Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a painless, soft, fluctuant mass, noted since [Age/Time]. Mass is non-pulsatile, non-tender, and exhibits transillumination. No history of rapid enlargement, overlying skin changes, or systemic symptoms (fever, weight loss). No associated dysphagia, dyspnea, or airway obstruction symptoms.
Clinical Examination Findings
Physical exam reveals a [Size: e.g., 5x4 cm] cystic, multiloculated mass located in the [Anatomical site: e.g., left posterior cervical triangle]. Mass is soft, compressible, and non-tender. Positive transillumination. No palpable thrill or bruit. Overlying skin is intact with no erythema or sinus tracts. Cranial nerve function intact. Airway patent.
Treatment Protocol
Surgical excision is the definitive treatment. Pre-operative imaging (MRI/CT) obtained to delineate extent and relationship to vital neurovascular structures. Discussion held regarding risks of recurrence, nerve injury (e.g., spinal accessory, facial), and potential for incomplete resection due to infiltrative nature. Sclerotherapy may be considered as an adjunct or alternative for macrocystic lesions.