Ultrasound-guided diagnosis on a parapharyngeal mass

Masses in the parapharyngeal area are rare and often due to infectious phenomena arising from the oral cavity or pharynx which lead to abscess formation. Less frequently, the lesion can be neoplastic. Tumours of the parapharyngeal space are rare, accounting for less than 1% of all head and neck neoplasms. We report the case of a patient who came to our observation for mandibular pain. Multiparametric diagnostic imaging was done thus showing a parapharyngeal mass. An ultrasound guided biopsy was performed by a transcutaneous route with a high median approach at neck level, to characterize the mass in the right tonsillar region. The histological examination reported the final histological diagnosis of sarcomatoid carcinoma.

Evaluation of multiparametric MRI differentiating pleomorphic adenoma from schwannoma in parapharyngeal space

PURPOSE

This study aimed to investigate whether multiparametric magnetic resonance imaging (MRI) including dynamic contrast-enhanced (DCE) and diffusion weighted (DW) MRI can differentiate pleomorphic adenoma (PA) from schwannoma in the parapharyngeal space.

METHODS

Forty-six patients with pathologically proven PAs and 47 schwannomas in the parapharyngeal space were enrolled. All patients underwent conventional MRI, and DW-MRI and DCE-MRI were performed in 30 and 33 patients, respectively. Fisher's exact, Mann-Whitney-U tests and Independent samples t-test were used to compare variables between PAs and schwannomas. Multivariate logistic regression analysis was used to examine the diagnostic performance of MRI parameters.

RESULTS

The PAs usually show lobulation sign, posterior displacement of ICA and attached to the parotid gland deep leaf, while bird beak configuration, anterior displacement of ICA and involvement of foramen jugular were more commonly seen in the schwannomas(all p < 0.001). The washout rate of PAs was found to be higher than that of schwannomas (p = 0.035), whereas no significance was found in the other DCE-MRI parameters and in ADCs(p > 0.05). Using a combination of conventional MRI features including lobulation sign, bird beak configuration, direction of internal carotid artery(ICA) displacement and attached to the parotid gland in multivariate logistic regression analysis, sensitivity, specificity, and accuracy in differential diagnosis of PAs and schwannomas were 97.8%, 91.5% and 94.6%, respectively.

CONCLUSION

Conventional MRI can effectively differentiate PAs from schwannomas in the parapharyngeal space with a high diagnostic accuracy. The DCE-MRI and DWI have limited added diagnostic value to conventional MRI in the differential diagnosis.

The Clinical and Surgical Characteristics of Parotid Tumors with Parapharyngeal Space Involvement-A Multicenter Experience of the Polish Salivary Network

Backgrounds/Objectives: Parotid gland tumors (PGTs) with parapharyngeal space (PPS) involvement have a specific clinical course and they can be a great challenge for surgeons, especially due to more difficult approaches and the risk of serious complications. The aim of this study is to present the characteristics of PGTs with PPS involvement. Methods: Retrospective, multicenter analysis of 1954 primary PGTs from 5 years (2017-2021) was performed. Comparative analysis was performed between groups with and without PPS involvement and included the following clinical and histopathological data: age, sex, place of residence, tumor size, FNAC result, percentage of malignant tumors, histological diagnosis, radicality of resection, and postoperative facial nerve (FN) dysfunction. Results: PPS involvement was found in 114 patients (5.83%). Secondary tumors affecting the deep lobe or the entire gland were predominant (46 and 60 cases, respectively). In a univariate analysis of tumors with and without PPS involvement, statistically significant differences were found in their size > 4 cm (12.97% vs. 37.72%), percentage of malignant tumors (7.12% vs. 17.55%), incidence of Warthin Tumors (WTs) (43.58% vs. 24.56%), percentage of R1 resection (5.53% vs. 12.50%), and rate of FN paresis (17.15% vs. 53.34%). Multivariate analysis showed that tumors with PPS involvement were statistically significantly characterized by larger size (tumors > 4 cm were 2.9 times more frequent), 2 times less frequent occurrence of WTs, and 1.6 times higher risk of FN paresis. Conclusion: PGTs with PPS involvement show certain clinical and histological differences and require more complex surgical accesses. Therefore, they cannot be treated as "ordinary" tumors occupying the deep lobe.

