The Journal of Laryngology and Otology

November 1998, Vol. 112, pp. 1092-1094

Mucocele mimicking a Warthin's tumour recurrence

D. REJALI, F.R.C.S., R. SIMO, F.R.C.S., M. SMALL, F.R.C.S.

Abstract
We report an unusual case of an extravasation mucocele complicating superficial parotidectomy. The tumour
excised was a Warthin's tumour. Three months following the primary surgery a cystic lesion appeared in the
parotid bed. It was initially thought to represent a recurrence. The area was re-explored and a mucocele excised.
The pathogenesis of mucoceles and the difficulties encountered when dealing with parotid tumour recurrence
are discussed.
Key words: Adenolymphoma; Parotid neoplasm; Post-operative complications

Introduction malignancy. Full blood count and urea and electrolytes

Warthin's tumour (adenolymphoma) is a benign mono-
morphic adenoma (Seifert et ah, 1986). It is the second
most frequently encountered tumour in salivary glands
after pleomorphic adenoma. It represents 15 per cent of all
epithelial salivary tumours. It typically occurs in the lower
part of the parotid salivary glands of men in their sixth or
seventh decades. Bilateral tumours are observed in 10 per
cent of cases (Seifert et ah, 1986). Adequate surgical
resection is usually curative. Post-operative complications
following superficial parotidectomy include facial nerve
palsy, Frey's syndrome, seroma/haematoma or wound
infections. Recurrence after adequate resection of this
tumour is reported to be between 0 and 12 per cent
(Leverstein et ah, 1997). Surgery for recurrent tumours is
difficult due to fibrosis and there is an increased risk of
damage to the facial nerve (Conley, 1988).
The occurrence of cystic lesions in the parotid region
after local surgery has been reported. These include
retention cyst after rhytidectomy - face lift - (Habal,
1978) and epidermoid cyst following otomastoid surgery
(Shaheen et ah, 1975; Thompson and Bradley, 1991).
We describe an extravasation mucocele as a complica-
tion of Warthin's tumour excision.
were normal. The liver function test showed an isolated
raised gamma GT. Chest radiograph was normal.
The patient subsequently underwent superficial paroti-
dectomy. A 3 cm in diameter nodule was removed with the
superficial parotid gland. Histopathological examination of
the specimen revealed the presence of a completely
excised Warthin's tumour (Figure 1). Post-operatively the
patient had neuropraxia of the marginal mandibular
branch of the facial nerve. This had resolved one month
later.
On review at three months later the patient had
developed a 1 cm non-tender swelling in the inferior
region of the right parotid bed (Figure 2). Fine needle
aspiration cytology revealed cyst debris, inflammatory cells
and macrophages.
Clinically it was felt that recurrence could not be
excluded and therefore she underwent re-exploration of
the parotid region. The deep lobe of the parotid gland and
an inferiorly placed one cm nodule was removed. The
histopathological examination of the specimen revealed a

Case report
A 66-year-old female was referred with a two-month
history of a painless swelling in the region of the angle of
the right mandible. Past medical history included hyster-
ectomy for papillary adenocarcinoma of uterus 20 years
prior to presentation. She had a history of heavy alcohol
intake. There are no other otolaryngological symptoms nor
other relevant past medical history. On examination a soft
non-tender 4 cm in diameter mass was noted in the tail of
the right parotid gland. There was no facial paralysis or
regional lymphadenopathy. There was no other abnor-
mality on otolaryngological or general examination. Fine
needle aspiration cytology revealed 2 ml of straw-coloured
fluid. The cytopathological examination of the fluid FIG. 1
showed cohesive epithelial cells, erythrocytes, macro- Histopathological section of the completely excised Warthin's
phages and amorphous debris. There was no evidence of tumour (H & E; X 50).

From the Department of Otolaryngology and Head and Neck Surgery, Royal Preston Hospital, Preston, UK.
Accepted for publication: 10 August 1998.

