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Case Report 


European Journal of Medical Case Reports

Volume 3(2):61–64

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Warthin’s tumor as “Earring” lesion of parotid gland: a case report

Shweta Sharma1, Bharat Bhushan Sharma2*, Neeru Kapur3, Shantanu Singh Chauhan3, Mir Rizwan Aziz4, Dileep Kumar Jha4

Received: 15 October 2018 Accepted: 28 April 2019

Type of Article: CASE REPORT Speciality: Radiology

Funding: None

Declaration of conflicting interests: None

Correspondence to: Bharat Bhushan Sharma

*Professor and HOD, Department of Radio Diagnosis, SGT Medical College, Gurgaon, India.

Email: bbhushan986 [at] gmail.com

Full list of author information is available at the end of the article.


ABSTRACT

Background:

Earring lesions in the neck region comprises spectrum of different pathologies. Papillary cystadenoma lymphomatosum (PCL) is one of such entity which falls in this spectrum. The cystic lesions of the tail of parotid gland can lead to utter confusion over the diagnosis especially about the site of origin. The exact anatomy has to be delineated for the correct location and the diagnosis. The wrong location and diagnosis can lead to many iatrogenic complications. The cross-sectional imaging plays a pivot role. Computerized tomography and Magnetic Resonance imaging can diagnose the entity fairly to the exact diagnosis.


Case Presentation:

We present 41-year female who presented with this type of pathology with small swelling at the angle of left mandible. She reported because of cosmetic reasons and was subjected to CT and MRI. Coronal sections were able to delineate the lesion in both Contrast enhanced computerized tomography (CECT) and Magnetic resonance imaging (MRI). The lesion after histological analysis turned out to be Warthin’s tumor.


Conclusion:

Ear ring lesions remain undiagnosed if not evaluated by cross-sectional radiological imaging. The concern becomes greater because of the malignant potential of these neoplasms.


Keywords:

Earring lesion, PCL, CT, MRI, malignant.

Introduction

Parotid masses differentiation is a challenging task for both the radiologists as well as the clinicians because of some being having malignant potential. The importance of these types of lesions is emphasized as there can be the damage of marginal branches of mandibular nerve during surgical maneuver [1]. It is very important to understand the anatomy of the gland before opining the specific pathology (Figure 1). Warthin’s tumor was named after the pathologist Alderd Scott Warthin in 1929. The lesion may not be visible or palpated because of the size and location. These are located in superficial lobe of the parotid gland and deep lobe is not involved. This is the second most common tumor of the superficial lobe. The correct diagnosis can avoid damage to the facial nerve and other iatrogenic effects.


Case Report

A 41-year-old female (Figure 2) presented to Otorhinolaryngology Outpatient Department with the swelling on the left side of the face of 2 years duration. The swelling had increased in size for the last 6 months without any pain. There was history of slight pain after eating something sour in taste.

There was no history of any trauma or fever related to these complaints. Locally, there was small soft fluctuating swelling immediately under the lobule of the left ear. No skin changes were noticed. Systemic examination was unremarkable. All the blood parameters were within the normal limits. Plain skiagram of the face and neck region did not reveal any soft tissue or bony pathology (Figure 3).

The patient was subjected to ultrasonography. There was cystic swelling present in the tail of the left parotid gland just below the ear lobule. This was well-defined region without any echoes from within it. All the surrounding structures were normal. Right parotid gland was unremarkable. Color flow imaging (CFI) did not show any blood flow within this lesion (Figure 4).

She was further evaluated by contrast enhanced computed tomography of the face and neck region. The encapsulated lesion was well demarcated from the rest of the parotid gland. The surrounding gland had shown normal enhancement. The location was confirmed in the tail region of the gland (Figure 5).

Magnetic resonance imaging study revealed well-defined mass in the tail region which was hypointense on T1WI and hyperintense in T2WI. Short tau inversion recovery (STIR) sequence had shown this as shining hyperintense lesion (Figures 68).

