Post-styloid Compartment Research Articles

Parapharyngeal Lipoma Extending to Skull Base: A Case Report with Surgical Approaches.

Parapharyngeal lipoma with skull base extension is rare tumor found in head and neck region. We report a case of 66 years old female patient with left side face swelling extending to neck. On clinical examination, it was found soft, non-tender, mobile swelling present over left side pre-auricular region. It was extending from pretragal area superiorly to left submandibular region inferiorly. CECT neck and fine needle aspiration cytology was done to know the benign nature of disease. It suggest tumor extending from skull base to C6 vertebral level in parapharyngeal space. Tumor was excised via Trans parotid-transcervical approach. Parapharyngeal lipomas are confined to either the prestyloid or post styloid compartments. We report an unusual parapharyngeal lipoma involving both the compartments of the parapharyngeal space.

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.

Surgical Parapharyngeal Space Tumor Analysis with Case Series Study.

Background The parapharyngeal space is a hypothetical region in the neck that stretches from the base of the skull to the bigger corner of the hyoid bone. The fascia that connects the styloid process to the tensor veli palatini separates the compartment into prestyloid and poststyloid compartments, with the prestyloid compartment being larger. In the general population, tumors of the parapharyngeal area are very uncommon, accounting for less than 1% of all head and neck neoplasms in the population. In this location, CT scanning and magnetic resonance imaging (MRI) exams are complimentary, and both tests should be performed to examine any lesions found. The most critical component of treatment is the total surgical removal of all the cancerous tissue. Identifying and treating primary parapharyngeal space (PPS) tumors are among the most challenging tasks in the treatment of head and neck cancer. They are also among the most aggressive ones. The primary goal of this study is to review our current knowledge at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, which serves as an academic tertiary referral center and a major teaching center. We will focus on clinical findings, tumor structure, tumor histological distribution, and surgical approaches. Materials and Methods The processing starts with two modules. The first module starts with the input images obtained from various patients and collected as a database. The second module starts with the collection of case series of nine patients undergoing excision via multiple different approaches: transoral, transcervical, transparotid, transmandibular, or infratemporal approach. All cases were conducted at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, between 2014 and 2018. All operative interventions were performed by an otolaryngology-head and neck surgeon. Results Our study comprised nine patients, of which two underwent transparotid and seven transcervical and combined transcervical/transparotid approach. Complications faced included a hematoma in one of our cases. Conclusion The transcervical approach appeared to be the superior surgical approach when facing a pleomorphic adenoma within the parapharyngeal space, arising from the deep lobe of the parotid gland or parapharyngeal space-occupying paraganglioma.

Locoregional Extension Patterns of Nasopharyngeal Carcinoma Detected by FDG PET/MR.

PurposeWe sought to define the locoregional extension patterns of nasopharyngeal carcinomas (NPCs) by positron emission tomography (PET)/magnetic resonance imaging (MRI) and to improve clinical target volume (CTV) delineation.MethodsBetween May 2017 and March 2021, 331 consecutive patients with nonmetastatic NPCs who underwent pretreatment, simultaneous whole-body PET/MRI for staging were included in this study.ResultsThe high-risk regions included the base of the sphenoid bone, the prestyloid compartment, prevertebral muscle, foramen lacerum, medial pterygoid plate, sphenoidal sinus, clivus, petrous apex, and foramen ovale. When the high-risk regions were invaded, the incidence rates of tumor invasion into the medium-risk regions increased. In contrast, when the high-risk regions were not involved, the incidence rates of tumor invasion into the medium-risk regions were mostly less than 10%, excluding the post-styloid compartment and oropharynx. According to the updated consensus guidelines of the neck node levels for head and neck tumors from 2013, level IIa (77.3%, 256/331), level IIb (75.8%, 251/331), and level VIIa (71.3%, 236/331) were the most frequently involved levels, followed by levels III (42.6%), Va (13.9%), IVa (8.8%), IVb (3.6%), Ib (3.6%), Vb (2.4%), VIIb (2.4%), VIII (1.8%), Vc (0.9%), and Xa (0.3%). Skip lymph node metastasis occurred in only 1.9% of patients.ConclusionsFor NPCs, primary disease and regional lymph node spread follow an orderly pattern, and a skip pattern of lymph node metastasis was unusual. Involved level radiotherapy might be feasible for cervical lymph node levels below the caudal border of cricoid cartilage and level VIIb.

