Recurrent chin swelling

A 32-year-old black woman came to the Oral and Maxillofacial surgery clinic with a 3-week history of an increasingly tender mass underneath her chin. She reported a history of chin trauma at age 4. The patient denied fever, chills, weight loss, and constitutional symptoms. The patient’s medical history was significant for hypertension, hypothyroidism, and asthma. She had been hospitalized for childbirth and pneumonia. Her medications included beclomethasone dipropionate (Beconase, Allen & Hanburys, Research Triangle Park, NC) and cromolyn sodium (Nasalcrom, Fisons Pharmaceuticals, Rochester, NY) by inhaler as needed. She was allergic to sulfa drugs and cephalosporins. She quit smoking tobacco 3 years ago and denied alcohol abuse. Her family history was noncontributory. Physical examination showed a well-developed, wellnourished, black woman appearing her stated age. Vital signs showed a blood pressure of 130/82 mmHg, a regular pulse of 62 beats/min, a regular respiratory rate of 18 breaths/min, and a temperature of 37.2”C. Facial examination showed a 2-cm, mildly tender, firm, linear nodule in the submental region. A well-healed scar was present over the mass. Oral examination was within normal limits. The neck was without lymphadenopathy, and the thyroid was mildly enlarged. The remainder of her physical examination was unremarkable. The lesion was excised under local anesthesia. Microscopic examination showed florid granulomatous inflammation with focal necrosis and very focal, polarizable foreign material. Special stains for acid-fast bacilli and fungi were performed and were negative (Fig IA, B). The patient returned to the Oral and Maxillofacial clinic 6 days later. The sutures were removed, and a well-healing incision was noted. The patient returned 1 week later for another postoperative visit and after that was instructed to return if necessary. Four months later, the patient presented to the clinic with increasing swelling and tenderness in the previous surgical