British Journal of Oral and Maxillofacial Surgery 45 (2007) 238239

Short communication

Bilateral intraparotid and extraparotid Warthins tumours

N. Shah , J.V. Tighe, A.W. Barrett, S. Kumar, J.P. Allen
Departments of Oral and Maxillofacial Surgery and Histopathology, Queen Victoria Hospital, Holtye Road, East Grinstead, West Sussex RH19 3DZ, UK Accepted 12 August 2005 Available online 3 October 2005

Abstract Warthins tumour is a benign adenoma in the parotid gland, but extraparotid and synchronous bilateral Warthins tumours may occur. In this report, we describe a patient with simultaneous bilateral involvement of the parotid glands and neck by multiple Warthins tumours, an occurrence not previously described. 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keyword: Warthins tumour

Introduction Warthins tumour (reviewed by Ellis and Auclair1 ) is an adenoma comprising 411% of all, up to 27% of benign, and as many as 34% of parotid salivary gland tumours, making it the second commonest after pleomorphic adenomas. Most tumours arise in patients over the age of 60. The aetiology appears to be related to smoking, which may explain why the male:female ratio is reaching parity despite a male preponderance in some series. Warthins tumours outside the parotid gland (usually the tail) and periparotid area are exceptional. Multicentric Warthins tumours are more common than any other salivary gland tumour; about 12% of patients develop multiple tumours, which may be bilateral. We report a case of a 78-year-old man with multiple bilateral swellings of the parotid glands and neck, histopathological examination of which showed to be Warthins tumours.

Case report A 78-year-old White man was referred by his physician with bilateral swellings of the neck which had been present for
Corresponding author. Noman Shah, SHO Oral and Maxillofacial Surgery. Tel.: +44 7961 483361. E-mail address: maxfax73@yahoo.co.uk (N. Shah).

more than 2 years. Apart from a 60-year habit of smoking 15 cigarettes a day, his medical history was unremarkable. Clinical examination showed swellings 30 mm 30 mm near the tail of the parotid glands on both sides, and further 15 mm swellings in the right and left neck at levels 23. The swellings were mobile, rm, and non-tender. Intraoral and nasoendoscopic examinations were normal, as was that of the cranial nerves. Panoral and chest radiographs were unremarkable. A provisional diagnosis of lymphoma was made. Ultrasound conrmed ve masses in the right supercial parotid gland, the largest 30 mm in diameter, and three in the left, the largest 17 mm in diameter. There were also multiple enlarged left internal jugular lymph nodes at the junction of levels 2 and 3, the largest of which measured 25 mm 15 mm. There were also two lesions 9 mm in maximum dimension on the right side of the neck at levels 23. All lesions were well dened and rounded in appearance, and lacked a heterogeneous echo texture and central hilar shadow. This suggested that they were not lymph nodes. A Trucut biopsy of the lesion in the tail of the right parotid was done under local anaesthetic. Histopathological examination showed a Warthins tumour. We did bilateral supercial parotidectomies and removed four lesions from the left neck. To reduce morbidity, the lesions in the right neck were left alone. Histopathology conrmed Warthins tumour in all the specimens, with no evidence of malignancy. The patient made an uneventful recovery and there has been no recurrence in 2 years.

0266-4356/$ see front matter 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2005.08.016

N. Shah et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 238239

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Fig. 1. Photomicrograph showing bilayered, eosinophilic oncocytic epithelium lining the cyst lumen, with haematoxyphilic lymphoid aggregates in the stroma. Haematoxylin and eosin, original magnication 200.

1929 after Aldred Scott Warthin wrote a review of parotid tumours and branchial cysts of the cervical region. Papillary cystadenoma lymphomatosum is an accurate, if cumbersome, synonymous term. Extraparotid tumours are rare, but have been reported in the submandibular gland,2 larynx, cheek, oropharynx, lower lip, palate, buccal fold, and the anterior margin of the sternocleidomastoid muscle at level 1.3 Eight percent of Warthins tumours arise in periparotid lymph nodes.4 Synchronous, unilateral parotid and nasopharyngeal Warthins tumours have been reported, as have unilateral, multicentric Warthins tumours of the retromandibular area and lateral aspect of the neck.5 There are several reports of bilateral tumours.6 However, this is to our knowledge the rst report of simultaneous bilateral involvement of the parotid glands and neck by multiple Warthins tumours. The clinical presentation was suspicious of malignancy, but all the tumours responded to simple excision.

Histopathology Sections showed circumscribed, papillary cystic tumours comprising epithelial and lymphoid elements. At high power, the epithelium comprised a double layer of eosinophilic oncocytes. The lumenal layer was columnar, whereas the outer layer was atter and abutted a well-organized lymphoid stroma (Fig. 1). There were no atypical features in any sample.

References
1. Ellis GL, Auclair PL. Tumors of the salivary glands. In: Atlas of tumor pathology, 3rd series, Fascicle 17. Washington DC: Armed Forces Institute of Pathology; 1996. 2. van der Wal JE, Davids JJ, van der Waal I. Extraparotid Warthins tumoursreport of 10 cases. Br J Oral Maxilofac Surg 1993;31:434. 3. Scasso CA, Papini M, Eligi C, Gheldardi F, Cagno MC, Bruschini P. An unusual neck mass: the Warthins tumor. Acta Otorhinolaryngol Belg 1998;52:557. 4. Synderman C, Johnson JT, Barnes EL. Extraparotid Warthins tumor. Otolaryngol Head Neck Surg 1986;94:16975. 5. Chae SW, Sohn JH, Shin HS, Choi JJ, Kim YB. Unilateral, multicentric Warthins tumor mimicking a tumor metastatic to a lymph node. A case report. Acta Cytol 2004;48:22933. 6. Seifert G, Bull HG, Donath K. Histologic subclassication of the cystadenolymphoma of the parotid gland. Analysis of 275 cases. Virchows Arch [A] 1980;388:1338.

Discussion Hildebrand rst described Warthins tumour in 1895 as adenolymphoma, but the entity acquired its current eponym in