Surgical treatment of benign parapharyngeal space tumours. Presentation of two clinical cases and revision of the literature

Parapharyngeal space (PPS) tumours, most of them benign, account for some 0.5% of tumours of the head and neck. The importance of these tumours lies mainly in two aspects: on the one hand, the difficulty of early diagnosis, due to the lack of symptoms in the initial stages and, on the other, the extreme complications of performing surgery in the parapharyngeal region. This article discusses two clinical cases of parapharyngeal space tumours: a 45 year old man and a 60 year old woman. We revise the scientific literature and analyse the diagnostic and therapeutic procedures used, placing special emphasis on describing the different surgical approaches to the parapharyngeal space: transcervical, transcervical-transparotid, transpalatal or transoral, transmandibular and orbitozygomatic, all of which, used alone or combined with others, allow for complete resection of these tumours with minimum morbidity.     

Parapharyngeal space benign tumours: Our experience

Only about 0.5% of all head and neck neoplasms occur in the parapharyngeal space (PPS) and approximately 80% of these tumours are benign lesions. Various surgical approaches some of which are associated with mandibulotomy to increase exposure have been described. This article describes our 16-years' experience in treating 60 PPS benign tumours with special focus on our surgical techniques intended to ensure adequate mass exposure and structure safety. On the basis of our experience we assert that mandibulotomy is currently not advocated in the surgical management of benign PPS tumours i.e. not even in very select cases. The transparotid approach is the treatment of choice for parotid gland lesions involving PPS and in cases of multinodular or uninodular pleomorphic adenoma relapse involving the PPS. The transcervical approach is suitable for the safe removal of even large PPS masses in most cases.     

Parapharyngeal space tumors: surgical approaches in a series of 13 cases

Tumors originating in the parapharyngeal space are rare; they comprise approximately 0.5% of head and neck tumors. Most (70–80%) are benign and the most frequent origins are salivary and neurogenic. The aim of this study is to present the surgical procedures used for the treatment of 13 patients with parapharyngeal space tumors; 11 of them were suffering from benign tumors (the most frequent being pleomorphic adenoma; 8 cases) and 2 from malignant lesions. The following surgical approaches were used: intraoral (2 cases), transcervical (4 cases) and transmandibular (7 cases) with different types of mandible osteotomies. The type of surgical approach was dictated by the type of the lesion (malignant or benign), the exact location, the size, the vascularity and the relation of the tumor to the neck neurovascular bundle. In all cases the selected surgical approach allowed the complete resection of the tumor, obtaining clear margins in cases of malignancy, without adding to the patient's preoperative morbidity. It was concluded that the surgical approach to the parapharyngeal space tumors must be adjusted to the tumor characteristics and be as wide is necessary to achieve its complete removal with safety.     

经口腔机器人手术在头颈外科中的应用

经口腔机器人手术(transoral robotic surgery,TORS)是近年来国际上头颈外科领域引人注目的一大进展,目前已成功应用于头颈-颅颌面肿瘤切除及游离皮瓣重建术。它突破了传统外科医师手术的概念,提高了手术质量,减小了手术创伤,极大地满足了患者的安全与美观需求,在头颈外科中的应用已被初步证实具有可行性和安全性。本文就TORS的组成、优点、应用现状及发展前景作一综述。     

Schwannoma of Parapharyngeal Space

The tumours of the parapharyngeal region account for only 0.5% of all the head and neck tumours. Interestingly schwanomas are much common in this region. Here a case of schwanoma of parapharyngeal space in a 24-year-old female is reported with an emphasis on surgical treatment.     

Surgical management of deep lobe parotid tumours with and without involvement of the parapharyngeal space

The diagnosis and treatment of deep lobe parotid tumours is challenging because of the complex surgical accessibility. There is a lack of studies describing the differences between deep lobe tumours that do and do not occupy the parapharyngeal space (PPS). Patients treated for deep lobe tumours occupying the PPS (PPS group) and not occupying the PPS (non-PPS group) were analysed retrospectively. A total of 227 patients were treated surgically for deep lobe parotid tumours between 1990 and 2019. Sixty patients (26.4%) presented with tumours that involved the PPS (PPS group), while 167 (73.6%) presented with tumours that did not occupy the PPS (non-PPS group). The majority of the PPS group tumours were removed using a transcervical or transcervical–transparotid approach. PPS group tumours were larger (P < 0.001), and tumour spill occurred more frequently in this group (benign tumours: P = 0.002; malignant tumours: P = 0.033). Complication rates did not differ between the PPS and non-PPS groups. A transcervical or transcervical–transparotid approach is the preferred method for the management of deep lobe parotid tumours that occupy the PPS in our practice. Tumour spill occurred more frequently in the PPS group, which is most probably due to the larger tumour size and more complex accessibility.     

