- Email: [email protected]
Ischaemic necrosis and facial palsy in Warthin's tumour of the parotid gland
Auris Nasus Larynx 29 (2002) 99 – 101 www.elsevier.com/locate/anl
Ischaemic necrosis and facial palsy in Warthin’s tumour of the parotid gland Sangeeta Maini a,*, J.E. Osborne b a
Department of ENT, Royal Gloucestershire Hospital, Great Western Road, Gloucester GLI 3NN, UK b Department of ENT, Glan Clywd Hospital, Bodelwyddan, North Wales LI18 5UJ, UK Received 9 April 2001; received in revised form 24 July 2001; accepted 27 July 2001
Abstract A 72-year-old patient with a Warthin’s tumor of the right parotid gland developed massive necrosis of the tumour associated with temporary facial palsy with subsequent macroscopic tumour disappearance. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Warthin; Necrosis; Palsy
1. Introduction Minor degrees of inflammation, fibrosis and necrosis are very common in adenolymphomas [1,2]. This case report describes two unusual phenomenon of facial paralysis and massive necrosis in a benign parotid tumor. As far as we know, only two previous cases of necrosis of Warthin’s tumor of parotid gland associated with facial palsy have been reported [3,4]. However, this is the first case in the literature describing massive necrosis of Warthin’s tumour with an associated facial palsy and subsequent clinical and radiological disappearance of the tumour.
rior to the right auricle, oval, mobile, nontender, firm in consistency and skin over swelling was normal in appearance (Fig. 1). Facial nerve function was normal bilaterally. No neck nodes were palpable. On ultrasound scanning, the right parotid contained a mixed echogenecity and a poorly defined mass measuring atleast 3.5× 2.5× 3.8 cm in diameter. Predominantly situated within the superficial lobe, but probably also involving the deep lobe (Fig. 2). The cystic areas seen were typical of a Warthin’s tumour, but the irregularity
2. Case report A 72-year-old male presented to ENT out patient department with a primary complaint of swelling over the right parotid region of 6 months duration. The swelling was painless and gradually increasing. On examination, the right parotid swelling was antero-infe-
* Corresponding author. Tel.: + 44-1452-52-8555; fax: + 44-174553-4160. E-mail address: [email protected] (S. Maini).
Fig. 1. Photograph of patient at initial presentation with right parotid tumour.
0385-8146/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 1 2 0 - 1
100
S. Maini, J.E. Osborne / Auris Nasus Larynx 29 (2002) 99–101
Fig. 2. Ultrasound showing a mass of atleast 3.5 × 2.5× 3.8 cm with several cystic areas predominantly situated in the superficial lobe.
(Fig. 3). The facial palsy was incomplete involving all its motor segments and was improving gradually. Ultrasound and fine needle aspirate were repeated revealing no obvious residual tumour (Fig. 4). At 1 year follow up there was no clinical evidence of tumor and facial palsy recovery was complete.
3. Discussion
Fig. 3. Photograph showing cicatrization of skin at the site of tumour rupture.
and hypervascularity on ultrasound,were unusual manifestations. Fine needle aspirate was cytologically diagnostic of a Warthin’s tumour. The patient was listed for right superficial parotidectomy. Four weeks after fine needle aspiration the parotid swelling underwent a rapid increase in size and ruptured exuding khaki coloured viscous fluid, associated with right sided otalgia and facial nerve weakness. The patient consulted his general practitioner and was commenced on oral antibiotics and steroids. The discharge continued for a few days with slow reduction in size. One month after the palsy developed, he was seen in the out patient department. No palpable swelling was present but there was cicatrization of the skin at the site of tumour rupture
In this patient, the initial cytology unequivocally confirmed a Warthin’s tumour. However, after the tumour rupture, no residual tumour could be detected clinically, cytologically or on ultrasound. Disappearance of the tumour can be explained by massive tumour necrosis. Inflammation, necrosis and fibrosis around the facial nerve branches can explain the temporary lower motor neurone facial palsy, which recovered completely once the inflammatory process settled. Necrotic adenolymphomas were apparently first described by Patey and Thackray [5]. They described three possible routes of infection via salivary ducts, lymphatics and blood stream. In our present case report, the needle aspiration was the most likely route of infection as there was a temporal relationship between aspiration and the development of symptoms. However, necrosis may also have been related to tumour size as these tumours are poorly vascularized [6]. One year follow up showed no clinical evidence of tumour, however, as Warthin’s tumours are slow growing, a recurrence at a later date is still a possibility.
S. Maini, J.E. Osborne / Auris Nasus Larynx 29 (2002) 99–101
101
Fig. 4. Ultrasound guided FNA performed on the 2 ×2 cm hypoechoeic area in the right parotid gland revealed no residual tumour.
References [1] Eveson JW, Cawson RA. Salivary glands tumors: a review of 2410 cases with particular reference to histological types, site age and sex distribution. J Pathol 1985;146:51 –8. [2] Seifert G, Bull HG, Donath K. Histological classification of adenolymphoma of the parotid gland. Analysis of 275 cases. Virchows Arch A (Pathol Anat) 1980;388:13 – 38.
[3] Eveson JW, Cawson RA. Infarcted adenolymphoma’s: a clinicopathological study of 20 cases. Clin Otolaryngol 1988;14:205 –10. [4] Newman L, Loukata RA, Bradley PF. An infarcted Warthin’s tumor presenting with facial weakness. Br J Oral Maxillofacial Surg 1993;31:311 – 2. [5] Patey DH, Thakrey AC. Infected adenolymphoma: a new parotid syndrome. Br J Surg 1970;57:569 – 72. [6] Warthin AS. Papillary Cystadenoma lymphomatosum. A rare teratoid of the parotid region. J Cancer Res 1929;13:116 – 25.
