Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... ·...
Transcript of Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... ·...
![Page 1: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/1.jpg)
ParapharyngealParapharyngealParapharyngealParapharyngealSpaceSpacepp
Khalid Khalid HussainHussain ALAL--QahtaniQahtania da d ussaussa Qa aQa aMD,MSc,FRCSMD,MSc,FRCS(c)(c)Assistant ProfessorAssistant ProfessorAssistant Professor Assistant Professor
Consultant of OtolaryngologyConsultant of OtolaryngologyAd H d & N k O lAd H d & N k O lAdvance Head & Neck Oncology , Advance Head & Neck Oncology ,
Thyroid Thyroid & & Parathyroid,MicrovascularParathyroid,MicrovascularR t tiR t ti dd Sk llSk ll B SB SReconstructionReconstruction, and , and Skull Skull Base SurgeryBase Surgery
![Page 2: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/2.jpg)
ObjectivesObjectivesObjectivesObjectives
• AnatomyAnatomy• Clinical evaluation
P th l• Pathology• Imaging• Surgical treatment• Nonsurgical optionsNonsurgical options
![Page 3: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/3.jpg)
AnatomyAnatomyAnatomyAnatomy
• Potential deep neck• Potential deep neck space
• Shaped as anShaped as an inverted pyramid
• Base of the pyramid: skull base
• Apex of the pyramid: greater cornu of the hyoid bone
![Page 4: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/4.jpg)
AnatomyAnatomyAnatomyAnatomy
• Superior:• Superior: small portion oftemporal bonetemporal boneand sphenoidbbones• Inferior:j ti f thjunction of theposterior belly ofthe digastric andthe hyoid bone
![Page 5: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/5.jpg)
AnatomyAnatomyAnatomyAnatomy
• Medial: pharyngobasilar fascia andMedial: pharyngobasilar fascia and pharyngeal wall
• Lateral:• Lateral: • medial pterygoid muscle fascia• Mandibular ramus• Mandibular ramus• Retromandibular portion of the deep lobe of the
parotid gland• Posterior belly of digastric muscle
![Page 6: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/6.jpg)
AnatomyAnatomyAnatomyAnatomy
• Lateral: two ligamentsLateral: two ligaments– Sphenomandibular ligament– Stylomandibular ligamenty g
• Posterior: vertebral fascia and paravertebral muscle
• Anterior: pterygomandibular raphe and medial pterygoid muscle fascia
![Page 7: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/7.jpg)
AnatomyAnatomyAnatomyAnatomy
• Tensor vascular• Tensor-vascular-styloid fascia separates pparapharyngeal spaces to two compartments:– Prestyloid
P t t l id– Poststyloid
![Page 8: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/8.jpg)
AnatomyAnatomyAnatomyAnatomy
![Page 9: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/9.jpg)
AnatomyAnatomyAnatomyAnatomy
• Prestyloid compartment contents:Prestyloid compartment contents:– Retromandibular portion of the deep lobe of
the parotid glandthe parotid gland– Minor or ectopic salivary gland– CN V branch to tensor veli palatini muscle– CN V branch to tensor veli palatini muscle– Ascending pharyngeal artery and venous
plexusplexus– Most fat
![Page 10: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/10.jpg)
AnatomyAnatomyAnatomyAnatomy
• Poststyloid compartment contentsPoststyloid compartment contents– Carotid artery
Internal jugular vein– Internal jugular vein– CN IX to XII
Cervical sympathetic chain– Cervical sympathetic chain
![Page 11: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/11.jpg)
Stylomandibular TunnelStylomandibular TunnelStylomandibular TunnelStylomandibular Tunnel
• Posterior ramus of the mandiblePosterior ramus of the mandible • Stylomandibular ligament
Sk ll b• Skull base• Path for deep parotid tumors
![Page 12: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/12.jpg)
![Page 13: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/13.jpg)
ClinicalClinical PresentationPresentationClinical Clinical PresentationPresentation
• Clinical detection is difficultClinical detection is difficult• Tumor size 2.5 to 3.0 cm to be detected
clinicallyclinically• Asymptomatic mass
– Mild bulging of soft palate or tonsillar region 51%
– Palpable mass at angle of mandible 53%
![Page 14: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/14.jpg)
Clinical PresentationClinical PresentationClinical PresentationClinical Presentation
![Page 15: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/15.jpg)
ClinicalClinical SymptomsSymptomsClinical Clinical SymptomsSymptoms
• Prestyloid:y– Serous otitis media– Voice change– Nasal obstruction– Dyspnea
• Poststyloid:• Poststyloid:– Compress CN 9th, 10th, 11th, 12th or sympathetic chain– Hoarseness, dysphagia, dysarthria, Horner’s y p g y
