咽旁间隙神经鞘瘤诊断及手术入路选择

目的探讨咽旁间隙神经鞘瘤的诊断与手术入路方式的选择。方法对咽旁间隙神经鞘瘤患者14例病历资料进行回顾性分析,术前根据CT和MRI判断肿瘤与扁桃体包膜距离关系及肿瘤主体位置考虑手术径路,与扁桃体包膜距离≤1cm、肿瘤主体突入到口内者行经口内径路,与扁桃体包膜距离1cm、瘤体主体突向外侧者经颈外径路,手术径路与肿瘤大小关系不大。经口内径路4例,颈外径路10例。结果所有患者均获得顺利手术,术后随访6个月～6年均未见复发。结论颈部CT、MRI及DSA是诊断及鉴别诊断的良好手段,手术径路取决于肿瘤与扁桃体包膜的距离及肿瘤主体位置,无论采取何种径路,均无严重的并发症。     

Measurement of parapharyngeal space using CT images

Parapharyngeal space can be defined as a potential space surrounded by deglutitional and masticator muscles and their covering, superficial and middle layer of deep cervical fascia. It is easily recognized in images provided by modern scanning devices, such as CT and MRI. Parapharyngeal space has traditionally been divided by styloid process and fascia of tensor veli palatini muscle (nasopharyngeal level) or fascia of stylopharyngeus muscle (oropharyngeal level) into two compartments, prestyloid and postsyloid spaces. The latter is often called as carotid space. Prestyloid portion exclusively contains fat tissue, which yields hypoabsorption area in CT films and high density area in MRI. In most of papers in radiological journals, the term of parapharyngeal space is regarded as its prestyloid portion which is clearly identified. Axial CT images of 144 patients without any naso- or oropharyngeal lesions were analyzed. Two reference levels of nasopharynx were adopted for the study. The upper level passes through the plane of fossa of Rosenmuller, and the lower reference level transects soft palate. The following parameters of the space were measured; Length and width of the whole space, length and width of prestyloid fatty space, and furthermore, width of pre- and poststyloid space, that were divided by a imaginary line parallel to the axis of the whole space (the upper level); Length and width of the whole space, length of base and height of a triangle of the prestyloid part (the lower level). While parapharyngeal space was symmetrical in the upper level, the rate of asymmetry amounted to a fourth in the lower level.(ABSTRACT TRUNCATED AT 250 WORDS)     

Malignant lymphoma in unusual areas of the head and neck: parapharyngeal space and temporal fossa

Primary malignant lymphomas of the parapharyngeal space are rare and only 28 cases are known to have been reported. No case of malignant lymphoma arising in the temporal fossa has been previously documented. The present paper reports a case of primary non-Hodgkin's lymphoma of the parapharyngeal space in a child and two cases of lymphoma of the temporal fossa in adults. All three cases were diagnosed histopathologically from biopsy specimens as diffuse, B-cell lymphomas. For diagnosis, inspection and bimanual palpation were most important in the parapharyngeal case and the temporal cases required more than one biopsy for the final diagnosis.     

Synovial sarcoma of the larynx

A 23 years old male presented with a soft cystic mass in the left paralaryngeal space since 3 months. Indirect laryngoscopy revealed a bulging of the left lateral pharyngeal wall. Histopathologic al examination of the biopsy proved it to be a synovial sarcoma. The case is the seventh case reported in literature.     

Unilateral tonsillar lymphoepithelioma with ipsilateral parapharyngeal space involvement: a case report

We report a case of unilateral tonsillar lymphoepithelioma with extension into the ipsilateral parapharyngeal space, and we review the clinical, histologic, and radiographic findings of the case. The patient presented with a tonsillar mass that was confirmed on biopsy to be lymphoepithelioma. Computed tomography demonstrated ipsilateral parapharyngeal space involvement. Association with Epstein-Barr virus was not assessed since it does not affect the treatment modality. We also review the literature and discuss the diagnosis and current treatment options.     

