Parapharyngeal tumours: a review of 23 cases

The anatomy of the parapharyngeal space is described and experience with 23 patients with parapharyngeal tumours seen over a 10-year period is reported. Despite reaching a large size, these tumours may be relatively asymptomatic, or be discovered incidently. CT scan, MRI, arteriography and fine needle aspiration are useful in establishing a diagnosis. The most common histological type (13/23 patients) was pleomorphic adenoma and these tumours were managed by transoral removal if small, or a combined transoral-external approach if large. No patient required a mandibulotomy for access and no benign tumour recurred. The outcome was poor in the 5 patients with malignant tumours and a more radical approach, midline mandibulotomy, should be considered if malignancy is suspected.     

Standardised method of selecting surgical approaches to benign parapharyngeal space tumours, based on pre-operative images

Many approaches to the parapharyngeal space have been reported. However, few reports describe parapharyngeal space tumours and the best surgical approach to these tumours. We retrospectively examined the surgical approaches we used to resect 22 parapharyngeal space tumours. In order to determine the best surgical approach for each tumour, we first subdivided the parapharyngeal space into six compartments, based on anatomical landmarks seen on computed tomography and/or magnetic resonance imaging scans. We then determined the location of each tumour relative to these six parapharyngeal space compartments. In our series of cases, we found that large tumours spanning the superior portion of the parapharyngeal space could be completely removed through a skull base approach. To remove a large tumour in the middle and inferior portion of the parapharyngeal space, a transparotid approach was the most suitable. Finally, a tumour in the inferior portion of the parapharyngeal space was best accessed through a transcervical approach.     

Primary haemangiopericytoma of the parapharyngeal space: an unusual tumour and review of the literature

Haemangiopericytoma is a rare soft tissue tumour, with great histological variability and unpredictable clinical and biological behaviour. The precise cell type origin is uncertain. One third of haemangiopericytomas occur in the head and neck area, but only a few cases have been reported regarding localization at the parapharyngeal space. Herewith, case is presented of a 54-year-old female, referred to our Department due to a parapharyngeal space tumour with non-specific imaging characteristics. The patient underwent radical excision of the tumour with a trans-cervical sub-mandibular approach. The histolopathologic examination revealed a neoplasm with the characteristic features of haemangiopericytoma. One year later, during the scheduled follow-up, the computerized tomography scan showed no evidence of recurrence or residual disease. The pre-operative evaluation of a haemangiopericytoma must include a thorough imaging evaluation with computerized tomography and magnetic resonance imaging, even if results may not be specific for haemangiopericytoma. Angiography and pre-operative embolization may be performed in cases of large tumours with significant vascularity. The treatment of choice is radical excision. The follow-up includes clinical evaluation every 6 months and annual magnetic resonance imaging for at least 3 years.     

Parapharyngeal space tumors. Our experience. I.P.O. Francisco Gentil,Lisbon

Primary parapharyngeal space tumours are rare, representing only a 0.5% of head and neck neoplasms. The authors report a case series review of 38 patients with parapharyngeal tumours who underwent surgical excision between 1975 and 1998. Twenty-six of them were female (68%) and twelve male (32%). Thirty-three tumours (87%) were benign and five (13%) were malignant being the Pleomorphic adenoma the most common neoplasm (39%). All patients were treated surgically: the trans-cervical approach was used in 19 cases, cervical-parotid in 5, the trans-parotid approach in 7 patients, transoral in 5, the cervical-parotid approach with mandibulectomy in 2 and the combined transoral-cervical approach in 1 case. Out of the 33 patients with benign neoplasms, 1 (a pleomorphic adenoma treated through a transoral approach) had a recurrence. Amongst the 5 with malignant disease, recurrence or persistent local tumour was seen in 4 cases; and of these, 3 with persistent local tumour after incomplete excision died.     

Tumours of the parapharyngeal space

A series of 14 parapharyngeal tumours has been studied with regard to their symptology, pre-operative evaluation and surgical management. High resolution computed tomography is now the best initial diagnostic study because it helps to determine the size and extent of the tumour, differentiate tumours of parotid and extraparotid origin, demonstrate degree of tumour vascularity, separate benign from malignant lesions, plan the surgical approach and predict prognosis.     

Síndrome del síncope del tumor del espacio parafaríngeo

There are several causes of syncopal attacks because of carotid sinus alterations. Recently parapharyngeal tumours have been implicated in its etiology. We reported a man with a cavum tumour who had several syncopes and an haemodynamical angina because of severe bradyarrhythmias. Implicated clinical entities in parapharyngeal space lesions syncope-syndrome, its physiopathological characteristics and differential diagnosis are discussed.     

