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Date posted: May 5, 2012

Dr Beenadas

Presenting complants.
A swelling on left side of neck, upper cervical region at inner angle of mandible,  4×4 c.m. in size – 2 years. Swelling is diffuse, firm, pulsatile, not tender and not movable. 

History of presenting complaints.
Complaints started  4 years back as a swelling that can be only identified  by touching that area. It gradually increased in size .There was no fever or any pain during mastication. Have a  palpable swelling at the right  inner angle of mandible that appeared about 10 years back. Done biopsy then and diagnosed as chronic non-specific sialadenitis. But it remains as such till now.

Had vomiting of water twice 3 years back and admitted  at hospital for 5 days. Then noted slurring of  speech and deviation of tongue to left side. Advised for further investigation. Now patient has occasional salivation and obstructed feeling with discomfort if food is chewed at left side of mouth. 

History of previous illness.

  • Hypertension for 15 years, taking one tablet per day.
  • Diabetis mellitus for 11 years, taking one tablet per day.
  • Hypercholesteraemia for 3 years. Taking no treatment. 

Treatment history.
Took allopathic treatment and done biopsy for swelling of right side 10 year back. Took allopathic treatment  for vomiting  and swelling of left side 3 years back. Both swellings not subsided. Advised follow-up treatment with MRI report and the patient refused to do that till now. 

Family history

  • No  history of similar complaints in family members.
  • Father  had no complaints.
  • Mother had hypertension
  • Patient is the elder member with 2 brothers and 1 sister. All are normal. 

Personal history.

  1. Life situation
  • Place of  birth  – Puthupanom
  • Educational  status  -  10th std.
  • Economic status  -  moderate.
  • Married , has 2  children.
  1. habits and hobbies.
  • Non-vegit.
  • Addicted  to tea.
  • Had habit of smoking, stopped 4 years back.
  1. domestic relations  – good.

Physical features.

  1. Generals

a) Funtionals :-

  • Appetite   – Normal, likes warm food.  Craves pungent food.
  • Thirst  – increased, likes normal water.
  • Sleep  – sleeplessness during night, for 3-4 months. feels sleepy during day, but not    sleeps.
  • Dreams – not particular. 

b)   Eliminations :-

  • Bowels  – constipated.
  • Urine  -  Normal.
  • Sweat  _ decreased.
  1. Response to :- No remarkable desires or modality.

Psychic features. : Easily irritated  and becomes angry.

Regionals.

  • Head   -  occasional vertigo, esp.  with hypertension.
  • Eyes   -   dim vision.
  • Mouth  – dark discoloration of tooth.
  • Bowels  – constipated, flatulence.
  • No other regional symptoms noticed. 

Physical examination.

  1. General
  • Built  – moderate.
  • Complexion – dark.
  • No wasting, not anaemic, no clubbing, no oedema,no jaundice,  no lymphadenopathy.
  • Normal gait
  • R.R – 18/ mit
  • P.R -  72/ mit.

2.  local examination
Left side  – visible swelling, 4 x 4 cm in size, firm, non tender, non movable mass,  with transmitted  pulsation. No redness or any rise of temperature.

Skin over it is freely  movable.

Right side  – not visible. 2 x2  cm in size, firm non tender, not movable, no pulsations, no redness or temperature. Skin over it is movable.

  1.  CNS  examination
  • HMF – Normal.
  • No cerebellar signs.
  • Cranial nerves – 9,10 &12 of left side affected. 

9th nerve –

  • Gag reflex absent on left side.
  • Touch sensation poor on post. third of tongue.
  • Tste sensation present on  posterior part of tongue

10th nerve

  • Gag reflex absent on left side.
  • Arch of palate of left side not move upwards.
  • Slurring speech – mild pharynx palsy of left side.
  • No bubbling or pooling of saliva in mouth.
  • No fluid regurgitation of fluid through nose.
  • No hoarseness

12th nerve

  • Tongue deviates to left side on protrusion.
  • Furrows in left side of tongue, papillae are destroyed.
  • No fasciculation of tongue
  • Wasting of tongue on left side
  • Strength of contraction on left side is decreased
  • Tone – left side of tongue is soft to touch than right side. 

