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Clinical Problem Solving: Pathology
April 2002

Pathology Quiz Case 2

Author Affiliations
 

FREDERIC B.ASKINMDWILLIAM H.WESTRAMD

Arch Otolaryngol Head Neck Surg. 2002;128(4):453. doi:

A 49-YEAR-OLD African American woman with no history of alcohol or tobacco abuse presented to our clinic with 2 head and neck masses. Her initial reason for seeking evaluation was a right-sided mass near the angle of the mandible. This mass was firm and uncomfortable but not painful; it had been progressively growing over the last several months. The second mass, which was on the left side of the midneck area, had been slowly growing for 1 year and was also not painful. The patient denied having fevers or night sweats but had experienced chronic pruritus and a 13.6-kg weight loss over the past 2 years. Her medical history was significant for chronic renal failure due to hypertension, and she had been dialysis dependent for the past 6 years.

In October 1997, she underwent a 2½-gland parathyroidectomy. The left inferior gland was not located on exploration; subsequently, only half of the left superior parathyroid gland was removed. In November 1998, the patient underwent resection of a firm, nontender growth on the right side of the mandible. Preoperative computed tomographic scanning indicated a focal expansile lesion involving the right mandibular neck-ramus junction (Figure 1). The findings of frozen section and final permanent section (Figure 2) analysis indicated a benign bony lesion. In August 1999, the patient presented to a different surgeon continuing to complain of polydipsia, joint pain, and depression. After August 1999, she underwent a subsequent unsuccessful neck exploration to locate the fourth parathyroid gland, and she refused any further explorations. The results of a recent sestamibi scan were negative, and the serum parathyroid hormone level was 1800 pg/mL (189.5 pmol/L). The patient presented to our clinic in August 2000 for further resection of her mandibular lesion, and at that time, a left-sided neck mass was noted. She refused to undergo fine-needle aspiration and was therefore scheduled for an open biopsy of the neck mass and resection of the mandibular lesion. A recontouring procedure was performed on the mandible, and open biopsy of the left neck mass revealed an 8-g soft, tan mass (gross findings are shown in Figure 3; microscopic findings, in Figure 4).

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