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A Perplexing Pediatric Parotid Mass

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A previously healthy 8-year-old boy presented to an outpatient clinic for further evaluation of a fluctuating right parotid mass that had been present for 3 years. The patient was not immunocompromised and denied any trauma to the area. In the 2 months prior, he had received multiple rounds of antibiotics from other health care professionals. Outside computed tomography of the face showed a 3-cm cystic structure in the superficial aspect of the right parotid gland with associated lymphadenopathy. An outside health care professional had attempted incision and drainage of the area with negative cultures. The patient presented to our clinic with an isolated right 2-cm fluctuant and tender mass overlying the parotid gland. There was no accompanying cervical lymphadenopathy, and facial nerve function remained fully intact. The patient denied fevers or systemic symptoms. Results of laboratory evaluation revealed normal complete blood cell count and erythrocyte sedimentation rate levels with negative infectious workup results for Epstein-Barr virus, cytomegalovirus, HIV, and tuberculosis (TB). Magnetic resonance imaging showed a 1.9-cm peripherally enhancing, centrally necrotic lesion overlying the superficial right parotid gland with multiple subcentimeter necrotic lymph nodes within the right parotid gland (Figure 1).

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B. Atypical mycobacterium infection

Shortly after his presentation to our clinic, the patient developed violaceous skin changes with purulent drainage, which appeared consistent with atypical mycobacterial or nontuberculous mycobacterial (NTM) infection (Figure 2). He subsequently underwent drainage and curettage. Histopathologic examination revealed acute chronic inflammation with negative cultures. The infectious disease service started antibiotics for NTM, but they were stopped owing to an adverse reaction. The patient remained asymptomatic for 10 months but had a recurrence in the same area with extension into the parotid gland without involvement of the masseter. He subsequently underwent wide local excision. Cultures returned positive for Mycobacterium abscessus.

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Article Information

Corresponding Author: Phayvanh P. Pecha, MD, Department of Otolaryngology–Head & Neck Surgery, College of Medicine, Medical University of South Carolina, Rutledge Tower, 135 Rutledge Ave, MSC 550, Ste 1130, Charleston, SC 29425 (pechap@musc.edu).

Published Online: January 6, 2022. doi:10.1001/jamaoto.2021.3879

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s mother for granting permission to publish this information.

References
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