Ischaemic necrosis and facial palsy in Warthin’s tumour of the parotid gland Sangeeta Maini a,*, J.E. Osborne b a
Department of ENT, Royal Gloucestershire Hospital, Great Western Road, Gloucester GLI 3NN, UK b Department of ENT, Glan Clywd Hospital, Bodelwyddan, North Wales LI18 5UJ, UK Received 9 April 2001; received in revised form 24 July 2001; accepted 27 July 2001
Abstract A 72-year-old patient with a Warthin’s tumor of the right parotid gland developed massive necrosis of the tumour associated with temporary facial palsy with subsequent macroscopic tumour disappearance. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Warthin; Necrosis; Palsy
1. Introduction Minor degrees of inflammation, fibrosis and necrosis are very common in adenolymphomas [1,2]. This case report describes two unusual phenomenon of facial paralysis and massive necrosis in a benign parotid tumor. As far as we know, only two previous cases of necrosis of Warthin’s tumor of parotid gland associated with facial palsy have been reported [3,4]. However, this is the first case in the literature describing massive necrosis of Warthin’s tumour with an associated facial palsy and subsequent clinical and radiological disappearance of the tumour.
rior to the right auricle, oval, mobile, nontender, firm in consistency and skin over swelling was normal in appearance (Fig. 1). Facial nerve function was normal bilaterally. No neck nodes were palpable. On ultrasound scanning, the right parotid contained a mixed echogenecity and a poorly defined mass measuring atleast 3.5× 2.5× 3.8 cm in diameter. Predominantly situated within the superficial lobe, but probably also involving the deep lobe (Fig. 2). The cystic areas seen were typical of a Warthin’s tumour, but the irregularity
2. Case report A 72-year-old male presented to ENT out patient department with a primary complaint of swelling over the right parotid region of 6 months duration. The swelling was painless and gradually increasing. On examination, the right parotid swelling was antero-infe-
* Corresponding author. Tel.: + 44-1452-52-8555; fax: + 44-174553-4160. E-mail address: [email protected] (S. Maini).
Fig. 1. Photograph of patient at initial presentation with right parotid tumour.
0385-8146/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 1 2 0 - 1
100
S. Maini, J.E. Osborne / Auris Nasus Larynx 29 (2002) 99–101
Fig. 2. Ultrasound showing a mass of atleast 3.5 × 2.5× 3.8 cm with several cystic areas predominantly situated in the superficial lobe.
(Fig. 3). The facial palsy was incomplete involving all its motor segments and was improving gradually. Ultrasound and fine needle aspirate were repeated revealing no obvious residual tumour (Fig. 4). At 1 year follow up there was no clinical evidence of tumor and facial palsy recovery was complete.
3. Discussion
Fig. 3. Photograph showing cicatrization of skin at the site of tumour rupture.
and hypervascularity on ultrasound,were unusual manifestations. Fine needle aspirate was cytologically diagnostic of a Warthin’s tumour. The patient was listed for right superficial parotidectomy. Four weeks after fine needle aspiration the parotid swelling underwent a rapid increase in size and ruptured exuding khaki coloured viscous fluid, associated with right sided otalgia and facial nerve weakness. The patient consulted his general practitioner and was commenced on oral antibiotics and steroids. The discharge continued for a few days with slow reduction in size. One month after the palsy developed, he was seen in the out patient department. No palpable swelling was present but there was cicatrization of the skin at the site of tumour rupture
In this patient, the initial cytology unequivocally confirmed a Warthin’s tumour. However, after the tumour rupture, no residual tumour could be detected clinically, cytologically or on ultrasound. Disappearance of the tumour can be explained by massive tumour necrosis. Inflammation, necrosis and fibrosis around the facial nerve branches can explain the temporary lower motor neurone facial palsy, which recovered completely once the inflammatory process settled. Necrotic adenolymphomas were apparently first described by Patey and Thackray [5]. They described three possible routes of infection via salivary ducts, lymphatics and blood stream. In our present case report, the needle aspiration was the most likely route of infection as there was a temporal relationship between aspiration and the development of symptoms. However, necrosis may also have been related to tumour size as these tumours are poorly vascularized [6]. One year follow up showed no clinical evidence of tumour, however, as Warthin’s tumours are slow growing, a recurrence at a later date is still a possibility.
S. Maini, J.E. Osborne / Auris Nasus Larynx 29 (2002) 99–101
101
Fig. 4. Ultrasound guided FNA performed on the 2 ×2 cm hypoechoeic area in the right parotid gland revealed no residual tumour.
References [1] Eveson JW, Cawson RA. Salivary glands tumors: a review of 2410 cases with particular reference to histological types, site age and sex distribution. J Pathol 1985;146:51 –8. [2] Seifert G, Bull HG, Donath K. Histological classification of adenolymphoma of the parotid gland. Analysis of 275 cases. Virchows Arch A (Pathol Anat) 1980;388:13 – 38.
[3] Eveson JW, Cawson RA. Infarcted adenolymphoma’s: a clinicopathological study of 20 cases. Clin Otolaryngol 1988;14:205 –10. [4] Newman L, Loukata RA, Bradley PF. An infarcted Warthin’s tumor presenting with facial weakness. Br J Oral Maxillofacial Surg 1993;31:311 – 2. [5] Patey DH, Thakrey AC. Infected adenolymphoma: a new parotid syndrome. Br J Surg 1970;57:569 – 72. [6] Warthin AS. Papillary Cystadenoma lymphomatosum. A rare teratoid of the parotid region. J Cancer Res 1929;13:116 – 25.