Parapharyngeal Tumors Research Articles

Transmandibular approach in parapharyngeal tumors: When to do it?

BackgroundMultiple approaches to the parapharyngeal space are described in the literature, each having its indications, advantages, and disadvantages. ObjectiveHighlighten the advantages of the transmandibular approach and state possible selection criteria for such approach in lesions affecting the parapharyngeal space. Patients and methodsThe transmandibular approach was used to excise the parapharyngeal space lesion in 11 consecutive patients. All the patients were clinically and radiologically evaluated before surgery. Fine needle aspiration cytology was done in two patients. Follow up period ranged from 1 to 8years. ResultsThe transmandibular approach allowed total removal of five big salivary tumors without capsular rupture, and safe excision of four carotid body tumors, a single vagal paraganglioma, and a single aneurysm of the internal carotid artery affecting the parapharyngeal space with easy distal control of the internal carotid artery. Preoperative angioembolization limited blood loss during surgery for the vascular lesions. Patients were followed up for 1–8years with no evidence of recurrence. Complications included plate infection in a single patient (9%), a single mortality, and cranial neuropathies in three patients which were not related to the approach. Ugly facial scars, lip hypoesthesia, dental losses, malocclusion, and temporomandibular joint pain or dysfunction were not reported. ConclusionThe transmandibular approach offers the widest access to the parapharyngeal space and allows safe complete excision of highly vascular and big swellings.

Clinical Usefulness of a Special Mosquito Clamp for Intraoperative Facial Nerve Monitoring for Tumors of the Parotid Gland and Parapharyngeal Space

Surgery of parotid gland and parapharyngeal tumors is one of the most common operations and identification and functional preservation of the facial nerve are considered to be important procedure in these operations. We developed a special mosquito clamp for facial nerve monitoring during dissection. This clamp is connected to a Nerve Integrity Monitoring System (NIM-Response® 2.0, Medtronic USA). By using this clamp, we can always monitor the facial nerve function during tissue dissection without the stimulating probe. We report herein on the clinical usefulness of the monitoring mosquito clamp and NIM system to preserve the facial nerve function in 10 cases of parotid gland and parapharyngeal tumor. Facial nerve function was well preserved in all cases, thus this monitoring clamp and NIM system are very useful for the preservation of facial nerve function during parotid and parapharyngeal tumor surgery.

Parapharyngeal space tumors: 61 case reviews

Parapharyngeal tumors account for 0.5% of head and neck tumors. They are difficult to diagnose because they have few symptoms and are surgically inaccessible. This retrospective study included 61 patients with parapharyngeal space tumors, treated in the last 20 years. The data, obtained from the medical records, included symptoms and clinical signs, diagnostic procedures, surgical approach, postoperative complications and histopathological findings. The most common symptoms were dysphagia, foreign body sensation, pain, and symptom-free patients. For precise tumor localization and its relation to adjacent structures, computerized tomography, magnetic resonance imaging and contrast angiography were used. All the patients were treated surgically. The commonest surgical approach was transcervical, followed by transoral and combined transcervical-transoral. Histopathological examination verified that the origin of these tumors was most frequently salivary or neurogenic.

Parapharyngeal Neurofibroma in a Pediatric patient

Parapharyngeal Neurofibroma in a Pediatric patient

Parapharyngeal Neurofibroma in a Pediatric patient

Parapharyngeal Neurofibroma in a Pediatric patient

Pleomorphic adenoma of minor salivary gland with therapeutic misadventure: a rare case report

BackgroundThe benign tumors of nasopharynx are least encountered tumors in otolaryngology, as nasopharynx is considered one of notorious anatomical site for the malignant tumors. Pleomorphic adenoma of the minor salivary gland of nasopharynx and parapharyngeal space is rare. We present a pleomorphic adenoma of minor salivary gland which was mismanaged.Case presentationAn adult male presented with left nostril obstruction for five months. The examination found big mass extending from nasopharynx to oropharynx. On CT scan, this tumor was quite big and extending to the parapharyngeal space. The FNAB found it a carcinoma but it did not respond to radiotherapy. The excision biopsy of tumor revealed it as pleomorphic adenoma. We found only five published reports on this tumor arising from nasopharynx.Discussion and conclusionAlthough, in this case report exact origin of the tumor could not be ascertained as it also appeared to be a parapharyngeal tumor but we kept the possibility of a nasopharyngeal tumor on the basis of clinical features. The pleomorphic adenoma of nasopharynx is rare. It can be misdiagnosed as malignant epithelial tumor on histopathology. The differentiation from its malignant variant is also difficult. A possibility of benign tumor should always be kept in nasopharyngeal growth with no evidence of metastasis, and histopathological diagnosis of growth should be available before any definitive treatment.

