Discussion
The head and neck regions accounts for 25 to 45 percent of benign schwannomas, and most of these arise in the eighth nerve but are relatively uncommon from the seventh or the fifth nerves. Neurogenic tumors found are mainly neurofibromas and schwannomas (Neurilemmomas). They represent a pathology, which is often not taken into account during clinical practice [
3].
Schwannoma of the parotid gland can arise either from the facial nerve (7
th) or from any other peripheral nerve running within the gland and it presents clinically as a primary salivary gland tumor [
4]. Sinonasal schwannomas arise from the branches of the trigeminal (5
th) nerve and autonomic nervous system, and most commonly involve the ethmoid and maxillary sinuses, followed by the nasal cavity, sphenoid and frontal sinuses. Cellular schwannoma tends to be located in the midline [
2].
Schwannoma of head and neck regions seems to affect patients in their fifth decade. Mean ages of 42 years, 44 years and 45 years were reported by Liu [
5], Caughey [
6] and Marco [
7] respectively. No characteristic symptom profile exists in intraparotid or nasal schwannoma. However, slow-growing, pain, tenderness, facial spasm or paralysis may be present in the first one [
8]. The presenting symptoms of second one include obstruction, rhinorrhea, epistaxis, anosmia, headache, dysphagia, hearing loss, facial or orbital swelling, and pain.
The tumor typically presents either as a localized lesion or as part of a generalized syndrome of neurofibromatosis generally known as neurofibromatosis type-1 (NF1) or von Recklinghausen disease of the skin which is associated with somatic mutations at the NF1 gene, a tumor suppressor gene located in the pericentromeric region of chromosome 17 [
9].
Grossly, schwannomas are solitary, encapsulated tumors usually attached to or surrounded by nerve. It appears to push axons aside and degenerative changes like cystic alterations or hemorrhagic necrosis are usually present [
10].
The critical step in the management of neurogenic tumors of head and neck is the diagnosis. They may be also discovered incidentally on imaging studies.
The use of fine-needle aspiration (FNA) to aid in the diagnosis is a common and appropriate practice in parotid schwannoma [
11,
12]. The cytology may reveal spindle-shaped cells with ill-defined cytoplasm, arranged in clusters (Verocay bodies). In most cases, results are inconclusive [
6].
Hence, a negative FNA finding alone should not delay or hinder surgical intervention when it is otherwise clinically indicated.
Magnetic resonance imaging (MRI) with gadolinium is the study of choice for imaging the suspected nerve lesions of the parotid and nasal cavity. On T1-weighted images, the main trunk of the nerve appears hypointense, with hyperintense surrounding fat tissue, it appears on high intensity within T2-weighted images [
13].
Macroscopically, sinonasal and intraparotid schwannomas range in size up to 7 cm. they are a well-delineated but non-encapsulated globular, firm to rubbery yellow-tan mass. The cut surfaces show tan-grey, yellowish, solid to myxoid and cystic tissue, commonly with haemorrhage [
2].
Histologically, two microscopic patterns of schwannomas exist, Antoni A and Antoni B. Antoni A lesions are characterized by broad interlacing ribbons of extended spindle cells with elongated nuclei arranged in waves, drifts and whorls. On cross section, these cylindrical cells produce a palisading pattern of nuclei about a central mass of cytoplasm called a Verocay body. Antoni B pattern is made up of very loose tissue, lacking the arrangement in the bundle and palisades, and is thought to be a degenerative form of Type A with a looser texture and polymorphism of cells separated by abundant myxoid, often microcystic matrix [
10].
Mitoses are usually absent and malignant transformation of schwannoma is exceptionally rare [
7]. Immunostaining for S-100 is required to establish the neural origin of the tumor, and smooth muscle actin (SMA) to rule out a leiomyoma such as our patients.
The differential diagnoses of intraparotid schwannoma should comprise the large diagnostic spectrum in which spindle cells are involved such as neurofibrome, fibroblastic/myofibroblastic tumors, most frequently nodular fasciitis, and fibromatosis with an infrequent myofibromatosis, fibroma, haemangiopericytoma, solitary fibrous tumor or inflammatory pseudotumor (inflammatory myofibroblastic tumor) [
14].
Intranodal palisaded myofibroblastoma is another tumor that must be taken into account in differential diagnosis [
15].
Like a cystic mass of the parotid, the most differential diagnoses include retention cysts, post-traumatic sialoceles, Warthin’s tumor, mucoepidermoid carcinoma and necrotic metastases [
14]. The differential diagnoses of nasal schwanoma include other mesenchymal benign spindle cell tumor like fibroma, leiomyoma, nodular fasciitis and inflammatory pseudotumor. other pathological differential diagnoses of our case would include hybrid peripheral nerve sheath tumors, perineurioma, cellular neurothekeoma, nerve sheath myxoma (classic neurothekeoma), desmoplastic neurothekeoma, superficial angiomyxoma (cutaneous myxoma) [
16], solitary neurofibroma with prominent differentiation of Meissner bodies, or spindle cell carcinoma [
9,
16].
Benign facial and trigeminal nerves schwannomas grow slowly and resection is not always indicated. Several authors have reported the occurrence of facial paralysis or several nasal symptoms when a simple biopsy or careful resection with apparent preservation of the function nerve is indicated [
2,
6].
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
IK, CL, HN and EH participated in the histopathological evaluation, performed the literature review, acquired photomicrographs and drafted the manuscript. HT and AA conceived and designed the study, gave the final histopathological diagnosis and revised the manuscript for important intellectual content. All authors read and approved the final manuscript.