Warthin tumor is a benign tumor of the salivary gland. The neoplasm mainly affects men of older age.
What is a Warthin tumor
Warthin tumor was first mentioned by the German surgeon Otto Hildebrand as early as 1895. At that time, the tumor still bore the name adenolymphoma. In 1910 the tumor was described in more detail by Heinrich Albrecht and Leopold Arzt and then in 1929 Warthin made it known as papillary cystadenoma lymphomatosum. Warthin’s tumor is also known as adenolymphoma or cystadenolymphoma papilliferum. The median age of onset is 62 years. The tumor is found preferentially in men between the ages of 60 and 70. Although manifestation in childhood is quite possible, the tumor develops extremely rarely before the age of 40. Although more and more men are affected by the tumor, the incidence rate has shifted in recent years. Whereas in the 1950s ten times more men than women were affected, today more and more women are becoming ill due to changes in lifestyle. It is expected that a gender balance in disease incidence will be achieved in the future.
Causes
The cause of tumor development is as yet unknown. Although the disease is usually classified as true neoplasms, the tumors could also be acquired multicystic reactive diseases. Thus, the tumors were shown to be polyclonal in origin. However, other studies showed that fusion genes between chromosome 11 and chromosome 19 are found in some of the Warthin tumors. Exactly the same changes were found in the so-called mucoepidermoid carcinoma, a malignant neoplasia. Researchers suspect that the tumor originates from heterotropic salivary gland ducts in lymph nodes. Heterotropic tissue is located outside its proper anatomical localization. In favor of this theory is the fact that Warthin tumors are often localized at the lower pole of the parotid gland. This is also where most of the lymph nodes are found. Still other hypotheses see the tumor as an adenomatous proliferation of tissue. This proliferation is thought to condition lymphocytic infiltration. Smoking is said to be a significant risk factor. Smoking probably increases the incidence of the disease eight- to tenfold. The risk increases the longer the affected person smokes. The intensity of tobacco consumption, on the other hand, seems to play only a minor role. Studies show that more than 90 percent of patients with a Warthin tumor are smokers. In addition, the risk of bilateral tumor is increased in smokers. Presumably, mitochondrial DNA is damaged by smoking. Thus, Warthin tumor cells often show absent mitochondrial DNA and pathologically altered mitochondria in histological examination. Increased disease incidence was also observed after exposure to ionizing radiation. For example, Warthin tumors occurred more frequently in survivors of atomic bomb explosions. The involvement of viruses in the development of the tumors is also under discussion. For example, the human herpes virus type 8 is often found in the cells of the tumor. In addition, the tumor occurs more frequently in HIV-infected patients. Various [[autoimmune disease]s also appear to be associated with parotid gland tumors.
Symptoms, complaints, and signs
The characteristic symptom of Warthin’s tumor is painless swelling in the parotid gland area. At the time of diagnosis, the tumor is usually between two and four centimeters in size. In extreme cases, however, it can be twelve or thirteen centimeters in size. Only one tenth of patients complain of pain. If the tumor tissue becomes inflamed, however, severe pain can occur. Compression of the facial nerve is also associated with pain. Facial paralysis (facial nerve palsy), on the other hand, is observed only in rare cases.
Diagnosis and course of the disease
Swelling around the parotid glands suggests a Warthins tumor. If suspected, imaging techniques are used to confirm the diagnosis. Ultrasound, computed tomography, or magnetic resonance imaging are appropriate for diagnosis. Scintigraphy is very rarely used for diagnosis. In most cases, a definitive diagnosis can only be made on the basis of a preoperative biopsy.Histologic examination reveals a tumor delineated by a thin connective tissue capsule. The tumor consists of epithelial areas and cysts embedded in lymphoid connective tissue. Cells and nuclei are usually normal in appearance. With the help of fine needle biopsy, correct diagnoses can be made in more than 95 percent of cases. At the latest, the diagnosis can be confirmed with the help of the removed tumor thanks to histological examination. Since the histological structure of the Warthin tumor is very characteristic, the diagnosis is usually unproblematic. Nevertheless, a differential diagnostic differentiation from lymphoepithelioma-like carcinoma and mucoepidermoid carcinoma must be made.