Parapharyngeal space ectopic thyroid with eutopic papillary thyroid cancer: A case report

BACKGROUND

Ectopic thyroid is a rare condition. Here we report an extremely rare case of parapharyngeal space ectopic thyroid, which has simultaneously found the papillary thyroid carcinoma of the eutopic thyroid.

CASE PRESENTATION

A 54-year-old woman was admitted to our hospital for a thyroid tumor and neck lymph nodes. CT and MR imaging revealed the presence of a thyroid right node, as well as a right parapharyngeal mass with a diameter of 2.5 × 2.3 cm. PET-CT was also performed to diagnose further, revealing that the suv metric of the PPS mass was 4.03. Considering that the mass was asymptomatic, we did not handle it at the first thyroid surgery. However, when the patient underwent a radioactive iodine scan before the radioactive iodine treatment, the imaging showed that the mass could intake the iodine. So, we arranged the second surgery for this mass, and the postoperative pathological examination confirmed the mass was well-differentiated thyroid tissue.

CONCLUSION

Parapharyngeal ectopic thyroid with eutopic thyroid cancer is extremely rare. Preoperative imaging examination can significantly avoid the missed diagnosis of this disease. Surgical resection is recommended for the ectopic thyroid while the eutopic thyroid is found to be malignant.

Schwanoma of the cervical sympathetic chain: A case report

INTRODUCTION AND IMPORTANCE

Any cranial, peripheral, or autonomic nerve in the body can give rise to a benign, slowly growing encapsulated nerve sheath tumor known as a schwannoma. The majority of parapharyngeal extracranial schwannomas, which typically have vagal origins, are located there. When they first appear, most swannomas are asymptomatic. Vague symptoms may be present in some people.

CASE PRESENTATION

She is a 35-year-old Ethiopian female patient presented with left lateral neck swelling of 11 years duration which was initially small but gradually increases to attain the current size. Associated with the swelling she had had dull aching pain in the same area. On examination, there was a 5*4 cm non-tender hard mass over the left cervical area which had an irregular border, fixed to the underlying structure but not to the overlying skin. Investigations were suggestive of cervical schwannoma. Finally, the patient was operated on and discharged improved.

CLINICAL DISCUSSION

The majority of schwannomas are solitary, however they can also be multifocal and plexiform when they are associated with neurofibromatosis. Schwannomas are typically asymptomatic until late in the course of the disease, when neurologic symptoms brought on by compression of the adjacent nerve may develop. The most popular diagnostic techniques for schwannomas include computed tomography (CT), MRI, ultrasonography, and fine-needle aspiration cytology (FNAC).

CONCLUSION

Cervical sympathetic chain schwannomas are uncommon tumors that typically manifest as asymptomatic unilateral neck masses without Horner's syndrome. For the diagnosis of cervical sympathetic chain schwannoma, imaging tests are crucial.

Surgical approaches for pleomorphic adenoma of the parapharyngeal space

OBJECTIVE

This study aimed to analyse the outcomes of surgery for pleomorphic adenoma of the parapharyngeal space in relation to the surgical approach.

METHOD

This was a single-centre retrospective data analysis conducted from January 2008 to December 2020 on all patients who underwent operation for pleomorphic adenoma originating from the parapharyngeal space.

RESULTS

Twenty-one patients with a mean age of 52.6 years were included. The transparotid-transcervical approach was the most common (52.4 per cent, n = 11) surgical approach, followed by transoral robotic surgery (28.6 per cent, n = 6) and conventional transoral surgery (19 per cent, n = 4). Post-operative complications included nine cases of transient partial facial nerve palsy and two cases of Frey's syndrome after the transparotid-transcervical approach and 2 cases of transient trismus and 1 pharyngeal wound dehiscence in the conventional transoral approach group. Complete macroscopic excision was always achieved, and no recurrence occurred during follow up.