Investigations

21-01-2004. CT Scan  – Head plain study. :- shows normal study of intracranial structures.

30-01-2004. FNAC  -  swelling of right cervical lymph node.:- shows chronic non specific

Sialadenitis. To rule out carotid body tumor.

Advice  – contrast CT / MRI before  excision biopsy

07-03-2008.

  • FBS – 130 mg/dl
  • PPBS – 295 mg/dl
  • Total cholesterol – 295 mg/dl
  • Triglycerides – 181 mg/dl.
  • HDL – 48mg/dl
  • LDL – 211mg/dl
  • VLDL – 36mg/dl 

Diagnosis of disease

Patient’s symptom

  1. occasional salivation
  2. obstructed feeling at left side of mouth when chewing food.

Disease symptoms

  1. A swelling 4×4 cm on left side of neck. upper cervical region at inner angle of mandible.
  2. Swelling is diffuse, firm, pulsitile, nontender and not movable.
  3. Slurring of speech
  4. Deviation of  tongue.

Provisional diagnosis : Lymphadenopathy 

Differential diagnosis

  • Mumps
  • Sialolithiasis
  • Salivary gland neoplasms
  • Carotid body tumor.

 Final diagnosis
Chronic non-specific sialadenitis. 

Diagnosis of patient

Totality of symptoms

  1. Easily Get Irritated And Angered
  2. Desires Tea
  3. Desires Warm Food
  4. Thirst For Large Quantities Of Water
  5. Sleeplessness During Night With Sleepy During Day
  6. Bowels Constipated.
  7. Sweat Decreased
  8. Dark Discoloration  Of Teeth
  9. Submaxillary Glands Swelling
  10. Tongue Palsy Left Side

Miasmatic expression

  • Psora
  • Easily Irritated And Gets Angry.
  • Vertigo
  • Salivation
  • Blackish Discoloration Of Teeth.
  • Constipation, Flatulence
  • Sycosis
  • Swelling Of Submandibular Gland.
  • Miasmatic diagnosis -  mixed miasmatic -  psora & sycotic.       

Medicine given.

  • 5-3-08 -  MER.SOL 200/1D.
  • 14-03-08 – MER.SOL 200/1D. and discharged.
  • Readmitted on 26-03-08
  • 29-04-08 – MER.SOL 200/1D.  

Salivary glands
The mucus membrane lining the mouth contains  about 750 minor salivary  glands called  bucal glands occurring throughout the upper respiratory tract – mucosa of lips, cheeks, palate, floor of mouth and retromolar area, oropharyx, larynx, trachea and sinuses, and  contributes 10 % of total salivary volume.

But major part of saliva is secreted by  salivary glands. There are 3 pairs of  salivary glands :   parotid,  submandibular (submaxillary) and sunlingual glands.

Parotid glands are located inferior and anterior to ears between skin and masseter muscle. Each secretes into oral cavity via parotid or stenson’s duct that pierces the buccinater muscle, to open into the vestibule opposite the upper 2nd molar teeth.

Submandibular gland are found beneath the base of tongue in the posterior part of floor of mouth. Their ducts, submandibular or wharten’s duct runs superficially under the mucosa on either side of midline of the floor of the mouth and enter the oral cavity proper on either side of lingual frenulum.

Sublingual glands are anterior to submandibular glands and their  duct, the lesser sublingual or Rivinus’s duct open into floor of mouth in the oral cavity.

The major salivary glands secretes in response to autonomic stimulation. The parotid secretion is serous or watery, the sublingual is mostly mucus and the submandibular

is a balance of the 2 elements. Hundreds of minor glands in cheeks and lips secretes mucus continuously.

Submandibular gland.

  • Anterior facial vein runs over the surface of gland.
  • Facial artery is found within facia.
  • Deep part of gland lies on hypoglossal muscle and is closely related to lingual nerve and inferior to hypoglossal nerve.
  • Drained by  submandibular duct – Wharton’ duct 

Inflammatory Disordes Of Salivary Gland.

