A 35-year-old male patient who came to the Head and Neck Surgery Unit of Primavera Hospital (Trujillo-La Libertad, Peru) with a large soft tumor in the right submaxillary region.
The patient had any history of trauma, infection, dysphagia, voice change or weight loss.
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Physical examination revealed a non-ructable, well circumscribed, painless, slightly mobile right submandibular soft tumor measuring 8 cm in diameter.
Bimanual fixation provided the same information. Oral cavity and oropharynx examination was normal.
The mandibular branch of the facial nerve was not affected and no other alterations were found.
No associated cervical lymphadenopathy was found.
The ultrasound study revealed complex cystic formation measuring approximately 59 × 26 × 54 mm, with a volume of 43.9 cc, with evidence of multiple septa of up to 3.5 mm thick.
A solid component was also observed in its right posterior edge, which showed no vascularity.
The inferior border showed a slightly echogenic area of 8mm thick, probably of non-vascularized solid type.
The right submandibular gland was observed displaced by the described lesion.
This finding led us to the diagnosis of a lesion that compromised the submandibular gland, additionally that the lesion contacted the anterior edge of the submandibular gland and showed an undefined irregular interface.
If necessary, magnetic resonance imaging should be requested, which was not possible due to the economic situation of the patient.
The diagnosis was cystic lesion of the submandibular gland.
Under general anesthesia, excision-biopsy of the lesion was performed through a submandibular approach with a low incision of 6 cm. It was observed that the lesion was in continuity with the submandibular gland.
Histopathological study of the sample confirmed a fibrotic wall retention cyst associated with a submandibular gland showing chronic obstructive changes, with little glandular component.
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The patient was discharged 24 h after surgery.
She remains asymptomatic and regular outpatient follow-up visits are indicated for 5 months.
