Parapharyngeal Tumors Research Articles

Video Laryngoscopes: A Boon for Parapharyngeal Tumors of Childhood

Parapharyngeal tumors often distort the airway anatomy leading to obstruction and hinderance for intubation thus posing a challenge for the anesthetist at securing airway with least damage to the nearby structures.
 We present our experience through a series of 5 such cases in children managed successfully using video laryngoscope.
 Working in places where availability of advanced airway equipment such as pediatric size fiberoptic is unavailable, a video laryngoscope can help to appropriately assess the airway and prevent disastrous outcomes.

Differentiation between pleomorphic adenoma and schwannoma in the parapharyngeal space: histogram analysis of apparent diffusion coefficient.

To elucidate the differences between pleomorphic adenomas and schwannomas occurring in the parapharyngeal space by histogram analyses of apparent diffusion coefficient (ADC) values measured with diffusion-weighted MRI. This retrospective study included 29 patients with pleomorphic adenoma and 22 patients with schwannoma arising in the parapharyngeal space or extending into the parapharyngeal space from the parotid region. Using pre-operative MR images, ADC values of tumor lesions showing the maximum diameter were measured. The regions of interest for ADC measurement were placed by contouring the tumor margin, and the histogram metrics of ADC values were compared between pleomorphic adenomas and schwannomas regarding the mean, skewness, and kurtosis by Wilcoxon's rank sum test. Subsequent to the primary analysis which included all lesions, we performed two subgroup analyses regarding b-values and magnetic field strength used for MRI. The mean ADC values did not show significant differences between pleomorphic adenomas and schwannomas for the primary and subgroup analyses. Schwannomas showed higher skewness (p = 0.0001) and lower kurtosis (p = 0.003) of ADC histograms compared with pleomorphic adenomas in the primary analysis. Skewness was significantly higher in schwannomas in all the subgroup analyses. Kurtosis was consistently lower in schwannomas but did not reach statistical significance in one subgroup analysis. Skewness and kurtosis showed significant differences between pleomorphic adenomas and schwannomas occupying the parapharyngeal space, but the mean ADC values did not. Our results suggest that the skewness and kurtosis of ADC histograms may be useful in differentiating these two parapharyngeal tumors.

Sleep-disordered breathing due to parapharyngeal space plexiform neurofibroma in neurofibromatosis-1: a case report and literature review

BackgroundNeurofibromatosis type 1 is an autosomal dominant disorder with an incidence of 1 in 3000 births. Neurofibromas can occur anywhere in the body. Of all the head and neck tumours parapharyngeal space tumours constitute 0.5%. Neurofibromas can constitute about 9% of all the neurogenic tumours (41%) of the parapharyngeal space. Prevalence of nasal obstruction and obstructive sleep-disordered breathing symptoms due to Plexiform neurofibroma in Neurofibromatosis type 1 is rare amounting to less than 0.5% of cases of parapharyngeal space tumours.Case presentationWe present a case report of a 24-year-old female patient of Neurofibromatosis type 1 who presented with obstructive sleep-disordered breathing symptoms due to Plexiform neurofibroma in the parapharyngeal space. She had complaints of progressive nasal obstruction with associated snoring, disturbed sleep, and daytime somnolence without any significantly large external neck swelling. She underwent excision of the right parapharyngeal tumor by combined trans parotid and transcervical approach. After histopathological examination, a diagnosis of Plexiform neurofibroma was made. On 1-year follow-up, she is doing well without any recurrence and her presenting symptoms of obstructive sleep-disordered breathing symptoms had improved.ConclusionThe symptoms of obstructive sleep-disordered breathing symptoms need to be kept in mind while evaluating such patients and careful attention needs to be given to the patients who report disturbed sleep. Neurofibromatosis type 1 is a multi-system disease which needs holistic care and approach. Such patients should be offered symptomatic treatment and leading questions on the quality of sleep should be asked. Any treatable cause of disturbed sleep like organic sleep disorder should be treated promptly in such patients.

