PARAPHARYNGEAL SPACE TUMORS

Dr Nikhil S B

Bibliography
Scott-Browns Otolaryngology, Head and Neck
Surgery, 6th and 7th Edition
Cummins Otolaryngology, Head and Neck
Surgery, 4th Edition
William W. Shockley, The Neck Diagnosis
and Surgery
Eugene N. Myers, Cancer of the Head and
Neck, 4th Edition

ANATOMY
Parapharyngeal Space

ANATOMY
Parapharyngeal Space

ANATOMY
Parapharyngeal Space
Prestyloid compartment

Retrostyloid compartment

Fat
Retromandibular parotid
Lymphnodes
Internal maxilary artery
Inferior alveolar nerve
Lingual nerve
Auriculotemporal nerve

Internal carotid artery

Jugular vein
Cervical Sympathetic chain
Cranial nerves IX-XII
Lymphnodes

ANATOMY
Parapharyngeal Space
Stylomandibular Tunnel
Extension
Medial vs Lateral tumors

Retropharyngeal Space Node of Rouviere

PARAPHARYNGEAL TUMORS

Account for 0.5% of all head and neck neoplasms

Benign: 80% Malignant 20%

Direct extension, metastasis, primary tumors

TUMORS OF THE PARAPHARYNGEAL SPACE

Direct Extension
Metastasis
Primary tumors
Salivary gland tumors (40 50%)
Neurogenic tumors (17 25%)
Miscellaneous (20%)

COMMON TUMORS

Minor salivary gland tumors

Benign mixed tumor
Origin
Growth pattern

COMMON TUMORS
Pleomorphic adenoma
Most common origin Deep lobe
Arises from island of salivary tissue or deep lobe of parotid
Growth pattern
Route of escape from deep lobe through stylomandibular hiatus
Extension into Infratemporal fossa

COMMON TUMORS
Malignant tumor of Parotid
Adenoid cystic Ca
Lateral extension picks off VII CN
Spl Characteristic

COMMON TUMORS
Neurogenic tumors
2nd most common tumor
3 categories

Schwannoma ( Neurilemmoma)
Neurofibroma
Ganglion Neuroma

COMMON TUMORS
Schwannoma ( Neurilemmoma)
Most common
Origin schwann cells
Growth pattern
Features

Schwannoma ( Neurilemmoma)

COMMON TUMORS
Neurofibroma
Dual origin
Charateristic Growth patern

Ganglion Neuroma
Rare
Characteristics

COMMON TUMORS
Chemodectoma / Paraganglioma
Arise from chemoreceptor organs along carotid bifurcation; trunk
of vagus; Jugular bulb
Carotid body tumors
Glomus vagale tumors
Glomus jugulare tumors

Incidence

Most common is Carotid body tumor followed by

Jugulotympanic and Vagal paraganglioma
Lack et al 0.012 % of all tumors; 1 in 30,000 Head & Neck
tumors

Incidence
Male : Female 2:1 (US); 1:8.3 (Mexico)

Most paraganglioma are solitary

Multiple seen in familial syndromes MEN II A & B

Biochemistry
APUD System
Convert Dopa & Dopamine to neurotransmitters
Biochemical synthesis of catecholamine Adrenal
Diet
Tyrosine ---- L-dopa ----Dopamine
Phenylalanine
Epinephrine

Norepinephrine

Biochemical Activity
Functional tumors 1 3 %
4 5 times increase in Norepinephrine presents clinically
24 hr urine collection for norepinephrine & metabolites
Routine testing for VMA & metanephrine not recommended

Physiology
Carotid sinus stretch receptors
Carotid body sensitive to PaO2, pH & blood flow
Carotid body sinus complex : Baroreceptor. Type I & II
Signals ---- Herrings nerve ---- IX ---- Medullary area of brainstem
---- Secondary signals ---- Excite Vagal centres ---- inhibit
Vasoconstrictive center
Stimulation causes parasympathetic response

Carotid Body Tumor

Origin
Growth pattern
Extension/
complication

Carotid Body Tumor

Classification 3 stage classification (Shamblin)

Glomus vagale
Similar to carotid body tumors
Distiguishing growth patterns
Easier excision

Glomus jugulare
origin
Growth patterns

Histology
Zellballen organized nested pattern of Type I cells
2 types of cells: Chief cells & Sustentacular cells
Chief cells
Derived from neural crest & are part of APUD
Contains secretory granules (stain with silver
hematoxylin (Argentation)
Chromogranins, Synaptophysin & NSE markers are positive in these
tumors

