Parapharyngeal Space Tumor: Submandibular Approach Without Mandibulotomy

[Research progress in the anatomy and surgical approach of the parapharyngeal space]

The parapharyngeal space, a complex fascial compartment within the head and neck region, encompasses crucial anatomical structures including blood vessels and nerves. Tumors occurring within this space are rare, with the majority being benign in nature. Surgical intervention remains the primary treatment modality; however, managing parapharyngeal space tumors poses significant challenges due to their intricate anatomical configuration. Conventional open surgical approaches have been associated with significant tissue damage and a high prevalence of postoperative complications. Recently, advancements in anatomical studies and surgical techniques have led to significant progress in understanding parapharyngeal space anatomy and improving surgical management. This article aims to provide a comprehensive overview of these developments.

Relevance of the Internal Jugular Vein for Surgery in the Upper Parapharyngeal Space

Objective: Tumors arising from the upper parapharyngeal space (UPPS) may have intimate relationships with the internal carotid artery (ICA) and the internal jugular vein (IJV). The significance of the ICA in UPPS has been sufficiently articulated, whereas the relevance of the IJV has not been addressed. This study aimed to assess the anatomical variations of the IJV within the UPPS, and to explore its implications for surgical procedures. Methods: An endoscopic dissection of the IJV was performed on 10 cadaveric specimens. In addition, 30 patients who underwent transoral or transcervical resection of UPPS tumors were retrospectively reviewed to characterize the IJV and its relation to the tumor. Results: On the cadaveric specimens, the IJV was located at the posteromedial and posterolateral aspects of the styloid process in 13 (65%) and 7 (35%) sides, respectively. In our clinical series, the IJV was not encountered in 18 patients with pre-styloid tumors. In 12 patients harboring retro-styloid tumors, the IJV was partially (n = 5) or completely (n = 7) compressed and was displaced into the posterolateral aspect of the tumor. The IJV was injured intraoperatively in 1 patient, requiring an immediate conversion to an open transcervical corridor that allowed its exposure and ligation without difficulty. Conclusion: This study characterizes the IJV and its relationship with adjacent neurovascular structures in the UPPS, which may provide further safeguards during transoral and transcervical procedures in the UPPS.

Transcervical Approach in a Thrice Recurrent Parapharyngeal Space Tumor

Parapharyngeal space tumors are rare and account for 0.5% of all head and neck tumors. Most of them are benign (95%), of which pleomorphic adenomas of the salivary gland are the most common. Due to their anatomical location, gaining surgical access while avoiding postoperative morbidity is the main limitation. We present the case of a 35-year-old male with a history of three transcervical resections of benign pleomorphic adenomas in the parapharyngeal space within the deep lobe of the parotid gland. The patient has been followed for more than ten years and maintains an adequate quality of life.

Different Approaches to the Overlapping Infratemporal Fossa and Parapharyngeal Spaces: a Case Series and Review of Literature

Parapharyngeal space and infratemporal fossa are 2 overlapping spaces in head and neck which have complex anatomy with vital neurovascular structures passing through them. Tumors of this region are extremely rare but majority of them (80%) are benign. Benign tumors of this region can lead to swellings in facial region, neck and oropharynx. Dysphagia may be a complaint of the patient. Many of these tumors have malignant potential. Removal of these tumors requires a good understanding of the anatomy of this space so that correct surgical approach can be selected. The surgeon needs to be adept in using the most suitable surgical approach for excision of these tumors. There are various approaches which can be used to access these deeply seated tumors but the issue of prime importance is selecting the appropriate approach for the various tumors here based on their size and their exact location in this complex anatomical space. Inappropriate approach can lead to inadequate tumor excision and can lead to injuries to the neurovascular structures in this region which can cause significant disability. The case series reported here describes the various approaches to this region and highlights the importance of correct selection of the surgical approach.

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.

Management of a prestyloid parapharyngeal first branchial cleft cyst from puncture to surgical excision and how a routine procedure can turn into an emergency

The anatomy of the parapharyngeal space (PPS) is complex and the differential diagnosis of tumours in this area broad. Although primary tumours of the PPS account for only 0.5% of head and neck neoplasms and are benign lesions in 80% of the cases, the surgical management is crucial and needs specific planning and evaluation of CT and/or MRI scans. In literature, there are several ways to surgically deal with PPS tumours and due to location and differentiation, can reach from transparotid, submandibular transcervical and transoral approaches, extending in a mandibulotomy, further radiotherapy. Parapharyngeal cleft cysts are extremely rare and their management can be complex. We describe the presentation, the diagnosis and further management of a 71-year-old woman with a 6 cm first branchial cleft cyst in the PPS from puncture over emergency tracheostomy to elective excision via a combined transcervical/transparotid and transoral approach. We highlight the importance of the differential diagnosis and the and the correct clinical management of this rare entity.

Endoscopy-Aided Combined Intraoral and Cervical Approach for a Huge Parapharyngeal Benign Tumor

We introduce here our surgical approach for the removal of a huge parapharyngeal tumor in 3 cases. Surgery was done under general anesthesia using transnasal intubation. Transoral manipulation was performed first. Using a tongue retractor and an angle widener, a wide surgical field was provided. Incision was made on the palate around the tumor. Tumor was separated from the surrounding tissue, preserving the tumor capsule. Then, a 5-cm small skin incision was made. Both parotid and submandibular glands were pushed upward, and the parapharyngeal space was opened. The tumor was also separated from the surrounding tissue. These manipulations were done under endoscopic observation. Finally, the tumor was pushed laterally and safely removed intraorally. After removal of the tumor, the wounds were closed, and vacuum drainage was settled for a few days. No apparent problems, such as malocclusion and facial palsy, occurred, and the patients were free from disease for more than 10 years. For the removal of a large parapharyngeal tumor, the mandibular swing approach is usually used; however, this approach is invasive, and certain sequelae, such as facial wound and malocclusion, may occur. Our technique enables the safe and less invasive removal of such a huge parapharyngeal benign lesion.