Complications
In most cases, Warthin tumor does not present with specific complications or a serious course. Since the tumor itself is benign, no direct treatment is usually necessary in this case, if the disease does not lead to severe restrictions in the patient’s daily life. The affected person suffers from a swelling in the area of the ear. The size of this swelling depends very much on the extent of the tumor, so that it can also have a negative effect on everyday life. In some cases, the Warthin tumor can lead to severe pain, so that patients are dependent on treatment. If the tumor damages and compresses the nerve, paralysis may occur in the face. If the nerve is completely damaged, this paralysis often cannot be repaired. Warthin’s tumor is treated with surgical intervention. No complications occur and the tumor can usually be completely removed, resulting in a positive course of the disease. With the early diagnosis and treatment of this tumor, the patient’s life course is also not negatively affected.
When should you go to the doctor?
Since self-healing usually cannot occur with Warthin tumor, the affected person is dependent on a visit to a doctor. This is the only way to prevent further complications and discomfort, so a doctor should be contacted at the first symptoms and signs of the disease. Thereby, especially men should see a doctor when the symptoms of Warthin’s tumor appear. In most cases, this tumor is noticeable by a strong swelling that appears in the area of the ear. This can usually be felt with the fingers. Likewise, severe pain in the ears is often an indication of a Warthin tumor if it occurs for no particular reason and does not disappear on its own. Furthermore, this tumor can also lead to swelling or paralysis of the whole face. A doctor should be consulted for these symptoms as well. The disease can be detected by a general practitioner or by an otolaryngologist. Further treatment usually takes place in a hospital. It cannot be universally predicted whether the disease will result in a decreased life expectancy for the affected individual.
Treatment and therapy
In general, Warthin tumor is completely removed surgically. The operation usually takes the form of a superficial parotidectomy. In this, the outer lobe of the parotid gland is completely removed or peeled out. Peeling (enucleation) is preferable because the operation time is significantly shorter. In addition, the complication rate is lower and the cosmetic result is better. In patients with a high risk of anesthesia, surgery is usually not performed. Warthin tumor does not grow aggressively or metastasize, so removal is not mandatory. It should be noted, however, that if the diagnosis is based solely on a fine-needle biopsy, malignant disease can easily be missed.
Prevention
The main risk factor for Warthin tumor appears to be smoking. Cigarettes and other tobacco products should therefore be avoided on a mandatory basis for prevention.
Follow-up
Once the Warthin tumor has been completely surgically removed during a parotidectomy, follow-up care follows. Unlike malignant tumors, which require regular follow-up, the period immediately after surgery is sufficient for benign Warthin tumor. The focus of the aftercare of the Warthin tumor is the control of wound healing.If the facial nerve has not been affected and there are no complications, no further follow-up is required. It usually takes about four weeks for the pain that occurs following the parotidectomy to subside. After the operation, the patient is allowed to move around. For about three days, he wears a wound drain to drain the wound fluid. It takes about six weeks to three months for the facial nerve to recover from the surgery. During this time, the surgical scar will also gradually heal. Sometimes there may be a prolonged numbness of the earlobe, which is usually unavoidable. There is often redness of the scar even half a year after the surgical procedure. In certain cases, the patient receives antibiotic medication for a few days after the surgery. Furthermore, a daily injection is given into the abdomen to prevent blood clots (thrombosis). If there is damage to the facial nerve, physiotherapy exercises are recommended to train the mimic movements.
What you can do yourself
A Warthin tumor usually requires surgical removal. A superficial parotidectomy is usually required, in which the tumor is completely removed. Patients’ self-help is limited to the typical general measures such as rest and sparing. Beforehand, it is important to prepare sufficiently for the hospital stay. After the tumor has been removed, the doctor must be consulted regularly. In the event of unusual symptoms, a visit to the doctor is recommended. The physician will give precise instructions regarding physical rest and further measures. Natural remedies help against the pain. The use of homeopathic preparations must be discussed with the doctor beforehand. A tumor disease is always a psychological burden. The patient should contact a self-help group or a therapist at an early stage in order to come to terms with the disease and exchange experiences. The Internet is a good place to obtain information. The German Cancer Society offers patients and relatives important contact points and information. The ENT physician in charge can also support treatment and aftercare and help the patient to quickly return to his or her usual daily life after the disease.