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.

AUTONOMIC INSTABILITY SECONDARY TO GLOMUS VAGALE PARAGANGLIOMA

Introduction Paragangliomas are rare vascular neuroendocrine tumors that arise from neural crest chromaffin cells that are associated with autonomic ganglion. A small subset of these tumors are found in the head and neck region and originate in the carotid and aortic bodies. Case description A 60-year-old woman presents with recurrent near syncopal episodes for 3 days associated with loss of appetite and 20-pound weight loss for 2 months. Two years ago, the patient presented with similar presyncopal episodes and Holter monitoring at that time showed multiple pauses up to 20 seconds, after which she was referred for dual chamber pacemaker implantation. During that time, a tilt table test and finometer measuring beat to beat blood pressure values was positive for sudden episodic hypotension and bradycardia every 2-3 minutes and were associated with lightheadedness and near syncope. Vitals during hospitalization showed BP ranging from 80s/50s to 130s/80s. Physical exam showed normal cardiopulmonary findings but revealed a right cervical mass along the angle of mandible, mildly tender to palpation. EKG showed an appropriately paced atrial rhythm at 59 beats per minute without any other abnormalities. As a result of her hypotensive episodes, the patient was started on fludrocortisone and pyridostigmine. CT neck with contrast showed a post styloid compartment mass with significant compression of R internal jugular vein and branches of R carotid artery. Subsequent angiography showed 4 × 3 × 3 cm. hypervascular mass in the upper right neck with displacement of carotid arteries and AV shunting into the R internal jugular vein. Findings were consistent with Glomus Vagale Paraganglioma and patient was discharged in stable condition for outpatient evaluation for surgical resection of mass. Discussion Indistinguishable from pheochromocytomas at the cellular level, paragangliomas are divided into catecholamine secreting sympathetic and nonfunctional parasympathetic neoplasms. Although most cases are sporadic, there is a link between paragangliomas and mutation of genes coding for Succinate Dehydrogenase (SDH) enzyme, Von Hippel Lindau, MEN2, and NF1 syndromes. Paragangliomas are usually asymptomatic and present as painless cervical masses. Glomus vagale, a particularly rare type of paraganglioma located near the vagus nerve, can present with tinnitus, dysphagia, or hoarseness. Carotid sinus compression by the cervical mass can lead to symptomatic hypotension and bradycardia, as seen in our case. The diagnosis of non-secretory paragangliomas includes 24-hour urine test to measure catecholamine and metanephrine levels and visualization of tumor via ultrasound, CT, or MRI which can show a “salt and pepper” appearance due to micro hemorrhage and hypervascularization. Treatment includes surgery, embolization, or radiotherapy. Conclusion Paragangliomas are uncommon tumors with glomus paragangliomas being a rare subtype. Because of their cellular composition and anatomic locations, they often cause autonomic instability. Further research should be performed to improve diagnosis and treatment.