Figure 1. Diagramatic representation of parotid gland and surrounding structures. (a) Main gland (red star) with tail of the superficial lobe (red arrow). Anterior boundary is by masseter muscle in close relation to the mandibular nerve. The layout of parotid duct should also be understood before surgery (white hollow arrow). (b) Parotid gland is seen in green color with nerve traversing through it (white solid arrow). The tumor location for the ear ring lesion is marked by grey region in the tail region of the gland.

Figure 2. Photo of 41-year-old female enface and profile with left parotid swelling below the ear lobule (horizontal and vertical blue arrows).

Figure 3. Plain X-ray face and cervical region. (a) Lateral and (b) anteroposterior views. There was no evidence of underlying bony or soft tissue abnormality. No calcification seen in both the parotid regions.

Figure 4. Ultrasonography (USG) of the left side of the face including parotid gland. (a) Long axis US image with high frequency linear probe (7 MHz) shows cystic lesion present in the tail region of superficial part of lobe (white hallo arrow). (b) CFI shows no flow in the lesion (inverted hallo arrow).

Figure 5. Contrast enhanced computerized tomography. (a) Axial section shows a well-defined “ring like” lesion behind the left mandible (vertical arrow). The lesion shows cystic component surrounded by the enhancing thin capsular wall. (b) Coronal section shows earring type of lesion below the external auditory meatus (horizontal arrow). (c) Left parasagittal section of the head and neck region shows the supero-inferior extent of the earring lesion (horizontal white arrow).

Figure 6. Magnetic resonance images. (a) T1WI axial section shows a well-defined hypointense lesion near the angle of the left mandible (vertical arrow). (b) T1WI coronal section shows the superoinferior extent of hypointense lesion (horizontal arrow).

Fine needle aspiration cytology (FNAC) was performed and this turns out be as Warthin’s tumor. Histopathology had shown multiple cystic spaces with epithelial papillary infoldings. These were surrounded by two uniform rows of epithelial cells. The epithelium had lymphoid stroma with germinal center formation. The patient had been advised surgical excision and now on follow up for the same.


Discussion

Hamilton et al. [1] describes the tail as inferior 2 cm of the superficial lobe of the parotid gland. Earring lesions in the tail of the parotids have to be differentiated from those masses which are either arising from sub mandibular gland or reflected by regional lymph nodes. These lesions are well encapsulated. Superficial layer of deep cervical fascia covers the parotid gland and this is suspended with zygomatic arch. The carotid space is separated from the gland by posterior digastric muscle. The differential diagnosis includes a long list of benign pathologies such as pleomorphic adenoma, Warthin’s tumor, infectious process, venous malformations, Sjogren disease, lymphatic malformation, lipoma, HIV lymphoepithelial lesion, first brachial cleft cyst and less likely lesions such as oncocytoma, sarcoid and lymph nodes [2]. Pleomorphic adenomas have 2%–25% chances of malignant degeneration. Malignant lesions at this site could be Non-Hodgkin lymphoma, metastasis, mucoepidermoid carcinoma and undifferentiated carcinomas. The pediatric age group had common atrio-venous malformations at this site [35]. Warthin’s tumor is also called as papillary cystadenoma lymphomatosum. This is benign tumor of cystic in consistency. This does not come with any alarming symptomatology [6,7]. The incidence is more common among the smokers. This requires to be differentiated from oncocytoma and sebaceous lymphadenoma [8,9]. The working diagnosis can be achieved by cross-sectional imaging. Ultrasonography with CFI will highlight the consistency and the vasculature of the tumor. Contrast enhanced computerized tomography (CECT) and contrast enhanced Magnetic resonance imaging (MRI) further shows the tissue characterization and the relationship to the adjoining structures. Diffusion Weighted Imaging with apparent diffusion coefficient further helped in segregating pleomorphic adenomas from other parotid tumors. FNAC is the initial step for confirming the diagnosis but sometimes histopathological specimen can only be the final answer [10]. The management requires complete surgical excision [11]. There is no incidence of recurrence.

