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Infrequent attender worried by swelling at side of face

35-year-old Mrs Graham, who rarely attends surgery, presents to the registrar with a swelling at the side of her face. This appeared over the

last few days. 'It doesn't hurt,' she says, 'but I was worried about what it might be.'

Dr Peter Moore explains.

How should you approach the problem?

Mrs Graham is clearly worried. She rarely attends the surgery and expresses her anxiety openly. As with every consultation, the registrar will need to take a detailed history and examination. Although she says the swelling has only been there a few days, is it an enlargement of an existing swelling? It is worth asking: 'When was it completely normal?'

Associated local symptoms are important. Ask about sore throat, unilateral hearing loss, earache and hoarseness. But none of these symptoms is strongly associated with a specific tumour except prolonged hoarseness, which can be associated with a cancer of the glottis.

We need to know about her general health, weight loss or other symptoms. Does she smoke? Any medication should be clear from the medical records, but has she taken anything else over the counter, including herbal remedies?

It is also important to explore the reason for her anxiety. Open, reflective, statements such as 'You seem worried' might lead to her opening up about her fears. Did she have a friend or relative with a facial tumour? This approach is more likely to be successful if the patient already knows the registrar.

What you should look for in the examination

The first question is the most obvious ­ does she actually have a swelling? It is not always easy to see, especially in obese patients. Some patients perceive abnormalities as a part of somatisation of emotional illness. No one's face is symmetrical. As she is not a frequent attender it would be dangerous to dismiss her concerns without follow-up, even if you cannot find a swelling. If there really is no organic pathology why has she presented now, having hardly ever come to the doctor before?

The lump will need to be carefully examined and you will need to remember the anatomy. Where does it appear to be arising? The most useful clinical sign of parotid swelling is a forward deflection of the ear lobe.

Anatomically, the neck is divided into two triangles. Check if there are any palpable cervical nodes, and where they are.

It is vital to check drainage areas ­ mouth, ears and thyroid. Are there any overt signs of infection ­ a temperature, tender salivary gland or pus from the salivary duct? Is there facial paralysis? This carries a poor prognosis in a parotid tumour.

What are the possible diagnoses?

She is young to develop a malignant tumour in the neck but that does not rule it out. This must be the first consideration. Missing a head and neck cancer could be disastrous. Malignant tumours cause 75 per cent of lateral neck masses in patients over 40. A metastatic deposit may not always be in the alimentary or upper respiratory tract. In one study, 40 per cent of head and neck cancers were squamous cell carcinomas from an unknown primary. However, they can be local primary tumours or lymphomas.

The commonest benign tumours of the parotid are the pleomorphic adenoma ­ or benign mixed tumour ­ and Wathin's tumour.

If it appears to be a swelling of the parotid gland and has features of infection it may be a stone or ascending sialadenitis. Stones are common and do not always cause symptoms ­ post-mortem studies show 1.2 per cent of the population have salivary calculi.

Other infective parotid swellings can be viral such as mumps. Rare infections include Epstein-Barr, HIV, staphylococcal, TB and toxoplasma.

It could also be a granuloma such as found in sarcoid, or autoimmune such as Sjogren's syndrome.

If the swelling is recent it cannot be due to a developmental abnormality such as a branchial cyst, haemangioma or laryngocoele. But these cannot be ruled out without a careful history. It is in the skin ­ a sebaceous cyst or lipoma?

How should she be managed?

Mrs Graham will almost certainly need an urgent referral for a fine-needle biopsy. In most areas this should be arranged through the two-week wait protocol. Treatment will depend on diagnosis and this will be made on the histology.

After a careful history and examination it is possible that there might be a benign explanation such as a sebaceous cyst. If clinically there is a salivary gland infection a course of antibiotics might be useful. However, if not, she should be referred immediately, and you must arrange to see her again soon.

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