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Patients often present to family physicians com- plaining of swellings or "knots" in their neck. Many represent benign lymphadenopathy. However, es- pecially in smokers and the elderly, this may be the initial presentation of life-threatening disease. We present a case of a worrisome neck mass in an older ex-smoker that proved to be a benign Warthin tumor. Although this is the second most common benign tumor of the parotid,1 neither we nor our colleagues were familiar with it. Furthermore, we could find no mention of it in the family medicine literature. The following case illustrates many of the features typical of Warthin tumor. This inter- esting tumor is the only benign neoplasm associ- ated with smoking.1 A better understanding of this tumor could help family physicians maintain a broader initial differential diagnosis in such cases and improve their understanding of the diagnostic approach to masses in this area. Case Report A 78-year-old white man with a history of mela- noma of the ear presented for evaluation of a neck mass. He first noted the mass 2 years earlier. He reported that it was larger at first but shrank slightly after a course of oral antibiotics. Since that time, its size had not changed. The mass was com- pletely asymptomatic. Review of systems revealed no hoarseness, dysphagia, or weight loss. Twelve years earlier, he had been diagnosed with level 1 Clark melanoma of the pinna of the left ear. He underwent prompt excision, and no recurrence had been noted on follow-up. Past medical history was also positive for multiple medical problems, includ- ing recurrent transient ischemic attacks, myocardial infarction, coronary artery bypass grafting, conges- tive heart failure, cardiac pacemaker, and automatic implanted cardiac defibrillator (AICD) for ventric- ular tachycardia. He was taking multiple medica- tions, including warfarin. Social history was posi- tive for 75 pack-years of smoking, although the patient quit 17 years before the visit. Physical ex- amination revealed a 2 2-cm nontender mass below the angle of the left jaw. The consistency of the mass was slightly softer than a typical lymph node. The mass was mobile and did not seem to be attached to either the skin or underlying structures. No other masses were noted in the head and neck. No adenopathy was noted in the groin, axilla, or extremities. Skin revealed no evidence of mela- noma recurrence. Because of the patient's pacemaker and AICD, magnetic resonance imaging (MRI) was not per- formed. Soft tissue computed tomography (CT) of the neck (without contrast because of prior anaphy- laxis from contrast) revealed a 2-cm mass at the lower pole of the parotid (Figure 1). The mass was dense with lower central density and well defined margins. Given the patient's history, the CT was read as highly suspicious for nodal metastasis of melanoma. Warfarin was temporarily suspended, and fine-needle biopsy was performed without complication. Biopsy revealed glandular epithelial cells in a lymphoid stroma, the characteristic his- tology of a benign Warthin tumor (see Figure 2). The patient recovered from the procedure un- eventfully. After discussion of treatment options, the patient chose no further treatment. Six months after biopsy, the mass remained asymptomatic and essentially unchanged.

Warthin Tumor: A Common, Benign Tumor Presenting as a Highly Suspicious Mass