Modified mandibulotomy as an approach to parapharyngeal space tumors: a case report

BackgroundA mandibulotomy approach has been introduced for removal of posteriorly-based tumors of the oral cavity, oropharynx, and certain parapharyngeal tumors with minimum morbidity.Case presentationA middle-aged male presented with a left-sided upper neck mass for last year and difficulty in swallowing for the past six months. A previous history of sclerotherapy and incision and drainage was present and a histopathological examination report from the incision and drainage-derived tissue was suggestive of lymphangioma. On examination, a single soft globular swelling measuring approximately 6 × 4 cm in the left infra-auricular region and a scar of previous incision and drainage measuring approximately 1 × 0.5 cm was present. Oropharynx: tonsillar bulge was present and reaching up to the uvula. Contrast-enhanced MRI revealed an enhancing lesion suggesting a vascular tumour affecting the pre and post-styloid compartment. The patient underwent surgical excision of the lymphangioma by a modified mandibulotomy approach to improve bony stability, avoiding lip split incision and tooth extraction for medically resistant lymphangioma. So, we introduced our modified technique of mandibulotomy in cases of medically resistant parapharyngeal space tumors with a modified lifting step osteotomy with a thin saw blade.ConclusionThe modified mandibulotomy approach provides a safe and effective means of tumor resection and this technique not only ensures complete tumour resection but also maintains the integrity and functionality of the mandible.

Extracranial Facial Nerve Schwannoma-Histological Surprise or Therapeutic Planning?

Schwannomas (neurilemomas) are benign, slow-growing, encapsulated, white, yellow, or pink tumors originating in Schwann cells in the sheaths of cranial nerves or myelinated peripheral nerves. Facial nerve schwannomas (FNS) can form anywhere along the course of the nerve, from the pontocerebellar angle to the terminal branches of the facial nerve. In this article, we propose a review of the specialized literature regarding the diagnostic and therapeutic management of schwannomas of the extracranial segment of the facial nerve, also presenting our experience in this type of rare neurogenic tumor. The clinical exam reveals pretragial swelling or retromandibular swelling, the extrinsic compression of the lateral oropharyngeal wall like a parapharyngeal tumor. The function of the facial nerve is generally preserved due to the eccentric growth of the tumor pushing on the nerve fibers, and the incidence of peripheral facial paralysis in FNSs is described in 20-27% of cases. Magnetic Resonance Imaging (MRI) examination is the gold standard and describes a mass with iso signal to muscle on T1 and hyper signal to muscle on T2 and a characteristic "darts sign." The most practical differential diagnoses are pleomorphic adenoma of the parotid gland and glossopharyngeal schwannoma. The surgical approach to FNSs requires an experienced surgeon, and radical ablation by extracapsular dissection with preservation of the facial nerve is the gold standard for the cure. The patient's informed consent is important regarding the diagnosis of schwannoma and the possibility of facial nerve resection with reconstruction. Frozen section intraoperative examination is necessary to rule out malignancy or when sectioning of the facial nerve fibers is necessary. Alternative therapeutic strategies are imaging monitoring or stereotactic radiosurgery. The main factors which are considered during the management are the extension of the tumor, the presence or not of facial palsy, the experience of the surgeon, and the patient's options.

PARAGANGLIOMA OF NECK IN MIDDLE AGED MALE: A CASE REPORT

Aim: To present a rare case of Paraganglioma of neck in an adult. Introduction: Paragangliomas of the head and neck represent rare benign tumors of neural crest origin that comprises of <0.5% of all head and neck tumors. A schwannoma, also referred to as neurilemmoma, is relatively uncommon slowly growing benign lesion which originates from peripheral neural sheath of any myelinated nerve. Parapharyngeal space tumours are very rare and account for only 1 % of all head and neck tumours. The clinical presentation of schwannoma varies with the anatomical area involved. Surgical excision has been the treatment of choice and recurrence is very rare. Methodology: A 24-year, male presented in ENT OPD with the complaints of swelling on the right side of neck since 2 years. On Examination, the patient had a swelling on right side of neck, extending from angle of mandible upto supraclavicular region, 10 x 6 cm in size, ovoid in shape, non-tender, smooth surface, well defined rounded margins & firm in consistency. On CECT Neck, a well circumscribed hypodense mass with poor enhancement not invading surrounding tissue was seen. On MRI-NECK study, a well-defined heterogenous mass on the right-side posterior to carotid vessels, suggestive of neoplastic lesion, mostly neurogenic stroma. Results: Surgical excision of swelling approximately 9 X 6 cm was performed under general anaesthesia. Conclusions: Schwannoma of the parapharyngeal tumor, should be included in the differential diagnosis of well circumscribed neck mass MRI &CT are highly informative and definitive diagnosis requires histopathological evaluation. From the literature review and experience in our patient, we conclude that in early-stage Cervical paraganglioma with a low risk of surgical complications, primary resection for cure is recommended.