Figure 7. Magnetic resonance images. (a) T2WI axial section shows hyperintense lesion near external auditory meatus (vertical arrow). (b) T2WI coronal section shows the superoinferior extent of hyperin tense lesion with well-defined outline (horizontal arrow).

Figure 8. MR STIR images. (a) Axial section shows well-defined hyper intense cystic lesion (yellow arrow). (b) Coronal section sows “earring” type of hyperintense well defined lesion (red arrow). (c) Left parasagittal section shows the lesion at the angle of left mandible (green arrow).


Conclusion

The evaluation of the parotid masses is a very challenging task because of their wide range of nature. This requires thorough evaluation for the management purpose. Cross-sectional imaging plays a pivot role in knowing the anatomical details and some features pointing their nature as per benign or malignant pathologies.


Acknowledgement

The authors would like to thank their Post Graduate student Manav Sethi and Mr Nitish Lacturer of Faculty of Allied Health Sciences for providing them good input about the case and carrying out investigations.


List of abbreviations

CECT Contrast enhanced computerized tomography
MRI Magnetic resonance imaging
CFI Color flow imaging
FNAC Fine needle aspiration cytology
STIR Short tau inversion recovery

Conflict of Interest

There is no conflict of interest.


Funding

None.


Consent for publication

Written consent of the patient was taken.


Ethical approval

Ethical approval is not required at our institution to publish an anonymous case report.


Author details

Shweta Sharma1, Bharat Bhushan Sharma2, Neeru Kapur3, Shantanu Singh Chauhan3, Mir Rizwan Aziz4, Dileep Kumar Jha4

  1. ENT Speciality registrar Flat No 9, Lakin House, Wawick, UK
  2. Professor and HOD, Department of Radio Diagnosis, SGT Medical College, Gurgaon, India
  3. Assistant Professor, Department of Radio Diagnosis, SGT Medical College, Gurgaon, India
  4. Senior Resident, Department of Radio Diagnosis, SGT Medical College, Gurgaon, India

References

  1. Hamilton BE, Salzman KL, Wiggins RH, Harnsberger HR. Earring lesions of the parotid tail. Am J Neuroradiol. 2003;24(9):1757–64.
  2. Sungur N, Akan IM, Ulsuoy MG, Ozdemir R, Kilinc H, Ortak HT. Clinicopathological evaluation of parotid gland tumors: a retrospective study. J Craniofacial Surg. 2002;13:26–30. https://doi.org/10.1097/00001665-200201000-00004
  3. Orvidas LJ, Kasperbauer JL, Lewis JEOlsen KD, Lesnick TG. Pediatric parotid masses. Arch Otolaryngol Head Neck Surg. 2000;126:177–84. https://doi.org/10.1001/archotol.126.2.177
  4. Robertson RL, Robson MB, Barnes PB, Burrows PE. Head and neck vascular anomalies of childhood. Neuroimaging Clin N Am. 1999;9:115–32.
  5. Jacques DA, Krolls SO, Chambers RG. Parotd tumors in children. Am J Surg. 1976;132:469–71. https://doi.org/10.1016/0002-9610(76)90321-4
  6. Maiorano E, Muzio L, Lo F, Piattelli GA. Warthin's tumor: a study of 78 Cases with emphasis on bilaterality, multifocality, and association with other malignancies. Oral Oncol. 2002;38:35–40. https://doi.org/10.1016/S1368-8375(01)00019-7
  7. Loannidis JP, Vassiliou VA, Moutsopoulos HM. Long-term risk of mortality and lymphoproliferative disease and predictive classification of primary Sjogren's syndrome. Arthritis Rheum. 2002;46:741–7. https://doi.org/10.1002/art.10221
  8. Urquart A, Hutchins LG, Berg RL. Pre-operative computed tomography scans of parotid tumor evaluation. Laryngoscope. 2001;111(Pt1):1984–8. https://doi.org/10.1097/00005537-200111000-00022
  9. Huisman TA, Holzmann D, Nadal D. MRI of chronic recurrent parotitis in childhood. J Comput Assist Tomogr. 2001;25:269–73. https://doi.org/10.1097/00004728-200103000-00021
  10. Zbaren P, Schar C, Hotz MA, Loosli H. Value of fine needle aspiration cytology of parotid gland masses. Laryngoscope. 2001;(Pt1):1989–92. https://doi.org/10.1097/00005537-200111000-00023
  11. Eisele DW, Johns ME. Complications of surgery of the salivary glands. In: David E (ed.). Complications in head and neck surgery. St Louis, MO: Mosby-Year Book Inc.; 1993. pp. 183–200.