  • Inflammation of salivary gland is called sialadenitis. Sialadenitis may be either acute, subacute or chronic inflammation of gland. 
  • Cause for acute submandibular  sialadenitis are
  • Viral – mumps
  • Bacterial – staphylococcal aures, streptococcus pyogens and strep.pneumoniae, secondary to obstruction. 

Chronic submandibular sialadenitis
Salivary calculi are the commonest cause of sialadeitis, other cause include stricture of the duct, fibrosis of papilla, etc. the causative organism is staphylococcus.

Chronic bacterial sialadenitis is a consequences of lowered salivary secretion and recurrent bacterial infection. When suspected bacterial infection is not responsive to therapy, the differential diagnosis should be expanded to include benign and malignant neoplasms, lymphoproliferative disorders, sjogren’s syndrome, sarcoidosis , tuberculosis, lymphadenitis, actinomycosis, and wegener’s granulomatosis.

Bilateral non-tender parotid enlargement occurs with diabetic mellitus, cirrhosis, bulimia, HIV/AIDS and drugs.

Differential diagnosis.

  1. chronic submandibular sialadenitis due to obstruction and trauma – stone formation (sialolithiasis). 90% of all salivary stones occur in submandibular gland (10 % in parotid gland ) because of their secretion contain mucus with high salivary viscosity. Patient usually presents with acute parotid swelling precipitated by eating and resolves completely 1-2 hours after  food. 80% of these stones are radio opaque and are identified by plain x ray.
  2. duct atrsia :-  neonate presents with submandibular swelling on affected side , associated with a retention cyst within the gland.
  3. ectopic or aberent  salivary gland – formed by invagination into the bone on the lingual aspect of  the gland.
  4. Salivary gland neoplasms – usually presents with slow growing painless swelling within the submandibular triangle. Only 50% are benign. Feature of malignant tumor include facial nerve weakness, rapid enlargement of swelling, indurations /ulceration of skin,  fixation to skin or underlying muscle cervical node enlargement. When presenting symptom is complete unilateral facial palsy results.(bell’s palsy – slow improvement within 6 months ). CT &  MRI confirms diagnosis.
  5. carotid body tumor (chemodectomas) – are paragangliomas and arise from the branchiomeric paraganglia at the carotid body. Tumor are usually benign, unifocal and non heriditory and presents as a non painful mass at the carotid bifurcation and have a characteristic “lyre” sign on carotid arteriogram – splaying the internal and external carotid artery. Biopsy is contraindicated due to their highly vascular nature. Common sequel from resection is cranial nerve injury.

Medicines

    • Submaxillary  gland  swellings –  anthrax, ars, ars.iod, arum.tri, bary.carb, bary.mur, brom, cal.carb, cham, clema, china, carb.ani, lyco, mer, nat.mur, nux.vom, phytol, psori,   nat.carb, nit.acid, rhus.tox, sil, staphy, sulphu.acid.
    • Glandular swellings -  mer.sol, con. mac, , psor,  lache, lycop, bell, china, sulph.acid, kali. bi, sulpher, cal.flour
    • Submaxillary gland inflammation – bary.mur, bell, dul, graph, kali.iod, lache, merc, nit.acid, phytolo, psorinum, puls, rhus.tox, sil, sul.acid, suloh, vat.vir.

Mercurius – glandular swelling with or without suppuration.

  • Induration of glands of throat and neck.
  • Cold swellings, abscesses, slow to suppurate..
  • Glands swell every time patient takes cold
  • Profuse perspiration, but does not relieve symptoms.
  • Ptyalism, profuse, fetid, coppery metallic taste.
  • Hepar – enlarged glands, suits the stage of suppuration.

Con.mac –   it produces ascending paralysis, weakness of mind and body with trembling.

  • Glands enlarged, induration of stony hardness, in persons of cancerous tendency, after bruises and injuries of gland.
  • Axillary glands pain with numb feeling down arm.
  • Debilitated subjects with marked tendency to induration

Cal.carb –   swellings of glands, with increased local and general perspiration.

  • Swellings are firm and hard.
  • Ice coldness in and on  head , much perspiration wets the pillow.
  • Mouth fills with sour water, offensive smell from mouth.