Pseudotumor of the head and neck masquerading as neoplasia

Four unusual cases of pseudotumor, which had clinical and radiographic findings suggesting neoplasia, are presented. One involved the maxillary sinus, destroying the lateral wall, and extending to the infratemporal fossa and the orbit. The second presented as an enlarging lacrimal gland tumor with ipsilateral parotid adenopathy, and the third as a large parapharyngeal mass that was diagnosed as a lymphoma on aspiration cytology. The fourth case documented the rare occurrence of a congenital pseudotumor, manifesting as proptosis in a neonate and thought to be a fibrosarcoma on frozen section study. Aggressive pseudotumors must be distinguished from malignancy to avoid unnecessary surgery or irradiation. Some cases can be distinguished from neoplasms by their dramatic response to oral steroid therapy, and others by characteristic features on CT or MRI. Due to the diverse cellular proliferation, aspiration cytology is infrequently helpful and diagnosis can be difficult on frozen section study. An approach to the diagnosis and management of pseudotumors is detailed.     

咽旁隙肿瘤的诊断及治疗

目的 了解咽旁隙解剖特征，提高咽旁隙肿瘤诊治水平。方法回顾分析近9年收治的45例咽旁隙肿瘤病人临床表现、影像学特征、外科径路、手术所见及手术后并发症，全部病人随访8个月～9年。结果良性肿瘤40例(其中神经源性肿瘤28例)，恶性肿瘤5例。术前CT或MRI能明确肿瘤的大小、位置、扩展范围、以及与周围结构的关系。术后出现伸舌偏斜2例，口角偏斜1例，Hoiner综合征4例，右上肢曲屈障碍1例，3例术后肿瘤复发再次手术治愈。结论原发性咽旁隙肿瘤以神经源性肿瘤多见，MRI和/或CT检查是诊断咽旁隙肿瘤及术前确定手术方案的基础，且MRI检查优于CT。根据病变的部位及特性，手术可选择经口径路、颈侧径路或颈侧联合径路切除肿瘤。     

Solitary fibrous tumor of the parotid gland extending to the parapharyngeal space

Solitary fibrous tumors (SFT) arise in the pleura and less commonly in extrapleural sites. Head and neck regions have included the nose and paranasal sinuses, soft palate, epiglottis, thyroid, parotid and submandibular glands, as well as the infratemporal fossa and parapharyngeal space. We report a case of SFT arising from the parotid gland and extending to the parapharyngeal space. To our knowledge, this is the fourth case of SFT originating from the parotid gland and is the largest of its kind among the extrapleural lesions described. The characteristics revealed by computed tomography and magnetic resonance imaging are presented. Received: 28 May 1997 / Accepted: 25 August 1997     

Rare cases of neurofibroina in the head and neck

Four cases of neurofibroma rare localized in parapharyngeal space and throat, in external ear and larynx are described. Three of them were isolated tumors and in one case--tumors in external ears developed in course of general Recklinghausen disease. Two cases of neurofibroma in parapharyngeal space had different clinical, CT and microscopic picture. In one case tumor protruded the throat obturating its oral part with osseous elements in its microscopic structure which caused characteristic CT picture. This one was excised through median mandibulotomy with good anatomical and functional result. The second case of parapharyngeal neurofibroma adherent to the superior cervical vertebra and only slightly dislocated the postero-lateral wall of the throat was excised through external cervical approach.     

Intramuscular epithelioid hemangioma of the parapharyngeal space

A clinical case of epithelioid hemangioma of the scalene muscle that occupied the parapharyngeal space is reported. The patient was a 34 year old man with a 2-month history of sensation of pharyngeal foreign body and mild dysphagia. The exploration revealed a tumor of the posterior and lateral wall of the oropharynx that extended from the rhinopharynx to the hypopharynx. The diagnostic sequence included CT, MRI, Doppler echography, and arteriography, which identified a right post-styloid tumor located behind and medial to the jugular vein, internal carotid artery, and vagal nerve, but did not affect arterial blood flow. The patient underwent surgical treatment consisting of lateral cervicotomy, tumor excision, and histological study.     

