Clinical diagnosis
Case 156
【Progress】
We have only one otorhinolarygologist, indicating unable to supply a major surgery. Then he was referred to the hospital where he was able to get medical service of surgical resection.
【Discussion】
As salivary glands in human, there are major salivary glands and minor salivary glands. As major salivary glands, parotid glands, submandibular glands and sublingual glands are listed. Accessory salivary glands sometimes appear near the main parotid salivary glands. Minor salivary glands exist as hundreds of number in the wall of the oral mouth.
Parotid glands exist as a pair and are the largest of the salivary glands. Parotid glands function to secrete the serous salivary fluids and amylase which turn starch into sugars. In the parotid glands, various structures pass thorough the parotid glands such as branches of facial nerve, a branch of trigeminal nerve, and branches of superficial temporal artery and maxillary artery. Then, after the surgical resection, the complication of facial nerve palsy and Frey syndrome are known to sometimes occur. Frey syndrome is in state of appearing redness and sweating at the previous site of the resected parotid glands in case of anticipation of eating food. Salivary glands are secreted under parasympathetic nerve and sweating is secreted from sweat glands under sympathetic nerve. It is believed that after the surgical resection of branches of autoimmune nerve, in the restoration process of autoimmune nerves, short circuit between parasympathetic nerve and sympathetic nerve arises, inducing sweat and redness in case of anticipation of eating food (1, 2).
As the swollen parotid gland, inflammation, autoimmune disease, benign tumor and carcinoma are listed. Parotitis arises from virus and bacteria. Mumps are known to occur mainly in childhood and bacterial parotitis and mycobacterium tuberculosis which arise from salivary gland tractb in adults. Sarcoidosis, Sjogren disease called Ig G4 related disease which includes Mikulicz disease are typical autoimmune disease. Of the benign tumor and carcinoma, benign tumor occupies approximately 80 %. The representative benign tumors in childhood are hemangioma and lymphangioma and in adults are pleomorphic adenoma (mixed tumor) and Warthin tumor. Pleomorphic tumor occurs in 80 % of the benign tumors, followed by Warthin tumor (3, 4). As the representative malignant tumors, metastatic lymph-node tumor, muco-epithelial carcinoma and adenoid cystic carcinoma are listed. More malignant tumor occur in the lower sized salivary gland, namely, malignant tumors most arise from minor salivary glands whereas benign tumors most arise from parotid gland (5 - 7).
Microscopically, salivary glands compose of serous acinus, mucous acinus, intercalated duct, striated duct and excretory duct. Based on bicellular theory, pleomorphic adenoma, Warthin tumor end adenoid cystic carcinoma arise from intercalated duct and mucoepidermoid carcinoma arises from excretory duct (5 - 7).
The characteristic clinical findings of Warthin tumor are as follows; smoking related tumor; the median age, 60th grade; parotid gland tail mass;
2nd most common benign parotid tumor; 20% multifocal: 30% cystic component (8 - 10). The characteristic findings of Warthin tumor on T1WI MRI were that cystic components contain cholesterol crystals appear as high-signal-intensity areas (8). In our case, he was 70ies and heavy smoker and his parotid tumor existed at the parotid gland tail with cystic components which were shown as high signal intensity on T1WI MRI.
【Summary】
We present a seventy two year-old male suffering from gradual increasing mass at the right parotid gland tail. It is borne in mind that after resection of parotid gland, facial nerve palsy and Frey syndrome often occurs because the branches of facial nerve and trigeminal nerve are often injured. Frey syndrome means that redness and sweating (sympathetic nerve) in case of anticipation of eating food (parasympathetic nerve) occur at the previous site of parotid gland which short circuit between parasympathetic nerve and sympathetic nerve arises. As the swollen parotid gland, inflammation (mumps, bacterial infection, mycobacterium tuberculosis), autoimmune disease (Sarcoidosis, Sjogren disease called Ig G4 related disease) and tumor (pleomorphic adenoma, Warthin tumor) and carcinoma (muco-epithelial cancer, adenoid cystic carcinoma, metastatic lymphnode) are listed. The characteristic findings of Warthin tumor are as follows; smoking related tumor; the median age, 60th grade; parotid gland tail mass;
2nd most common benign parotid tumor; cystic components contain cholesterol crystals appear as high-signal-intensity areas on T1WI MRI.
【References】
1.Francesco P, et al. "Frey's Syndrome". New England Journal of Medicine. 355: 66. doi:10.1056/NEJMicm040462.
2.Kragstrup, Tue W, et al. "Frey Syndrome—An Underreported Complication to Closed Treatment of Mandibular Condyle Fracture? Case Report and Literature Review". Journal of Oral and Maxillofacial Surgery. 2011; 69 : 2211–2216.
3.Wilson KF, et al. "Salivary gland disorders". American Family Physician. 2014; 89 : 882–8.
4.Mehanna H, et al. "Salivary gland swellings". BMJ. 2012; 345: e6794. doi:10.1136/bmj.e6794. PMID 23092898.
5.Stenner M, et al. Current update on established and novel biomarkers in salivary gland carcinoma pathology and the molecular pathways involved. Eur Arch Otorhinolaryngol. 2009 Mar. 266(3):333-41.
6.Pinkston JA, et al. Incidence rates of salivary gland tumors: results from a population-based study. Otolaryngol Head Neck Surg. 1999 Jun. 120 (6):834-40.
7.Licitra L, et al. Major and minor salivary glands tumours. Critical Reviews in Oncology/Hematology. 2003;45(2):215–225.
8.Ikeda M, et-al. Warthin tumor of the parotid gland: diagnostic value of MR imaging with histopathologic correlation. AJNR Am J Neuroradiol. 2004;25 (7): 1256-62.
9.Minami M, et-al. Warthin tumor of the parotid gland: MR-pathologic correlation. AJNR Am J Neuroradiol. 14 (1): 209-14.
10.Joe VQ, et al. Tumors of the parotid gland: MR imaging characteristics of various histologic types. AJR Am J Roentgenol. 1994;163 (2): 433-8.
2019.8.7