A 24-Year-Old Female with a Growing, Painful Forehead Mass

Case at a Glance

A 24-year-old female presented with a three-year history of a hard, growing mass on her forehead. Despite initial pain and consultations with neurologists, both CT and MRI scans were reported as normal, leading to a diagnostic and therapeutic dilemma.

Patient's Story

The patient, a 24-year-old female, reported the development of a hard, palpable mass on her forehead near the hairline approximately three years prior. Initially, the lesion was associated with significant pain, prompting her to seek medical evaluation. She consulted two different neurologists to investigate the source of the pain. During this period, she was prescribed a beta-blocker (propranolol, under a brand name for migraine prophylaxis), which provided some pain relief. However, she discontinued the medication due to concerns about long-term use. Over time, the pain subsided to a dull ache present only upon direct pressure, but she noted that the mass itself appeared to be slowly increasing in size, causing her significant concern.

Initial Assessment

On physical examination, a firm, non-mobile, subcutaneous mass was palpated on the upper forehead near the anterior hairline. The lesion felt fixed to the underlying bone. The overlying skin was intact with no discoloration. The mass was tender to deep palpation. The remainder of the neurological and physical examination was unremarkable. The patient's primary concern was the progressive growth and the lack of a definitive diagnosis.

The Diagnostic Journey

Due to the initial presentation with pain, the patient underwent both a CT and an MRI of the head. According to the patient, the official reports for both scans were interpreted as 'normal,' with no acute intracranial pathology identified. One of the consulting physicians reportedly dismissed the finding as part of her natural skull contour. Frustrated by the lack of answers, the patient continued to seek explanations. A subsequent informal review of the MRI images by others suggested the lesion was visible, though its exact nature—whether originating from bone or overlying soft tissue—was debated. The initial 'normal' reports likely focused on ruling out intracranial causes for her pain rather than characterizing the superficial lesion itself, highlighting a potential discrepancy between the radiologist's report and the specific clinical question.

Final Diagnosis

Given the clinical characteristics (hard, immobile, slow-growing, fixed to the underlying structure) and location, the leading working diagnosis was a Forehead Osteoma. Osteomas are benign bone tumors that commonly occur on the skull. Other less likely differential diagnoses included a calcified pilomatricoma or another form of soft tissue calcification. A definitive diagnosis would require histopathological analysis following excision.

Treatment Plan

The patient was advised to obtain a referral to a specialist, such as a plastic surgeon or dermatologist, who is experienced in evaluating and managing cutaneous and subcutaneous lesions. The recommended plan included:

1. Re-evaluation of Imaging: Obtaining the original CT and MRI scans for a targeted review by the new specialist, with a focus on characterizing the forehead lesion.
2. Consider Further Imaging: An ultrasound could potentially be used to better delineate the mass from surrounding soft tissues if ambiguity remained.
3. Surgical Excision: Discussion of surgical removal for several reasons: to alleviate symptoms (tenderness), address cosmetic concerns related to its growth, and most importantly, to obtain a tissue sample for definitive histopathological diagnosis. Given the likely size and location, an endoscopic or direct-incision approach would be feasible.

Outcome and Follow-up

The patient was encouraged to pursue a specialist consultation to establish a definitive diagnosis and treatment plan. This case underscores the importance of clinical-radiological correlation; a physical finding should not be dismissed even with an initially 'normal' imaging report. Persistence in seeking a diagnosis is crucial when a patient's symptoms and clinical findings are not fully explained by initial investigations. Follow-up after excision of a benign osteoma typically involves routine post-operative care, with a very low rate of recurrence.