Summary of the case

Patient 1 41-years old female
Final Diagnosis 2 Warthin’s tumor
Symptoms 3 Swelling and mild pain in the left side of the face
Medications (Generic) 4 Symptomatic
Clinical Procedure 5 -----
Specialty 6 Radiology


How to Cite this Article
Pubmed Style

Sharma S, Sharma BB, Kapur N, Chauhan SS, Aziz MR, Jha DK. Warthin's tumor as "Earring" lesion of parotid gland: a case report. EJMCR. 2019; 3(2): 61-64. doi:10.24911/ejmcr/173-1539620111


Web Style

Sharma S, Sharma BB, Kapur N, Chauhan SS, Aziz MR, Jha DK. Warthin's tumor as "Earring" lesion of parotid gland: a case report. https://www.ejmcr.com/?mno=12891 [Access: November 15, 2019]. doi:10.24911/ejmcr/173-1539620111


AMA (American Medical Association) Style

Sharma S, Sharma BB, Kapur N, Chauhan SS, Aziz MR, Jha DK. Warthin's tumor as "Earring" lesion of parotid gland: a case report. EJMCR. 2019; 3(2): 61-64. doi:10.24911/ejmcr/173-1539620111



Vancouver/ICMJE Style

Sharma S, Sharma BB, Kapur N, Chauhan SS, Aziz MR, Jha DK. Warthin's tumor as "Earring" lesion of parotid gland: a case report. EJMCR. (2019), [cited November 15, 2019]; 3(2): 61-64. doi:10.24911/ejmcr/173-1539620111



Harvard Style

Sharma, S., Sharma, . B. B., Kapur, . N., Chauhan, . S. S., Aziz, . M. R. & Jha, . D. K. (2019) Warthin's tumor as "Earring" lesion of parotid gland: a case report. EJMCR, 3 (2), 61-64. doi:10.24911/ejmcr/173-1539620111



Turabian Style

Sharma, Shweta, Bharat Bhushan Sharma, Neeru Kapur, Shantnu Singh Chauhan, Mir Rizwan Aziz, and Dileep Kumar Jha. 2019. Warthin's tumor as "Earring" lesion of parotid gland: a case report. European Journal of Medical Case Reports, 3 (2), 61-64. doi:10.24911/ejmcr/173-1539620111



Chicago Style

Sharma, Shweta, Bharat Bhushan Sharma, Neeru Kapur, Shantnu Singh Chauhan, Mir Rizwan Aziz, and Dileep Kumar Jha. "Warthin's tumor as "Earring" lesion of parotid gland: a case report." European Journal of Medical Case Reports 3 (2019), 61-64. doi:10.24911/ejmcr/173-1539620111



MLA (The Modern Language Association) Style

Sharma, Shweta, Bharat Bhushan Sharma, Neeru Kapur, Shantnu Singh Chauhan, Mir Rizwan Aziz, and Dileep Kumar Jha. "Warthin's tumor as "Earring" lesion of parotid gland: a case report." European Journal of Medical Case Reports 3.2 (2019), 61-64. Print. doi:10.24911/ejmcr/173-1539620111



APA (American Psychological Association) Style

Sharma, S., Sharma, . B. B., Kapur, . N., Chauhan, . S. S., Aziz, . M. R. & Jha, . D. K. (2019) Warthin's tumor as "Earring" lesion of parotid gland: a case report. European Journal of Medical Case Reports, 3 (2), 61-64. doi:10.24911/ejmcr/173-1539620111