Dr. Mamoon's Guide to Tumors of the Parapharyngeal Space
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para-pharyngeal space tumors
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Dr. Mamoon's Guide to Tumors of the Parapharyngeal Space
- 1. Dr. Mamoon
- 2. INTRODUCTION • less then 1% of Head and neck neoplasms • 70-80% are benign • Radiological imaging very important for diagnosis • Surgical excision is the primary treatment • Morbidity of surgery should be considered along with natural history of disease in making a treatment plan
- 3. ANATOMY
- 7. Prestyloid : deep lobe of parotid, fat, and lymph nodes Poststyloid : internal carotid a., internal jugular v., CNs IX-XII, sympathetic chain, and lymph nodes
- 8. • 40-50 % are salivary gland neoplasm • 80-90 % pleomorphic adenoma • 20% malignant –mucoepdermoid ca.,acinic cell ca Carcinoma ex pleomorphic adenoma . • Major vessels are displaced posteriorly and parpharyngeal fat displaced medially Prestyloid space
- 9. • 25-30% are neurogenic in origin • Major vessles are displaced anteriorly Poststyloid space
- 10. TUMORS OF THE PPS • Primary Tumors • Primary lymphoproliferative disease • Metastatic lymph nodes • Tumors extending from adjacent structures
- 11. Direct Extension Nasopharynx Oral cavity Oropharynx Mandible Maxilla Temporal bon
- 12. Metastasis • Follicular thyroid cancer • Papillary thyroid cancer • Medullary thyroid cancer • Osteogenic sarcoma • Squamous cell carcinoma
- 13. Primary tumors Salivary gland tumor Neurovascular tumors Miscellaneous tumors
- 14. Salivary Gland Tumors • Most common PPS neoplasms: 40-50% • Pleomorphic adenoma 80-90% • Mucoepidermoid most common malignant • Less than 5% parotid tumors involve the PPS
- 15. Salivary Gland Tumors • Located in prestyloid space • From deep lobe of parotid or minor salivary glands • On CT or MRI a fat plane between the parotid and a prestyloid mass indicates minor salivary gland origin • Displace the internal carotid posteriorly
- 17. Schwannoma • Most common neurogenic neoplasm • Vagus, sympathetic chain most common • Benign and slow growing • Generally don’t affect nerve of origin • Less than 1% malignant • Displace internal carotid anteriorly
- 18. Paraganglioma Second most common Highly vascular Arise from vagus , carotid body, jugular bulb • Bilateral 10%, familial 30% • Part of MEN IIA or IIB (medullary thyroid carcinoma, pheochromocytoma, parathyroid hyperplasia-with or without mucosal neuromas)
- 19. • Secrete catecholamines 1-3% • Malignant 3-10% • Classically, paragangliomas mobile anterior-posterior but not up and down • Glomus vagale displace carotid anteriorly • Carotid body tumors splay internal and external carotid – “lyre” sign
- 20. Neurofibromas • 3rd most common neurogenic tumor • From Schwann cells and fibroblasts • Unencapsulated (involve nerve) • Multiple • Part of Neurofibromatosis type I
- 21. Miscellaneous Tumors • Wide variety of tumors • 20%of total PPS tumors • Lymphoma, hemangioma, teratoma, Lipoma , branchial cleft cyst , arteriovenous malformation, internal carotid aneurysm
- 22. Clinical features Late presentation Neck swelling Oropharyngeal swelling Pain Cranial nerve palsy Dysphagia ,dyspnea Trismus ETD Hoarseness of voice Hypertension ,flushing
- 23. Evaluation Detailed history Complete head and neck examination Pulse and blood pressure Cranial nerves Bimanual palpation Bruit, thrill IDL Neither AJCC nor International union against cancer have given any staging for pps tumor
- 24. Investigations FNAC Ultrasound guided CT-guided FNAC procedures are essential for lesions that are not directly detectable without imaging techniques
- 25. Special investigations 24-hour urine collection for catecholamines Vanillylmandelic acid (VMA) Metaiodobenzylguanidine scan (MIBG)
- 26. IMAGING CT MRI ANGIOGRAPHY PET SCAN
- 27. CT Locates tumor to prestyloid vs postyloid Fat plan between mass and parotid Displacement of carotid artery Enhancement of lesion Bone erosion Limited soft tissue detail -MRI
- 33. MRI Most useful study Relationship of mass and other soft tissue and carotid more easily seen than with CT Characteristic appearance of tumor types on MRI allows preoperative Dx 90-95% of patients
- 38. Angiography Used to all enhancing lesions Gold standard for relation ship to blood vessels Differentiate neurogenic and vascular Main indication is planning for surgical treatment Balloon occlusion test
- 40. Treatment Mainly surgical excision Radiation therapy . Poor surgical candidate unresectability Failure of balloon occlusion test
- 41. Surgical Rx Preoperative workup Pre.op. counselling Preoperative embolization of tumors > 3cm size with obvious feeding vessel Functioning paragangliomas should be identified and pre op alpha and beta blockers should be given
- 42. Surgical approaches Depends on location. Size , suspicion of malignancy ,relationship to neurovascular structures, surgeon experience Goal is to achieve optimal exposure and vascular control without significant morbidity
- 43. Trans-oral Trans-cervical +/- mandibulotomy Trans-parotid Trans-cervical-Parotid Infratemporal fossa Transcervical-transmastoid
- 44. Transoral Has been used for small, benign , prestyloid tumor Very limited exposure Increased risk of tumor rupture and spillage, Risk of injury to neurovascular structure Not recommended
- 45. Transcervical Reserved for pre and post styloid tumors Transverse incision at level of hyoid Submandibular gland displaced or removed Digastric muscle retracted or its tendon is divided
- 51. Transparotid For small deep lobe parotid tumors Superficial parotidectomy Division of stylomandibular ligament Dissect around mandible May use mandibulotomy
- 52. Transcervical-parotid Deep-lobe parotid tumors with PPS extension Extend cervical incision up infront of ear identification facial nerve Divide posterior belly digastric Divide stylomandibular ligament, styloglossus, stylohyoid close to styloid process
- 53. Transmandibular Approaches Both the lateral mandibulotomy and the median mandibul- otomy-transpharyngeal approach Very large tumors Malignancy Vascular tumors extending to skull base Need a tracheostomy
- 54. infratemporal fossa approach Preauricular lateral infratemporal fossa approach Skull base or infratemporal fossa involvement
- 55. Transcervical-transmastoid Cervical incision carried postauricularly Mastoidectomy Remove mastoid tip exposing jugular fossa Facial nerve may need to be dissected from Fallopian canal
- 56. Nonsurgical Management Poor surgical candidates, failed balloon occlusion, elderly, unresectable lesions, would require sacrifice of multiple cranial nerves • Observation for stable tumor • Radiation for growing tumor
- 57. Observation Benign and asymptomatic Paragangliomas grow 1 -1.5 mm per year Mortality less than 10% per year for untreated
- 58. Radiation Not used for cure Arrest the growth Metastatic tumor Postoperative irradiation is recommended for high-grade malignancies or when wide surgical margins cannot be obtained.