ghrelin receptor br Discussion Intraglandular nerve schwanno

Discussion Intraglandular nerve schwannoma, solitary [4] or multiple [5], was reported in the major salivary gland, including, most often the parotid, even, the sublingual glands [6]. The clinical picture of intraparotid facial nerve schwannoma (IPFNS) is, paradoxically, that of slowly growing asymptomatic swelling with sporadic cases of neural involvements [3]. In our reported case of solitary IPFNS, the patient has developed an asymptomatic slowly growing neural tumor. Even paresis of the motor facial nerve was not evident. However, the histological picture, read by two professors who are well-versed in head and neck pathology, was misguiding. This may be attributed to the close similarity of schwannomas, in small sections, to pleomorphic adenoma or to the several phenotypes IPFNS may display [7–9]. Speaking of the categorization of the tumor, malignancy cannot be ruled out based on fine needle, tru-cut or on frozen-section biopsies [3]. Eschewing the inaccuracy of fine needle biopsies in salivary tumors, a sonar-guided pre-operative tru-cut biopsy was obtained in our case. Ultrasound studies (US), on salivary glands, can differentiate benign lesions from the malignant ones [10]. This distinction is of an enormous significance. Although mitoses are usually absent in intraparotid facial nerve schwannoma and malignant transformation is exceptionally rare, few cases have been recently manifested a malignant transformation. This posed a diagnostic challenge in managing similar cases [11–13]. Moreover, US, CT and MRI are reliable methods in diagnosing salivary glands tumors clinically. Since there is no statistical difference between such methods, using US for diagnosis was preferred to MRI because US is much cheaper, given the financial stand of our patient, and less time-consuming. US study is also preferred to CT to avoid the unnecessary exposure to the ionized ghrelin receptor and renal overload [14]. Histologically, arrangements of Antoni A, with typical Verocay bodies, and Antoni B are typically seen in IPFNS. Antoni B architecture is considered degenerated areas of Antoni A where myxoid stroma, microcystic degenerative changes and several xanthoma cells can be observed. Although Verocay bodies are frequently seen in schwannomas, they can also be present in other lesions. So, endothelial vessels with ectasia, thrombosis or perivascular hyalinization must be combined with such Antoni arrangements and Verocay bodies to establish the diagnosis of schwannoma. . Cytological atypia, mitotic figures and necrosis are caveats of malignancy transformation [3,15]. Recently, collisions of IPFNS with neurofibroma [16], as well as with monomorphic adenoma [17] were reported. This crystalizes the diagnostic challenge of approaching such elusive intraparotid lesions. Getting a second opinion is, therefore, recommended. Taxonomically, According to the proposal of Marchioni et al. [18], a classification of IPFNS according to its position in the facial nerve pathway has been introduced. There, IPFNS is subdivided into four types based on the preservation of the facial nerve trunk and/or the terminal branches. Conservatively, type A tumors are excisable with preserving the facial nerve while Type B tumors are resected with partial sacrifice of the peripheral branches of facial nerve or their distal divisions. However, Types C and D denote more radical surgical intervention where tumors require, in type C, sacrificing the main trunk of the facial nerve for their resection. Moreover, type D tumors require resecting the trunk and its main divisions. The presented case was considered “type A”. The differential diagnosis of IPFNS should include pleomorphic adenoma, myoepithelioma, neurofibroma [19], perineurioma [20], malignant schwannoma [11] and adenoid cystic carcinoma. The mainstay treatment of IPFNS is the surgical excision.
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