1092
CLINICAL RECORDS
FIG. 2
Non-tender swelling in the inferior region of the right parotid
bed.
one cm extravasation mucocele (Figure 3). The deep lobe
of the parotid gland showed features of atrophy and
fibrosis. The patient had no facial weakness post-opera-
tively.
On review one month following re-exploration she had
developed a superficial wound infection secondary to a
retained suture which was removed in clinic. She was
placed on oral antibiotics. On subsequent review the
wound healed satisfactorily.
FIG. 3
Histopathological section of the excised extravasation muco-
cele (H & E; x 50).
1093
At nine months following re-exploration she remains
well with no evidence of recurrence.
Discussion
Primary parotid gland cysts in adults are rare, represent-
ing five per cent of all parotid tumours (Richardson et al,
1978; Pieterse and Seymour, 1981; Cohen et al, 1984).
These fall into three categories: epidermoid, branchial and
ductal (retention) cyst (Pieterse and Seymour, 1981).
Parotid cysts can occur in association with tumours. The
most frequent association occurs with Warthin's tumour
(Richardson et al, 1978).
Mucoceles are round circumcised lesions that contain
mucus. They are classified into retention and extravasation
mucoceles. The latter are common in younger patients and
occur most frequently in the minor salivary glands of the
lower lip, cheek, floor of mouth, tongue, palate and upper
lip (Seifert et al, 1986). The aetiology of these is traumatic.
The lesions can be produced experimentally by ligation or
division of a salivary duct (Bhaskar, 1975). The competing
factors that determine the formation of a mucocele are the
rate of mucus production and the speed of phagocytosis of
the extravasated mucus (Seifert et al, 1986). The muco-
celes previously reported in the parotid are of the retention
variety (ductal cyst). The pathogenic process being partial
obstruction of the duct due to kinks, microliths or
inspissated secretions (Seifert et al, 1986). There are no
reports of the extravasation variety as a primary occur-
rence in the parotid gland.
Well recognized complications of superficial parotidect-
omy include haematoma, facial paralysis, damage to
cutaneous sensory nerves,fistulaformation, seroma, Frey's
syndrome and trismus (Shaheen, 1997).
Superficial parotidectomy is a commonly performed
surgical procedure. It is surprising that localized extra-
vasation mucoceles have not been reported previously as a
complication of this procedure. The reasons for this may
be due to the fact that most of the saliva-producing
parenchyma of the gland is excised. The deep lobe
generates only small quantities of saliva which can usually
be phagocytosed before noticeable accumulation (Seifert
et al, 1986). This may also explain why there are reported
cases of mucoceles in the parotid region after rhytidectomy
(Habal, 1978). The saliva-generating capacity of the
parotid gland remains intact and inadvertent trauma to a
major salivary duct results in extravasation of more mucus
than can be reabsorbed. An alternative destiny for any
mucus produced by any remaining functioning gland is
leakage from the wound as a salivary fistula or to form a
diffuse 'seroma' which usually resolves with conservative
management and/or repeated aspirations. In the above
patient these processes did not occur, and mucus accumu-
lated and formed an isolated collection resembling a
recurrence.
The recurrence of Warthin's tumour after adequate
excision is rare. In the study by Leverstein et al. (1997) the
reported recurrence was 0 per cent. The causes of
recurrence include inadequate excision due to capsular
dissection, gross spillage or multicentricity (Conley, 1988).
When encountered with a recurrence of a benign tumour
after adequate excision it is important to review the
original histology. On review up to three per cent of the
original histopathological diagnosis can be changed
(Conley, 1988). Conley in 1988 recommended pre-opera-
tive computed tomography (CT) scan and/or magnetic
resonance imaging (MRI) when investigating recurrent
tumours. This assesses the extent of the lesion allowing
better surgical planning. In this case the skin overlying the
1094
lesion was thin and the lesion superficial. It was felt that in
this case further imaging would not alter the management
strategy.
It is difficult to make a prospective diagnosis of parotid
cystic lesions. Clinical and radiological assessment is
inaccurate. The position of the cysts - usually under the
dense parotid facia - makes physical examination unreli-
able. Radiology is at present unable to reliably differenti-
ate between the secondary fibrotic and atrophic changes
which occur in the salivary tissues surrounding benign cysts
and malignant tumours associated with cysts (Cohen et ah,
1984). Fine needle aspiration cytology cannot differentiate
between cysts in isolation from those which are a part of a
neoplasm (Ishikawa et ah, 1991). The safe option as in the
above case, is to re-explore.
Re-exploration has a significantly higher morbidity. The
fibrosis and scarring make the dissection more difficult.
The facial nerve is at increased risk because it can be
difficult to differentiate and separate it from scar tissue.
The normal anatomy may also be distorted (Conley, 1988).
Ideally a surgeon experienced in parotid surgery should
perform the procedure with the assistance of facial nerve
monitoring. The patient should be aware of the increased
risks prior to consent.
In conclusion we feel that the extravasation mucocele
should be included as a complication of superficial
parotidectomy. These can be difficult to differentiate
from recurrence of a Warthin's tumour as the cytopatho-
logical and radiographic features can be non-specific. Re-
exploration of the parotid bed is necessary but the higher
morbidity should be taken into consideration.
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Address for correspondence:
D. Rejali,
30 Frances Avenue,
Gatley,
Cheadle,
Cheshire SK8 4BJ.