Autonomic Instability Secondary to Glomus Vagale Paraganglioma

Introduction Paragangliomas are rare vascular neuroendocrine tumors that arise from neural crest chromaffin cells that are associated with autonomic ganglion. A small subset of these tumors are found in the head and neck region and originate in the carotid and aortic bodies. Case description A 60-year-old woman presents with recurrent near syncopal episodes for 3 days associated with loss of appetite and 20-pound weight loss for 2 months. Two years ago, the patient presented with similar presyncopal episodes and Holter monitoring at that time showed multiple pauses up to 20 seconds, after which she was referred for dual chamber pacemaker implantation. During that time, a tilt table test and finometer measuring beat to beat blood pressure values was positive for sudden episodic hypotension and bradycardia every 2-3 minutes and were associated with lightheadedness and near syncope. Vitals during hospitalization showed BP ranging from 80s/50s to 130s/80s. Physical exam showed normal cardiopulmonary findings but revealed a right cervical mass along the angle of mandible, mildly tender to palpation. EKG showed an appropriately paced atrial rhythm at 59 beats per minute without any other abnormalities. As a result of her hypotensive episodes, the patient was started on fludrocortisone and pyridostigmine. CT neck with contrast showed a post styloid compartment mass with significant compression of R internal jugular vein and branches of R carotid artery. Subsequent angiography showed 4 × 3 × 3 cm. hypervascular mass in the upper right neck with displacement of carotid arteries and AV shunting into the R internal jugular vein. Findings were consistent with Glomus Vagale Paraganglioma and patient was discharged in stable condition for outpatient evaluation for surgical resection of mass. Discussion Indistinguishable from pheochromocytomas at the cellular level, paragangliomas are divided into catecholamine secreting sympathetic and nonfunctional parasympathetic neoplasms. Although most cases are sporadic, there is a link between paragangliomas and mutation of genes coding for Succinate Dehydrogenase (SDH) enzyme, Von Hippel Lindau, MEN2, and NF1 syndromes. Paragangliomas are usually asymptomatic and present as painless cervical masses. Glomus vagale, a particularly rare type of paraganglioma located near the vagus nerve, can present with tinnitus, dysphagia, or hoarseness. Carotid sinus compression by the cervical mass can lead to symptomatic hypotension and bradycardia, as seen in our case. The diagnosis of non-secretory paragangliomas includes 24-hour urine test to measure catecholamine and metanephrine levels and visualization of tumor via ultrasound, CT, or MRI which can show a “salt and pepper” appearance due to micro hemorrhage and hypervascularization. Treatment includes surgery, embolization, or radiotherapy. Conclusion Paragangliomas are uncommon tumors with glomus paragangliomas being a rare subtype. Because of their cellular composition and anatomic locations, they often cause autonomic instability. Further research should be performed to improve diagnosis and treatment.

Chondrosarcoma in the Parapharyngeal Space; Site of Origin an Enigma.

Chondrosarcoma of the head and neck region is a rare disease, representing approximately 0.1% of all head and neck neoplasms. We present a case of a 30year old male who presented with swelling in the right retroauricular region since 4years. Magnetic resonance imaging and computed tomography showed lesion with its epicentre in the post styloid compartment of right parapharyngeal space with superior extent around the petrous apex. The surgical procedure considered was excision. Surgical excision was challenging in view of difficult surgical access due to close and intricate relation with neurovascular structures of head and neck and an unsual pattern of spread.

Penetrating knife injury to infratemporal region: case report and review of literature

Infra Temporal Fossa (ITF) injuries with retained knife handle are quite uncommon. ITF has a complex anatomy and is divided into prestyloid and post styloid compartments. We reviewed the literature and found one reported case. We are presenting another such rare case. A 22-year-old male presented in emergency room with a retained knife injury to the left face in front of left tragus. Clinically the patient was stable haemodynamically. CT showed the knife lying in left extra cranial infratemporal region, and the tip dangerously close to carotid canal, foramen ovale, and foramen spinosum and lateral orbital wall. After careful assessment it was decided to take the patient for simple extraction of knife in OT and prepare neck for ligation of external carotid if required. The knife was successfully removed and the patient has been followed up for 1 year with no residual problems. ITF injuries are uncommon and dangerous particularly ones which go into retrostyloid region and penetrate cranial cavity. If patient is stable clinically and imaging suggests pre styloid ITF injury, then after consulting a multidisciplinary team these may be treated by simple knife extraction in operation theatre with good outcome.

A modified method for locating parapharyngeal space neoplasms on magnetic resonance images: implications for differential diagnosis.

