Modified Essay Questions, MEQs in General Surgery - Warthin's Tumor


# A 60-year-old man presents to you in surgery OPD with a history of painless slowly growing swelling in the left preauricular region for last 2 years. 
1. List 4 common differential diagnoses.
- Salivary gland tumor: Warthins tumor (adenolymphoma), pleomorphic adenoma
- Preauricular lymph nodes
- Granulomatous disease- TB, Sarcoidosis

2. Mention the examination finding which suggests the swelling is arising from the parotid.
a. Pushes the ear lobule upward
b. swelling in front, below and behind the ear
c. Retromandibular groove is obliterated

3. Describe the method of palpation of deep lobe of the parotid.
- Palpate bi-manually with one finger inside the mouth just in front of the tonsil and behind 3rd molar and the other hand behind ramus of the mandible.

4. Describe the course of the facial nerve in relation to the parotid gland.
- After emerging from the stylomastoid foramen, it hooks around the condyle of mandible enters the substance of parotid and divides into 2 major branches- zygomaticotemporal and cervicofacial. It divides the parotid into superficial and deep lobe (fasciovenous plane of Patey). This nerve gives rise to 5 branches which are connected like the foot of goose, hence called pes anserinum.

5. Describe the course of parotid duct.
- It is a thick walled duct about 5 cm long. It runs forward and slightly downwards on the masseter. At the anterior border of masseter it turns medially and pierces:
i. The buccal pad of fat,
ii. Buccopharyngeal fascia, and
iii. Buccinator

The duct runs for a short distance between the buccinators and oral mucosa. Finally,  it turns medially and opens into the vestibule of mouth (gingivobuccal vestibule) opposite the 2nd upper molar teeth.

6. Describe the Method for palpation of parotid duct.
- It is palpated bi-digitally with the index finger inside the mouth and thumb over the cheek. If it is indurated, it sometimes can be palpated by rolling a finger over the taut masseter.

7. Mention the physical sign which will suggest the malignant nature of the swelling. 
- Large in size, infiltrates skin, facial nerve paralysis, red dilated veins over the surface, the presence of lymph nodes in the neck, tumor feels stony hard.

On examination, the swelling is soft and fluctuant. Facial nerve not involved.
8. State the most probable diagnosis.
 - Warthin's tumor, adenolymphoma

Open surgical biopsy is not recommended.
9. Mention the reasons in favor of the above statement.
a. Injury to the facial nerve.
b. Seeding of tumor in the subcutaneous plane which causes recurrence in 40-50% of cases.

10. Mention the treatment.
- Superficial parotidectomy

11. Classify parotid tumors.

- A. Epithelial

Benign Malignant
Pleomorphic Adenoma Malignant mixed Tumor
Warthin's Tumor Acinic cell carcinoma
Oncocytoma Adenocarcinoma
Adenoma (others) Adenoid cystic carcinoma
Basal cell adenoma Mucoepidermoid Carcinoma
Canalicular Adenoma Squamous cell carcinoma
Ductal Papilloma Undifferentiated (others)
B. Non epithelial
- Lipoma
- Lymphoma
- Neurofibroma
- Sarcoma
- Lymphangioma