Branchial cyst of the parapharyngeal space: report of a case and surgical approach considerations

INTRODUCTION: Neoplasms arising within the parapharyngeal space are rare and represent approximately 0.5% of all head and neck tumors. The majority of these lesions consist of minor salivary gland tumors, tumors of the deep lobe of the parotid gland, and tumors of neurogenic origin (paragangliomi and schwannomi), while branchial cysts are extremely rare. Despite advances in radiographic images, surgical excision remains the definitive technique for the diagnosis of parapharyngeal space tumors. RESULTS AND DISCUSSION: The authors report a case of branchial cyst of the parapharyngeal space excised through a combined transcervical-transmandibular approach and discuss the several surgical techniques proposed to approach this type of tumors.     

Surgical approach to benign primary tumors of the para-pharyngeal space

Surgical access to tumors of the parapharyngeal space can be performed by transoral or trancervical approaches. Risk of intraoperative bleeding and difficulties in radical enucleation represent the disadvantages of transoral approach. This approach must be performed for small and inferomedial lesions, or for preoperative biopsy when necessary. Transcervical approaches can be distinguished in transparotid or transmandibular, or submandibular. Before the late '70s all parapharyngeal masses were approached by transparotid access, with facial nerve manipulation in all cases. CT and MR techniques now allow the right presumptive preoperative diagnosis in 90% of patients. To avoid the risk of injury of the facial nerve when possible, transparotid approach is now limited to the lesions with parotid origin. Transmandibular and submandibular approaches allow an adequate exposure and a direct access to the parapharyngeal space. Personal experience with 6 patients presenting primitive tumors of the parapharyngeal space is reported and surgical approaches proposed in the literature are reviewed.     

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.     

Giant Parapharyngeal Space Pleomorphic Adenoma of the Deep Lobe of Parotid Presenting as Obstructive Sleep Apnoea: A Case Report & Review of the Diagnostic and Therapeutic Approaches

Introduction

Salivary gland tumours constitute about less than 4 % of all head and neck tumours. Pleomorphic adenoma, also called benign mixed tumour, is the most common tumour of the salivary glands. About 80–90 % of these tumours occur in the major salivary gland mainly parotid gland and 10 % of them occur in the minor salivary glands.

Aims and Methods

Aim of this case report is to discuss the unique case of giant parotid pleomorphic adenomas arising in the deep lobe involving the parapharyngeal space and difficulty in respiration at sleep during nights repoted at this institute. The patient was undergoing treatment for obstructive sleep apnea syndrome when she reported at this institute for disturbed sleep. Diagnosis was based on computed tomography scan and magnetic resonance imaging and cytology by means of fine needle aspiration biopsy.

Conclusion

An exhaustive pre-operative diagnostic algorithm is mandatory before approaching such lesions involving parapharyngeal space. Fine needle aspiration biopsy is, in our opinion, mandatory to avoid histological surprises. The surgical approach varies according to the location of the tumour and should provide excellent visibility with wide surgical exposure to secure local neurovascular structures.     

内镜辅助下经口入路与口外入路切除咽旁间隙巨大良性肿瘤的效果比较

目的: 比较内镜辅助下经口入路(endoscopy-assisted transoral approach,EATA)与口外入路(external approaches, EAs)2种手术方式在巨大良性咽旁间隙肿瘤(parapharyngeal space tumors, PSTs)切除术中的临床效果。方法: 将62例PST患者分为EATA组和EA组,比较2组患者围术期及术后的临床数据,采用SPSS 21.0软件包对数据进行统计学分析。结果: 所有肿瘤均完整切除。EATA组中6例患者术中转为口外入路。EA组中8例患者术中采用内镜进行辅助手术。EATA组的术中出血量、引流总量、术后疼痛评分、总住院天数均显著少于EA组(P<0.05),术后面容外形满意度评分显著高于EA组(P<0.05)。结论: 采用EATA手术方式切除咽旁间隙良性巨大肿瘤,可以减少手术创伤,获得更好的术后面容外形。然而,2种术式联合应用,可获得更好的手术效果。     

