Case Presentation:

This is an 80–year–old Caucasian man who was admitted to the hospital with complaints of bilateral upper neck swelling, mainly in the pre–auricular and infra–auricular region, worsened over the last 5 days. The swelling was first noticed on the left side, which slowly increased in size, accompanied by swelling on the right side. He did not report any fevers, chills, swallowing difficulty or ear discomfort. He denied any history of trauma or similar episodes in the past. He had a 60–pack–year history of smoking. On admission, he was afebrile, and hemodynamically stable. Physical examination revealed a swelling in the pre–auricular and infra–auricular region bilaterally; left sided swelling was larger than the right and was tender on palpation, however there was no redness or warmth. Intra–oral examination was normal with no purulent discharge from the opening of the Stensen’s duct. Bilateral ear examination showed normal tympanic membranes. There was no appreciable lymphadenopathy, with a normal cardio–pulmonary examination. Labs revealed neutrophilic leucocytosis, and elevated BUN and creatinine. Based on clinical diagnosis of parotid cellulitis, he was started on intravenous cefazolin and metronidazole. Blood cultures resulted negative. After no significant clinical improvement was noted in 3 days, CT of the neck was done which showed an abscess in the left parotid and a phlegmon in the right parotid, with relatively minimal amount of extra–parotid lymphadenopathy. A bedside incision and drainage of the left parotid was performed, cultures of which were insignificant. The patient did not have any fevers and the leucocytosis gradually resolved. A follow–up CT of the neck showed multiple bilateral cystic and solid parotid masses suggesting neoplastic process. Bilateral fine needle aspirations and core biopsies suggested bilateral Warthin tumors. The probable etiology for this patient’s primary complaint was bilateral Warthin tumors with acute infection of left parotid tumor. Surgical treatment was planned as an outpatient, per ENT recommendations.

Discussion:

Common causes for parotid swellings are acute bacterial sialadinitis, tumors and suppurative parotitis. Suppurative parotitis would generally present with unilateral swelling, fever, local pain, tenderness along with dysphagia and trismus. Warthin tumors are mainly benign growths of the parotid, with significant propensity for multifocality and bilaterality. It is seen more in males, and has a strong positive correlation with smoking.

Conclusions:

Parotid swellings are common in elderly individuals, and both suppurative parotitis and tumors are likely causes. Bilateral, painless parotid swellings should always hint toward possible tumors, especially benign tumors such as Warthin tumors. The possibility of superadded infection should be considered based on clinical findings.