A study of the course of the internal carotid artery in the parapharyngeal space and its clinical importance

The differences in the course and shape of the internal carotid artery (ICA) in the parapharyngeal space were investigated to determine the possible risks for serious hemorrhage during tonsillectomy, drainage of peritonsillar abscess, soft palate injuries, adenoidectomy and velopharyngeoplasty. The course of the ICA was studied in the parapharyngeal spaces of 50 adult cadavers. From each specimen, circumferential sections were obtained and they stained with hematoxylin–eosin and Verhoeff’s elastic staining. The cervical course of the ICA showed no curvature in 70 cases; but in 25 cases it had a medial curve, and five cases showed kinking out of a total 100 dissected carotid sheaths. In two cases, kinking of the ICA was related to the pharyngeal wall. The histological examination of all kinking specimens demonstrated depletion and decreasing muscle tissue in tunica media and an increase was observed in vasa vasorum numbers in the tunica adventitia of ICA. The dissections and integrity losses were seen in tunica media and tunica adventitia. The vessel wall of histological structure change were detected in kinking specimens and lays the groundwork for the vessel wall to get easily harmed or torn either directly or indirectly by decreasing the elasticity and soundness of the wall. The transposition of the ICA artery in submucous position becomes important for otorhinolaryngologists when its aberrant course causes a widening in the retropharyngeal or parapharyngeal tissues and an impression on the pharyngeal wall. Curving and kinking of the ICA can constitue a risk factor for acute hemorrhage in routine surgical procedures, which are performed by inexperienced surgeons.     

Evaluation and surgical approaches to tumors of the parapharyngeal space

BACKGROUND: Tumors of the parapharyngeal space encompass a wide variety of benign or malignant neoplasms. The purpose of this study was to evaluate our experience with the history, diagnosis and management of parapharyngeal tumors. PATIENTS AND METHODS: In a retrospective study the data of 19 patients who underwent surgical excision between 1995 and 2001 were analyzed with regard to presenting signs and symptoms, histologic diagnosis, imaging technique and surgical approach. 12 patients were female, 7 male. The youngest patient was 17, the oldest 72 years of age (mean: 47). RESULTS: Two thirds of the resected tumors were benign. Eight tumors originated from salivary glands, neurogenic tumors were found in 6 patients, malignant lymphomas in two cases. CT was performed in 16 patients, an additional MRI was indicated in 5 patients due to the superior soft-tissue resolution. In one patient arteriography revealed a paraganglioma. Preoperative localization of the tumor was possible in all cases. The transcervical approach was performed in the majority of cases (7). An intraoral excision (4) in combination with a transcervical approach (3), transcervical-tarnsmandibular (1) or a midfacial degloving (2) was performed less frequently. CONCLUSION: Benign parapharyngeal tumors prevail. In the majority of cases they originate from the salivary glands. CT and MRI are the diagnostic procedure of choice to select the surgical approach with the least morbidity. MRI should be preferred since it provides superior soft-tissue resolution, multiplanar imaging, identification of the vascular structures and no exposition to ionizing radiation. Arteriography should be performed if indicated by MRI findings. Incisional biopsy or fine needle biopsy should be performed only in cases which appear to be unresectable. Intraoral excisions should be indicated only for small tumors. The majority of tumors can be excised using the transcervical approach. Excessive tumor growth or tumors growing close to the skull base may indicate an infratemporal approach or a mandibulotomy.     

Primary oropharyngeal tuberculosis causing destruction of uvula—A rare presentation

Despite the contact of pulmonary secretions and the mucous membranes of the upper respiratory tract with a high bacillary load, tuberculosis of the head and neck area, excluding laryngeal forms, is exceptional and constitutes only 2–6% of extra pulmonary tuberculosis and 0.1–1% of all forms of tuberculosis. Oral cavity tuberculosis is uncommon, out of which primary pharyngeal tuberculosis is extremely rare. We present a case of an ulcerative lesion in a 7-year-old female subsequently proven to be primary oropharyngeal tuberculosis. There was an erosion of uvula and posterior soft palate. There was also an ulcerated area on adjacent area of left tonsillar fossa with slough over posterior pharyngeal wall.     

