Case presented in National ENT conference in serena hotel, Islamabad in Dec. 2015 Author Dr. Ghulam Saqulain HOD Dr. Jawad Ahmed Assoc. surgeon Dr. Zaimal Shahan PGT

1. Dr. Zaimal Shahan
PGT
Capital Hospital,CDA
Islamabad
Pleomorphic Adenoma of Minor
Salivary Gland in
Parapharyngeal Space

2. Introduction
Most common Parapharyngeal space tumors are PLEOMOROHIC ADENOMAS.
Pleomorphic adenomas in the parapharyngeal space usually arise from deep lobe of the parotid,
however they very rarely develop denovo from displaced or abberant salivary gland tissue within
lymph node*.
We report a case of a large primary pleomorphic adenoma.
It arised de novo from a minor salivary tissue in the right parapharyngeal space and presented
with difficulty in breathing.
Tumor was removed by transoral transpalatal approach..
* H. Chijiwa, T. Mikhoki, B.Shir, et.al . Clinical Study of parapharyngeal space tumors. The journal of laryngology and otology. 2009; 123:100-103

3. Epidemiology
Parapharyngeal space tumors account for some 0.5% of head and neck neoplasms . 82%
being benign and 18% malignant.* Plemorphic adenomas being the most common benign
parapharyngeal tumors (34%) *.
On the other hand minor salivary gland neoplasms account for 22% of all salivary
neoplasms **, majority being malignant.
Pleomorphic adenoma is more common in females than in males (2:1 ratio).
When it originates from the minor salivary glands, the tumor most commonly involves
the palate followed by lip, buccal mucosa, floor of mouth, tongue, tonsil, pharynx,
retromolar area and nasal cavity **.
A comprehensive review of literature shows very few reports of peomorphic adenoma
arising "de novo" in the parapharyngeal space **
* Riffat F, Dwivedi R.C, Palme C, Fish B, Jani P. A systematic review of 1143 parapharyngeal space tumors reported over
20 years. Oral Oncology. 2014;50(5):421-430
** AH Hakeem, B Hazarika, SA Pradnan, R Knnan. Primary Pleomorphic adenoma of minor salivary gland in the parapharyngeal
space. World Journal of Surgical Oncology. 2009:7:85
*** Varghese BT, SebastianP, Abraham EK, Mathews A. A case report:"Pleomorphic adenoma of minor salivary gland in the
parapharyngeal space".World Journal Surgical Oncol. 2003,1:2

4. Diagnosis
The cornerstone for diagnostic evaluation is appropriate
radiologic investigation
1. Imaging studies
• CT scan
• MRI
1. Histopathology
• FNAC

5. Treatment
Surgical excision is the treatment of choice:
 Transcervical approach
 Transparotid approach
 Extended transmandibular approaches
 Transoral approach

6. CASE PRESENTATION

7. Patient Profile
• Age : 61 Years
• Gender : Male
• Residence : Islamabad
• Admitted through OPD on 21st
January 2013

8. Presenting Complaint
• Breathing difficulty since 2
years

9. History
• A 61 year old male presented in Otolaryngology outpatient department with
history of difficulty in breathing for 2 years associated with Headache off
and on, sore throat and difficulty in swallowing due to a mass in the
pharynx.
• On inquiry he complained of a painless slowly progressing swelling in the
nasopharynx on the right side for 7 years
• He was also advised surgery six months back but he left against medical
advice.
• There was no history of smoking or alcohol intake
• There was history of DM for last 5 years and HTN for the last 8 years

10. Examination
• Soft palatal and lateral
pharyngeal wall buldge
on Rt. Side extending
beyond midline and down
up to the tonsil.
• No swelling in neck.
• Normal nasal patency.
• Tympanic Membrane and
hearing was normal

11. CT Scan
CT SCAN NECK WITH CONTRAST (11.O1.13)
•Revealed a well defined soft tissue density mass centered in Right Parapharyngeal
space
•37 mm transverse x 28 mm AP diameter with craniocaudal length of 43 mm.
•Mass was oval in shape with surrounding smooth margins.
•It compressed base of tongue.

17. MRI Scan
MRI SCAN NECK WITH CONTRAST (19th
Feb,2013)
• Revealed a well defined soft tissue mass in parapharyngeal space on the right
side.
• 42 mm transverse and 39 mm AP diamension with 52 mmm craniocaudal extent.
• It is causing midline shift and resultant narrowing of oropharynx and part of
nasopharynx.
• The mass is isointense on T1W1 while it is hypertintense on T2W1.
• There are few foci inside the mass which are hyperintense on T1 and few brighter
on T2
• Mass is pushing carotid space laterally but fat plane between the mass and carotid
space is
intact.
• No lymphadenopathy, bony involvement, intracranial extension noted
• D/D

22. Incisional Biopsy
• Incisional biopsy was
done on 5th
January
2013 under G/A.
• Histopathology reports
Chordoma

23. Provisional Diagnosis
He was diagnosed as a case of chordoma
&
his excision was planned

24. Surgery
• Mass was removed by
Transpalatal per-oral
approach by splitting
soft palate in Midline.

25. Per-op findings:
 Large mass in
nasopharynx,
oropharynx and causing
palatal buldge.
 Well defined
encapsulated mass was
easily enucleated.

29. Post-op Care
Post Operative recovery was uneventful.
Injection Augmentin 1gm I/V BD
Injection Diclofenic sodium 75 I/M SOS
Mouth wash gargles

30. Gross examination
Two off white well defined nodular pieces of tissue
4 x 2 x 1.5
3 x 2.5 x 1.5
Cut Surface: Shiny, soft and homogenous.

31. Histopathology
Pleomorphic Adenoma :
•Chondromyxoid background
•Focally encapsulated
•Nests and tubules of epithelial and
myoepithelial cells
.

34. FINAL DIAGNOSIS
Pleomorphic adenoma of Minor Salivary Glands in
Parapharyngeal Space

35. Follow Up
Regular two monthly follow up was maintained
No recurrence reported.