Surgical Management of Parapharyngeal Space Tumours in A Single Tertiary Care Center

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Indian J Otolaryngol Head Neck Surg

https://doi.org/10.1007/s12070-018-1447-8

ORIGINAL ARTICLE

Surgical Management of Parapharyngeal Space Tumours


in a Single Tertiary Care Center
Pradeep Pradhan1 • Chappity Preetam1 • Pradipta Kumar Parida1 •

Swagatika Samal1 • Dillip Kumar Samal1

Received: 8 June 2018 / Accepted: 4 July 2018


Ó Association of Otolaryngologists of India 2018

Abstract Because of the inaccessibility and overcrowding approach can be effectively applied specially for extensive
of the vital neurovascular structures, management of the PPS tumours associated with satisfactory clinical outcomes.
parapharyngeal space (PPS) tumour is always a challenge
to the surgeons. Here we have discussed the clinical find- Keywords Parapharyngeal space tumour 
ings and management of the PPS tumours with special Surgical management  Outcomes
concern to the surgical approaches. It is a retrospective
study containing 14 patients of PPS tumour from June 2015
to January 2018 in the department of Otorhinolaryngology Introduction
and Head Neck Surgery in a tertiary care referral hospital.
14 consecutive patients with PPS tumours were included in The parapharyngeal space (PPS) is a three dimensional fat
the study. The retrospective clinical data, diagnostic pro- filled compartment extending from the skull base to the
cedures, surgical approaches and the complications were greater cornue of hyoid bone. The styloid process and the
analyzed after 12 months of surgery. Of 14 patients tensor veli palatine muscle again divide it further into
included in the study, 10 patients were males and 4 were prestyloid and poststyloid compartment according to the
females. Prestyloid and poststyloid spaces were involved in anatomical location. The prestyloid compartment is closely
28.57% and 71.42% cases respectively. Transcervical related to the deep lobe of the parotid and the post styloid
excision of the tumours were performed in 10 patients, 2 space predominantly harbors the neurovascular bundles i.e.
patients had undergone transcervical-transoral approach. IX, X, XI and XII cranial nerves, the cervical sympathetic
Transcervical transmandibular and transcervical transpar- chain, the internal jugular vein, the internal carotid artery.
otid excision of tumours were performed in one patient Due to the wide structural variation, a wide range of
each. Facial nerve injury was detected in 3(21.42%) tumours have been found in the PPS [1, 2] and later
patients. Injury to the internal carotid artery and wound accounts for approximately 0.5–1.5% of all head and neck
infection were detected in one patient each. Radiological tumors [3, 4]. The majority (80%) of them are benign in
imaging, especially the MRI helps by narrowing the nature [3–9]. In order of frequency, pleomorphic adenoma
spectrum of the differential diagnosis distinguishing the of salivary gland is the most common, followed by neu-
benign from malignant lesions, especially in cases where rogenic tumour [4, 5, 8, 10]. Prestyloid tumours mostly
FNAC is contraindicated. Although the transcervical arise from the deep lobe of the parotid and the post styloid
approach is commonly practiced, the combined surgical tumours mostly originate from the neurovascular tissue.
Patients presentation usually depend upon the size and
extension of the tumour in the PPS and sometimes these
& Pradeep Pradhan tumours gets unnoticed because of their small size. The
padiapradhan@gmail.com patients get symptomatic after the size of the lesions
1 becomes more than 2.5–3 cm [6, 8]. Being a soft tissue
Department of ENT and Head Neck Surgery, All India
Institute of Medical Sciences, Bhubaneswar, Odisha 751019, lesion, contrast enhanced Magnetic resonance imaging
India (MRI) is considered as the primary radiological imaging

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Indian J Otolaryngol Head Neck Surg