syndrome• Cranial nerve paralysis, pain, trismus suggest
malignancymalignancy
![Page 16: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/16.jpg)
PathologyPathologyPathologyPathology
• Benign 80%Benign 80%
M li t 20%• Malignant 20%
• Direct extension, metastasis, primary tumors
![Page 17: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/17.jpg)
Direct ExtensionDirect ExtensionDirect Extension Direct Extension
• MandibleMandible• Maxilla
N h• Nasopharynx• Neck• Oral cavity• OropharynxOropharynx• Temporal bone
![Page 18: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/18.jpg)
MetastasisMetastasisMetastasisMetastasis
• Follicular thyroid cancerFollicular thyroid cancer• Papillary thyroid cancer
M d ll th id• Medullary thyroid cancer• Osteogenic sarcoma• Squamous cell carcinoma
![Page 19: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/19.jpg)
Primary TumorsPrimary TumorsPrimary TumorsPrimary Tumors
• Three categories:Three categories:• Salivary gland tumors
• Neurogenic tumors
• Miscellaneous tumorsMiscellaneous tumors
![Page 20: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/20.jpg)
Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosis
• Location of the tumor:Location of the tumor: – Prestyloid:
• Salivary gland neoplasm• Salivary gland neoplasm • Lipoma• Rare neurogenic tumorsg
– Poststyloid:• Schwannoma• Paraganglioma• Neurofibroma
![Page 21: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/21.jpg)
Salivary Gland TumorsSalivary Gland TumorsSalivary Gland TumorsSalivary Gland Tumors
• Most common PPS neoplasms: 40-50%Most common PPS neoplasms: 40 50%• Prestyloid masses
Pl hi d 80 90%• Pleomorphic adenoma 80-90%• Mucoepidermoid most common malignant• Less than 5% parotid tumors involve the
PPS
![Page 22: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/22.jpg)
Salivary Gland TumorsSalivary Gland TumorsSalivary Gland TumorsSalivary Gland Tumors
• Located in prestyloid spaceLocated in prestyloid space• From deep lobe of parotid or minor
salivary glandssalivary glands• On CT or MRI a fat plane between the
tid d t l id i di tparotid and a prestyloid mass indicates minor salivary gland origin
• Displace the internal carotid posteriorly
![Page 23: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/23.jpg)
Neurogenic Tumors: 17Neurogenic Tumors: 17--25%25%Neurogenic Tumors: 17Neurogenic Tumors: 17 25%25%
• SchwannomaSchwannoma
P li• Paraganglioma
• Neurofibroma
![Page 24: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/24.jpg)
SchwannomaSchwannomaSchwannomaSchwannoma
• Most common neurogenic neoplasmMost common neurogenic neoplasm• Vagus, sympathetic chain most common
B i d l i• Benign and slow growing• Generally don’t affect nerve of origin• Less than 1% malignant• Displace internal carotid anteriorlyDisplace internal carotid anteriorly
![Page 25: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/25.jpg)
ParagangliomaParagangliomaParagangliomaParaganglioma
• Second most common• Arise from nodose ganglion of vagus, extend
superiorly from carotid body, extend inferiorly f j l b lbfrom jugular bulb
• Bilateral 10%, familial 30%P t f MEN IIA IIB ( d ll th id• Part of MEN IIA or IIB (medullary thyroid carcinoma, pheochromocytoma, parathyroid hyperplasia- with or without mucosal neuromas)ype p as a t o t out ucosa eu o as)
![Page 26: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/26.jpg)
ParagangliomaParagangliomaParagangliomaParaganglioma
• Secrete catecholamines 1-3%Secrete catecholamines 1 3%• Malignant 10%
Cl i ll li bil• Classically, paragangliomas mobile anterior-posterior but not up and down
• Glomus vagale displace carotid anteriorly• Carotid body tumors splay internal and y p y
external carotid – “lyre” sign
![Page 27: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/27.jpg)
NeurofibromasNeurofibromasNeurofibromasNeurofibromas
• 3rd most common neurogenic tumor3 most common neurogenic tumor• From Schwann cells and fibroblasts
U l t d (i l )• Unencapsulated (involve nerve)• Multiple• Part of Neurofibromatosis type I
![Page 28: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/28.jpg)
Miscellaneous TumorsMiscellaneous TumorsMiscellaneous TumorsMiscellaneous Tumors
• Wide variety of tumorsWide variety of tumors
20% f t t l PPS t• 20% of total PPS tumors
• Lymphoma, hemangioma, teratoma, lipoma, branchial cleft cyst, arteriovenous p , y ,malformation, internal carotid artery aneurysmy
![Page 29: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/29.jpg)
Work upWork upWork upWork up
• Complete HN Hx & examComplete HN Hx & exam
I i• Imaging
• FNA after imaging
