Surgical Management of Parapharyngeal Tumors: Our Experience

Context Tumors of parapharyngeal space (PPS) are rare and histologically diverse. The management of these tumors requires diligent assessment and planning with due consideration of various anatomical and pathological aspects of the lesion. Aims This retrospective study aims to present our experiences in the clinical and pathological aspects of PPS tumors with a critical evaluation of management. Settings and Design Retrospective analytical study. Methods and Material The electronic medical records of 60 cases of PPS tumors, managed surgically from 2007 to 2017, were reviewed and analyzed using SPSS 22 software. The mean follow-up duration was 44 months. Results The mean age was 45 years with a male-to-female ratio of 1.7 (38:22). The majority of the tumors were benign (71.7%) and the most common presentation being upper neck mass or oropharyngeal mass. Histologically, neurogenic tumors were most common (43.3%) PPS tumors, followed by tumors of salivary gland origin. Magnetic resonance imaging was used as a diagnostic modality in 70% of cases, and computed tomography scan and positron emission tomography/CT were used in 26.7 and 3.3% of cases, respectively. In our study, the diagnostic accuracy of fine-needle aspiration cytology was 71% for benign and 47% for malignant lesions. The most common approach for surgery used was transcervical (72%). Conclusion The study reveals that cranial nerve palsy is the most common complication associated with PPS tumors. Completely resected, malignant tumors originating within PPS have a good prognosis, as compared with tumors extending or metastasized to PPS.

Surgical Outcome of Parapharyngeal Tumour

Background: Parapharyngeal tumours are rare accounting for 0.5-1.5% of all head neck tumuors. The anatomy of the Parapharyngeal space (PPS) is responsible for a wide variety of tumours arising from PPS. Objective: Evaluation of the strategy for parapharyngeal tumor surgery based on preoperative symptoms, clinical signs, imaging investigations and histopathology. Methodology: This retrospective study was carried out in the Department of Otolaryngology and Head Neck surgery in Bangabandhu Sheikh Mujib Medical University (BSMMU) included 32 patients were underwent surgery for primary parapharyngeal tumors between January 2018 and December 2019. Informed written consent was obtained from the patients prior to their inclusion in the study. In regard to histologic type there were 21 cases salivary gland origin tumors and 11 of neurogenic tumors. The following data were evaluated preoperative symptoms, histological type, surgical approach and complications patients were evaluated following a laboratory investigations. Results: The most common symptoms of these tumors were a neck swelling. Total of 18 tumors were located in the prestyloid and poststyloid space cases were located 10(31.25%) and 4(12.50%) in the pre and poststyloid. Majority 12(37.50%) was found pleomorphic adenomaof deep lobe of parotid gland followed by 6(18.75%) were schwannoma,4(12.50%) were neurofibroma, 3(9.38%) were ectopic salivary gland tumor,2(6.25%) were mucoepidermoid carcinoma, 2(6.25%) were adenocarcinoma. First bite syndrome and lower lip palsy were common post operative complications. Transcervical approach was the most often performed approach in this study (56.25%). Conclusion: Parapharyngeal tumours most often derived from parotid gland. Most of them are non-malignant. Pleomorphic adenoma is the more common. Surgical resection being the main stay of treatment. Tumours of this complex anatomy call for careful preoperative planning and great skill for selecting the right approach and for management with minimal morbidity and recurrence. Bangladesh J Otorhinolaryngol; April 2021; 27(1): 66-72

A Retrospective Analysis of Surgery in Prestyloid Parapharyngeal Tumors: Lateral Approaches vs Transoral Robotic Surgery

Introduction Surgery is the standard treatment for most tumors in the prestyloid parapharyngeal space (PPS) but it can be a challenging procedure because of the anatomical complexity of the area. Prestyloid surgery can be performed with various lateral approaches or with a medial approach using transoral robotic surgery (TORS) – either alone or in combination with a transcervical incision. Here we report our experience in the surgical management of prestyloid PPS tumors. Materials and Methods We have retrospectively compared results with lateral or medial approaches to surgical resection of prestyloid tumors. Between 2015 and 2020, 28 patients with prestyloid PPS tumors underwent surgery at our center: 14 with lateral approaches, including transcervical, transcervical-parotid, and transcervical-mandibular, 12 with TORS, and two with TORS plus a transcervical incision. Surgical time, post-surgical complications, length of hospital stay, need for feeding tube, and relapse-free survival in the two patient groups. Results Pleomorphic adenoma was the most frequent tumor and 60.7% of the tumors were benign. Tumor volume and maximum length were similar in patients undergoing surgery with a lateral approach and in those undergoing TORS. Intraoperative image guidance and ultrasound were used in 33% of TORS. TORS was associated with less surgical time, fewer complications, and shorter hospital stays. Survival rates were similar in the two groups. Conclusion The medial approach by TORS offers better surgical results in prestyloid tumors than the open lateral approach and can be refined by intraoperative guidance.

