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Pea sized lump raised behind ear. It is soft and movable. What is this and the treatment?

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The attached image is of the back-side of the right ear of a 4 year old female. There is a pea sized dark blue raised area. It is soft and movable. There is no pain when touched. She is not symtomatic in any way. Two doctors and no answers. "wait and see" is the advice we received two months ago. The issue has not grown or decreased. We need to know what we are dealing with and possible treatments. Thank you.
Posted Fri, 17 Aug 2012 in Ear, Nose and Throat Problems
Answered by Dr. Raju A.T 5 hours later

Thanks for your query.

Also I really appreciate the way the query is being presented to me.

The image shows a post auricular nodule, most common conditions which present as in her is Lipoma or a Post auricular Lymph node.

Both appear soft mobile and with bluish skin overlying it by hampered blood supply due to skin stretching.

The Lipoma is a benign tumor of fat cells with very rare chances of getting malignant.The increase in the size is one warning sign in such nodules.

The Post auricular Lymph nodes are ones which get enlarged where there any kind of infection in the vicinity.The lymphnodes play a important role in local immunity and are of the size unnoticeable normally.When there is any infection the node gets enlarged.

The best way to ascertain the exact diagnosis is by FNAC (Fine needle aspiration cytology).Here a small amount of material from the nodule is taken and examined under microscope.This will give detailed insight about the condition and its management.

As per my above considered differential diagnosis, the treatment of both would be excision only.

Hope I answered your query.

Wish you good health.

Above answer was peer-reviewed by
Follow-up: Pea sized lump raised behind ear. It is soft and movable. What is this and the treatment? 2 days later

Thank you for your explanation.

A few questions:

1. Her GP assured me that it was not lymph node related. Her ENT said she 'didn't think' it was lymph node related. I never rule anything out until I know exactly what I am dealing with. The question: if it is lymph node related in that area, other lymph nodes would have some similar appearance, correct? In her case, there are none. This leads me to believe that it is not lymph node, but please expalin if only one lymph node can have a specific reaction while others do not?

2. Lipoma. I thought of this as well, though it is highly unusual to have a blood related lipoma, correct? Most lipoma's are clear in color from what I can determine. Hers clearly is blood under the skin.

3. Can it be vascular related? i.e. Can this be an aneurism or weakened vein that is bulging in that location? Exactly what veins are immediately behind an ear and if there is an issue with one, how serious is it?

4. Again relating to vascular, can this be a blood clot in a vein?

5. We did not observe any signs of trauma and have sort of ruled out a bruise because she did not complain of any injury or pain that we know of, but could this be a hemotoma? If so, what could have caused it? How would it be treated?

6. After my direct enquiry to her ENT, and noticing that the ENT had zero answers for us, I urged her to consider imaging. To my horror she was actually considering MRI or CTScan which we would never allow for exploratory purposes especially when the doctor was so obviously incompetent in diagnosis. But she did agree to schedule an ultrasound, which I am in agreeance with. I don't mind observing external for a time, but I want to know what is internally going on. Given this, what should we look for on an ultrasound? What signs or symptoms related specifically to this issue should we be aware of?

7. What natural ayurvedic remedies are available to reduce the inflamed area or possibly disolve the blood?

Thank you in advance for your answers.
Answered by Dr. Raju A.T 11 hours later

Thanks for writing back.

1) You are right in saying that a single lymphnode involvement is always rare, but sentinel lymph node is the one always gets involved first since the interconnecting lymphatic channels get blocked when there is enlargement of the sentinal node the other nodes are involved later in time by the anastomotic channels directly from the infection site.

Also one or more lymph nodes involved can present as a single node due to matting.

2) Yes, the view of the node in the image may rise a suspicion of lipoma but the feel on touch may disagree.Hence a hand on examination is must to be sure of its diagnosis.

3)Yes, if it feels like a balloon filled with water and warm in temperature and see the bluish hue disappearing on pressure , it could be a venous swelling then.Such swelling though not XXXXXXX as they do not burst open due to low pressure inside the vein , surgical excision may be needed for definitive treatment.

4)The consistency is the main differentiating point.If its hard and tender then it could be a clot , if soft and yielding then it is a venous swelling.

5)Hematoma is nothing but a clot.It usually follows a injury. I doubt it to be the condition here based on your description of the consistency.In case, treatment is by excision only.

6)The child may not present with symptoms if it is an venous swelling , a lipoma or a lymph node.Well, if the diagnosis of lymph node is considered then a through examination of the vicinity has to be made to rule out any infections.

Ultrasound scan would be a gold standard here , this may help to know type of matter filling the swelling which will narrow down the possibilities well.

7)I would recommend a local surgical treatment rather than generalised blood thinning medication which have their own unfavourable side effects.

Hope I cleared all your doubts,

Wish you a good health.
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