副咽頭間隙に進展した頭蓋底髄膜腫例

Skull-base and parapharyngeal tumors require intricate treatments due to its anatomic complexity, variations in histological type, and the site often involves the presence of critical blood vessels and nerves. Diagnostic imaging and fine-needle aspiration cytology are thus essential. We report a case of skull-base meningioma extending to the parapharyngeal space in which we made a definitive diagnosis by biopsy (as grade I) and took a wait-and-see approach. A 52-year-old woman had complained of a headache since June 2006 and was seen in the neurology department at our hospital in July. A tumor from around the left jugular foramen to parapharyngeal space was revealed by magnetic resonance imaging (MRI) and she was referred for consultation to the neurosurgical department and our department. It was difficult to establish the diagnosis from the clinical manifestation and diagnostic images due to the tumor's complicated anatomy, therefore it was confirmed by biopsy instead of cytology. It can be said that biopsy is useful to determine therapeutic measures for the skull-base meningioma because it is less invasive and can verify a histological type compared with the complete removal of the tumor.

Transoral and combined transoral–transcervical approach in the surgery of parapharyngeal tumors

The goal of parapharyngeal space (PPS) tumor surgery is to obtain adequate visualization to ensure complete removal with preservation of the surrounding nerves and vessels. Different surgical approaches have been described. Transoral approach is the most controversial one due to cited limited exposure, risk of tumor spillage, and possibility of neurovascular injury. We performed retrospective analysis of 26 consecutive patients who had undergone transoral or combined transoral-transcervical resection of PPS tumors from January 1997 to December 2007. Both approaches were safely employed to remove selected PPS tumors. Majority of treated tumors were pleomorphic adenomas (14 minor salivary gland and 7 deep lobe parotid gland tumors). Two cases of malignant salivary gland tumors, 4 nerve sheath tumors and 1 lymphangioma were also excised. Mean tumor size was 6.1 cm (range 2-11 cm). Visualization was felt to be adequate and dissection safe. Radical resection was achieved in 24 cases. Near-total resection was achieved in two cases where otherwise other approach would be suitable but cannot be undertaken because of patient refusal and comorbidities. Patients with malignant tumors had postoperative radiotherapy. Radically treated cases are disease free. One of the near-totally resected tumors needed revision surgery. Neither major complications nor disordered healing were observed. Transoral approach provides access to selected cases of PPS tumors based on preoperative imaging methods and fine-needle aspiration cytology. Risk of non-radical resection is acceptable. It can be combined with external approach to achieve safe resection of some benign tumors which would need transmandibular approach.

Fine needle aspiration cytology of parapharyngeal tumors

Background:Parapharyngeal tumors are rare and often pose diagnostic difficulties due to their location and plethora of presentations.Objectives:The study was undertaken to study the occurrence in the population and to evaluate the exact nature by fine needle aspiration cytology (FNAC).Materials and Methods:A total of five hundred and six cases of lateral neck lesions were studied over three and half years. Of these 56 suspected parapharyngeal masses were selected by clinical and radiological methods. Cytopathology evaluation was done by fine needle aspiration cytology with computed tomography and ultrasonography guidance wherever necessary. Histopathology confirmation was available in all the cases.Results:On FNAC diagnosis could be established in 54 cases while in two cases the material was insufficient to establish a diagnosis. The tumors encountered were, pleomorphic adenoma (33), schwannoma (3), neurofibroma (11), paraganglioma (5), angiofibroma (1) and adenoid cystic carcinoma (1). Four false positives and two false negative cases were encountered. Overall sensitivity was 96%, with specificity of 99% and accuracy being 98.8%.Conclusions:With proper clinical and radiological assessment, FNAC can be extremely useful in diagnosing most of these lesions except a few which need histopathological and even immunohistochemical confirmation.

Peroral fine needle aspiration cytology of parapharyngeal tumors: a study of 67 cases.

Peroral fine needle aspiration cytology (FNAC) was carried out to diagnose parapharyngeal tumors in 67 patients from January 2000 to January 2008. The inflammatory lesions were excluded in the present study. The age of patients ranged from 6 years to 72 years. Analysis of results showed 35 benign tumors and 32 malignant neoplasms. Correlation with histopathology showed a diagnostic accuracy of 92.5% with no false positive report. No complication was encountered in the present study. FNAC can replace incisional biopsy which may be hazardous in this area. Immediate treatment can be planned based on the FNAC report. Such a large series of parapharyngeal tumors diagnosed by FNAC has hardly been reported in India.

A Modified Lip Split Incision

The lip splitting incision along with a mandibulotomy or mandibulectomy increases access to intraoral, pharyngeal, and parapharyngeal tumors and also the cervical spine.1 It has been used in head and neck surgery for access since the mid-19th century when it was first described.2

Surgical management of parapharyngeal tumors - our experience

Fifteen cases of parapharyngeal tumors treated surgically in ENT department of Calcutta National Medical College in last 2 years were included, 80% cases were of benign tumors, most common being schwannomas. Most important investigation was found to be CT scan. The study gives an overview regarding the surgical approach, based upon the extent and histology of the tumor and transcervical approach was found to be most efficient for all practical purpose.