Bary. Carb –affect glandular structures, hypertrophied and indurated glands.

  • Degenerative  changes. Submaxillary glands and tonsils swollen.
  • Takes cold easily with stitches and smarting pain.
  • Specially indicated in infancy and old age.
  • Paralysis of tongue. Smarting burning pain in tip of tongue.
  • Dribbling of saliva.

Bary. Mur & bary. Iod  have a special power over the absorbents

  Iodine -      indolent swelling that are torpid and sluggish, which are large, hard and

  • Usually painless, esp. about the neck.
  • Enlarged bronchial and mesenteric glands. 

Various combinations of iodine are thrustworthy in glandular ailments.

Bary.iod -  for tonsillar enlargements.

Ars.iod – Enlarged scrofulous glands, accompanied by anaemic conditions,debilitating night sweats and corrosive irritating discharges.

Fer.iod & cal.iod – glandular enlargements with engorgements and hypertrophies.

Belladonna – glandular swellings of inflammatory character with rapid swelling threatening suppuration.

  • Glands are red, heavy and sensitive.
  • Red shining streaks radiates from glands  with great heat and stitching pains indicates Bell.. involves the substance of gland.

Apis – involves more surface.

Spongia – glandular remedy with swellings in cervical region with  tension and painful to touch. Goiter hard and large with suffocative attacks.

Graphites – enlargement of glands of neck, axilla and mesenteric glands in debilitated .

  • Swellings are painful, sensitive and associated with skin affection.
  • Great tendency to take cold.

Silicea –  suppurating inflammation of glands.  Fistulous openings leading down to the glands.

Cal.flour – long lasting and indolent glandular enlargements of cervical glands where the hardness is pronounced. Enlagements of mesenteric and bronchial glands, worse in damp weather,  better from hot fermentation and rubbing.

Cistus –   Glandular enlagement, especially of submaxillary glands wit caries of the  jaw.

  • Glands become inflamed, indurated and ulcerated.
  • Impure breath is an indication.

Lapis albus – enlagement of mesenteric glands and chronic glandular swellings in scrofulous children.

  • Swollen glands have a certain amount of plasticity rather than stony hardness
  • Goiter with anaemic symptoms and increased appetite

Bromine – enlargement of glands, parotids swellen.

  • It suits light complexioned, blue-eyed children who suffer from enlarged tonsils
  • Hard swellings of external cervical glands.
  • It softens induration of submaxillary and parotid gland
  • Swellings are hard and elastic.

Carbo ani – indurated axillary glands. Glands are as hard as a stone and the surrounded     tissues are even hard.  Induration is the keynote.

Carg.veg – induration of mamae, burning pains and tendency to suppuration.
Badiaga – enlargement of glands with induration, indurated buboes.

Sulphur – great remedy for scrofulous glandular enlargements; inguinal, axillary, submaxillary and subcutaneous glands are  affected.

Asimina triloga 

  • Tonsils and submaxillary glands enlarged.
  • Desire for icy cold things
  • Marked hoarseness.

Anthracinum

  • Septic inflammation with terrible burning
  • Induration and oedema of cellular tissue.
  • Ulceration, sloughing and intolerable burning.

Hippozaenium

  • Nosode, for consumption, cancer, syphilis.
  • All glands in face are swollen, painful, form abscess.
  • Lymphatic  swellings.
  • Articular non- fluctuating swellings.

Scrophularia nodosa

  • Enlarged glands are present.
  • For Hodgkin’s disease.
  • Scrofulous swellings.

Phytolocca

  • Tumor of breast with enlarged axillary gland
  • Tonsils and fauces swollen
  • Cannot swallow anything hot.
  • Shooting pains into ear on swallowing.
  • Pains fly like electric shocks.

Dulcamera

  • Specific action on skin , mucus membrane and glands.
  • Swelling of parotids.
  • Swelling and indurated glands from cold.
  • Facial neuralgia, worse slightest exposure to cold. 

Dr.Beenadas
Lecturer, Department of MM
Govt. Homeopathic Medical College. Calicut

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