Facial and Neck Mass- Football

Abstract

HISTROTY: 17 year old high school football defensive back/receiver had developed a left neck mass over the last week following pre-season tackling drills. He had presented to the local emergency room 5 days prior and was sent home on Keflex and Ibuprofen. On follow up to his Pediatrician 2 days prior, the mass was felt to be a hematoma of the SCM and he was taken off of the Keflex and told he would be out for the season. He presented to our office for a second opinion on return to play. On further questioning, he admitted to increasing size of the mass, fever, chills, nightsweats and weight loss. He reported restricted cervical range of motion secondary to the pain and mass with some complaints of left arm heaviness. PHYSICAL EXAMINATION: On exam, there was pronounced warmth, tenderness and swelling over the left facial/cervical region with associated cervical lympadenopathy and restricted cervical motion in all planes. Cranial nerves were intact and there was normal symmetric sensation and reflexes but he had noted (4/5) weakness of left shoulder abduction, flexion and extension. DIFFERENTIAL DIAGNOSIS: Facial/neck abscess Hematoma Burner/Stinger Cervical radiculopathy Upper trunk brachial plexopathy. TEST AND RESULTS: CT Scan on day 2: Ring enhancing lesion posterior to the left parotid gland. MRI performed on day 8: Left neck fluid collection with ring enhancement likely representing parotid abscess and extensive edema. Cervical spine and spinal cord appear normal. FINAL/WORKING DIAGNOSIS: Parotid abscess, originally misdiagnosed as hematoma of the SCM with associated temporary upper trunk neuropraxia from mass/edema relieved with surgical drainage. TREATMENT AND OUTCOMES: Consultation with ENT, admission to acute care with IV antibiotics and emergent surgical drainage. Out of practice/games for 3 weeks. Gentle cervical range of motion and non-contact conditioning exercises started at week 2. Progression to cervical/upper limb strengthening and continuation of non-contact conditioning exercises at start of week 3. By end of 3 weeks post-op, the incision site was well healed. Return to full play with extra pad over incision site. Left upper extremity strength returned to full 5/5 and symmetric. Had full, painless ROM and able to meet demands of sport.