Tuesday, 27 December 2016

70 year old man with neck mass

Title :- History in patient's voice

Disclaimer:-
This is a de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

I was fine and had no problems till  4 months ago. no Diabetes, no Hypertension, but one day i got malaria, for 1 month got treatment but it didn't weny well, then diagnosed with typhoid 3 months ago and then got treated for another two month, then swelling started on my neck 1 month ago, it was small, around size of an almond, but it pain, and so i got to hospital. I Took medicine from Dr. but it kept increasing, then i got admitted because of large size it caused difficult to swallow then difficulty in speaking and also some pain.

I used to chew pan before 1980, since then i left and i never did smoking or alcoholism.
Since 4 month when fever started my digestion never did well.
It feels lil warm, and pain when touched. Also i am feeling that mass have started on opposite side of face also and it is even bigger.

I have also started having cough now and need to spit it, and difficulty in breathing.
While breathing it makes sound "kharr kharr"

Since 2-3 years i am using spects if need to read something, and didn't had any surgery or medication till 4 months since when fever started.













Rakesh Biswas Would be good to have your inputs on this https://lh3.googleusercontent.com/.../IMG_20161228_130031... neck mass Dr Nidhi, Dr Anoj, Dr Satish, Dr Agamya, Dr Sandie, Dr Prasanna
UnlikeReply1December 28 at 10:10pmEdited
Boudhayan Dm Adding Dr. Manish Gulia to the discussion...... Sir and Nidhi Sehgal Maam will be able to provide the maximum inputs at this point......Invite Dr. Soumik Chaudhuri to discuss the risks from a Cardiologist's view point.........Invite ENT specialists Dr. Arjun Dasgupta Dr Shantanu Panja to the discussion about the approach to this case as the patient might be heading towards one of the Kolkata institutes once the diagnosis is established........Will request Dr. Anupam Datta Somnath Gooptu to discuss the possibilities including the risks of malignancy.......request Dr. Devmalya Bhattacharya - and Dr. Shilpa Bhartia to discuss abt the possibilities and the way out........Avinash Kumar pls add a few more images
LikeReply2Yesterday at 7:45amEdited
Boudhayan Dm Harshith Kramadhari Request his inputs as a student in Interventional Radiology. Trilochan Agrawal request his inputs too
LikeReplyDecember 28 at 10:37pm
Anupam Datta The history says the mass is 1 month of going to this proportion....CT features are suggestive of big central necrosis (and certainly not a cystic component) along with destruction of the ramus of the mandible.... Such masses which are > 1 cm size, central necrosis capsular breach and mandibular destruction are most likely to be malignant...an FNA should give us a clear picture from here...
LikeReply1December 28 at 10:37pm
Anupam Datta Its most likely a level 2-3 lymph node that has infiltrated into the right parotid...having seen the limited scans I feel we need to rule out a parotid primary vs metastatic secondary in a lymph node...but yes all after an FNA
LikeReply1December 28 at 10:40pm
Nidhi Sehgal Looks like...necrotic lymph nodes with internal jugular vein thrombosis...
LikeReply1December 28 at 11:01pm
Nidhi Sehgal Tried fnac...but only blood came out
UnlikeReply1December 28 at 11:02pm
Arjun Dasgupta Massive mass. Infiltrating . Destructive. What is it?
LikeReply1December 28 at 11:07pm
Rakesh Biswas Thanks for the inputs Dr Arjun, Dr Anupam, Dr Nidhi and Boudhayan. So far this appears to be just an internal jugular thrombosis and we are still searching for a primary. Here's http://qjmed.oxfordjournals.org/content/104/3/209 some literature (case series) reporting primary internal jugular vein thrombosis to the tune of 20%. Dr Chandra Mouli, Dr Shilpa Bhartia for inputs
LikeReplyYesterday at 7:06am
Rakesh Biswas Dr Nidhi if we see this other reported patient http://www.sciencedirect.com/.../pii/S175500170900089X... with a left IJV thrombus the right sided IJV appears to have taken up contrast remarkably well in the transverse section but we didn't notice the s...See More
UnlikeReply1Yesterday at 7:14am
Rakesh Biswas Here's http://medcraveonline.com/JOENTR/JOENTR-02-00019.pdf another patient with right sided IJV along with an extensive evidence based review.
LikeReplyYesterday at 7:27am
Rakesh Biswas Avinash, Boudhayan we need to inquire if this patient had sore throat along with the fever he had for the last 3 months. See this report here: http://www.jabfm.org/content/28/3/425.long. Again in this patient Dr Nidhi a distinct difference can be seen when compared with the left IJ vein http://www.jabfm.org/content/28/3/425/F2.expansion.html
UnlikeReply1Yesterday at 7:49am
Arjun Dasgupta IJV thrombosis alone does not explain the mandibular infiltration
LikeReply2Yesterday at 8:15am
Boudhayan Dm Invite my senior teachers Dr. Arup Kumar Kundu Dr. Madhuchanda Kar Dr. Asok Sengupta Dr. Angira Dasgupta to the discussion
LikeReplyYesterday at 8:27am
Prasanna Datta Fibreoptic laryngoscopy and nasopharyngoscopy are planned today, leta see what happens.
LikeReplyYesterday at 10:05am
Rakesh Biswas Dr Nidhi the nasal endoscopy findings today suggest a nasal tumor and yet when Avinash reviewed the CT again with the radiologist present there he was told that the CT doesn't show any such lesion. Will be looking forward to your reviewing te CT tomorrow and if still the CT is normal we may have to review the nasal endoscopy Dr Prasanna, Boudhayan?
UnlikeReply1Yesterday at 5:00pm
Prasanna Datta Nasal endoscopy done today, showing smooth, rounded mass occupying nasopharynx. In laryngoscopy the vocal cords cant be seen, the mass in the neck has pushed the pharyngeal wall medially , so vocal cords cant be seen properly.
LikeReply1Yesterday at 5:12pm
Prasanna Datta May be it is a lymphoma but biospy is pending
LikeReply1Yesterday at 5:24pm
Rakesh Biswas Thanks Dr Prasanna. Dr Nidhi it seems an accessible lymph node had been spotted on CT and a USG guided FNA was planned from it today but it appears that it wasn't done today. Would it be possible to do it tomorrow?
LikeReply122 hrs
Rakesh Biswas FNAC from the left cervical lymph node has been done yesterday and the report is awaited Dr Nidhi, Dr Prasanna, Dr Manish
LikeReply125 mins
Nidhi Sehgal No bony erosion
LikeReply123 mins
Nidhi Sehgal There is a hypo area in supraglottic larynx (rt pyriform sinus )extending up to to left preepiglottic space
LikeReply21 mins
Rakesh Biswas Thanks Dr Nidhi, I guess this answers Dr Arjun's concerns about the bony mandibular infiltration? Dr Prasanna how do we explain the discrepancy between the CT and endoscopy findings. Apparently there is a large mass in the nasopharynx but none visible in CT and no remarkable lesion on video-endoscopy but a hypo area in supraglottic larynx (rt pyriform sinus )extending up to to left preepiglottic space. Should we repeat the video laryngoscopy to re-examine this CT finding?

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