Journal Reading

ACCESS TO THE PARAPHARYNGEAL SPACE

OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

Supervisor :
dr. Dindy Samiadi, M.D, Sp.T.H.T..K.L(K), FAAOHNS
Presentant : Tita Puspitasari

DEPT OF OTORHINOLARYNGOLOGY – HNS

SCHOOL OF MEDICINE PADJADJARAN UNIVERSITY
BANDUNG
2019
 The parapharyngeal space (PPS)

• Skull base →hyoid

• Contains fat, the
carotid artery, IJV,
lower cranial nerves
and sympathetic
nerve.
• Separated by the
styloid process,
tensor veli palatini
muscle and its fascia
(brown).
 Prestyloid PPS

• Mass lateral
oropharynx, displacing
the tonsil medially.
• Anterolaterally by the
medial Pterygoid
muscle
• Posterolaterally by the
deep lobe of the
parotid gland
• Extends hyoid bone
inferiorly to the skull
base superiorly
• Contains mainly fat.
 Examples of masses commonly encountered
in the prestyloid PPS

Pleomorphic
adenoma, to medial
pterygoid,
submandibular
salivary gland, and
hyoid bone
Direction of displacement of fat as seen on CT or MRI with
prestyloid PPS mass (light blue)
Pleomorphic adenoma of pre-styloid PPS displacing fat
anteromedially
 Poststyloid PPS

• Mass extending into the upper lateral neck in the

lateral oro- or nasopharynx/dysfunction nerves IX-
XII, /Horner’ syndrome.
• Medially : Pharyngobasilar fascia above +
superior constrictor muscle of the pharynx. I
• Contains : ICA, IJV, lower cranial nerves IX -XII,
and the sympathetic trunk.
• Displace the PPS fat anterolaterally
Direction of displacement of fat as seen on CT or
MRI with poststyloid mass (light blue)
Carotid body tumour in poststyloid PPS, splaying the
internal and external carotid arteries
CT scan of poststyloid vagal schwannoma : Direction of
displacement of fat and medial displacement of carotid vessels
 Determine The Following Before Surgery:

• Benign / malignant: Bhe needle biopsy may be

done transcervically or transorally.
• Vascularity: A paraganglioma may be suspected
on CT or MRI, and confirmed angiographically.
• Vascular tumours → preoperative embolisation,
radiation.
• Poststyloid/ Prestyloid (the parotid gland)→
surgical approach e.g. transcervical +/- total
parotidectomy.
Approaches to PPS: transoral + mandibulotomy (green); transcervical
submandibular (yellow), transparotid (blue), and transcervical +
mandibulotomy (red)
 Transcervical submandibular approach to
prestyloid tumours

Exposured :
• Facial artery
• Mandible
• Submandibular gland

• Digastric muscle
 Prestyloid Surgical Approaches

• Benign, well defined, surrounded by fat, not

tethered to structures (major nerves and vessels),
can generally be removed.
• Situated between the hyoid bone and the skulll.
• Transcervical submandibular approach.
• Rarely a transoral approach + mandibulotomy
required.
• A large tumour from the deep lobe of the parotid
→ combined transcervical and transparotid
approach.
Transcervical submandibular approach to
prestyloid tumours
• A horizontal skin crease incision level hyoid
bone.
• Identified submandibular salivary gland
(SSG) + digastric muscle .
• The anterior facial vein is ligated + divided.
• The capsule of the SSG is incised.
• Retracting the
posterior belly
of digastric
posteriorly,
• the mandible
superiorly,
• the
submandibula
r gland
anteriorly
Access to prestyloid PPS mass via transcervical
submandibular approach.
Delivery of prestyloid PPS pleomorphic adenoma via
transcervical submandibular approach
 Transoral Approach to Prestyloid Tumours
• = Extended
tonsillectomy,
• May include
midline or
paramedian
mandibulotomy
for additional
access.
• Disadvantage :
neck is not
opened and the
vessels not
exposed.
 Combined Transcervical Submandibular and
Transparotid Approach to Prestyloid Tumours

• Even large prestyloid tumours e.g. Arising from

the deep lobe of the parotid gland
• Resected via a combination of transparotid and
transcervical approaches.
Pleomorphic adenoma arising from deep lobe of parotid
extending into PPS resected by combined transcervical
submandibular and transparotid approach.
 Poststyloid PPS Surgical Approaches
• Avoiding injury ICA, IJV, lower cranial and sympathetic
nerves →Horner’s and “1st Bite” syndromes.
• Restricted by vertical ramus mandible, parotid gland,
facial nerve, styloid process with its muscular and
ligamentous attachments.
• Mostly benign, tethered to/arise from major nerves
and vessels.
• Good exposure via transcervical and/or transparotid
approaches.
• Rarely : Mandibulotomy
 Transcervical Approach to The Poststyloid PPS

• Tumours extending up the level of the styloid

process : Smaller carotid body, glomus vagale
tumours, lower lying schwannomas.
• Transverse skin crease incision.
• Identified : X, XI, and XII nerves, carotid bifurcation,
IJV.
• Remove the using sharp dissection.
• Posterior belly of digastric retracted superiorly, or
divided to provide access deep to the parotid gland.
Transcervical resection of glomus vagale
 Transparotid Approach to the Poststyloid
• Masses situated closer to the skull base.
• The superficial lobe of the parotid gland is
elevated off the facial nerve, the nerve freed from
the deep lobe,
• Deep parotid lobe is resected→exposes the styloid
process.
• Medial styloid → contents of the poststyloid PPS.
• Excising the styloid process with a bone nibbler,
retracting the mandible anteriorly and inferiorly
• Dividing the posterior belly of the digastric.
Operative field following resection of carotid body tumour
Poststyloid PPS located medial to internal carotid artery
Transparotid access to poststyloid PPS in
TERIMA KASIH