• If paraganglioma is suspected need to check 24 hour urine for catecholamines:check 24 hour urine for catecholamines: VMA, metanephrines, etc
![Page 30: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/30.jpg)
ImagingImagingImagingImaging
• CTCT
MRI/MRA• MRI/MRA
• angiography
![Page 31: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/31.jpg)
CTCTCTCT
• Locates tumor to prestyloid vs retrostyloidLocates tumor to prestyloid vs retrostyloid• Fat plane between mass and parotid
Di l t f tid• Displacement of carotid• Enhancement of lesion• Bone erosion due to malignancy• Limited soft tissue detailLimited soft tissue detail
![Page 32: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/32.jpg)
![Page 33: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/33.jpg)
MRIMRIMRIMRI
• Most useful studyMost useful study
R l ti hi f d tid• Relationship of mass and carotid more easily seen than with CT
• Characteristic appearances of tumor types pp ypon MRI allows preoperative Dx in 90-95% of patientsp
![Page 34: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/34.jpg)
PleomorphicPleomorphic AdenomaAdenomaPleomorphicPleomorphic AdenomaAdenoma
• Low signal intensityLow signal intensity on T1
• High signal intensity g g yon T2
• Displace carotid pposteriorly
![Page 35: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/35.jpg)
SchwannomaSchwannomaSchwannomaSchwannoma
• High signal intensityHigh signal intensity on T2
• Displace carotid panteriorly
![Page 36: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/36.jpg)
ParagangliomaParagangliomaParagangliomaParaganglioma
• Numerous flow voidsNumerous flow voids• “Salt and pepper”
appearancepp• Displace carotid
anteriorlyy
![Page 37: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/37.jpg)
AngiographyAngiographyAngiographyAngiography
• Used to be all enhancing lesionsUsed to be all enhancing lesions• Gold standard for relationship to great
vesselsvessels• Differentiate neurogenic and vascular• Remember “lyre” sign• Balloon occlusion test if possible sacrificep
![Page 38: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/38.jpg)
“Lyre” sign“Lyre” signLyre signLyre sign
![Page 39: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/39.jpg)
AngiographyAngiographyAngiographyAngiography
• Tumor embolization can be performed onTumor embolization can be performed on paragangliomas 24 hours prior to procedureprocedure
M fib i ki di ti• May cause fibrosis making dissection difficult
![Page 40: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/40.jpg)
Surgical approachesSurgical approachesSurgical approachesSurgical approaches
• TransoralTransoral• Transcervical
T i l P tid• Transcervical-Parotid• Transparotid• Cervical-transpharyngeal “swing”• Infratemporal fossaInfratemporal fossa• Transcervical-transmastoid
![Page 41: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/41.jpg)
TransoralTransoralTransoralTransoral
• Has been used for small benign tumorsHas been used for small, benign tumors
V li it d• Very limited exposure
• Increased risk of tumor spillage, neurovascular injuryj y
![Page 42: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/42.jpg)
TranscervicalTranscervicalTranscervicalTranscervical• Transverse incision at
level of hyoid• Submandibular gland
displace or removeddisplace or removed• Increase exposure by
releasing digastric, stylohyoid styloglossusstylohyoid, styloglossus from hyoid, cut stylomandibular ligament, mandibulotomymandibulotomy
![Page 43: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/43.jpg)
TranscervicalTranscervical--parotidparotidTranscervicalTranscervical parotidparotid
• Extend cervical incision up infront of earExtend cervical incision up infront of ear• Allows identification facial nerve
Di id t i b ll di t i• Divide posterior belly digastric • Divide stylomandibular ligament,
styloglossus, stylohyoid close to styloid process
![Page 44: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/44.jpg)
TranscervicalTranscervical--parotidparotid approachapproachTranscervicalTranscervical parotid parotid approachapproach
![Page 45: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/45.jpg)
TransparotidTransparotidTransparotidTransparotid
• For deep lobe parotid tumorsFor deep lobe parotid tumors• Superficial parotidectomy
F i l t t d• Facial nerve retracted• Dissect around mandible• May use mandibulotomy
![Page 46: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/46.jpg)
CervicalCervical--transpharyngealtranspharyngealCervicalCervical transpharyngealtranspharyngeal
• “mandibular swing”g• Large or highly
vascular tumors• Mandibulotomy