advised to each patient suspicion of PPS tumour. It pro- was the predominant complaint which was observed in
vides valuable information regarding the size and extension 8(57.14%) patients and 4(28.57%) patients presented with
of the tumour also distinguishes the malignant from a swelling over the parotid gland. Of the 8 cervical swelling,
benign lesion and their spatial relation to the vital neu- 3 of them were pulsatile in nature and later diagnosed as
rovascular structures for a proper preoperative planning the carotid body tumour. One patient presented with dys-
[6]. Fine needle aspiration cytology (FNAC) is the definite phagia and one had a painless oropharyngeal mass. All the
investigation advised for PPS tumours towards the diag- patients were subjected for contrast-enhanced MRI and
nosis which can be undertaken through a transcervical or angiography was advised in 3(21.42%) cases because of
intraoral route except for the vascular tumours. Treatment the suspicion of vascular tumour. Of the 14 cases of PPS
is primarily by surgical excision of the tumour with tumour, prestyloid space was involved in 4(28.57%) cases
preservation of the neurovascular structure. It can be and 10(71.42%) patients had tumours in the post styloid
undertaken by a simple transcervical or combined tran- space. Of the 3 patients with carotid body tumour, 2
scervical transparotid approach in majority of the cases. patients had Shamblin type I tumour and one patient was
Transcervical transmandibular or transcervical transoral Shamblin type III. Cross cerebral circulation was assessed
approaches can be utilized in few selected cases of larger in one patient of Shamblin type III carotid body tumour and
tumours where adequate exposure is required for complete it was found adequate. None of the patients had undergone
excision of the tumour [1, 4, 6]. In the present study, we embolization in the preoperative period. Of the 14 cases,
have shared our experience in the management of the PPS FNAC was advised in 11 cases as rest 3 cases were clini-
tumours and discussed their respective surgical approach cally diagnosed as carotid body tumour. Again of the 11
and the complications. patients subjected for FNAC, the confirmed tissue diag-
nosis was achieved in 9 cases when it was compared with
the final histopathological report. In 2 cases, the preoper-
Materials and Methods ative FNAC was suggestive of neurofibroma came out as
schwannoma in the final tissue diagnosis (Table 2). Of 14
It is a retrospective study containing 14 patients of para- patients, 10 patients had undergone transcervical excision
pharyngeal space tumours from June 2015 to January 2018 of the tumour and 4 patients required the combined
in the department of Otorhinolaryngology and Head Neck approach for excision of the tumour. Again out of the 4
Surgery at All India Institute of Medical Sciences, Bhu- patients, 2 patients had undergone transcervical-transoral
baneswar, a tertiary care apex hospital in the eastern zone approach through mandibulotomy, one had undergone
of India. All consecutive patients with PPS tumours were transcervical transmandibular approach and one had
included in the study. The medical record was reviewed undergone transcervical transparotid approach for the
and the clinical, radiological, and pathological data were excision of the tumour (Fig. 1).
analyzed retrogradely. In the clinical data, the symptoms, An overview of a transcervical transmandibular
signs, diagnostic procedures, surgical approaches, and approach for a PPS pleomorphic adenoma extending to the
significant intraoperative/postoperative complications were infratemporal fossa has been demonstrated in Figs. 2, 3 and
analyzed. The preoperative CT/MRI findings were assessed 4. Facial nerve injury (marginal mandibular branch) was
for the size, location, vascularity, and the extension of the detected in 3(21.42%) patients. The internal carotid injury
tumour. Data obtained were statistically analyzed with was detected in one patient during the surgery of a carotid
SPSS statistics 22 (IBM, Chicago, USA). The average body tumour (Table 3). One patient had a wound infection
follow-up period was 12 months (range 11–18 months). and salivary leakage in the postoperative period, which had
Patients were reviewed in the tumour clinic at the end of 3, led for a longer hospital stay and it was successfully
6, and 12 months period after surgery where the clinical managed with conservative treatment with aseptic pressure
and radiological assessment were undertaken to rule out the dressing.
disease recurrence.

Discussion
Results
Because of the difficulty in the exposure and overcrowding
Total 14 patients were included in the study of which 10 of the vital neurovascular structures, excision of the PPS
were males and 4 were females. The age of the patients was tumours are always a challenge to the operating surgeons.
varied from 22 to 66 years (mean 39 ± 14.50). The Here we have discussed the clinical findings, diagnosis, and
demographic data and the patients clinical profile have treatment of the parapharyngeal space tumours along with
been demonstrated in the Table 1. Painless neck swelling the different surgical approaches and their complications.

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Table 1 Demographic profile of the patients in the study


S. no. Age/sex C/F Site of origin FNAC

1. 55/M Parotid swelling Lt parotid Pleomorphic adenoma


2. 33/M Neck swelling Lt carotid Not done
3. 22/M Neck swelling Lt carotid Not done
4. 66/F Neck swelling Rt carotid Not done
5. 40/M Neck swelling Lt vagus Neurofibroma
6. 23/F Neck swelling Rt vagus Schwannoma
7. 48/M Dysphagia Lt parotid Pleomorphic adenoma
8. 20/M parotid swelling Lt parotid Pleomorphic adenoma
9. 31/F parotid swelling Rt vagus Schwannoma
10. 18/M parotid swelling Rt parotid Pleomorphic adenoma
11 37/M Neck swelling Lt vagus Schwannoma
12. 47/M Neck swelling Rt vagus Schwannoma
13. 52/M Oropharyngeal mass Lt parotid Schwannoma
14. 28/F Neck swelling Lt vagus Neurofibroma