The parapharyngeal space (PPS) is an inverted pyramid-shaped deep space in the head and neck region, and a variety of tumors, such as salivary gland tumors, neurogenic tumors, nasopharyngeal carcinomas with parapharyngeal invasion, and lymphomas, can be found in this space. The differential diagnosis of PPS tumors remains challenging for radiologists. This study aimed to develop and test a modified method for locating PPS tumors on magnetic resonance (MR) images to improve preoperative differential diagnosis. The new protocol divided the PPS into three compartments: a prestyloid compartment, the carotid sheath, and the areas outside the carotid sheath. PPS tumors were located in these compartments according to the displacements of the tensor veli palatini muscle and the styloid process, with or without blood vessel separations and medial pterygoid invasion. This protocol, as well as a more conventional protocol that is based on displacements of the internal carotid artery (ICA), was used to assess MR images captured from a series of 58 PPS tumors. The consequent distributions of PPS tumor locations determined by both methods were compared. Of all 58 tumors, our new method determined that 57 could be assigned to precise PPS compartments. Nearly all (13/14; 93%) tumors that were located in the pre-styloid compartment were salivary gland tumors. All 15 tumors within the carotid sheath were neurogenic tumors. The vast majority (18/20; 90%) of trans-spatial lesions were malignancies. However, according to the ICA-based method, 28 tumors were located in the pre-styloid compartment, and 24 were located in the post-styloid compartment, leaving 6 tumors that were difficult to locate. Lesions located in both the pre-styloid and the post-styloid compartments comprised various types of tumors. Compared with the conventional ICA-based method, our new method can help radiologists to narrow the differential diagnosis of PPS tumors to specific compartments.

Unusual Parapharyngeal Space Neoplasms.

Parapharyngeal space is a potential space in the neck in the form of an inverted pyramid and can be divided into pre- and post-styloid compartment. Salivary gland tumors commonly arise from the pre-styloid compartment and neurogenic tumors and paragangliomas from the post-styloid compartment. These tumors can have a highly variable presentation due to their location which often also makes it difficult to get a confirmed pre-operative diagnosis due to their inaccessibility. In such cases, diagnosis is often radiological. We present two cases of parapharyngeal space masses, where, in spite of thorough pre-operative workup, final diagnosis turned out to be a surprise.

Surgical Management of Parapharyngeal Space Tumors: Our Experience

The purpose of this study is to evaluate parapharyngeal space (PPS) tumors with regards to clinico-pathological features and pre-operative assessment and also to analyze the benefits of transcervical approach in the management of PPS tumors. We performed retrospective analysis of patients who had undergone transcervical resection of PPS tumors from May 2006 to May 2009 at KLES Dr. Prabhakar Kore Hospital and M. R. C, Belgaum. Patients were diagnosed on the basis of clinical examination, FNAC and magnetic resonance imaging. All patients were observed with an annual follow-up of at least 3years by physical examination and ultrasonographic evaluation. The total number of patients were four; with three males and one female patient. Their age varied from 20 to 55years with a mean age of 36years. There were two cases of neurilemomas, one case of carotid body tumor and one case of pleomorphic adenoma. All four patients underwent surgical excision of tumor by transcervical approach. There were no major post-operative complications. All four patients are alive with no recurrence in the 3year follow-up period. Transcervical approach is versatile, flexible and provides good access to the narrow PPS. This approach also provides good vascular control and reduced risk of post-op complications. We recommend transcervical approach even for large sized pre-styloid and post-styloid compartment benign tumors which are free from deep lobe of parotid.

Parapharyngeal Space Tumors

ABSTRACTParapharyngeal space is a potential space in the neck extending from skull base to the greater cornu of hyoid bone. It is divided in prestyloid and poststyloid compartment by the fascia joining styloid process to tensor veli palatini. Tumors of parapharyngeal space are uncommon, comprising of less than 1% of all head and neck neoplasms. CT Scanning and MRI investigations is complimentary and both studies should be performed for evaluation of lesions in this area. Complete surgical excision is the mainstay of treatment.