Role of Robotics in Non-oropharyngeal Head and Neck Tumours.

Transoral robotic surgery has been gaining widespread acceptance for the treatment of oropharyngeal malignancies. It has shown tremendous growth in the field of non-oropharyngeal malignancies like thyroidectomy, neck dissection, and parapharyngeal tumours. Many studies have aimed at studying the safety and efficacy of the technique. The literature is abundant for procedures and treatment protocols for oropharyngeal malignancy; however, there is paucity on its usability in non-oropharyngeal malignancy. We aim to review the literature to analyse the usability of robotics in non-oropharyngeal tumours and study the evolution and future applications of robotics in head and neck cancer. A thorough literature search using keywords "Transoral robotic surgery", "TORS", " Robotics in Head and Neck", " Robot-assisted Neck Dissection", " Robotic Thyroidectomy", " Robotic Laryngectomy", " Robotics in salivary gland disease", " Parapharyngeal space", "Systematic review", and "Meta-analysis" was done. The articles were reviewed individually by each author for a dedicated sub-heading. A narrative review was formulated under the subheadings-thyroid surgery, salivary gland, neck dissection, parapharyngeal space, and laryngectomy. The role of robotics has expanded with the advances in technology. Non-oropharyngeal head and neck disease can be approached using robotics. Careful patient selection provides a significant advantage of function and cosmesis and helps in avoiding inadvertent complications. With our growing experience, we might see a surge in robot-assisted head and neck surgery.

A CASE REPORT OF ACINIC CELL CARCINOMA OF PARAPHARYNGEAL SPACE

Introduction: Parapharyngeal space is an inverted pyramid shaped space . Bounded superiorly by skull base, inferiorly by hyoid bone, prevertebral fascia posteriorly , buccopharyngeal fascia medially , medial pterygoid, mandibular ramus ,parotid laterally . Parapharyngeal tumours are rare and account for only 0.5% of head and neck tumour. Acinic cell carcinoma of parapharyngeal space is a very rare presentation.

Schwanoma Parafaringeo. Reporte de caso

Parapharyngeal tumor lesions present a low incidence, representing between 0,5 and 0,8% of all head and neck tumors. Approximately 80% show benign behavior. The uniqueness of these lesions derives from their complex anatomical situation and the symptoms with which they usually appear, being in most cases nonspecific and almost always derived from the compressive effect produced by the lesion on the oropharynx and the oropharynx. Schwannomas of the parapharyngeal space are very rare tumors that originate from the sheath of schawnn, generally slow growing, and are usually asymptomatic. Treatment is surgical, often complex due to the anatomical location.The case of a 42-year-old female patient with a diagnosis of Schwannoma in the left parapharyngeal region, demonstrated by incisional biopsy, is presented; undergoing surgical treatment, which was carried out without complications.

A retrospective analysis of surgery in prestyloid parapharyngeal tumors: Lateral approaches vs transoral robotic surgery.

ObjectiveSurgery is the standard treatment for most tumors in the prestyloid parapharyngeal space (PPS) but it can be a challenging procedure because of the anatomical complexity of the area. Prestyloid surgery can be performed with various lateral approaches or with a medial approach using transoral robotic surgery (TORS)—either alone or in combination with a transcervical incision. We have retrospectively compared our center's results with lateral and medial approaches.MethodsBetween 2015 and 2020, 28 patients with prestyloid PPS tumors underwent surgery at our center: 14 with lateral approaches, including transcervical, transcervical‐parotid, and transcervical‐mandibular, and 14 with medial approaches (12 with TORS and two with TORS plus a transcervical incision). We compared surgical time, postsurgical complications, length of hospital stay, need for feeding tube, and relapse‐free survival in the two patient groups.ResultsPleomorphic adenoma was the most frequent tumor and 60.7% of the tumors were benign. Tumor volume and maximum length were similar in the two groups of patients. Intraoperative image guidance and ultrasound were used in 33% of TORS. TORS was associated with less surgical time, fewer complications, and shorter hospital stays. Recurrence rates were similar in the two groups.ConclusionThe medial approach by TORS offers superior results in prestyloid tumors than the open lateral approach and can be refined by intraoperative guidance. Level of Evidence: 4

Surgical Management of Parapharyngeal Tumors: Our Experience.