Diagnosis and therapy of aggressive fibromatosis (extra-abdominal desmoid) in the head and neck area

Desmoid tumours (extraabdominal desmoids, aggressive fibromatosis) are rare connective tissue tumours, that grow infiltratively and destructively. The analysis of the course of disease in three patients suffering from desmoid tumours in the head and neck region (regio submandibularis, regio parotidea, parapharyngeal space) confirmed the data in literature that painless swelling and dysfunction are the first non-specific signs of the disease. Morphologically reactive fibromatosis and fibrosarcoma should be considered (amongst others) in differential diagnosis. CT and MR scans are useful in determining the extent of the tumours and help to distinguish the tumour from nerves, vessels and bone. Surgery is the therapy of choice in the head and neck region. Primary surgery was performed in our patients. Due to recurrences two of our patients have been operated on several times including major plastic reconstructive surgery. One patient died three and a half years after primary treatment due to sarcomatous degeneration. A large parapharyngeal recurrence was successfully reduced by percutaneous radiation therapy in our second patient. Follow-up of our third patient was NAD 15 months after resection of a large parapharyngeal/mediastinal process including blocking of two cervical vertebrae. Summing up, desmoid tumours are rare connective tissue tumours in the head and neck region with a destructive biological behaviour similar to malignant tumours and a high recurrence rate. Surgery is the treatment of choice. In recurrences or if the tumour is not properly resectable, radiation must be considered, whereas the chemotherapeutical approach is not yet well established.     

The place of imaging in the investigation of the parotid and parapharyngeal space]

What strategy should be adopted and what results should be expected from imaging techniques in the various pathological process affecting the parotid and parapharyngeal space? When the pathological process is associated with morphological changes in the parotid, it is sometimes necessary to have recourse to imaging. MRI is the method of choice. Pathology in the parapharyngeal space (PPS) always requires an MRI and/or CT scan. It is necessary to have a very thorough understanding of the anatomy of the PPS and associated spaces to obtain a precise preoperative assessment and, where possible, an indication of the nature of the lesion.     

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.     

Neurogenic tumours of the parapharyngeal space in the paediatric age group.

Two cases of neurogenic tumours of parapharyngeal space in children of 7 years old are presented. Difficulties during the diagnosis, investigations and management are discussed along with a review of the available literature. CAT scan with sialography, carotid angiography during surgery, angle mandibulectomy and liberal incision to expose the great vessels for better control of bleeding are stressed to minimise the peri-operative complication and to assist in complete removal of the tumours.     

Malignant triton tumour of the parapharyngeal space

We report the clinical course in a 25-year-old male patient of neurofibromatosis with malignant triton tumour (MTT). Triton tumour is a peripheral nerve sheath tumour with rhabdomyoblastic differentiation. This is relatively rare tumour of head and neck region and only 26 cases have been reported to date. The present case is the first reported MTT of parapharyngeal space, one of the most aggressive course among all head and neck MTTs, resulting in the death of the patient within three months following surgical resection. The aggressive nature of this tumour necessitates adjuvant therapeutic measures in addition to radical surgery in order to obtain better survival rates.     

The value of sonography in salivary gland tumors

In a prospective study, 178 patients with tumours of the salivary glands were examined both clinically and by ultrasound. All patients have since been operated upon, and the diagnosis was confirmed histologically. The diagnostic accuracy of clinical examination is compared with that of ultrasound. Every tumour of the salivary glands could be diagnosed by ultrasound. In the benign group, an exact diagnosis of the tumour type was possible in 83% of cases. In the malignant group an exact diagnosis was only possible in 57% of cases. Furthermore, it is possible with ultrasound to recognise multiple and bilateral tumours, to determine whether a tumour is intra- or extraglandular, and to show the nature of the tumour (cyst, abscess, central necrosis) to a much greater extent than with clinical examination alone. In addition, a fairly good assessment of the cervical and intraglandular lymph nodes is obtained. We believe that ultrasound is of great importance in the diagnosis of tumours of the salivary glands.     

Pleomorphic adenoma causing acute airway obstruction

A case is reported of a pleomorphic adenoma of the minor salivary glands of the oral cavity presenting with acute airway obstruction. This is the first reported case to our knowledge of a mixed salivary tumour of the upper respiratory tract causing upper airway obstruction and acute respiratory failure. The patient had to be intubated and transferred to the intensive care unit. After an elective tracheostomy was performed, the adenoma was excised from its fibrous capsule. It was found to originate from the soft palate and occupied the parapharyngeal space. A high index of suspicion should be kept in order to diagnose tumours of the parapharyngeal space with unusual presentation. These tumours which are usually benign should be considered in the differential diagnosis from more common infectious or traumatic conditions and surgical morbidity should be minimal.     