CONCLUSION

These three approaches can provide adequate tumour visualisation, a high rate of clear excisional margins and an acceptable morbidity.

The development of a clinical algorithm for the diagnosis of tumours in the parapharyngeal space. A systematic review

INTRODUCTION

Parapharyngeal space (PPS) is defined as a deep space, located around the upper pharynx, in the shape of an inverted pyramid. Primary tumours in this region are rare, accounting for 0.5% of head and neck neoplasms, and most are benign. The objective of this study is to propose a new study algorithm based on a systematic review and our experience.

MATERIALS AND METHODS

A cross-sectional and analytical study was carried out through review of the clinical records of our hospital. Patients with tumours of the parapharyngeal space operated from January 2010 to December 2019 and a systematic review of Pubmed studies from the last 5years were included. We considered clinical signs, diagnostic methods, presumptive diagnosis and histopathological findings. Statistical analysis was performed with STATA v.14 software.

RESULTS

53 of our cases and 1392 from the review were included. The clinical algorithm showed a sensitivity of 76.4% and a specificity of 96.3%, with an AUC of 0.57 for diagnosis.

DISCUSSION

Complementary radiological examinations are essential in the topographic diagnosis of the tumour. Angio-MRI links the tissue of origin of the tumours and provides the highest diagnostic certainty. FNA has some disadvantages in PPS, but it is useful in some patients.

CONCLUSION

The proposed algorithm contributes to obtaining excellent results in the management of these tumours because it turned out to be effective in diagnosis, and this enables improved surgical planning.

Primary neoplasms of the parapharyngeal space: diagnostic and therapeutic pearls and pitfalls

PURPOSE

Parapharyngeal space neoplasms (PSNs) are rare tumors of the head and neck region. In this study, we report our institutional experience with PSNs over a 27-years period.

METHODS

Patients treated between 1992 and 2018 were identified through our tumor board database. Data concerning demographics, clinical presentation, disease features, treatment, complications and follow-up were obtained retrospectively.

RESULTS

In total, 48 patients were identified. Most patients had benign tumors (67.5%), with pleomorphic adenoma and schwannoma being the most frequent entities. Malignant tumors represented the remaining 32.5% of neoplasms. Concerning tissue of origin, 67.5% of neoplasms originated from salivary glands and 17.5% were neurogenic. The vast majority of PSNs required open surgical approaches (77%). The most frequent reversible and irreversible complications included paralysis of facial, vagal, and hypoglossal nerves (transient 62.5%, permanent 31.3%). Tumor recurrences occurred in 16.7% of our patients.

CONCLUSION

Neoplasms of the parapharyngeal space (PPS) are rare. In our series, consistent with the literature, most patients had benign tumors. Fine-needle aspiration cytology (FNAC) and/or transoral biopsy in selected cases combined with radiographic imaging are helpful to plan the optimal approach (open/transoral) and extent of primary surgery. Close follow-up in malignant neoplasms is crucial to assess recurrence early. We present one of the largest recent studies on PPS tumors treated in a center. Given the low incidence of these tumors, our results contribute to the existing sparse evidence regarding the management and outcome of such tumors.

The intraoral growth patterns of parapharyngeal tumors: A proposed classification system

OBJECTIVE

Nearly half of parapharyngeal space (PPS) tumors present as an intraoral mass, which is diagnostically challenging. In this study, we studied whether preoperative growth patterns were associated with histopathological diagnosis for planning surgery.

METHODS

We performed a cross-sectional study in patients with PPS tumors. A simplified classification scheme based on intraoral tumor growth patterns (patterns 1 and 2) was then proposed. In pattern 1, tumors bulge submucosally to the oropharynx from the soft palate, with the center convexity above the uvula. In pattern 2, tumors bulge submucosally to the oropharynx from the lateral oropharynx wall, with the center convexity below the uvula. The association of this classification with postoperative histopathological diagnosis and surgical-related events was studied.