Transoral robotic approach for schwannoma of the larynx

We present a rare case of schwannoma of the supraglottic larynx in a 30-year-old woman with a 5-year history of dysphonia. Excision of the mass was performed by transoral robotic surgery (TORS) without complication using the robotic da Vinci Surgical System, 0-degree three-dimensional endoscope, 5-mm microinstruments compatible with the da Vinci robot, and an FK retractor. Transoral robotic surgery rendered good exposure that allowed complete tumor resection. An external approach and tracheotomy were not necessary in this case. We found that TORS was practicable, efficient, and nonhazardous for the resection of a supraglottic schwannoma. We propose TORS for the treatment of large benign and selected malignant laryngeal tumors.     

Management of parapharyngeal giant pleomorphic adenoma

Introduction

Pleomorphic adenoma (PA) is found rarely in the parapharyngeal space (PPS). Because of late diagnosis due to slow growth, close proximity to vital neurovascular structures and risks of surgery, it poses a great difficulty for both diagnosis and surgical management. The preferred surgical approach to the PPS is the cervical?Ctransparotid including a total parotidectomy with facial nerve preservation combined with a cervical access for dissection of cranial nerves and vascular structures thus allowing a safe removal of the tumor together with the parotid deep lobe. We report herein our experience in the management of giant PAs involving the prestyloid PPS and describe a not well-documented transparotid route by preservation of the parotid superficial lobe in combination with an intraoral approach.

Patients and methods

In this retrospective study, three cases of patients having giant PAs involving the PPS are evaluated. All patients had signs of foreign body sensation in the throat and a growing mass bulging in the oropharynx. Diagnosis was based on MRI and upon preoperative intraoral biopsy. The average tumor size was 5.7?cm. Patients underwent surgery and excision of tumors via transparotid?Cintraoral approach. In two cases, the superficial lobe was preserved and afterwards put back in its anatomic location.

Results

All patients were discharged without complications, and no recurrences were observed.

Conclusions

Preoperative diagnosis management of PPS giant tumors should be based on imaging and upon open transoral biopsy if possible. The transparotid?Cintraoral approach provided adequate visibility to remove large PAs involving the prestyloid PPS.     

咽旁颞下区肿瘤的诊断和手术治疗体会

目的:探讨位于颞下窝、咽旁间隙肿瘤的临床表现及诊断方法 ,分析颈侧入路及耳屏前入路的手术疗效,总结治疗心得体会。方法:回顾分析2010—2014年间,15例颞下窝、咽旁间隙肿瘤患者临床资料,包括影像学、组织学检查,分别采用单纯颈侧入路、颈侧入路+下颌骨劈开外旋术或耳屏前切口入路方式切除肿瘤。结果:15例患者均完整切除肿瘤,术后随访1~5年,13例良性肿瘤均无复发,2例恶性肿瘤患者无瘤生存3~5年。结论:术前行增强CT和MRI可明确颞下窝、咽旁肿瘤占位及大小,对手术方案的制定有一定帮助,但不应完全依照影像学检查结果实施手术。利用颈侧软组织可让性,能有效切除咽旁间隙体积较小的肿瘤。对于位置较高且粘连较重的良性肿瘤及侵袭性较强的恶性肿瘤,可考虑采用"颈侧入路+下颌骨劈开外旋术"或"耳屏前切口入路+颧弓切断术"切除。     

Endoscopy-assisted transoral resection of large benign parapharyngeal space tumors

We have evaluated the outcomes of endoscopically-assisted resection of large benign tumours of the parapharyngeal space by an intraoral approach. Six patients with primary benign tumours were treated in this way. The lesions were pleomorphic adenomas, Warthin's tumour, and schwannoma. The sizes of the tumours varied from 4 × 4 cm to 7 × 7 cm. All tumours were removed completely without rupture and without damage to the facial nerve. No patient developed any permanent postoperative complications such as damage to the facial nerve, salivary fistula, or limited mouth opening. The cosmetic effects were excellent. The patients were followed up for 8 to 21 months without recurrence. Endoscopically-assisted transoral resection of large benign tumours of the parapharyngeal space is a simple and safe technique that achieves excellent aesthetic and functional results.     