Verlaufsvarianten der Arteria carotis interna als wichtige Differenzialdiagnose von Raumforderungen im Pharynxbereich

A case of a 78-year-old man with globus syndrome is reported who was referred to our department because of a tumor of the right parapharyngeal wall. Radiological and endoscopic examination revealed that the tumor was caused by an extracranial kinking of the right internal carotid artery. Variations of the anatomical position of the internal carotid artery in the parapharyngeal space are potentially at risk during routine ENT-procedures such as adenoidectomy and tonsillectomy or during endoscopic procedures with diagnostic biopsies. Data about the frequency of variations of the clinical course of the internal carotid artery dorsolateral of the lateral pharyngeal wall vary in literature from 4% to 66%. By cost-effective ultrasound and duplex-ultrasound, computed-tomography, magnetic resonance imaging with angiography or by conventional angiography a wide variety of different diagnostic imaging methods is available. While coiling of the internal carotid artery is ascribed to embryological malformation, elongation and kinking of the artery are due to atherosclerosis or fibromuscular dysplasia. These variations are often asymptomatic but they can also cause symptoms from globus syndrome to cerebrovascular insufficiency producing ischemic attacks or infarction. This case report emphasizes the clinical importance of variations of the clinical course of the internal carotid artery as a differential diagnosis of parapharyngeal tumors since iatrogenic injuries during routine pharyngeal surgery with disastrous outcome were frequently reported in literature. Unexperienced ENT-surgeons should be warned and experienced ENT-surgeons should be reminded of those dangerous variations.

The prognostic significance of tumor vascular invasion and its association with plasma Epstein-Barr virus DNA, tumor volume and metabolic activity in locoregionally advanced nasopharyngeal carcinoma

Parapharyngeal tumor invasion is a known predictor of distant recurrence in stage II-III nasopharyngeal carcinoma (NPC). This study evaluated the prognostic significance of parapharyngeal and cavernous sinus vascular invasion in stage III-IV NPC, and its association with plasma Epstein-Barr virus (pEBV) DNA, disease stage, tumor volume and metabolic activity. Eligible patients underwent magnetic resonance imaging (MRI), 18F-fluorodeoxyglucose (FDG)-positron-emission tomography (PET) and blood sampling for pEBV DNA before undergoing concurrent chemoradiotherapy. Relationship between treatment outcome and tumor vascular invasion was analyzed using Cox regression. Logistic regression was used to analyze the association between vascular invasion and other cofactors. Fifty seven patients with predominantly T3-T4 or N2-N3 stage disease were enrolled. Parapharyngeal invasion was present in 56% and cavernous sinus invasion in 19% of tumors. Multivariate analysis showed that tumor vascular invasion did not predict treatment outcome, while tumor FDG-uptake was the only significant factor that predicted survival and recurrence. Tumor vascular invasion was associated with T-stage, but not pEBV DNA or tumor volume. Parapharyngeal and cavernous sinus invasion were not significant predictors of distant recurrence following chemoradiotherapy in our cohort with locoregionally advanced NPC.

頭頸部領域に発生した血管周皮細胞腫の２例

A hemangiopericytoma is a rare perivascular mesenchymal tumor originating from Zimmerman's pericytes and shows variable malignant potential. Here we report two additional cases of hemangiopericytoma in the head and neck region. One was located in the sinonasal cavity, and the other was in the parapharynx. Endonasal surgery was performed for the sinonasal tumor. Preoperative embolization followed by endoscopic sinus surgery achieved complete excision of the tumor with reduction of intraoperative hemorrhage. There has not been any recurrence for over 65 months to date. The parapharyngeal tumor was excised by retraction of the submandibular gland (cervical approach). There has not been any recurrence for over 96 months to date. Immunohistochemical analysis was helpful for definitive diagnosis of the two tumors. Here in we discuss the diagnosis and treatment of hemangiopericytoma.

