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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

Parapharyngeal Space Neoplasms

Grand Rounds Presentation

February 18, 1998

Kyle Kennedy, M.D.

Anna Pou, M.D.

introduction
Introduction
  • Anatomy
  • PPS Neoplasms
  • Presentation and Evaluation
  • Surgical Approaches
  • Complications
introduction1
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
anatomy
Anatomy
  • potential space lateral to upper pharynx
  • inverted pyramid shape
  • fascial compartmentalization
anatomy1
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.
anatomy2
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
pps neoplasms
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
salivary gland neoplasms
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
neurogenic neoplasms
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)
presentation and evaluation
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
presentation and evaluation1
Presentation and Evaluation
  • radiographic imaging (CT, MRI, angiography)
  • assessment of catecholamine production
  • embolization
  • fine needle aspiration bx
surgical approaches
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
surgical approaches1
Surgical Approaches
  • cervical or cervical-parotid
  • cervical or cervical-parotid with midline mandibulotomy
  • cervical approach adequate for removal of majority of tumors
complications
Complications
  • neurovascular injury
  • mandibulotomy complications
  • tumor recurrence
  • other complications
conclusions
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