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Karuturi Rounds 77 > What is your Differential Diagnosis of this Neck Mass?

An 84 year old white man presents with a mobile mass on his right parotid area, been there for 4 years and doesn't bother him much. It's nontender and mobile and soft on the exam. What is your differential? ( Hint:he had it on the other side of his neck and it was biopsied)

What is your Differential Diagnosis of this Neck Mass?

Image Credit :

Dr. Mahaveer Mukkamalla, MD

Family Physician

Belmont Community Health Center

Bellaire, OH, USA

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Permalink Reply by abdullah demirkan on October 15, 2012 at 4:19pm

wharton tumour ( its possibility to be bilateral than the other tumours)

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Permalink Reply by Subrahmanyam Karuturi on October 17, 2012 at 1:11pm

Biopsy Report - Warthin's Tumour or Papillary Cystadenoma Lymphomatosum

Papillary Cystadenoma Lymphomatosum—Warthin's Tumors

First described by Aldred Warthin in 1929, Warthin's tumor is the second most common benign salivary gland neoplasm behind pleomorphic adenoma. Warthin's tumor is also known as papillary cystadenoma lymphomatosum or adenolymphoma. The term “adenolymphoma” is often confused with malignant lymphoma and therefore the use of this term should be discouraged. Papillary cystadenoma lymphomatosum is an accurate descriptive term but is somewhat cumbersome compared with the most favored term of Warthin's tumor. Warthin's tumor accounts for approximately 10% of all parotid tumors and is found almost exclusively in the parotid gland. Warthin's tumor is associated with a higher male preponderance and is more prevalent in whites than in other racial groups. Bilateral Warthin's tumors occur in 10% of cases and may be simultaneous. As previously discussed, Warthin's tumor is associated with cigarette smoking, which may be due to irritation of ductal epithelium by tobacco smoke, which initiates tumorigenesis.

Clinically, patients with Warthin's tumor present with an asymptomatic, slow-growing mass often in the superficial lobe of the parotid gland at the angle of the mandible. However, a few patients will present with swelling, pain, and other inflammatory changes, which may be secondary to an immunologic response of the lymphoid element.

On gross pathologic examination, Warthin's tumors are usually spheric or ovoid masses that are encapsulated with a smooth or lobulated surface. Papillary cysts are commonly found on sectioning and contain mucoid brown fluid. Solid gray tissue encapsulates white nodules of lymphoid tissue. Microscopically, the combination of papillae of eosinophilic epithelia projecting into cystic spaces and lymphoid matrices is a distinct and pathognomonic histologic feature. The typical cystic lining is arranged in two cell layers of even rows. The apical or luminar tall columnar and basal cuboidal cells contain small dark nuclei and abundant granular pink cytoplasm (oncocytes). The granular eosinophilia of oncocytes is due to abundant mitochondria present in the cytoplasm. Treatment of Warthin's tumor is surgical excision, usually a parotidectomy with facial nerve preservation. Inadequate excision or tumor multicentricity may explain tumor recurrence.

Reference : Flint: Cummings Otolaryngology: Head & Neck Surgery, 5th ed.