Tumors of the parapharyngeal space are rare tumors comprising less than 1% of all head and neck neoplasms. They are mainly salivary gland or neurogenic tumors. Clinical presentation is very variable. Surgical resection by different approaches remains to be the best possible treatment option. We present a case of 45 years old female patient admitted at the ENT Department due to the unilateral hearing loss and swallowing difficulties. Clinical examination revealed the
diagnosis of a pleomorphic adenoma of the parapharyngeal space. Tumor was surgical (transorally) excised. Two years following the surgery there is no recurrence of the initial symptoms and primary disease

Marijan Kovačić

Milan Rudić

Zoran Kranjčec

English

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Coll. Antropol. 36 (2012) Suppl. 2: 193–195Case reportTransoral Excision of a Parapharyngeal SpaceTumor: Case ReportMarijan Kova~i}, Milan Rudi} and Zoran Kranj~ecZadar General Hospital, Department of Otorhinolaryngology and Head and Neck Surgery, Zadar, CroatiaA B S T R A C TTumors of the parapharyngeal space are rare tumors comprising less than 1% of all head and neck neoplasms. Theyare mainly salivary gland or neurogenic tumors. Clinical presentation is very variable. Surgical resection by differentapproaches remains to be the best possible treatment option. We present a case of 45 years old female patient admitted atthe ENT Department due to the unilateral hearing loss and swallowing difficulties. Clinical examination revealed thediagnosis of a pleomorphic adenoma of the parapharyngeal space. Tumor was surgical (transorally) excised. Two yearsfollowing the surgery there is no recurrence of the initial symptoms and primary disease.Key words: parapharynx, parotid gland, transoral surgical approachIntroductionParapharyngeal space tumors are rare tumors com-prising less than 1% of all head and neck neoplasms. Ma-jority of these tumors (70–80%) are benign while 20–30%of these tumors are malignant1,2. They can arise fromany structure contained within the parapharyngeal spa-ce. The parapharyngeal space is a space lateral to the up-per pharynx shaped like an inverted pyramid, extendingfrom the skull base superiorly to the greater cornu of thehyoid bone inferiorly. The parapharyngeal space consistsof two compartments. The anteromedial or prestyloidcompartment containing the retromandibular portion ofthe deep lobe of the parotid gland, adipose tissue, andlymph nodes associated with the parotid gland, and aposterolateral or poststyloid compartment containingthe internal carotid artery, the internal jugular vein, IX–XII cranial nerves, the sympathetic chain, and lymphnodes1,2. This difference between the prestyloid and post-styloid space is used in imaging studies and can help inachieving the correct diagnosis preoperatively. Most pa-rapharyngeal space tumors are of salivary (prestyloidcompartment) or neurogenic origin (poststyloid compart-ment), although metastatic lesions, lymphoreticular le-sions, and a variety of uncommon, unusual lesions maydevelop in this location1,3. Surgery is the main therapyoption for tumors of the parapharyngeal space. Thechoice of surgical approach depends on the size of the tu-mor, its location, its relationship to the great vessels, andthe suspicion of malignancy2–5. We present a case of aparapharyngeal space tumor presenting as an intraoraltumor mass and discuss its diagnostic and treatment op-tions.Case ReportWe report a case of a 45 year old female patient admit-ted at the ENT Department due to a unilateral (left)hearing loss and swallowing difficulties several monthsprior to hospitalization.The patient was in a good general health with no con-comitant diseases. Clinical examination revealed an oro-pharyngeal tumor mass with the intact mucosa. Fineneedle biopsy was performed and the diagnosis was thetumor mixtus. The MSCT imaging showed a cystic