The intraoral growth patterns of parapharyngeal tumors: A proposed classification system

Objective: Nearly half of parapharyngeal space (PPS) tumors present as an intraoral mass, which is diagnostically challenging. In this study, we studied whether preoperative growth patterns were associated with histopathological diagnosis for planning surgery. Methods: We performed a cross-sectional study in patients with PPS tumors. A simplified classification scheme based on intraoral tumor growth patterns (patterns 1 and 2) was then proposed. In pattern 1, tumors bulge submucosally to the oropharynx from the soft palate, with the center convexity above the uvula. In pattern 2, tumors bulge submucosally to the oropharynx from the lateral oropharynx wall, with the center convexity below the uvula. The association of this classification with postoperative histopathological diagnosis and surgical-related events was studied. Results: Twenty-two patients were enrolled in this study (12 with pattern 1, 10 with pattern 2). Of these, 91.7% (11/12) of pattern 1 tumors were salivary gland tumors ( P < .001), and 90% (9/10) of pattern 2 tumors were neurogenic ( P < .001). Pattern 2 tumors had fewer bleeding complications or needed external approaches when a transoral approach was chosen. Conclusions: This new classification of PPS tumors facilitates the prediction of salivary gland and neurogenic tumors and can improve the accuracy of preoperative radiologic diagnosis. This system will be helpful for planning surgical interventions, such as implementing transoral approaches.

Nodular Oncocytic Hyperplasia of Bilateral Parotid Glands With Parapharyngeal Space Extension

Oncocytic tumors comprise a group of rare benign neoplasm of salivary glands, accounting for less than 1% of all salivary gland tumors. Nodular oncocytic hyperplasia characterized by multiple unencapsulated oncocytic nodules in the salivary glands is an extremely rare condition. We report a case of bilateral nodular oncocytic hyperplasia of parotid glands with parapharyngeal space extension in an 80-year-old woman whose initial presentation was recurrent parotitis. Our case may be the first report of nodular oncocytic hyperplasia in the parapharyngeal space, arising from the parotid gland. The patient underwent total parotidectomy and excision of parapharyngeal tumors using a transparotid transcervical approach, and at the 2-year follow-up, no evidence of recurrence was found.

A Facelift Procedure for Resection of Benign Parapharyngeal Tumors

Objective: The feasibility, surgical outcomes and possible risks and complications encountered during a facelift procedure for patients with parapharyngeal space (PPS) tumor were analyzed. Method: This retrospective analysis examined 10 patients who had undergone surgery for PPS tumor using a facelift incision at our institutes between April 2015 and August 2019. Results: This study included four retro-styloid (benign nerve sheath tumor) and six pre-styloid tumors (pleomorphic adenoma). Average tumor dimensions were 4.1 x 4.2 x 3.8 cm respectively. None of the patients needed conversion to conventional open resection. Transient sensory changes in the auricle occurred in 30 % of the patients; however, all recovered within four months. In all the patients, postoperative scars were fully concealed by the auricle and hair. No recurrences were detected during a mean follow-up period of 16.6 months. Conclusions: The facelift procedure provides adequate visualization, workspace and excellent cosmetic results in properly selected cases.

Transoral Excision of Parapharyngeal Tumors

Objectives: The transoral approach for parapharyngeal space tumors has been criticized due to its restrictive exposure and increased rate of vascular and nerve injuries. However, for certain tumors—namely those that are prestyloid, benign, and well-encapsulated—the transoral approach reduces overall morbidity while providing direct access. Transoral surgeons can rely on this approach for select tumors seen clearly on intraoral examination in the bulging lateral pharynx. In this article and with a supplemental operative technique video, we demonstrate our transoral approach in these select patients. Methods: We reviewed our 26 cases using this approach and chose a representative case of a 50-year-old man who presented with a large, prestyloid, encapsulated parapharyngeal mass affecting his voice and swallowing. A transoral approach to the parapharyngeal tumor is illustrated. Results: A vertical curvilinear incision is completed from the hamulus to below the inferior extent of the tumor. Blunt dissection of the tumor capsule proceeds inferiorly. Controlled violation of the tumor capsule can aid in visualization. After tumor delivery, the wound is irrigated and closed. Conclusions: In our experience, the transoral approach is an effective method to access well-encapsulated, prestyloid parapharyngeal space tumors. Patient selection is important when considering a transoral approach.