Surgical Access to Parapharyngeal Space Tumours -The Manipal
02 Parapharyngeal Tumors
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Dr Nikhil S B
PARAPHARYNGEAL SPACE TUMORS
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Bibliography
• Scott-Brown’s 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
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ANATOMY
Parapharyngeal Space
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ANATOMYParapharyngeal Space
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ANATOMYParapharyngeal Space
Prestyloid compartment
• Fat• Retromandibular parotid• Lymphnodes• Internal maxilary artery• Inferior alveolar nerve• Lingual nerve• Auriculotemporal nerve
Retrostyloid compartment
• Internal carotid artery• Jugular vein• Cervical Sympathetic chain• Cranial nerves IX-XII• Lymphnodes
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Stylomandibular Tunnel
• Extension
• Medial vs Lateral tumors
ANATOMYParapharyngeal Space
Retropharyngeal Space – Node of Rouviere
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PARAPHARYNGEAL TUMORS
Account for 0.5% of all head and neck neoplasms
Benign: 80% Malignant 20%
Direct extension, metastasis, primary tumors
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TUMORS OF THE PARAPHARYNGEAL SPACE
Direct Extension
Metastasis
Primary tumors
Salivary gland tumors (40 – 50%)Neurogenic tumors (17 – 25%)Miscellaneous (20%)
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COMMON TUMORS
Minor salivary gland tumors
Benign mixed tumor
Origin
Growth pattern
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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
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COMMON TUMORS
Malignant tumor of Parotid
Adenoid cystic Ca
Lateral extension picks off VII CN
Spl Characteristic
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COMMON TUMORS
Neurogenic tumors
2nd most common tumor
3 categories – Schwannoma ( Neurilemmoma)
Neurofibroma
Ganglion Neuroma
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COMMON TUMORS
Schwannoma ( Neurilemmoma)
Most common
Origin – schwann cells
Growth pattern
Features
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Schwannoma ( Neurilemmoma)
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COMMON TUMORS
Neurofibroma
Dual origin
Charateristic Growth patern
Ganglion Neuroma
Rare
Characteristics
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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
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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
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Incidence
Male : Female – 2:1 (US); 1:8.3 (Mexico)
Most paraganglioma are solitary
Multiple seen in familial syndromes – MEN II A & B
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Biochemistry
APUD System
Convert Dopa & Dopamine to neurotransmitters
Biochemical synthesis of catecholamine – Adrenal
Diet Tyrosine ---- L-dopa ----Dopamine
PhenylalanineEpinephrine Norepinephrine
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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
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Physiology
Carotid sinus – stretch receptors
Carotid body – sensitive to PaO2, pH & blood flow
Carotid body – sinus complex : Baroreceptor. Type I & II
Signals ---- Herring’s nerve ---- IX ---- Medullary area of brainstem
---- Secondary signals ---- Excite Vagal centres ---- inhibit
Vasoconstrictive center
Stimulation causes parasympathetic response
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Carotid Body Tumor
Origin
Growth pattern
Extension/ complication
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Carotid Body Tumor
Classification – 3 stage classification (Shamblin)
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Glomus vagale
• Similar to carotid body tumors• Distiguishing growth patterns• Easier excision
Glomus jugulare
• origin
• Growth patterns
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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
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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
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COMMON TUMORS
Meningioma
Intracranial tumors
Extends into infratemporal fossa and then to parapharyngeal space
Ameloblastoma
Maxillary
Mandibular
Horizontal ramus
Ascending ramus
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OTHER COMMON TUMORS
Metastasis to the space
Closely related to – Nasopharynx – Oropharynx – Nose & PNS – BOT – Parotid
Common metastatic
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SPREAD WITHIN SPACE
Extension along path of least resistance
Medial and lateral extension
Inferior and superior extension
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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
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Parapharyngeal tumors
Signs
Neck swelling Fig
Palatal /Pharyngeal swelling Fig
Parotid Mass
Trismus
Vascular thrill/ bruit
Secretory otitis media
Vocal cord palsy
Tongue deviation
Shoulder weakness
Horner’s syndrome
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INVESTIGATIONS
CT Scan
• Locates tumor to prestyloid vs retrostyloid
• Bone erosion due to malignancy
• Limited soft tissue detail
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MRI
• Relationship of mass to adjacent structures
• Characteristic appearances of tumor types on MRI allows preoperative Dx in 90-95% of patients
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MRI
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MRI
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MRI
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MRI
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MR Angiography
• Gold standard for relationship to great vessels
• Differentiate neurogenic and vascular
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Vascular displacementTumors 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
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Tissue diagnosis
FNAC accuracy rate - 88 - 95%
Improved with guided FNAC
Problems in FNAC – Tumor seeding Few cells in vascular tumors False positive
Investigations
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INVESTIGATIONS
Other investigations
111Indium octreotide scan MIBG Scan Tumor markers
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TREATMENT
SURGICAL Transoral
Transparotid
Transcervical
Transpharyngeal with mandibulotomy
Combined trans mastoid- transcranial
CHEMOTHERAPY
RADIOTHERAPY
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Transoral
• Indicated in small tumors
• Adv – direct appch
• Disadv – Limited exposure
Tumor spillage
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Transparotid (Lateral) approach
A. Total Conservative Parotidectomy
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TREATMENT
Transparotid (Lateral) approach
B. Conservative Lateral approach
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Transparotid (Lateral) approach
B. Conservative Lateral approach
TREATMENT
C. Radical Lateral approach
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TREATMENT
Transcervical approach ( Inferior approach)
Blind dissection of the tumor
Division of Medial pterygoid ms
Medial and anteromedial dissection from Sup constrictor ms
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With or without mandibulotomy
Increase exposure by releasing digastric, stylohyoid, styloglossus from hyoid, cut stylomandibular ligament, mandibulotomy
TREATMENT
Transcervical approach
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TREATMENT
Transpharyngeal with mandibilotomy approach
• Suitable for ITF and PPS tumors• Used for large PPS tumors
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Transcervical-transmastoid
• Cervical incision carried postauricularly
• Mastoidectomy
• Remove mastoid tip exposing jugular fossa
• Facial nerve may need to be dissected from Fallopian canal
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TREATMENT
Radiotherapy
Neoplasms PPS
NPC highly curable (3 yr survival 60 – 66%)
Vagal paraganglioma and Glomus jugulare – control by RT
Observation
Paraganliomas grow 1.0-1.5 mm per year
Mortality less than 10% per year for untreated
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TREATMENT
Chemoradiation
NPC; Rhabdomyosarcoma and other sarcomas
5 FU and Cisplatin for SCC
Doxorubicin – for glandular neoplasms
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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%
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Lateral neck mass
Back
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Oropharyngeal Mass
Back