tumormeasuring 5x5cm in diameter firmly attached to thedeep lobe of the parotid gland originating from the ptery-gopalatine fossa and spreading towards the oro and naso-pharynx. Tumor cranially spread towards the skull baseand laterally extended to the ramus of the mandible andC1–2 vertebrae (Figure 1). The angiography was per-formed and showed moderate compression of the inter-nal carotid artery by the tumor but not its infiltration.Audiometric findings revealed the left side conductivehearing loss. Laboratory findings were within reference193Received for publication October 15, 2011U:\coll-antropolo\coll-antro-(Suppl 2)-2012\19 Kovacic.vp7. prosinac 2012 11:01:12Color profile: DisabledComposite  150 lpi at 45 degreesrange. Under the general anesthesia the tumor was re-moved by the transoral approach (Figure 2). Post-opera-tive period was uneventful. Final diagnosis was pleomor-phic adenoma, Tumor mixtus (Figure 3). Two yearsfollowing the surgery the patient is free of any recurrentdisease.DiscussionMajority of parapharyngeal space tumors are eithersalivary glands tumors originating from the deep lobe ofthe parotid gland or neurogenic tumors originating fromthe cranial nerves, the cervical symphatetic chain or theglomus bodies (chemoreceptors). Metastatic tumors aremainly thyroid carcinoma, osteogenic sarcoma, and squa-mous cell carcinoma. Tumors may also extend from sur-rounding structures and spread to the parapharyngealspace (i.e. mandible, maxilla, nasopharynx, neck, oralcavity, oropharynx, and temporal bone)5. Patients withparapharyngeal space tumors should undergo a compre-hensive history and complete head and neck examination(careful inspection and examination of the oropharynxand neck, and assessments of the functional integrity ofthe cranial nerves). Clinical presentation is very vari-able. Tumors can present as an oropharyngeal or neckmass or with other symptoms such as dysphagia, dys-pnea, unilateral conductive hearing loss, hoarseness, truevocal cord palsy, Horner’s syndrome and symptoms ofcatecholamine excess like hypertension and flushing1,5.In our case the tumor presented as an oropharyngealmass and patient complained of a unilateral hearing lossand swallowing difficulties several months prior to ad-mittance. The CT scan can provide excellent imaging ofthe parapharyngeal space. The imaging characteristicsand anatomic location of tumors originating in para-pharyngeal space (prestyloid or poststyloid compartmenttumors) can help in diagnosis. Fine needle aspiration ofthe lesion can be useful in some cases but this shouldonly be performed after imaging to rule out a vascularlesion6. If paraganglioma are suspected the patient shouldundergo a 24-hour urine collection for vanillymandelicacid and metanephrines. In the present case the MSCTimaging showed a cystic tumor originating from thepterygopalatine fossa firmly attached and not differenti-ated from the deep lobe of the parotid gland. Surgery isthe best treatment option for parapharyngeal space tu-mors. Different surgical approaches exist (transoral,transcervical, trannscervical-transparotid, transcervical--transmandibular and infratemporal-fossa approach).Nonoperative management of parapharyngeal space le-sions is an option for elderly patients, those who have acomorbid disease, unresectable lesions and for those whohave benign, slow-growing tumors. In the present caseafter thorough clinical evaluation we decided to removeM. Kova~i} et al.: Parapharyngeal Space Tumor, Coll. Antropol. 36 (2012) Suppl. 