Context Tumors of parapharyngeal space (PPS) are rare and histologically diverse. The management of these tumors requires diligent assessment and planning with due consideration of various anatomical and pathological aspects of the lesion. Aims This retrospective study aims to present our experiences in the clinical and pathological aspects of PPS tumors with a critical evaluation of management. Settings and Design Retrospective analytical study. Methods and Material The electronic medical records of 60 cases of PPS tumors, managed surgically from 2007 to 2017, were reviewed and analyzed using SPSS 22 software. The mean follow-up duration was 44 months. Results The mean age was 45 years with a male-to-female ratio of 1.7 (38:22). The majority of the tumors were benign (71.7%) and the most common presentation being upper neck mass or oropharyngeal mass. Histologically, neurogenic tumors were most common (43.3%) PPS tumors, followed by tumors of salivary gland origin. Magnetic resonance imaging was used as a diagnostic modality in 70% of cases, and computed tomography scan and positron emission tomography/CT were used in 26.7 and 3.3% of cases, respectively. In our study, the diagnostic accuracy of fine-needle aspiration cytology was 71% for benign and 47% for malignant lesions. The most common approach for surgery used was transcervical (72%). Conclusion The study reveals that cranial nerve palsy is the most common complication associated with PPS tumors. Completely resected, malignant tumors originating within PPS have a good prognosis, as compared with tumors extending or metastasized to PPS.

A rare lesion of the wanderer’s nerve with an unusual postoperative complication: vagal nerve schwanomma

<p class="abstract">Vagal nerve schwannomas are rare parapharyngeal tumours which was first described by Figi in 1933. Hoarseness is the most common symptom. Occasionally, a paroxysmal cough may be produced on palpating the mass. This is a clinical sign, unique to vagal schwannoma. Presence of this sign, along with a mass located on the medial border of the sternocleidomastoid muscle, should make clinicians suspicious of vagal nerve sheath tumours. However, in our case, the patient presented to us with a swelling in the neck and no other symptoms. MRI in the pre-operative work-up is helpful in defining diagnosis and in evaluating the extent and the relationship. A careful intracapsular enucleation with nerve-sparing technique remains the treatment of choice in order to avoid nerve injury which can lead to vocal cord paralysis. Horner’s syndrome following cervical surgeries is a rare phenomenon. Its occurrence following excision of a vagal schwannoma can occur due to direct injury to cervical sympathetic chain during excision or indirect injury due to traction on the sympathetic chain. Here is a case report of a patient diagnosed with left vagal scwanomma who developed horner’s syndrome post operatively.</p>

Surgical Outcome of Parapharyngeal Tumour

Background: Parapharyngeal tumours are rare accounting for 0.5-1.5% of all head neck tumuors. The anatomy of the Parapharyngeal space (PPS) is responsible for a wide variety of tumours arising from PPS.
 Objective: Evaluation of the strategy for parapharyngeal tumor surgery based on preoperative symptoms, clinical signs, imaging investigations and histopathology.
 Methodology: This retrospective study was carried out in the Department of Otolaryngology and Head Neck surgery in Bangabandhu Sheikh Mujib Medical University (BSMMU) included 32 patients were underwent surgery for primary parapharyngeal tumors between January 2018 and December 2019. Informed written consent was obtained from the patients prior to their inclusion in the study. In regard to histologic type there were 21 cases salivary gland origin tumors and 11 of neurogenic tumors. The following data were evaluated preoperative symptoms, histological type, surgical approach and complications patients were evaluated following a laboratory investigations.
 Results: The most common symptoms of these tumors were a neck swelling. Total of 18 tumors were located in the prestyloid and poststyloid space cases were located 10(31.25%) and 4(12.50%) in the pre and poststyloid. Majority 12(37.50%) was found pleomorphic adenomaof deep lobe of parotid gland followed by 6(18.75%) were schwannoma,4(12.50%) were neurofibroma, 3(9.38%) were ectopic salivary gland tumor,2(6.25%) were mucoepidermoid carcinoma, 2(6.25%) were adenocarcinoma. First bite syndrome and lower lip palsy were common post operative complications. Transcervical approach was the most often performed approach in this study (56.25%).
 Conclusion: Parapharyngeal tumours most often derived from parotid gland. Most of them are non-malignant. Pleomorphic adenoma is the more common. Surgical resection being the main stay of treatment. Tumours of this complex anatomy call for careful preoperative planning and great skill for selecting the right approach and for management with minimal morbidity and recurrence.
 Bangladesh J Otorhinolaryngol; April 2021; 27(1): 66-72

The intraoral growth patterns of parapharyngeal tumors: A proposed classification system.