A Case Report on Parapharyngeal Nerve Cell Tumor (Schwannoma)

The Parapharyngealspace (PPS) is shaped like an inverted pyramid, extending from the skull base superiorly to the greater cornu of the hyoid bone inferiorly. The superior border of the PPS comprises a small area of the temporal and sphenoid bones, including the carotid canal, jugular foramen, and hypoglossal foramen. The PPS is limited anteriorly by the pterygomandibular raphe and pterygoid fascia and posteriorly by the cervical vertebrae and prevertebral muscles. The medial border of the PPS is the pharynx, and the lateral border is comprised of the ramus of the mandible, the medial pterygoid muscle, and the deep lobe of the parotid gland. Below the level of the mandible, the lateral boundary consists of the fascia overlying the posterior belly of the digastric muscle. The fascia from the styloid process to the tensor veli palatini divides the PPS into an anteromedial compartment (i.e. prestyloid) and a posterolateral (i.e. poststyloid) compartment. The prestyloid compartment contains the retromandibular portion of the deep lobe of the parotid gland, adipose tissue, and lymph nodes associated with the parotid gland. The poststyloid compartment contains the internal carotid artery, the internal jugular vein, CNs IX-XII, the sympathetic chain, and lymph nodes. Tumors of the PPS are uncommon, comprising less than 1% of all head and neck neoplasms. Both benign and malignant tumors may arise from any of the structures contained within the PPS. Of PPS tumors, 70–80% are benign, and 20–30% are malignant. Most PPS tumors are of salivary or neurogenic origin, although metastatic lesions; lymphoreticular lesions; and a variety of uncommon, miscellaneous lesions may arise in this location [1]. Schwannoma are the most common peripheral nerve tumor also referred to as neurilemmoma or neurinoma. This benign tumor arises from myelin in peripheral nerve. The most characteristic presentation is a mass lesion with point tenderness and shooting pain on direct palpation.

Endoscopic Transnasal Transmaxillary Transpterygoid Approach to the Parapharyngeal Space: An Anatomic Study

The aim of this study was to assess the feasibility of an endoscopic approach to the parapharyngeal space through a transnasal route. For this purpose, an anatomic study was conducted. The target area was studied separately on each side in 4 adult cadaver heads. To simulate actual endoscopic surgery, the dissection was performed thoroughly under the rigid endoscope. The surgical steps and extent of surrounding tissue resection necessary for the approach were evaluated. Both the pre- and poststyloid compartments could be exposed with restricted sacrifice of the surrounding tissue around the pterygoid process. Adding a wide sphenoidotomy and subpetrous bone resection, the surgical exposure could be extended at the medial temporal skull base including the medial infratemporal fossa. Although its usefulness has to be further verified in the clinical setting, the present results of the anatomic dissection indicate the potential of the approach to become a novel technique for treatment of a lesion in the parapharyngeal space.

An Organizing Hematoma in the Parapharyngeal Space

Organizing hematomas occur in many locations and simulate neoplasms. They all have similar structure, with a central mass of blood, a wall of granulation tissue, and dense, fibrous tissue at the periphery. There have been sporadic reports of organizing hematoma not only in soft tissue but also in brain, adrenal gland, lung and maxillary sinus. We report a case of nontraumatic head and neck organizing hematoma---one that occurred in the parapharyngeal space (PPS), a site that has not been previously reported. By doing so, since idiopathic organizing hematoma may occur, we hope to promote awareness and consideration of organizing hematoma in the differential diagnosis of tumor in the post-styloid compartment of the PPS, especially in patients with history of trauma or bleeding tendency.

Roof of the parapharyngeal space: defining its boundaries and clinical implications.

The roof of the parapharyngeal space (PPS) is poorly defined. Although it is generally described as having prestyloid and poststyloid compartments, we believe that these terms are imprecise. Therefore, we define its boundaries, partition, and compartments. We completed macroanatomical and microanatomical dissections in 10 specimens from 5 human cadaver heads; bone measurements in 50 dry skulls; and axial and coronal cross-sectional studies in 2 cadaveric specimens. The PPS roof is bordered laterally by the medial pterygoid fascia and medially by the pharyngobasilar fascia. The tensor veli palatini fascia (TVPF) partitions this roof into an anterolateral compartment containing fat and part of the deep lobe of the parotid gland, and a posteromedial compartment containing the cartilaginous part of the eustachian tube, internal carotid artery, internal jugular vein, and cranial nerves IX through XII. The anteroposterior length measures 32 mm (range, 26.1 to 36.9 mm), and the mediolateral width measures 16.3 mm (range, 12.1 to 21.3 mm). The PPS roof has 3 important bony landmarks (ie, scaphoid fossa, styloid process, sphenoid spine); 3 important fasciae (ie, medial pterygoid fascia, TVPF, pharyngobasilar fascia); and 2 compartments, which are anterolateral and posteromedial to the TVPF. We believe that this is the first report to specifically focus on the roof of the PPS.