Simultaneous primary pleomorphic adenoma in parotid gland and minor salivary gland in the parapharyngeal space

The majority of salivary gland tumours present as a single mass in one gland. Sometimes multiple primary neoplasms can be seen in more than one salivary gland. The most common tumour is Warthin's tumour. Multiple primary pleomorphic adenomas are extremely rare. Most of them are in the major salivary glands. The author reports the first case of simultaneous pleomorphic adenomas in the parotid gland and minor salivary gland at the parapharyngeal space.     

Lipoma of the parapharyngeal space

A 75-year-old gentleman presented to our department with dysphagia, nocturnal cough and dysphonia. Clinical examination revealed a large parapharyngeal mass extending from the left nasopharynx to the glottis. A magnetic resonance imaging scan confirmed the lipomatous nature of the lesion and elegantly demonstrated its anatomy. We discuss the aetiology and management of such lesions and focus on the diagnostic radiology of the parapharyngeal space.     

Chest computerized tomography scanning in patients presenting with head and neck cancer

Between 1 to 16% of patients with head and neck squamous cell carcinoma (HNSCC) have synchronous tumours; the majority (>50%) occurring within the lung. Previous studies have relied upon endoscopy and chest radiographs. The aim of this study was to determine the incidence of synchronous intrapulmonary tumours in this group of patients using computerized tomography (CT) scanning. Over 36 months, 111 consecutive patients were assessed at presentation by contrast enhanced CT scanning from the skull base to the diaphragm. Chest scans showed intrapulmonary lesions in 17 patients and 10 have, with time, been confirmed as neoplastic. These allowed treatment of three primary bronchial carcinomas following radical treatment of the index tumour and cancellation of radical treatment in five patients with metastases. Two patients with possible metastases at presentation underwent radical treatment to the index tumour with subsequent follow-up confirming metastatic chest disease. All 10 patients eventually died of either locoregional or metastatic disease. This is one of the first prospective reports of chest scanning in patients with head and neck cancer. An additional chest scan in this group, many of whom undergo a staging scan of the neck, requires an extra 10 min with no further contrast and in this study yielded a synchronous tumour rate of 9%.     

Tumores primarios del espacio parafaríngeo. Nuestra experiencia en 51 pacientes

Introduction and objectivesTumours of the parapharyngeal space are rare, representing only 0.5 % of head and neck oncology. The aim of this study is to present our experience with the diagnosis and therapies for these tumours.Patients and methodThis study is a retrospective review of 51 patients diagnosed as having tumours of the parapharyngeal space and treated surgically between 1984 and 2006. Tumours originating in the deep lobe of parotid gland were excluded.ResultsSeventy percent of the parapharyngeal space neoplasms were benign and thirty percent malignant. Pleomorphic adenoma was the most common neoplasm (37 %), followed by miscellaneous benign tumours (34 %), paraganglioma (21 %), and neurogenic tumours (8 %). Surgery was chosen in all case, with the transcervical approach used in 32 cases, the cervical-transparotid approach in 13 cases, the transmandibular approach in 4 cases (with mandibulectomy in 1 patient), the transoral approach in 1 case, and the infratemporal fossa approach in 1 case. The most common complications were those deriving from damage to nerve structures.ConclusionsMost parapharyngeal space tumours can be removed surgically with a low rate of complications and recurrence. The transcervical approach is the most frequently used.     

Parapharyngeal space tumours a radiological and surgical correlation

The parapharyngeal space is a deeply situated space on either side of head. Clinical assessment of lesions in this space in very difficult. 28 patients with parapharyngeal space masses diagnosed and managed in the department of Otorhinolaryngology and Head & Neck Surgery of Postgraduate Institute of Medical Education and Research. Chandigarh were studied. 8 patients were excluded as the tumour could not be removed en-bloc in these. 20 were analysed further.     

The interesting case - case no. 60. Fibrolipoma of the parapharyngeal region

Tumours of the parapharyngeal region represent 0.5 % of all head and neck tumours. Most of them are benign and derive from the salivary gland tissue or have neurogenic offspring (neurolemmoma and paraganglioma). Fibrolipoma of the parapharyngeal space are extremely rare. There are only case reports found occasionally in the literature. We report about case of fibrolipoma in the parapharyngeal space of a 65-years-old man. Symptoms, diagnostic, differential diagnostic, as well as treatment will be discussed in context with the international literature.