Nearly half of parapharyngeal space (PPS) tumors present as an intraoral mass, which is diagnostically challenging. In this study, we studied whether preoperative growth patterns were associated with histopathological diagnosis for planning surgery. We performed a cross-sectional study in patients with PPS tumors. A simplified classification scheme based on intraoral tumor growth patterns (patterns 1 and 2) was then proposed. In pattern 1, tumors bulge submucosally to the oropharynx from the soft palate, with the center convexity above the uvula. In pattern 2, tumors bulge submucosally to the oropharynx from the lateral oropharynx wall, with the center convexity below the uvula. The association of this classification with postoperative histopathological diagnosis and surgical-related events was studied. Twenty-two patients were enrolled in this study (12 with pattern 1, 10 with pattern 2). Of these, 91.7% (11/12) of pattern 1 tumors were salivary gland tumors (P < .001), and 90% (9/10) of pattern 2 tumors were neurogenic (P < .001). Pattern 2 tumors had fewer bleeding complications or needed external approaches when a transoral approach was chosen. This new classification of PPS tumors facilitates the prediction of salivary gland and neurogenic tumors and can improve the accuracy of preoperative radiologic diagnosis. This system will be helpful for planning surgical interventions, such as implementing transoral approaches.

Parapharyngeal Tumours: Our Experience in a Tertiary Care Hospital

Introduction Tumours of parapharyngeal space are rare. Surgical excision is the mainstay of its management. However, approach to the space is rather difficult. The transcervical approach is most commonly practiced as opposed to the transoral approach, due to fear of complications. The present study aims to study the two approaches with respect to treatment outcomes and complications. Materials and Methods A prospective study was conducted from July 2018 to December 2019 (1.5 years) at the Department of ENT in a tertiary care Hospital. A total of 10 cases of parapharyngeal tumours were selected; 5 of involving the prestyloid compartment underwent transoral surgery and the other 5 involving the post styloid compartment underwent transcervical surgery. The results of surgery and complications were studied. Results The mean age of presentation was 36.5 yrs. Male: Female ratio was 3:2. There were 9 benign and 1 malignant case in the study. The most common presentation was an asymptomatic oropharyngeal mass (80%). The most common pathological type was pleomorphic adenoma of the salivary gland (50%). Conclusion We found that the transoral approach is as effective as transcervical approach in surgical cureand contrary to the popular belief, it is associated with fewer complications.Hence, carefully selected cases can be safely managed by this approach.

Management of a Giant Para-Pharyngeal Space Pleomorphic Adenoma of Deep Lobe of Parotid Gland Without Mandibular Swing Approach in a 17-Year Old Patient: Rare Case Report.

Pleomorphic adenomas comprise of 0.5% of all head and neck tumors. Pleomorphic adenoma affects patients from 4th to 6th decades. 10-12% of Pleomorphic adenomas arise from deep lobe of parotid gland that grow medially and involve the parapharyngeal space. Investigations play a role of paramount importance in treatment of para-pharyngeal tumors. CT scanning aids in evaluating the bone structures and possible calcification of the tumors. MRI provides precise tumor margins and the relationship of the tumor with its adjacent vital structures. The most common approaches to access these masses are the trans-oral, trans-mandibular, transcervical and trans-parotid trans-cervical approaches. Complete surgical excision of the lesion is the treatment of choice for such PPS tumors. The choice of surgical approach should enable the surgeon to maximize exposure for complete resection of the tumor while minimize functional and cosmetic morbidity. The various mandibulotomies are median mandibulotomy, para-symphyseal osteotomy, horizontal osteotomy, inverted 'L' osteotomy and double mandibular osteotomy. We report a rare case of giant pleomorphic adenoma arising from the deep lobe of parotid gland of the parapharyngeal space in a young patient. The excision was done in to without the mandibular swing approach making it one of the rare case reports.