Prognostic influence of parapharyngeal space involvement in nasopharyngeal carcinoma

Purpose: To assess the prognostic influence of parapharyngeal space involvement in nasopharyngeal carcinoma (NPC).Methods and Materials: From January 1987 to December 1994, 197 untreated NPC patients were examined by CT scan before treatment. The parapharyngeal space was separated into pre-styloid and post-styloid compartments on axial images by the styloid process. Potentially significant parameters were analyzed by both univariate and multivariate methods using SPSS 8.0 software.Results: The actual survival, disease-free survival, and local failure-free rates were affected by the presence of parapharyngeal space involvement (p = 0.0115, p = 0.0035, p = 0.0367, respectively). The 5-year actual survival, disease-free survival, and the local failure–free rates in the patients without parapharyngeal space disease, or with pre-styloid and post-styloid compartment involvement were 87.9%, 88.0%, 96.9% and 75.0%, 71.2%, 93.7% and 60.5%, 57.7%, 86.8%, respectively. Parapharyngeal space involvement correlated well with lymphadenopathy and advanced N disease. Distant metastasis is more likely in the presence of obvious post-styloid compartment involvement (p = 0.0153). Age is a strong prognostic factor for survival.Conclusion: Parapharyngeal tumor involvement has significant predictive value. The parapharyngeal space involvement affects local tumor failure, regional tumor failure, and distant metastasis. Its survival rate is low

Extracranial Head and Neck Schwannomas: A Review of 8 Years Experience

Schwannomas of the head and neck are uncommon tumors that arise from cranial, peripheral or autonomic nerves. In this study we review a series of 52 cases of schwannoma originating in the head and neck region over an 8-year period. All the tumors were benign, with the exception of one malignant schwannoma. The age range of the patients studied was 13-76 years and there was a predilection for males. Twenty-five schwannomas occurred in the scalp, face and external ear canal, 9 in the oral or nasal cavity and 18 in the neck. Seven cases of neck schwannoma originating from the major nerve system were found in the parapharyngeal space, all of which were located in the post-styloid compartment. Cervical plexus schwannomas originated either in the peripheral nerves or in an unidentified area of the nervous system; seven tumors were found in the posterior triangle of the neck and two in the anterior triangle. Two of the tumors originating in the brachial plexus were located in the posterior neck and one in the anterior neck. Tumors originating in the vagus nerve or sympathetic chain were all located in the anterior triangle of the neck.

Neurilemomas of the parapharyngeal space.

To review the surgical management of neurilemomas of the parapharyngeal space (PPS). Retrospective survey of the clinical presentation, radiological features, surgical approaches, surgical findings, and postoperative neurological sequelae of neurilemomas of the PPS. Academic tertiary care head and neck referral center. Fourteen patients with neurilemomas of the PPS, 12 were in the poststyloid compartment. Preoperative evaluation with computed tomography and/or magnetic resonance imaging with or without angiography. Surgical resection was performed through a transcervical approach. Radiological features, adequacy of surgical approach, and neurological sequelae of surgery. Radiological studies could distinguish prestyloid from poststyloid tumors and, with poststyloid tumors, can usually differentiate between glomus tumor and neurilemoma. The transcervical approach permitted adequate surgical access. Five of the tumors in the poststyloid space were neurilomomas originating from the sympathetic nervous system, and all 5 patients with these tumors developed Horner syndrome postoperatively. Computed tomographic and/or magnetic resonance studies should be routinely obtained to evaluate tumors of the PPS, but angiography is indicated only in selected cases. Both prestyloid and poststyloid neurilemomas can be resected through a transcervical approach. Resection of neurilemomas has an attendant risk for neurological dysfunction.