Pauline Balkaransingh, MD, MBBS

An 11-year-old boy with a 1-week history of progressive left facial pain comes to see you. His mother explains that she originally thought the pain was because of his new retainer, but the pain has progressed to his ear. He has not had cough, sore throat, or nasal symptoms. The mother now believes the pain is because of an ear infection.

You examine the boy, expecting to find just that, but the physical examination is benign with an oral temperature of 37.8°C and nonerythematous tympanic membranes. He does, however, have a slight firm swelling just below his left mastoid process that you believe is a swollen tonsillar lymph node, but there are no other enlarged lymph nodes felt throughout the rest of his head and neck examination. His pharynx is erythematous with minimal swelling of the left tonsil. You prescribe a 7-day course of amoxicillin-clavulanate for the apparent lymphadenitis and send him home. 

A week later, you are surprised to find that your patient has returned. When entering the room, his mother complains that the antibiotics were not strong enough. Her son's pain has not improved, and now she thinks the infection has spread to his sinuses because he is describing nasal congestion and pain broadening along the left side of his face.  

You probe his past medical history further and learn that he had a "facial mass" removed at 1 year. Further investigation clarifies this mass as a benign spindle cell lesion with myxoid differentiation in the right maxillary region. Other than the antibiotics recently prescribed, the patient has not been taking any medications. 

You do a more thorough physical examination at this visit, confused by his lack of improvement. He is afebrile, with normal vital signs. He is alert and in no acute distress; however, you note that he is mouth breathing. His pupils are equally round and reactive to light and accommodation, with intact extraocular muscles. The tympanic membranes are not bulging or erythematous. The throat exam reveals a left-sided tonsillar mass that is slightly erythematous but without exudates. It appears to have increased to almost twice the size of the right tonsil. In addition, the swelling you believed to be an enlarged left tonsillar lymph node is now greater than 1 cm in diameter, firm, and slightly tender to palpation.  

His cardiovascular examination shows regular rate and rhythm without murmurs, rubs, or gallops. The lung fields are clear to auscultation. The abdomen is soft, nontender without masses. You find no additional lymphadenopathy. His neurologic examination is nonfocal. 

You believe the examination is still most consistent with an unresolved lymphadenitis. However, given the progression of his symptoms, you refer him to your ear, nose, and throat (ENT) physician colleague for evaluation.  

The next week, you receive a phone call from your ENT colleague who agrees with your suspected diagnosis and tells you cefdinir may have better efficacy in this case. However, to rule out a more serious cause such as malignancy, he has also arranged a computed tomography (CT) scan of the neck. You are pleased with this conclusion and go home to enjoy your afternoon off.  

Your patient returns the next day. He is now having difficulty swallowing and is unable to breathe through his nose. You perform a physical examination for the third time and find the left-sided tonsillar mass has increased and now displaces the uvula to the opposite side. The submastoid mass has also increased to 2 cm in size. 

Concerned about these changes, you probe for more history with the mother and find that the patient also has appeared to be losing weight over the past 3 weeks. The mother denies fevers during this time; however, the patient endorses "feeling hot" several times. In addition to nasal congestion, the mother has noted a "nasally sounding" voice for the past week and a half. There has been no shortness of breath or difficulty breathing. 

Articles

An 11-year-old boy with a 1-week history of progressive left facial pain comes to see you.

Author | Pauline Balkaransingh, MD, MBBS

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