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Case received on the 8th December 2016 from New Foundations Medical Missions in the river Niger Delta, Nigeria, of a 19 year old man with a Parotid swelling over four months, tender, firm to palpate, no encroachment into oral cavity. Attached USS showing heterogenous cyst 6cm diameter. Systemically well. No fever, no lymphadenopathy. Could you suggest diagnosis and possible treatment?

The case was allocated to an Endocrinology, Internal Medicine consultant in Brisbane, Australia who asked a number of questions and discussed the case with a Maxillo/facial surgeon, who agreed that the most likely diagnosis is parotid tumour very probably malignant. That makes biopsy and histology the likely course to follow if that is possible in your setting. I am pleased that the Swinfen team has referred Sunny to their Maxillo/facial expert.

A Maxillo/facial Surgeon from the UK was involved in the case with comments: “I agree with the points made regards infectious, inflammatory and granulomatous conditions. The size and rate of growth suggests a malignant process. Other signs that would suggest this would be ipsilateral lymphadenopathy and impairment of the facial nerve.” He also stated that there was some echogenic lumps at the periphery of the lesion which may be a soft sign for a nematode. “It may be worth reviewing the image again for a worm shaped/ or moving string like shape within it, assuming non haematological disease would be at least a diagnostic /therapeutic superficial parotidectomy and if FNAC demonstrates malignancy then total parotidectomy may be worthwhile.”

Our UK systems operator informs the New Foundations Mission that we have a contact with Mercy Ships and how would the referrer like to proceed? Case was passed on to Mercy Ships 15/12/2016. As the young man lived near the clinic this was fantastic news. Passport and visa was arranged.

Message was received from the referring doctor in March 2017 – “you will share our joy that today Sunny was seen by the team on the Mercy Ship at Cotonou and surgery was completed. After ‘pulling’ their canoe all night to reach our clinic from their remote riverine community both he and his father were escorted to Lagos, where they switched to local taxi to take them into Benin and liaise with the Mercy ship. Sunny is recovering well.”

This case started on the 8th December 2016, 64 messages were exchanged through the Swinfen system involving an Endocrinologist/Internal medicine specialist from Australia, a Max.Facial surgeon from the UK and the Swinfen System operators, working together with the New Foundations Medical Mission and Mercy Ships. We estimate that this case would have cost around £5,000 if fees had to be paid.

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