With a preoperative clinical diagnosis of synchronous, multicentric bilateral Warthin tumors, the patient underwent staged superficial parotidectomies beginning with the larger tumors in the left parotid gland. With a modified Blair incision (Figure 2.85h), the patient underwent left superficial parotidectomy that began with the identification of the parotid capsule (Figure 2.85i). The main trunk of the facial nerve was identified and preserved with superficial elevation of the specimen (Figure 2.85j). The specimen was delivered (Figure 2.85k and l). Two Warthin tumors were later diagnosed in the specimen on permanent sections (Figure 2.85m). The resultant tissue bed and facial nerve dissection is appreciated (Figure 2.85n). At five months following left superficial parotidectomy, the patient was prepared for right superficial parotidectomy (Figure 2.85o–q). His facial nerve was intact bilaterally. He underwent repeat CT scanning (Figure 2.85g) that demonstrated one tumor in the superficial lobe of the right parotid gland (Figure 2.85r–t) that was larger than that noted on the initial CT scan obtained five months earlier. He underwent right superficial parotidectomy with identification and preservation of the facial nerve (Figure 2.85u–x). Final pathology confirmed the presence of one Warthin tumor (Figure 2.85y). The patient's postoperative course was unremarkable and he sustained no morbidity with either surgical procedure.
TAKE‐HOME POINTS
1 Warthin tumors should be suspected when patients present with multicentric unilateral and/or bilateral tumors of the parotid glands.
2 Staging the performance of the bilateral superficial parotidectomies is prudent to avoid the possibility of bilateral facial nerve palsies if bilateral surgery was performed synchronously and postoperative facial nerve weaknesses were noted bilaterally.
3 Repeat CT scanning in staged parotid surgeries permits the assessment of interval growth of masses prior to the second parotid surgery. The increased growth of the mass in this case increased the pretest probability of a neoplastic process, and specifically a Warthin tumor.
Figure 2.85. The patient demonstrates obvious left facial swelling in the region of the parotid gland (a–c). Axial (d), coronal (e), and sagittal (f) views demonstrate two tumors in the superficial lobe of the left parotid gland. Additionally, an enhancing but smaller tumor is noted in the right parotid gland (g). Synchronous, bilateral Warthin tumors are the suspected diagnoses. The patient underwent left superficial parotidectomy via a modified Blair incision (h). The skin flap is elevated anteriorly, superficial to the parotid capsule (i). The main trunk of the facial nerve and its peripheral branches are identified as the specimen is elevated (j). The specimen is delivered and inspected on its lateral (k) and medial surfaces (l). Final pathology identifies Warthin tumors of the left parotid gland (m). The resultant tissue bed and dissected facial nerve are noted (n). The patient is noted at five months postoperatively (o–q). A repeat CT scan is obtained and axial (r), coronal (s), and sagittal (t) images identify a larger tumor of the right parotid gland than was noted at the time of the patient's original presentation. He underwent a right superficial parotidectomy via a modified Blair incision (u). The specimen is elevated off the identified and preserved facial nerve (v). The specimen is delivered (w) and the resultant tissue bed is noted (x). Final pathology confirmed the clinical suspicion of Warthin tumor of the right parotid gland (y). (m = Hematoxylin and eosin, original magnification × 100; y = Hematoxylin and eosin, original magnification × 100).
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