Recurrent plexiform schwannoma involving the carotid canal

Plexiform schwannoma (PS) is a rare variety of benign nerve sheath tumor characterized by a multinodular plexiform growth pattern. PS is usually confined to the head and neck or skin. The pre-operative diagnosis of PS is difficult, and this has lead to a common misdiagnosis as a schwannoma. In addition, studies have indicated that an incomplete resection of PS often results in tumor recurrence. Here we describe a rare case of PS presented in the parapharyngeal space. Our case involved a 36-year-old man with swelling of the pharynx, who presented with a soft cervical mass. MRI revealed a multinodular mass in the left parapharyngeal space, and further pathological diagnosis by the referral hospital indicated schwannoma. A cervical approach was taken and the tumor was removed with preservation of the nerve sheath by intracapsular resection. The tumor recurred within one year after the first surgery in the same lesion of the left parapharyngeal space. The second surgical approach was a combination of a facial dismasking flap and trans-pterygopalatine fossa. The mass was resected completely, and the diagnosis of PS was confirmed by histopathology. While schwannoma commonly occurs in the head and neck, parapharyngeal space PS is rare, and pre-operative pathological diagnosis of PS is difficult. MRI studies of PS revealed distinctive features that we found useful in pre-operative diagnosis. Intracapsular resection of PS with nerve preservation has a very high recurrence rate of the tumor. Therefore, if MRI findings suggest PS we recommend removing the tumor completely without nerve preservation will offer the most curative outcome.     

Clinical study of parapharyngeal space tumors

We clinically studied 31 cases of parapharyngeal space tumor treated between 1988 and 2002, and compared histological findings and preoperative diagnosis. Pleomorphic adenoma was the predominant tumor, accounting for 35.5%. Schwannoma and paraganglioma were next at 26.6%. In determining pathological diagnosis, fine needle biopsy and imaging were useful. Important factors in imaging diagnosis are inspecting the degree of enhancement in CT or MRI, investigating the existence of flow void on MRI, and discriminating whether the origin is pre- or post-styloid.     

Comparison of CT and MRI in diagnosis of parapharyngeal tumors]

Recently, the usefulness of CT and MRI in diagnosing parapharyngeal tumors has been established. At the same time, several modalities for these imagings, i.e. plane and enhanced CT, T1, 2 weighted MRI and Gadolinium enhanced MRI, have been developed. We compared the image findings of 12 tumors involving the parapharyngeal space with their operative records. T1 was most suited to diagnosing the sites of origins of tumors because of its superior depiction of the internal carotid artery and parapharyngeal fat. Enhanced CT was also superior in depicting these structures, but in cases where the parapharyngeal fat was diminished, or the parapharyngeal fat had been invaded by malignant tumor, enhanced CT was inferior to T1. The spatial resolution of T2 was poor, T2 was thus not useful in diagnosing the sites of origins of tumors. Because tumor intensity tended to be similar to that of fat in Gadolinium enhanced MRI imaging, Gadolinium was not as useful as T1. In diagnosing the extents of tumors, we examined the depiction of both tumor-fat and tumor-muscle interfaces. With regard to the depiction of the tumor-fat interface, enhanced CT and T1 were most useful. In diagnosing the tumor-muscle interface, Gadolinium enhanced MRI was most suitable. The net result is that MRI is superior to CT.     

Histologic and clinical assessment of primary extranodal non-Hodgkin malignant lymphomas of the head and neck region

The authors presented 27 cases of primary extranodal non-Hodgkin's malignant lymphomas of the head and neck area in patients treated surgically in the ENT Department in the years 1996-2001. We observed tumors in the various areas: palatine tonsil, naso-pharynx, eye socket, paranasal sinuses, parapharyngeal space and lingual base. In the course of the diagnostic process we examined the patients carefully to be sure that the cancer had not disseminated. We used some imaging techniques such as: ultrasonography, CT and MRI. We also used the needle aspiration biopsy, as a additional examination. However the material was not significant in the most cases and we were unable to make a definitive diagnosis on the basis of this method alone. After prior examinations we performed the radical operations and removed the tumours. In each case the postoperative material was examined using immunohistochemical methods. Afterwards the pathomorphological diagnosis was made by the specialists. Next the patients were observed and treated in the Haematological Department and Radiotherapy Department. In all cases pathomorphological diagnosis were performed on the base of usage postoperative histochemical examinations. All treated patients were performed as diagnostic preoperative USG, CT, MRI and fine-needle biopsy aspiration exam. All patients for further treatment were observed at Haematological Department.     

