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An unusual presentation of an asymptomatic neck mass.

[FIGURE 1 OMITTED]

A 55-year-old man was referred by his dermatologist for a left neck mass that had been enlarging over the preceding few months. He had no history of recent trauma or infections and denied any smoking or alcohol history. He noted only mild neck discomfort upon palpation; otherwise, he was asymptomatic.

On examination a 2 x 2-cm, firm, nontender mass was found at the midlevel of the posterior triangle of the left neck. It had limited mobility and extended deep into the subcutaneous tissues. The rest of the ENT examination, including endoscopy, was negative.

Computed tomography (CT) showed a 1.0 x 1.2-cm, ovoid focus area of increased density, most likely representing a calcified left, level-III lymph node. The findings suggested a postinflammatory node with unusual enhancement. No other lymphadenopathy was noted on the CT scan (figure 1).

The patient was scheduled for excision of the mass, and the overlying soft tissue was dissected free. The collection of tissue was then opened, and a piece of wood was found in the center of the mass (figure 2). Postoperatively, the patient had no complications.

The patient was later informed of the intraoperative findings. He was then able to recall that 40 years earlier, he had been involved in a motorcycle accident and a tree branch had penetrated his neck. He had had an exploratory procedure performed on his neck, and the branch had been removed. He had no further symptoms or findings until this presentation, 40 years later. On reexamination of his neck, a fine, well-healed, thin scar was noted, which was camouflaged in a neck crease.

The pathology report was consistent with granulation tissue, with a foreign body giant cell reaction and an attached piece of wood.

[FIGURE 2 OMITTED]

This case demonstrates a very late presentation of a foreign body reaction to wood in the neck. Although the patient had had an initial workup and exploratory surgery at the time of his accident, the small wood chip was obviously missed. Furthermore, the CT scan obtained at our facility did not show any characteristic findings, such as a mass, that suggested the presence of a foreign body.

Small, wooden foreign bodies have been shown to have nondescriptive CT findings, leading to delayed diagnosis and treatment. (1,2) Magnetic resonance imaging might prove to be more useful in cases in which a wooden foreign body is suspected. (1)

Although in our case, the patient did not initially reveal the history of trauma, and the scar had become nearly unnoticeable, a thorough history and physical with a high index of suspicion in patients with a history of penetrating neck trauma should elicit the appropriate diagnosis in most cases. (2)

References

(1.) Imokawa H, Tazawa T, Sugiura N, et al. Penetrating neck injuries involving wooden foreign bodies: The role of MRI and the misinterpretation of CT images. Auris Nasus Larynx 2003;30 Suppl:S145-7.

(2.) Krimmel M, Cornelius CP, Stojadinovic S, et al. Wooden foreign bodies in facial injury: A radiological pitfall. Int J Oral Maxillofac Surg 2001;30(5):445-7.

From the Osborne Head and Neck Institute, Los Angeles.

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Title Annotation:HEAD AND NECK CLINIC
Author:Nach, Rapahel; Smith, Lorraine M.; Zandifar, Hootan
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Aug 1, 2011
Words:520
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