RESULTS

Twenty-two patients were enrolled in this study (12 with pattern 1, 10 with pattern 2). Of these, 91.7% (11/12) of pattern 1 tumors were salivary gland tumors (P < .001), and 90% (9/10) of pattern 2 tumors were neurogenic (P < .001). Pattern 2 tumors had fewer bleeding complications or needed external approaches when a transoral approach was chosen.

CONCLUSIONS

This new classification of PPS tumors facilitates the prediction of salivary gland and neurogenic tumors and can improve the accuracy of preoperative radiologic diagnosis. This system will be helpful for planning surgical interventions, such as implementing transoral approaches.

Efficacy of Transnasal Endoscopic Fine-Needle Aspiration Biopsy in Diagnosing Submucosal Nasopharyngeal Carcinoma

OBJECTIVES/HYPOTHESIS

The routine practices of examining submucosal lesions are not suitable for deep lesions. Therefore, we evaluated the efficacy of non-real-time image-guided transnasal endoscopic fine-needle aspiration biopsy (FNAB) in diagnosing nasopharyngeal carcinoma (NPC) with submucosal lesions.

STUDY DESIGN

The effectiveness evaluation of diagnostic methods.

METHODS

Fifty suspected NPC patients who failed in conventional biopsies were enrolled in this study. The efficacy, maneuverability, and safety of FNAB in diagnosing these intractable cases were evaluated.

RESULTS

The definitive diagnostic results of these 50 patients were NPC (34/50, 68.0%), nasopharyngeal necrosis (1/50, 2.0%), nasopharyngeal mucositis (12/50, 24.0%), and other cancers (3/50, 6.0%), respectively. The results of the diagnostic efficacy of FNAB were sensitivity, 89.2%; specificity, 100.0%; positive predictive value, 100.0%; negative predictive value, 76.5%; and accuracy, 92.0%, respectively. The area under the receiver operating characteristic curves was 0.946 (95% confidence interval = 0.884-1.00, P < .001). No severe complications occurred after FNAB.

CONCLUSIONS

FNAB can improve the diagnostic efficiency of NPC occurring in the submucosal space. It can be an additional option for routine nasopharyngeal biopsy and is worthy of clinical application.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1798-1804, 2021.

Tumor, host and surgery related factors predisposing to cranial nerve deficits after surgical treatment of parapharyngeal space tumors

Propose

Identification of relevant features acquired on preoperative evaluation of parapharyngeal space (PPS) tumors or related to the performed surgical approach that are predictive of the most important complication of surgical treatment of these tumors, cranial nerve palsy.

Methods

This was a retrospective analysis of 68 patients with PPS tumors treated with surgical resection in a tertiary referral center from 2009 to 2019. The preoperative clinical symptoms, age, sex, tumor size, location, histopathological type, surgical approach, radical resection, intraoperative bleeding and the occurrence of complications were collected, evaluated and compared.

Results

Cross-table and chi-square test results revealed that cranial nerve deficits were more common in neurogenic tumors than in other types, including malignant tumors (χ² = 6.118, p = 0.013); the cervical approach was selected more often for neurogenic tumors (χ² = 14.134, p < 0.001); neurogenic tumors were more frequently removed intracapsularly (χ² = 6.424, p = 0.011); and neurogenic tumors were more likely to be located in the poststyloid area (χ² = 17.464, p < 0.001). The two-sample t test revealed a significant correlation between age and the prevalence of cranial nerve complications (t = 2.242, p = 0.031). The mean age in the group of patients with cranial nerve palsy was 45.89 years, and that of the group without complications was 54.69 years. The results of logistic regression confirmed that the risk of nerve deficits was almost 8 times higher for neurogenic tumors (OR = 7.778, p = 0.01). None of the other analyzed variables related to tumor or surgery was significantly correlated with an increased risk of cranial nerve dysfunction.

