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Parapharyngeal Space Neoplasms

Parapharyngeal Space Neoplasms. Grand Rounds Presentation February 18, 1998 Kyle Kennedy, M.D. Anna Pou, M.D. Introduction. Anatomy PPS Neoplasms Presentation and Evaluation Surgical Approaches Complications. Introduction. PPS neoplasms account for approx. 0.5% of head and neck tumors

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Parapharyngeal Space Neoplasms

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  1. Parapharyngeal Space Neoplasms Grand Rounds Presentation February 18, 1998 Kyle Kennedy, M.D. Anna Pou, M.D.

  2. Introduction • Anatomy • PPS Neoplasms • Presentation and Evaluation • Surgical Approaches • Complications

  3. Introduction • PPS neoplasms account for approx. 0.5% of head and neck tumors • PPS anatomy is complex with many important neurovascular structures • most PPS neoplasms are benign • surgical resection mainstay of therapy • systematic preoperative evaluation essential for proper treatment planning

  4. Anatomy • potential space lateral to upper pharynx • inverted pyramid shape • fascial compartmentalization

  5. Anatomy • superior-small portion of temporal bone • inferior-junction of post. belly of digastric m. and greater cornu of hyoid bone • posterior-fascia overlying vertebral column and paravertebral mm. • medial-pharyngobasilar fascia/superior pharyngeal constrictor m. complex • lateral-med. pterygoid fascia, mandibular ramus, retromandibular parotid, post. belly digastric m.

  6. Anatomy • fascial compartmentalization • fascia from tenson veli palatini to styloid process and its muscle complex • prestyloid region-deep lobe of parotid, fat, and lymph nodes • poststyloid region-internal carotid a., internal jugular v., CNs IX-XII, sympathetic chain, and lymph nodes • stylomandibular ligament and tunnel

  7. PPS Neoplasms • primary neoplasms-approx. 80% benign and 20% malignant • approx. 50% from deep lobe of parotid or minor salivary gland tissue and 20% of neurogenic origin

  8. Salivary Gland Neoplasms • majority are benign pleomorphic adenomas • intraparotid origin-retromandibular portion of gland, deep lobe, or tail of gland • extraparotid origin-ectopic rests of salivary gland tissue

  9. Neurogenic Neoplasms • most common-neurilemmoma or scwhannoma arising from vagus n. or sympathetic chain (usu. do not affect n. of origin) • paraganglioma or chemodectoma from vagal or carotid bodies (approx. 10% malignant and 10-20% multicentric) • neurofibroma (typically multiple and intimately asso. with n. of origin)

  10. Presentation and Evaluation • signs and symptoms often subtle until tumor has substantially enlarged • asymptomatic mass, lump in throat, fullness of neck and/or pharynx, cranial n. deficits • delay in diagnosis not uncommon • detailed Hx with complete head and neck exam

  11. Presentation and Evaluation • radiographic imaging (CT, MRI, angiography) • assessment of catecholamine production • embolization • fine needle aspiration bx

  12. Surgical Approaches • external most common • adequate exposure for complete tumor removal • identification, preservation, and control of vital neurovascular structures • minimize morbidity and mortality • approach design should allow for extension to provide additional exposure as necessary

  13. Surgical Approaches • cervical or cervical-parotid • cervical or cervical-parotid with midline mandibulotomy • cervical approach adequate for removal of majority of tumors

  14. Complications • neurovascular injury • mandibulotomy complications • tumor recurrence • other complications

  15. Conclusions • PPS is complex anatomical region containing many vital structures • majority of PPS neoplasms are salivary or neurogenic tumors • surgical resection treatment of choice • careful preoperative planning essential • cervical approach adequate for majority of tumors • flexible approach with minimal M&M

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