Table 2 Demonstration of the surgical approaches and the final pathology in the study population
S. no. Tumour size (cm) Surgical approach Final diagnosis Complications

1. 5.2 9 2.5 9 3.5 cm Transport id transmandibular Pleomorphic adenoma Grade III facial palsy
2. 3.0 9 2.0 9 2.0 cm Transcervical Carotid body tumour Marginal mandibular palsy
3. 5.0 9 3.0 9 5.0 cm Transcervical Carotid body tumour Vagus and internal carotid injury
4. 4.3 9 2.7 9 2.1 cm Transcervical Carotid body tumour None
5. 4.5 9 3.4 9 3.5 cm Transcervical Schwannoma None
6. 3.5 9 2.7 9 3.0 cm Transcervical Schwannoma None
7. 5.1 9 2.9 9 5.3 cm Transparotid with transoral Pleomorphic adenoma Marginal mandibular palsy
8. 6.0 9 4.5 9 5.2 cm Transcervical Pleomorphic adenoma None
9. 4.9 9 3.0 9 6.0 cm Transcervical with transoral Schwannoma Wound infection
10. 4.4 9 3.4 9 5.0 cm Transcervical Pleomorphic adenoma None
11. 5.2 9 7.0 9 7.9 cm Transcervical Schwannoma Marginal mandibular palsy
12. 4.7 9 3.0 9 4.2 cm Transcervical Schwannoma None
13. 5.2 9 4.2 9 3.1 cm Transcervical Schwannoma None
14. 4.7 9 3.3 9 4.2 cm Transcervical transparotid Schwannoma None

Tumours affecting the PPS are mostly benign in nature of the consecutive patients attending the outpatient
(benign: malignant 4:1) as described in the previous liter- department with relatively a small sample size. Being
ature [4, 8, 9]. Again, based on the sites of origin, salivary benign, these are very slow growing and painless tumours
tumours are the most common, followed by the neurogenic and often get unnoticed by the patients unless it causes
tumour followed by the paragangliomas affecting the PPS significant dysphagia or hoarseness. Although neck swel-
[11, 12]. Salivary gland tumours are predominantly found ling is the most common clinical presentation in PPS
in the prestyloid compartment and the neurogenic tumours tumours [13], patients can have wide range of symptoms
are in the poststyloid compartment respectively, and later including swelling in the oral cavity, dysphagia, and stri-
arise mostly from the vagus nerve [3, 10]. dor. When it is compared between the prestyloid and post
But in the present study, 71.42% of the tumours were styloid tumours, dysphagia is the primary complaint of the
affecting the poststyloid compartment and in 28.57% cases, prestyloid tumours and the post styloid tumours usually
the tumours were found in the prestyloid space. This become symptomatic unless these causes functional
variation in the site could be due to the retrospective data impairment in one or more of the cranial nerves. Although

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Indian J Otolaryngol Head Neck Surg

Fig. 1 Shows the clinical


presentations of the patients of
the parapharyngeal space
tumours

Fig. 2 Contrast enhanced MRI


(T2-weighted) axial and sagittal
cuts of an parapharyngeal space
pleomorphic adenoma
extending to the infratemporal
fossa and the skull base

Fig. 3 a Shows a parapharyngeal space pleomorphic adenoma extending to the infratemporal fossa and b shows the infratemporal fossa after
complete excision of the tumour through transmandibular approach

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Indian J Otolaryngol Head Neck Surg

Fig. 4 a Histopathological section shows a well encapsulated tumour containing eosinophilic secretion with vacuolated cytoplasm and
comprising of myoepithelial cells in chondromyxoid background bland nuclear chromatin (H&E 400 9)
(H&E 40 9). b Shows myoepithelial cells forming small tubules