anteriorly, incise along floor of mouthalong floor of mouth to anterior tonsillar pillar
• Need a tracheotomy
![Page 47: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/47.jpg)
Infratemporal fossaInfratemporal fossaInfratemporal fossaInfratemporal fossa
• Preauricular lateral infratemporal fossaPreauricular lateral infratemporal fossa approach
• Skull base or infratemporal fossa i l tinvolvement
![Page 48: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/48.jpg)
TranscervicalTranscervical--transmastoidtransmastoidTranscervicalTranscervical transmastoidtransmastoid
• Cervical incision carried postauricularly
• Mastoidectomy• Remove mastoid tip
exposing jugular fossa• Facial nerve may need to• Facial nerve may need to
be dissected from Fallopian canal
![Page 49: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/49.jpg)
Nonsurgical ManagementNonsurgical ManagementNonsurgical ManagementNonsurgical Management
• Poor surgical canidates failed balloonPoor surgical canidates, failed balloon occlusion, elderly, unresectable lesions, would require sacrifice of multiple cranialwould require sacrifice of multiple cranial nerves
• Observation• Observation• Radiation
![Page 50: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/50.jpg)
ObservationObservationObservationObservation
• Paraganliomas grow 1 0-1 5 mm per yearParaganliomas grow 1.0 1.5 mm per year
B i• Benign
• Mortality less than 10% per year for untreated
![Page 51: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/51.jpg)
RadiationRadiationRadiationRadiation
• Not curableNot curable
U d f l l t l• Used for local control
• Some shrink, mostly stops growth
• Local control 90-100% reported
![Page 52: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/52.jpg)
Key things to remember:Key things to remember:Key things to remember:Key things to remember:
• Prestyloid vs PoststyloidPrestyloid vs. Poststyloid• Most are benign
Pl hi t t l id• Pleomorphic most common prestyloid• Neurogenic tumors are poststyloid• “Surgery is mainstay of therapy
![Page 53: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/53.jpg)
Hi tHi tHistoryHistory• 50 y old F.50 y old F.
• CC :• CC :- Large cervical goiter.
• PMHx:- Asymptomatic goiter.
![Page 54: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/54.jpg)
P/EP/EP/EP/E• Neck:Neck:- Large goiter.
• HN exam:- Normal
![Page 55: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/55.jpg)
U/S NeckU/S NeckU/S NeckU/S Neck
- Large multinodular goiter,more in left idside.
- On Left side ,no distinct nodules were measureable.
- On right side largest nodule 1 5 cmOn right side,largest nodule 1.5 cm.- No adenopathy.
![Page 56: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/56.jpg)
CTCT NecKNecKCT CT NecKNecK
![Page 57: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/57.jpg)
CTCT NeckNeckCT CT NeckNeck
• Goitrous thyroid with dominant noduleGoitrous thyroid with dominant nodule arising from left inf lobe.
• No lymphadenopathy.
• Incidental 3cm lesion in left paraphryngealIncidental 3cm lesion in left paraphryngeal space region,suspicious for pseudoaneurysmpseudoaneurysm.
![Page 58: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/58.jpg)
AngiogramAngiogramAngiogramAngiogram
![Page 59: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/59.jpg)
AngiogramAngiogramAngiogramAngiogram
![Page 60: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/60.jpg)
AngiogramAngiogramAngiogramAngiogram
L l ft i t l tid t• Large left internal carotid artery aneurysm2.25 cm by 3.29 cm,at skull base.
![Page 61: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/61.jpg)
TreatmentTreatmentTreatmentTreatment
• Tracheostomy Mandibular Osteotomy andTracheostomy,Mandibular Osteotomy and Swing Transoral Approach to left parapharngeal space and left Cervicalparapharngeal space and left Cervical Neck Dissection.
ANDAND• Resection and Repair of internal carotid
artery aneurysm.
![Page 62: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/62.jpg)
SurgerySurgerySurgerySurgery
![Page 63: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/63.jpg)
SurgerySurgerySurgerySurgery
![Page 64: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/64.jpg)
SurgerySurgerySurgerySurgery
![Page 65: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/65.jpg)
SurgerySurgerySurgerySurgery
![Page 66: Parapharyngeal Space - KSUfac.ksu.edu.sa › sites › ... › files › parapharyngeal_space... · Parapharyngeal Space Khaadlid HHussain ALL--QaQa ahtani MD,MSc,FRCSMD,MSc,FRCS(c)(c)](https://reader033.fdocument.pub/reader033/viewer/2022052423/5f0d011d7e708231d4383396/html5/thumbnails/66.jpg)
F/UF/UF/UF/U