Extraskeletal Ewing's Sarcoma of parapharyngeal space

Extraskeletal Ewing's Sarcoma (EES) of head and neck region, is a rare soft tissue tumour morphologically similar to the commoner Ewing's Sarcoma arising from bone. We report a case of EES in parapharyngeal space in a 6-year-old male; who presented with stridor. CT scan of neck showed soft tissue mass in right parapharyngeal space with intraorbital and intracranial extention. Histopathological examination showed round cell tumour and immunohistochemistry was positive for CD99 and Vimentin. The patient responded very well to Concurrent Chemoradiation. An extensive review of English literature, to the best of our knowledge, did not reveal any previous case of EES in parapharyngeal space in children; although one similar case in a 53-year male is reported.     

Palatal eversion for the treatment of combined nasopharyngeal stenosis and tonsillar pillars adhesion

ObjectiveRarely the tonsillar pillars and the soft palate became adherent to the posterior nasopharyngeal wall by strong fibrous tissue due to excessive dissection and cauterization during surgery leading to nasopharyngeal stenosis. Therefore, many treatment modalities are being tried to cure this problem. The aim of this study is to explore our results of modifying the basic technique to accommodate those patients with combined nasopharyngeal stenosis and tonsillar pillars adhesions in one stage. Study Design: Case series.MethodsThis study was conducted on 10 patients with combined nasopharyngeal stenosis and tonsillar pillars adhesions after adenotonsillectomy. They were subjected to treatment by palatal eversion through dividing the soft palate in the midline to separate each pillar from the pharyngeal wall in continuation with each half of soft palate and removal of the fibrous tissue causing stenosis. This was followed by eversion and fixation of the two palatal divisions on either side to allow complete epithelialization of the stenotic area. Postoperative follow-up was done for one year by the flexible nasopharyngoscopy, perceptual speech analysis, and polysomnography.ResultsThe flexible nasopharyngosopic examination of the 10 patients at the end of post-operative period revealed a freely mobile soft palate with no nasopharyngeal stenosis or palatal fistula. Velopharyngeal function and speech assessment by perceptual speech analysis was normal in all 10 cases. No obstructive episodes were recorded in polysomnograms.ConclusionsPalatal eversion is a promising technique in the treatment of post-adenotonsillectomy of combined nasopharyngeal stenosis and tonsillar pillars adhesion. It is recommended to be used on a wider scale of patients and other indications as nasopharyngeal stenosis following uvulopalatoplasty and post nasopharyngeal radiotherapy. The level of evidence: 4 (case series).     

Schwannomas of the parapharyngeal space and jugular foramen

Schwannomas or neurilemmomas are among the most common neoplasms occupying the parapharyngeal space, yet only 107 cases have been previously reported. Neurilemmomas involving the jugular foramen are extremely rare. Only 55 cases have been reported in the world literature. The neoplasm occurred in the parapharyngeal space in three of our patients and in the jugular foramen in another patient. Of the tumors located in the parapharyngeal space, the nerve of origin in one of them was the glossopharyngeal, which is extremely rare. Adequate exposure for complete excision of parapharyngeal space tumors is best obtained through an external incision and should not be attempted transorally. In the jugular foramen case, the neoplasm arose from the vagus nerve high in the neck and extended intracranially in a “dumbbell” shape into the posterior cranial fossa. Total removal was successfully accomplished in one stage, by using a subtotal temporal bone resection — upper neck — posterior cranial fossa approach. Surgical removal is the treatment of choice. Schwannomas rarely recur following complete excision.