Table 3 Complications of surgery according to Clavien–Dindo chance of hemorrhage. Surgery is the primary modality of
classification treatment for the symptomatic parapharyngeal space
Postoperative tumours although few patients may be require active
Grade I Facial nerve palsy 3 (21.42%) surveillance in view of the inadvertent injury of the neu-
Grade II Wound infection 2 (14.28%) rovascular structure, especially in asymptomatic patients
Grade III Hemorrhage 1 (7.14%) with a small tumour size. Surgical approach mostly
depends upon the size and extension of the tumour in the
PPS and its anatomical relation to the neurovascular
both CT and MRI are the standard radiological investiga- structures, especially tumours in the poststyloid compart-
tion recommended for a PPS lesion, we had preferred MRI ment. Most of the PPS tumours are removed through the
in all cases because of it defines superior tissue abnormality transcervical approach as was evident in the present study
and provides adequate information regarding the extension, where complete excision of the tumours were achieved in
invasion, and regional metastasis for the proper surgical 10(71.42%) cases. This approach was very much suit-
planning for complete excision of the tumour [2, 14]. able for the tumours with limited medial extension with a
Angiography may be required in specific cases of vascular submandibular extension.
tumours, especially for the carotid body and glomus Transcervical transparotid approach can be used for the
tumours where there is the higher chance of neurovascular tumours, especially in the prestyloid compartment arising
damage. In the present study, only 3 patients with sus- from the deep lobe of the parotid. Other combined surgical
pected carotid body tumours were subjected for MR options like the transcervical transoral or transcervical
angiography to look for the predominant vascular mandibular approach can be utilised depending upon the
involvement and the spatial relationship of the tumour to medial extension of the PPS tumour. In the present study,
the great vessels. FNAC was the foremost and most one patient had undergone transcervical transparotid exci-
definitive investigation advised for all the patients of sion the tumour and two had undergone transcervical
parapharyngeal space lesions for the primary diagnosis transoral excision through a paramedian mandibulectomy
either through an intraoral route or through the transcer- and mandibular swing. One patient had undergone tran-
vical route except the vascular tumours with a diagnostic scervical transmandibular approach due to the extensive
accuracy of about 73.1% [15]. infratemporal extension of the tumour. Although combined
In the present study, the diagnostic accuracy of FNAC surgical approach is very rarely performed in the routine
was found to be 81.81% which could be due to the small surgical practice, still these are adopted for extensive and
size of the sample and atypical distribution of the disease in recurrent tumours where greater range of exposure is
the PPS. Although FNAC plays a major role for the initial required than the standard transcervical/transcervical
tissue diagnosis of the parapharyngeal tumours, still a transparotid approach [16–18]. Each of the surgical
complete clinical and radiological correlation is always approach has its own complications and the most common
required, especially for the highly vascular tumours where being the marginal mandibular injury which can happen to
FNAC is absolutely contraindicated because of the higher all the surgical procedure irrespective of the type of the

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Indian J Otolaryngol Head Neck Surg

tumour. In the present study, of the 14 patients undergoing Conclusion


transcervical excision, 3(21%) had the marginal mandibu-
lar palsy in the immediate postoperative period although Because of the inaccessibility and overcrowding of the
one patient gets recovered after 48 h of conservative vital neurovascular structures, excision of the PPS tumours
treatment. It could be because of the surgical manipulation is a challenge to the surgeons. Although FNAC is very
of the deep fascia during the excision of the submandibular much helpful in the diagnostic workup of the PPS tumours,
gland, which was performed in almost all the cases as a one should keep in mind the discrepancy in the cytological
primary step to assess the PPS. Of the 4 patients under- and pathological findings. Radiological imaging especially
going combined transcervical approach, one patient had the MR helps by narrowing the spectrum of the differential
grade III facial palsy in the immediate postoperative per- diagnosis distinguishing the benign from a malignant
iod, which could be due to the overstretching in the and lesion. Although the transcervical approach is the standard
later gets improved to grade I after 6 weeks with the surgical procedure practiced, patients may require the
conservative management. There were no other significant combined approach excision of the tumour, especially for
complications found in these patients. With the recent extensive PPS tumours with satisfactory outcomes.
advancement of endoscopic transoral Robertic surgery as
described by Duek et al. [19] tumours of PPS can be well Compliance with Ethical Standards
managed as an adjunct procedure to the standard external Conflict of interest The authors declare that they have no conflict of
approach. All the tumours were benign in nature as con- interest.
firmed by the final pathological examination and there were
no features suggestive of any malignancy. The average Funding This research has received no financial grant from any
funding agency, commercial or not-for-profit sectors.
follow-up period was 12 months (range 11–18 months) and
there was no tumour recurrence as confirmed by radio- Ethical Standards All procedures performed in studies involving
logical examination and there was no death of any patient human participants were in accordance with the ethical standards of
detected during the 12 months of follow-up period. One the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
patient operated for a carotid body tumour had injury standards.
during the surgery due to the advanced stage of the disease
(Shamblin type III) which was effectively managed by the Informed Consent Written informed consent has been taken from
cardiothoracic team with saphenous venous grafting and each patient prior to the surgery and same has been informed to the
institute reviewer board. No part of the body has been demonstrated in
there was no motor neuron palsy detected in the postop-
the case report without the permission of the concerned patient.
erative period, although patient had mild dysphagia, which
was adequately taken care by swallowing rehabilitation.
This is a single centered a small population study of the References
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