower border of the mandible with intact overlying skin (Fig. 1). The patient had normal mouth opening and showed no neurological deficit. Palpable mobile lymph nodes were evident at ipsilateral submandibular and deep cervical levels with no tenderness. Intra-orally, the swelling involved the ipsilateral buccal region and extended medially to the posterior lower alveolus, retromolar trigone and the ascending ramus of the mandible, with erythematous overlying mucosa (Fig. 2). Computed tomography (CT) scan, revealed an expansile lesion involving the left masticatory region, extending from the condylar process to the angle of the mandible, with bicortical erosion, and osteoblastic activity (Fig. 3). The CT findings were reported as a potentially malignant tumor. Routine laboratory blood tests were unremarkable. Incisional biopsy under local anesthesia was obtained from the lesion lateral to the ramus of the mandible. The histopathological study showed a dense chronically inflamed fibrous tissue with evidence of ill-defined granulomas with scattered multinucleated Langhans giant cells. The Ziehl-Neelsen (ZN) stain for acid-fast bacilli (AFB) detection yielded negative results in both the lesion specimen and the pharyngeal expectorate. The chest x-ray of the patient revealed bilateral enlarged hilar lymph nodes. Further investigations by Mantoux test produced 25 mm of induration at 48 h, and a PCR for MTB of blood was positive. Quadruple anti-tubercular therapy was then started at a specialized center of respiratory diseases. At the latest follow-up, one year after the diagnosis, the swelling nearly disappeared with complete resolution for the accompanying symptoms.