Conclusion

Surgical resection of tumors other than neurogenic tumors of the PPS reveals no significant risk for permanent neural dysfunction. Tumor size also had no significant effect on the risk of postoperative nerve palsy.

Oral core-needle biopsy in the diagnosis of malignant parapharyngeal space tumors

OBJECTIVE

To confirm the pre-treatment diagnosis of parapharyngeal space malignancy could aid the treatment plan.

METHODS

For patients with suspected malignant parapharyngeal space tumors following preoperative imaging, oral biopsy was conducted for pathological diagnosis with the use of 22-G biopsy needles.

RESULTS

A total of 11 patients were enrolled. There were three previously diagnosed cases of head and neck malignancy, and eight cases were newly diagnosed. The tumor diameters were in the range of 3 to 5.5 cm. Ten cases (90.9%) achieved positive results, of which eight cases (72.7%) obtained positive results with one puncture and two cases obtained positive pathological results with two punctures. One case did not obtain positive results with two punctures; open surgical resection was performed for this patient. There were no complications such as needle track implantation, heavy bleeding or neurological damage symptoms during the puncture process.

CONCLUSIONS

Oral biopsy is a minimally invasive, safe and effective technique for the diagnosis of parapharyngeal space tumors. It is easy to operate and could facilitate a comprehensive treatment plan for parapharyngeal space malignancies.

Image-guided transnasal endoscopic fine needle aspiration or biopsy of parapharyngeal space tumours

BACKGROUND

Parapharyngeal space biopsy is an important investigation in the management of parapharyngeal space tumours. These tumours are relatively rare and the surgeon is often faced with a wide range of differential diagnoses. There are several ways to access the parapharyngeal space, with varying degrees of associated morbidity.

METHODS

This paper describes a seldom used, but a simple and safe, image-guided endoscopic approach to parapharyngeal space biopsy that enables tissue to be obtained transnasally. The procedure is conducted under general anaesthesia using computed tomography image guidance via the LandmarX system, with transnasal access to the parapharyngeal space achieved using a sampling needle.

RESULTS

This procedure is relatively simple, safe and reproducible. It is a less invasive approach to parapharyngeal space biopsy, and one which has been successfully used by the senior author for years without any significant morbidity.

CONCLUSION

Transnasal image-guided endoscopic aspiration or biopsy of the parapharyngeal space is a novel technique that has not been previously described.

Surgical treatment of parapharyngeal space tumors: A report of 29 cases

The present study aimed to establish a strategy for parapharyngeal space (PPS) tumor surgery based on preoperative symptoms, clinical signs, imaging and histological examination. A retrospective cohort study was conducted with 29 adult patients who underwent surgery for primary PPS tumors from 2008-2015. The following data was obtained: Preoperative symptoms of the patient, histological type of the tumor, surgical approach and complications. Of the 29 patients who underwent surgery to remove a PPS tumor, 16 presented with neurogenic tumors and 13 with salivary gland tumors. The most common symptom was the presence of a neck mass. Preoperative computed tomography and magnetic resonance imaging were performed to evaluate the size and location of the tumors. The majority of the salivary gland tumors were located in the prestyloid space, whereas all neurogenic tumor cases were poststyloid. A total of 21 of the 29 patients (72.4%) underwent a preoperative fine needle aspiration (FNAC) examination. FNAC contributed to preoperative diagnosis in 9 of these cases (42.9%). In parotid tumors of the prestyloid space, facial nerve palsy was a common postoperative complication. In the case of neurogenic tumors, a common complication was the postoperative palsy of the nerve of tumor origin. The strategy for PPS surgery, from the preoperative diagnosis to the operative method, remains controversial. The data on pre- and postoperative symptoms, imaging and histological diagnosis, and the selection of surgical method depending on a neurogenic or salivary tumor origin in the present study indicated that improving the method of examination, carefully selecting the method of approach and accurately managing surgery leads to complete tumor removal, and that the use of nerve-preserving techniques may reduce the likelihood of complications.