Sinister Snoring in A Child

Introduction. Snoring in a child is not uncommon and is frequently caused by adenotonsillar hypertrophy, or rarely, by some sinister lesions. High clinical suspicion for head and neck malignancy is warranted in a child with atypical snoring presentation associated with neck swelling.Case. We present a case of parapharyngeal Lymphoma in a child who presented with progressively worsening snoring. Clinical examination revealed swelling on the left side of the neck, with medialization of the left lateral pharyngeal wall, suggesting a left parapharyngeal tumor. A subsequent biopsy confirmed the diagnosis of Lymphoma. Chemotherapy was initiated immediately.Conclusion. The presentation of head and neck Lymphoma in a child can be vague. Early recognition and treatment are crucial to improve the survival of a child.

Endoscopic-assisted Transoral Approach to Parapharyngeal Space Tumours

Parapharyngeal space tumours are rare, mostly benign and present few symptoms, being difficult to diagnose it early. CT scan and MR are necessary for topographical diagnosis. Surgical resection is the best possible treatment option, but the approach remains a challenge, as there are several vital elements contained in the parapharyngeal space and, thus, adequate visualization is needed. Different surgical approaches have been described: transcervical-submandibular, transparotid, transmandibular, transoral and combined approaches. Transoral approach is the most controversial one due to cited limited exposure, which can lead to neurovascular injury or incomplete removal of the lesion. It is seldom performed and only for small, extra-parotid and non-vascular tumours of the parapharyngeal space. Wide access to endoscopic equipment in our institute allowed us to perform medium to large benign parapharyngeal tumour resection usig the transoral approach. The use of endoscopic assistance for transoral approach provided direct and magnified visualization of the parapharyngeal space, reducing tissue damage, ensuring adequate hemostasis (which lead to less amount of bleeding) and also confirming complete resection prior to closure. In addition, compared to transcervical approach, transoral approach shortened hospitalization time and improved cosmetic appearance. Benign parapharyngeal space tumours not involving critical structures from the parapharyngeal space can be completely resected by an endoscopic-assisted transoral approach with good functional and cosmetic outcome.

Fibrous hamartoma of infancy (FHI) of the parotid region in a 3-year-old female presenting as a huge parapharyngeal tumor: A very rare case presentation

Introduction: Fibrous hamartoma of infancy (FHI) is a rare, benign tumor arising from the lower dermis and subcutaneous tissue. It usually occurs in children below two years of age and is often misdiagnosed as being of malignant nature. It most commonly effects the lower extremities, very rarely involves the head and neck region, and is commonly found in males. Microscopically, it is a poorly circumscribed and non-capsulated tumor comprising of interlacing fascicles of pale eosinophilic myofibroblasts and stellate shaped fibroblasts with island of mature adipocytes. Case Report: We report a very rare case of FHI of parotid gland in a 3-year-old female child, posing a diagnostic difficulty for management. The site, size, and age of presentation of the tumor were unique. This tumor is common in males but our case was a female child. Our patient presented with involvement of the parotid, submandibular and upper neck area with a huge size of around 7 × 8 cm which was causing mild swallowing difficulty due to intraoral swelling in the child. Cytopathology from the lesion demonstrated spindle cell lesion, the differential diagnosis of which is often malignant in pediatric age group. We took a biopsy for confirmatory diagnosis and after histopathological diagnosis of FHI proceeded with complete surgical excision. Conclusion: Treatment of choice for these benign tumors is complete surgical excision, with excellent prognosis.

Contemporary Management of Parapharyngeal Tumors.

Management of parapharyngeal tumors is challenging due to the complex anatomic nature of the space and the wide range of pathologies encountered. This article will review the anatomy, common pathologies, and management of parapharyngeal masses. Surgical strategies are also reviewed. Masses of the parapharyngeal space are most commonly benign (80%). More recent longitudinal studies have shown that observation and non-surgical therapy are indicated in many cases. When surgery is indicated, innovative endoscopic and robotic-assisted techniques allow for improved visualization and complete tumor removal while avoiding significant blood loss, tumor spillage, and injury to surrounding nerves and vessels. Management of parapharyngeal masses should consider morbidity of surgical resection versus the natural course of the disease. Surgical strategy is determined by location, size, and pathology. Adequate access is needed surgically to ensure complete resection and avoid tumor rupture.