DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Left cheek mass.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who presents for possible seizure activity. She had a stroke three months ago with resultant left hemiparesis. Yesterday, she developed diffuse shaking event and was temporarily non-conversive. She did not lose consciousness. Given the history of stroke, she was admitted for neurology evaluation and possible seizure activity. She does have a history of a cyst in the left cheek region, dating back to at least six months ago. At that time, it was evaluated and she was treated with 10 days of antibiotics. The cyst seemed to decrease somewhat though may have spontaneously drained, per the patient’s recollection. Over the past three weeks, it has again become more prevalent. The patient is otherwise largely asymptomatic without localized pain. It is mildly tender when palpated. She did have an outpatient appointment made, though her son does not recall the definite name or type of physician. CT scan revealed evidence of a well-circumscribed cyst adjacent to the left posterolateral maxillary bone and just below the maxillary sinus. In addition, there was partial opacification of the left maxillary sinus. She does have evidence of prior sinus surgery, including antrostomies and ethmoidectomies. She states this was performed approximately eight years ago. She has been afebrile.
PAST MEDICAL HISTORY: Hypertension, diabetes, atrial fibrillation, hypothyroidism, and history of colitis.
MEDICATIONS: Levoxyl, Cardizem, prednisone, digoxin, Vytorin, metoprolol, Diovan, aspirin, omeprazole, hydrochlorothiazide, Asacol, potassium, and Novolin N.
ALLERGIES: PENICILLIN.
FAMILY HISTORY: The patient states that multiple siblings had problems with their sinuses.
SOCIAL HISTORY: The patient denies smoking or alcohol use. A portion of the history is obtained from her son.
REVIEW OF SYSTEMS: The patient states she was on anticoagulant therapy previously for her atrial fibrillation, though due to GI bleeding, this was stopped. She states she had taken steroids for history of colitis. She and her caregiver and son describe inability to move the left side of the body. She denies dysphagia or speech difficulties. She denies airway complaints. She denies nasal congestion, rhinorrhea or postnasal drainage.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.8 degrees, heart rate 100, respirations 18, blood pressure 152/64, and saturation 97% on room air.
GENERAL: The patient is pleasant and cooperative.
HEENT: The auricles are nontender. Canals are without erythema or edema. Tympanic membranes are intact. Extraocular movements are intact. Cranial nerves II through XII are intact with the exception of left lower two-third facial paresis. We will grade this as a 3/6 on the House-Brackmann scale. Submandibular glands are normal to palpation. Face and intraoral examination are notable for a cystic mass closely adherent to the posterolateral left maxilla. This is an edentulous region of the maxilla, estimated approximately 4.5 x 4.5 cm size. There are no sites of drainage or induration surrounding the primary cystic mass.
NECK: Supple without palpable lymphadenopathy or mass. No thyromegaly.
PROCEDURE: Intranasal examination was performed both with anterior rhinoscopy and subsequently with a flexible laryngoscope. She has some slightly purulent crusting in the left middle meatus, which was debrided with Bennett forceps. A portion of this felt postnasally, and she produced it through the mouth. There was light bleeding from the mucosa. Otherwise, no obvious polyp or purulence.
LABORATORY DATA: White blood cell count 10.8, hematocrit 38.4, and platelet count 208,000. Neutrophils are mildly elevated at 80%. PTT is 20.6, PT 12.8, and INR 0.94. BUN 26 and creatinine 1.0.
Maxillofacial CT, coronal and axial views, are reviewed. This shows a cystic mass, closely related to the left posterolateral maxilla. Its superior aspect abuts the inferior wall of the maxillary sinus. There may be a small area of bony dehiscence in the maxillary sinus, and there is corresponding mucosal thickening in the floor of the left antrum. In addition, there is some remodeling of the left maxillary bone. These findings are suggestive of possible odontogenic/dental-based cyst. Alternatively, it may be related to the maxillary sinus process. Maxillary sinusitis may also be secondary to the underlying cyst causing some local inflammatory change. There is no significant soft tissue inflammation surrounding lesion, which suggested this is not an acute abscess. It was larger when compared to the prior films earlier this year. The ethmoid, frontals, and sphenoid sinuses are essentially clear with the exception of minimal mucosal thickening.
IMPRESSION: Left premaxillary cyst. Origin may be from the maxillary bone, maxillary sinus or surrounding soft tissues.
PLAN: We would like to get the opinion of an oral surgeon to see if this may be an odontogenic/bone-based cyst. We do suspect benign etiology based on its well-circumscribed appearance though given some bony remodeling cannot completely rule out a malignant process. Given the increased size over the past three weeks, we have recommended initiation of Cleocin 300 mg p.o. t.i.d. for one week. Also began saline nasal spray for intranasal crusting as well as warm compresses and salt water rinse to the mouth. The patient’s son expressed understanding and agreed with this plan. Certainly, we will need to take into consideration the ongoing neurology workup prior to any potential intervention.