2: 193–195194Fig. 1. MSCT scan showing tumor mass of the left parapharyn-geal space attached to the deep lobe of the parotid gland.Fig. 2. Tumor excision by the transoral surgical approach.Fig. 3. Excised tumor measuring 5x5cm in diameter. Final diag-nosis was pleomorphic adenoma.U:\coll-antropolo\coll-antro-(Suppl 2)-2012\19 Kovacic.vp23. studeni 2012 16:06:08Color profile: DisabledComposite  150 lpi at 45 degreesthe tumor transorally. This approach was reported to bebest suitable for small, isolated pleomorphic adenomasthat originate from a small salivary gland in the soft pal-ate or lateral pharyngeal wall tumors. The main disad-vantage of this approach is limited exposure, increasedrisk of tumor spillage, and possibility of neurovascularinjury. However, this approach gives the best possiblepostoperative recovery for the patient (lack of postopera-tive scar, no damage to the cranial nerves, preservationof the superficial lobe of the parotid gland and facialnerve, absence of Frey’s syndrome, no need for mandibu-lar osteotomy)7–10. In order to perform this kind of ap-proach for larger tumors like it was in our case, the sur-geon must have a comprehensive understanding andsurgical skills for treatment of tumors of parapharyngealspace. Postoperative period was uneventful and two yearsfollowing the surgery there is no recurrence of the pri-mary symptoms and disease. The recurrence rate of be-nign parapharyngeal space neoplasms following surgicalextirpation ranges from 0–9%5. Radiation therapy couldbe also considered as a treatment for some parapharyn-geal space tumors primarily for malignant neoplasm andin patients with paragangliomas who are poor surgicalcandidates.R E F E R E N C E S1. GOURIN CG. JOHNSON JT. Parapharyngeal space tumors. Ac-cessed September 2011. Available from: URL: http:/emedicine.medscape.com/article/849385-overview#a0102. — 2. SUAREZ-FENTE V, LLO-RENTE-PENDAS JL, GOMEZ-MARTINEZ J, GARCIA-GONZALEZ LA,LOPEZ-ALVAREZ F, SUAREZ-NIETO C. Acta Otorrinolaringol Esp, 60(2009) 19, DOI: 10.1016/S0001-6519(09)70313-9. — 3. EISELE DE,NETTERVILLE JL, HOFFMAN HT, GANTZ BJ. Head Neck, 21 (1999)154, DOI: 10.1002/(SICI)1097-0347(199903)21:2<154::AID-HED9>3.0.CO;2-W — 4. HUGHES KV III, OLSEN KD, MCCAFFREY TV. HeadNeck, 17 (1995) 124, DOI: 10.1002/hed.2880170209. — 5. CARRAU RL,MYERS EN, JOHNSON JT. Laryngoscope, 100 (1990) 583. — 6. ARNA-SON T, HARD RD, TAYLOR SM, TRITES JR, NASSER JG, BULLOCKMJ. Diagn Cytopathol, 40 (2012) 118, DOI: 10.1002/dc.21508. — 7. IN-FANTE-COSSIO P, GONZALES-CARDERO E, GONZALES-PEREZ LM,LEOPOLDO- RODADO M, GARCIAPERLA A, ESTEBAN F. Oral Ma-xillofac Surg, 15 (2011) 211, DOI: 10.1007/s10006-011-0289-2. — 8. PRE-SUTTI L, MOLTENI G, MALVE L, MARCHIONI D GHIDINI A, TASSIS, CHIARINI L, ALICANDRI-CIUFELLI M. Eur Arch Otorhinolaryngol,269 (2012) 265, DOI: 10.1007/s00405-011-1594-y. — 9. BRADELEY PJ,BRADELY PT, OLSEN KD. Curr Opin Otolaryngol Head Neck Surg, 19(2011) 92, DOI: 10.1097/MOO.0b013e328342b9b4. — 10. DIMITRIJE-VIC JM, JESIC SD, MIKIC AA, ARSOVIC NA, TOMANOVIC NR. Int JOral Maxillofac Surg, 39 (2010) 983, DOI: 10.1016/j.ijom.2010.06.005.M. Rudi}Zadar General Hospital, Department of Otorhinolaryngology, B. Peri~i}a 5, 23 000 Zadar, Croatiae-mail: milan.rudic@yahoo.comTRANSORALNA EKSCIZIJA TUMORA PARAFARINKSA: PRIKAZ SLU^AJAS A @ E T A KTumori parafaringealnoga prostora predstavljaju svega 1% od ukupnih tumora glave i vrata. Naj~e{}e su porijekla`lijezda slinovnica ili neurogenoga porijekla. Klini~ka prezentacija je vrlo varijabilna. Kirur{ka resekcija predstavljanajva`niji oblik lije~enja. U radu prikazujemo slu~aj bolesnice koja se javja na Odjel za bolesti uha, grla i nosa zbogvi{emjese~ne jednostrane zaglu{enosti i te{ko}a gutanja. Klini~kom obradom (MSCT radiolo{ka obrada, citolo{kapunkcija) ustanovljen je pleomorfni adenom parafaringealnoga prostora. Transoralnim pristupom reseciran je tumor.Dvije godine postoperativno nema znakova recidiva osnovne bolesti.M. Kova~i} et al.: Parapharyngeal Space Tumor, Coll. Antropol. 36 (2012) Suppl. 2: 193–195195U:\coll-antropolo\coll-antro-(Suppl 2)-2012\19 Kovacic.vp23. studeni 2012 16:06:08Color profile: DisabledComposite  150 lpi at 45 degrees

Transoral Excision of a Parapharyngeal Space Tumor: Case Report

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