Metastasis of maxillary carcinoma to the parapharyngeal space: rationale and technique for concomitant en bloc parapharyngeal dissection.

PURPOSE: En bloc resection of the primary tumor and regional lymph nodes is the classic method of surgery in cases of head and neck cancer, but it is not performed in cases of carcinoma of the maxillary gingiva or antrum for anatomic reasons. One of the reasons for the poor prognosis of patients with maxillary cancer and N+ stage necks is thought to be recurrence in the parapharyngeal space, which is out of the surgical field in radical neck dissection. The purpose of this study was to discuss the rationale and indication for en bloc resection and parapharyngeal dissection for maxillary cancer. PATIENTS AND METHODS: Ninety-nine patients with maxillary cancer (54 in the gingiva and 45 in the antrum) treated at our institution between 1980 and 2000 were studied retrospectively. RESULTS: In 4 patients, there was recurrence in the parapharyngeal spaces despite good control of tumors in the maxilla and the neck. These 4 patients had all undergone resection of maxilla and neck lymph nodes separately. We also report the case of a patient with carcinoma of the maxillary antrum who underwent en bloc resection of the maxilla and neck. After radical neck dissection, parapharyngeal dissection was performed with a mandibular ramus osteotomy approach, and the maxilla and neck tissue were resected en bloc. CONCLUSIONS: Although en bloc resection causes more extensive surgical damage, it may be useful in patients with maxillary cancer who have metastasis in the upper jugular lymph nodes.     

Schwannoma of the parapharyngeal space

A schwannoma (or neurilemmoma) of the parapharyngeal space is a rare tumor in the head and neck region arising from the sheath of cranial nerves and/or the sympathetic chain. In the early stages of growth, there is usually a lack of symptoms because of the anatomical localization and slow growth of the tumor. The large dimension of the mass at presentation makes it difficult to perform a functional surgery, and in many cases the operation worsens the nerve status. The choice of surgical approach is of paramount importance in both preserving nerve function and achieving vascular control. The authors report a case and discuss the English literature.     

经口内镜辅助下切除咽旁间隙良性肿瘤6例报道

目的 对经口内镜辅助下切除咽旁间隙肿物的手术方法进行评价。方法 选择6例咽旁间隙良性肿瘤患者（男4例,女2例,平均年龄41.7岁）,经口内镜辅助下切除肿物。其中多形性腺瘤4例,腺淋巴瘤1例,神经鞘瘤1例。肿瘤大小4 cm×4 cm~7 cm×7 cm不等。结果 肿瘤均被完整切除,术后未出现面神经损伤、涎漏或开口受限等并发症。该术式极好地保护了患者的容貌外观。随访8~ 21个月（平均14.7个月）,均无复发。结论 经口内镜辅助下切除咽旁间隙巨大良性肿物简单、安全,美观和功能良好。     

咽旁间隙肿瘤

本文对我院收治的89例咽旁肿瘤作了回顾分析。术前32例病人作了针吸活检，50例作了CT检查；全部病人均行手术治疗，大多数病人经腮腺和经颈部入路手术。结果在32例针吸活检病人中27例诊断正确，50例CT检查中36例可准确判断肿瘤的位置，组织学见良性肿瘤72例（81％），恶性肿瘤17例（19％），咽旁肿瘤中以混合瘤最为多见，共37例（42％）；术后良性肿瘤复发10例（14％），恶性肿瘤12例（74％）。结果显示针吸活检和CT对咽旁肿瘤的术前诊断和评估十分必要和关键，经腮腺入路和经颈部入路是最常用的手术进路，咽旁肿瘤的术后复发率高。     

Soft-tissue chondroma of the masticatory space

Soft-tissue chondroma is an infrequent, benign, cartilaginous tumour that is uncommon in the head and neck region. Single-location chondromas rarely evolve into malignant neoplasms. Chondromas are composed of hyaline cartilage with focal calcification. There have been a few reports published of cases of soft-tissue chondroma of the neck and parapharyngeal space. Here is described a new location of this tumour in the masticatory space.