Parapharyngeal space tumors by J. Shah
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This document discusses tumors of the parapharyngeal space, including: 1) The parapharyngeal space has two compartments - the prestyloid and poststyloid - containing different structures. 2) Tumors most commonly arise from salivary glands or nerves and include pleomorphic adenoma, schwannomas, and paragangliomas. 3) Imaging with CT, MRI, and angiography is used to identify tumors and plan surgical approaches if needed. 4) Surgical treatment depends on tumor type and location, with the goal of complete resection while preserving neurological function. Non-surgical options include observation or radiation for select cases.
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Parapharyngeal space tumors by J. Shah
- 1. The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology 2012 Parapharyngeal Space Tumors Jatin P. Shah
- 2. Outline • Anatomy • Pathology • Clinical evaluation • Imaging with CT, MRI, angiography 2012 • Surgical treatment
- 3. Anatomy of the Parapharyngeal Space • Potential space • Inverted pyramid with floor at skull base, tip at hyoid, and bounded by the pharyngeal wall medially and the mandible 2012 laterally
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- 5. Prestyloid Compartment Masticator Space • Fat • Retromandibular parotid • Lymph nodes 2012
- 6. Poststyloid Compartment Carotid Space • Internal carotid artery • Jugular vein • Sympathetic chain • Cranial nerves IX-XII 2012 • Lymph nodes
- 7. Incidence • Account for 0.5% of all head and neck neoplasms • Benign: 80% Malignant 20% 2012
- 8. Primary Tumors • Salivary gland tumors • Neurovascular tumors • Miscellaneous tumors 2012
- 9. Salivary Gland Tumors • Most common PPS neoplasms: 40-50% • Pre styloid masses in Masticator space • Pleomorphic adenoma 80-90% • Mucoepidermoid most common malignant 2012 • Less than 5% of all parotid tumors
- 10. Neurogenic Tumors: 17-25% • Post Styloid masses in the Carotid space • Schwannoma or Neurileimoma • Paraganglioma 2012
- 11. Paragangliomas • May be multiple • May be familial • Genetic predisposition ( PGL 1,2,3,and4) • PGL 1,3 & 4. ( SDHD, SDHB and SDHC) • PGL 2 , SDHB and SDHC autosomal dominant 2012 • SDHD imprinted from paternal line
- 12. Paragangliomas • Carotid Body tumor • Vagus nerve • Symathetic Chain • Hypoglossal nerve • Other cranial nerves or from 2012 paraganglionic tissue in pps
- 13. Miscellaneous Tumors • Wide variety of tumors • 20% of total PPS tumors • Lymphoma, hemangioma, teratoma, lipoma, branchial cleft cyst, arteriovenous malformation, internal carotid artery aneurysm 2012 • Soft tissue sarcomas
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- 17. Imaging • CT • MRI / MRA • Angiography 2012
- 18. Paraganglioma • Numerous flow voids on MRI • Intense contrast enhancement on CT • Salt and pepper appearance • Displaces carotid arteries anteriorly 2012
- 19. Angiography • Was used in the past to differentiate between neurogenic tumors and vascular lesions ( Paragangliomas) • Balloon occlusion test if possible sacrifice of carotid artery • Now used only when embolization is planned 2012
- 20. Surgical Approaches • Transoral • Cervical with or without mandibulotomy • Cervical-parotid • Transparotid • Infratemporal fossa • Transcervical-transmastoid 2012
- 21. Transoral • Has been used for small, benign tumors • Very limited exposure • Increased risk of tumor spillage, neurovascular injury 2012 • Generally NOT recommended
- 22. Transparotid • For deep lobe parotid tumors • Superficial parotidectomy • Facial nerve retracted • Dissect around mandible 2012 • May use mandibulotomy
- 23. Deep Lobe Parotid Tumor 2012
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- 28. Cervical • With or without mandibulotomy • Transverse incision at level of hyoid • Submandibular gland displaced or removed • Increase exposure by releasing digastric, stylohyoid, styloglossus from hyoid, cut stylomandibular ligament, or may have to 2012 do mandibulotomy
- 29. Carotid Body Tumors Shamblin s Classification Type I Type II Type III 2012
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- 45. Schwannoma of Sympathetic Chain 2012
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- 51. Transcervical- Transmastoid • Cervical incision carried postauricularly • Mastoidectomy • Remove mastoid tip exposing jugular fossa • Facial nerve may need to be dissected 2012 from Fallopian canal
- 52. Infratemporal Fossa • For intracranial extension • Preauricular lateral infratemporal fossa approach • Skull base or infratemporal fossa involvement • Can combine with frontotemporal 2012 craniotomy
- 53. Complications • Neurovascular injury/sequelae • Mandibulotomy complications • Tumor recurrence • Other complications 2012
- 54. Nonsurgical Management • Poor surgical candidates, failed balloon occlusion, elderly, unresectable lesions, would require sacrifice of multiple cranial nerves • Observation for stable tumors 2012 • Radiation for growing tumors
- 55. Radiation • Does not irradicate the tumor • Arrests growth • Some shrink, mostly remain stable • Local control in 90-100% 2012
- 56. Observation • Paragangliomas grow 1.0-1.5 mm per year • Benign and asymptomatic • Mortality is rare for untreated tumors • R T may be employed if significant growth is observed 2012
- 57. Algorithm for Management of Neurovascular Tumors of the Parapharyngeal Space Carotid Body Tumors (No Neurological Injury) Young Old Surgery Surgery? 2012
- 58. Algorithm for Management of Neurovascular Tumors of the Parapharyngeal Space Vagus: Sympathetic Chain or Hypoglossal Paraganglioma Young Old Single Nerve Multiple Cranial Observation Sacrifice Nerve Injury Growth Stable Surgery Observation R.T. Observe Growth Stable 2012 Surg or R.T. Observe