Prognostic influence of parapharyngeal extension in nasopharyngeal carcinoma

Conclusions. Advanced parapharyngeal tumor involvement in nasopharyngeal carcinoma (NPC) had significant predictive value associated with poorer treatment outcome. Further subclassification of parapharyngeal invasion may be considered in the TNM staging system. Objectives. We conducted a retrospective study to elucidate the effect of parapharyngeal extension on treatment outcomes in patients with NPC who were treated with radiotherapy or concurrent chemoradiotherapy (CCRT). Patients and methods. A total of 99 patients with newly diagnosed NPC were enrolled in this study. The parapharyngeal space invasion examined by CT scan was identified and graded according to Sham and Choy's classification. Potentially significant parameters were analyzed by both univariate and multivariate methods using SPSS software. Results. The overall survival, recurrence-free survival, locoregional control survial and distant metastasis-free survival rates were affected by the presence of parapharyngeal space involvement (p<0.0001, p<0.0001, p<0.0001, p=0.002, respectively). In multivariate analysis accounting for all previously known prognostic factors, parapharyngeal invasion was associated with increased risk for any recurrence, locoregional recurrence, distant metastasis, and overall survival. After adjusting with TNM classification, parapharyngeal invasion was still an independent prognostic factor in NPC.

副咽頭間隙良性腫瘍に対する手術法の検討

The aim of this paper was to describe our surgical technique and retrospective review of the treatment of benign parapharyngeal tumors. We used a modified transcervical approach in twelve patients with large tumors. Pathological diagnose comprised 7 cases of pleomorphic adenoma, 4 cases of schwannoma, and 1 case of oncocytoma. The mean maximal tumor diameter was 4.8cm (range: 2.0-9.0cm) and the mean vertical distance from the skull base was 1.3cm (range: 0-3.5cm). The mean surgical time was 198 minutes (range: 104-369 minutes), and the mean blood loss was 82ml (range: 25-200ml). The average follow-up time was 37 months (range: 8-74 months) and there was no clinical or radiological signs of residual or recurrent tumor. The modified transcervical approach facilitates the removal of large tumors, but only in benign cases.

Glossopharyngeal neuralgia with syncope as a sign of neck cancer recurrence

Glossopharyngeal neuralgia with syncope as a sign of neck cancer is a very rare condition. A review of the literature revealed only 29 cases formerly reported. We present the first Brazilian case of such association. A 68-year-old man presented with paroxysmal excruciating pain over the right side of the neck, sometimes followed by syncope. Given the suspicion of recurrent tumor from a previously treated neck malignancy, a computed tomography scan was performed and a right parapharyngeal tumor was shown. Pain and syncope were successfully controlled with carbamazepine and the patient underwent palliative radiotherapy.

Robotic Radiosurgery vs. Brachytherapy as a Boost to Intensity Modulated Radiotherapy for Tonsillar Fossa and Soft Palate Tumors: The Clinical and Economic Impact of an Emerging Technology

As a basis for making decisions regarding optimal treatment for patients with tonsillar fossa and soft palate tumors, we conducted a preliminary investigation of costs and quality of life (QoL) for two modalities [brachytherapy (BT) and robotic radiosurgery] used to boost radiation to the primary tumors following external beam radiotherapy. BT was well established in our center; a boost by robotic radiosurgery was begun more recently in patients for whom BT was not technically feasible. Robotic radiosurgery boost treatment has the advantage of being non-invasive and is able to reach tumors in cases where there is deep parapharyngeal tumor extension. A neck dissection was performed for patients with nodal-positive disease. Quality of life (pain and difficulty swallowing) was established in long-term follow-up for patients undergoing BT and over a one-year follow-up in robotic radiosurgery patients. Total hospital costs for both groups were computed. Our results show that efficacy and quality of life at one year are comparable for BT and robotic radiosurgery. Total cost for robotic radiosurgery was found to be less than BT primarily due to the elimination of hospital admission and operating room expenses. Confirmation of robotic radiosurgery treatment efficacy and reduced morbidity in the long term requires further study. Quality of life and cost analyses are critical to Health Technology Assessments (HTA). The present study shows how a preliminary HTA of a new medical technology such as robotic radiosurgery with its typical hypofractionation characteristics might be based on short-term clinical outcomes and assumptions of equivalence.

Treatment of an acute salivary fistula after parotid surgery: botulinum toxin type A injection as primary treatment

A salivary fistula is a relatively uncommon but troublesome complication after parotid surgery. Most cases are self-limiting and respond well to conservative therapy (compression dressings). However, this treatment may require weeks before its effect becomes evident. We present the first report of direct administration of botulinum toxin type A as an effective primary treatment for an acute salivary fistula after parotid surgery, in the absence of other, more conservative treatment. A 47-year-old man with a 7-day history of sore throat was found to have a parapharyngeal tumor originating from the deep lobe of the parotid gland. He underwent tumor removal via a trans-paroticocervical approach. However, on postoperative day 7, the patient was noted to have massive salivary discharge from the surgical incision during a meal. We administered a transcutaneous botulinum toxin type A injection without a pressure dressing. One day after the injection, the salivary discharge from the incision line disappeared completely and there was no evidence of recurrent sialorrhea in the 6 months following the procedure. This report suggests that the injection of botulinum toxin type A is a highly effective and relatively safe primary method of treatment for an acute postparotidectomy salivary fistula, and not merely an alternative to more conservative therapy.