Extracranial schwannoma in the carotid space: A retrospective review of 91 cases

BACKGROUND

Schwannomas of the vagus nerve and cervical sympathetic nerve are rare; hence, only limited information exists regarding their diagnosis and clinical management.

METHODS

We conducted a retrospective review of the clinical features, imaging studies, and treatment results of patients with schwannoma of the vagus nerve and schwannoma of the sympathetic nerve.

RESULTS

Of 91 patients, 91% (n = 83) were preoperatively diagnosed with schwannoma tumors. Using the hyoid bone as an anatomic landmark, the location of the schwannoma of the vagus nerve in the carotid space was significantly different to the location of schwannoma of the sympathetic nerve (p = .003). Although 52 of the 76 patients followed up (68%) had postoperative nerve weaknesses, 13 patients (50%) and 14 patients (53.8%), respectively, fully recovered from schwannoma of the vagus nerve and schwannoma of the sympathetic nerve.

CONCLUSION

In the carotid space, schwannomas of the vagus nerve are usually located below the hyoid bone, whereas schwannomas of the sympathetic nerve more commonly arise from the suprahyoid compartment. Accurate preoperative diagnosis and the intracapsular enucleation surgical approach decreased the incidence of postoperative morbidity. © 2016 Wiley Periodicals, Head Neck 39: 42-47, 2017.

Histopathologic classification of parapharyngeal space tumors: a case series and review of the literature

The objective of the study is to present a large case series of parapharyngeal space tumors (PPST) and the most comprehensive literature review of tumor histopathologic distribution. The study was designed as internal case series and full Pubmed/MEDLINE electronic database review in a tertiary academic medical center. Tumor histopathology and patient demographics were obtained from a comprehensive Pubmed/MEDLINE database review, as well from an internal case series of 117 patients referred to our center between 1993 and 2013. Main outcome and measures of the study were to define the age, gender, and histopathology of PPST within a large internal case series and among the current body of published literature, and to propose a diagnostic and treatment algorithm for these tumors. Our cohort included 117 cases, 58 females and 59 males, with benign tumors comprising 85 % (n = 99) and malignant tumors 15 % (n = 18). A systematic review of published literature from 1963 to the present revealed 37 case series, and when combined with our present series, yielded a total of 2160 cases. Benign tumors are most common (78.8 %), with tumors of salivary gland (44.4 %), neural (34.4 %), and vascular (2.64 %) origin representing the largest subtypes. Pleomorphic adenomas (30.9 %), paragangliomas (13.1 %), and schwannomas (12.3 %) comprised the majority of all cases. Due to their rarity, data regarding the histopathologic distribution of PPST is scarce. We provide one of the largest case series and the most comprehensive review of these tumors in the literature to date, and offer our algorithm for evaluation and treatment.

Tumors of the cervical sympathetic chain--diagnosis and management

BACKGROUND

Tumors originating from the cervical sympathetic chain are uncommon but important entities in the differential diagnosis of parapharyngeal space masses.

METHODS

We conducted a retrospective review of patients presenting with tumors of the cervical sympathetic chain.

RESULTS

Twenty-four patients presented between 1994 and 2010. Presenting symptoms were dysphagia (n = 7.29%), neck mass (n = 7.29%), throat fullness (n = 4.17%), and Horner syndrome (n = 2.8%). Although radiologic images showed classic lateral displacement of the carotid arteries in 10 patients (42%), in 9 patients (38%) the radiologic findings demonstrated splaying of the carotid arteries similar to carotid body tumor, and in 5 patients (20%), the findings were indeterminate. Twenty-one patients underwent surgical removal of the tumors with pathology revealing 10 paragangliomas, 10 schwannomas, and 1 neurofibroma. Horner (57%) and first-bite (33%) syndromes were the most common complications.

CONCLUSIONS

Although anterolateral displacement of the carotids is suggestive of a sympathetic tumor, absence of these findings does not rule out this entity. To this end, we have included in this review a guide to preoperative radiologic diagnosis of parapharyngeal space lesions.