COMMON TUMORS
Angiofibroma
Arises close to sphenopalatine foramen
Grows into the nasopharynx or into pterygopalatine fossa

Chordoma
Derived from primitive notochord
Presents as swelling in the prevertebral region behind
nasopharynx
Involvement of lower CNs

COMMON TUMORS
Meningioma
Intracranial tumors
Extends into infratemporal fossa and then to parapharyngeal space

Ameloblastoma
Maxillary
Mandibular
Horizontal ramus
Ascending ramus

OTHER COMMON TUMORS

Metastasis to the space
Closely related to Nasopharynx
Oropharynx
Nose & PNS
BOT
Parotid
Common metastatic

SPREAD WITHIN SPACE

Extension along path of least resistance
Medial and lateral extension
Inferior and superior extension

Parapharyngeal tumors
Symptoms
Painless Swelling in neck (54%)
Palatal /Pharyngeal swelling ( 11%)
Dysphagia ( 12%)
Hoarseness of voice (7%)
Foreign body sensation
Pain ( 10%)
Otalgia

Trismus ( < 11%)

Airway obstruction
Hearing loss
Syncope

Parapharyngeal tumors
Signs
Neck swelling

Tongue deviation
Fig

Palatal /Pharyngeal swelling Fig

Parotid Mass
Trismus
Vascular thrill/ bruit
Secretory otitis media
Vocal cord palsy

Shoulder weakness
Horners syndrome

INVESTIGATIONS
CT Scan
Locates tumor to prestyloid vs retrostyloid
Bone erosion due to malignancy
Limited soft tissue detail

MRI
Relationship of mass to adjacent structures
Characteristic appearances of tumor types on MRI
allows preoperative Dx in 90-95% of patients

MRI

MRI

MRI

MRI

MR Angiography
Gold standard for relationship to great vessels
Differentiate neurogenic and vascular

Vascular displacement
Tumors

Vascular Displacement

Deep Lobe of Parotid

ICA displaced Posteriorly

Minor salivary gland tumor

ICA displaced Posterolaterally

Neurogenic tumor

ICA displaced anteriorly

Vagal paraganglioma

ICA displaced Anteromedially

Carotid body tumors

Splaying of ICA and ECA

Investigations
Tissue diagnosis
FNAC accuracy rate - 88 - 95%
Improved with guided FNAC
Problems in FNAC Tumor seeding
Few cells in vascular tumors
False positive

INVESTIGATIONS
Other investigations
111Indium octreotide scan
MIBG Scan
Tumor markers

TREATMENT
SURGICAL
Transoral
Transparotid
Transcervical
Transpharyngeal with mandibulotomy
Combined trans mastoid- transcranial
CHEMOTHERAPY
RADIOTHERAPY

Transoral
Indicated in small tumors
Adv direct appch
Disadv Limited exposure
Tumor spillage

Transparotid (Lateral) approach

A. Total Conservative Parotidectomy

TREATMENT
Transparotid (Lateral) approach
B. Conservative Lateral approach

TREATMENT
Transparotid (Lateral) approach
B. Conservative Lateral approach

C. Radical Lateral approach

TREATMENT
Transcervical approach ( Inferior approach)

Blind dissection of the tumor

Division of Medial pterygoid ms
Medial and anteromedial dissection from Sup constrictor ms

TREATMENT
Transcervical approach

With or without mandibulotomy

Increase exposure by releasing digastric, stylohyoid, styloglossus

from hyoid, cut stylomandibular ligament, mandibulotomy

TREATMENT
Transpharyngeal with mandibilotomy approach
Suitable for ITF and PPS tumors
Used for large PPS tumors

Transcervical-transmastoid
Cervical incision carried
postauricularly
Mastoidectomy
Remove mastoid tip
exposing jugular fossa
Facial nerve may need to
be dissected from
Fallopian canal

TREATMENT
Observation
Paraganliomas grow 1.0-1.5 mm per year
Mortality less than 10% per year for untreated

Radiotherapy
Neoplasms PPS
NPC highly curable (3 yr survival 60 66%)
Vagal paraganglioma and Glomus jugulare control by RT

TREATMENT
Chemoradiation
NPC; Rhabdomyosarcoma and other sarcomas
5 FU and Cisplatin for SCC
Doxorubicin for glandular neoplasms

PATTERNS OF FAILURE
Recurrence of benign lesions
Malignant transformation of benign lesions

PROGNOSIS AND SURVIVAL

84 % are benign
67 % of malignant tumors are from salivary glands
Tumor specific 5 yr survival (97%)
5 yr survival of malignant tumors 85%

Lateral neck mass

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Oropharyngeal Mass

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