Neck and Parapharyngeal Space Neoplasms

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Neck and Parapharyngeal Space Neoplasms

Head and Neck Surgery
Author Credentials 

Jonas T. Johnson, MD
Professor and Chairman, Department of Otolaryngology
University of Pittsburg
Pittsburg, PA

John D. Cramer, MD
Department of Otolaryngology
University of Pittsburg
Pittsburg, PA

Module Summary

Tumor involvement of the parapharyngeal space is a challenging aspect of head and neck surgery. Most parapharyngeal space tumors are benign of salivary gland or neurogenic origin. Modern imaging is essential for evaluation and treatment planning. Treatment is primarily surgical and various surgical approaches can be tailored to an individual neoplasm. However, observation for select patients with asymptomatic neurogenic tumors may be warranted. 

Module Learning Objectives 
  1. Describe the surgical anatomy of parapharyngeal space.  
  2. Define the pre- and poststyloid parapharyngeal space on imaging and predict tumor histology based on imaging characteristics.
  3. Recognize therapeutic options and limitations. 
  4. Identify potential and expected post-treatment complications. 

Anatomy

Learning Objectives 
  1. Describe the fascial layers that define the parapharyngeal space. 
  2. Recognize the fascia that separates the poststyloid parapharyngeal space from the prestyloid parapharyngeal space. 
  3. Understand the contents of the pre- and poststyloid parapharyngeal space. 
References 
  1. Joo W, Funaki T, Yoshioka F, et al. Microsurgical anatomy of the infratemporal fossa. Clin Anat. 2013;26:455-469. [EBM level N/A] 
     

Pathogenesis

Learning Objectives 

Indicate the cell of origin of a paraganglioma and the typical growth rate.

References 
  1. Jansen JC, van den Berg R, Kuiper A, et al. Estimation of growth rate in patients with head and neck paragangliomas influences the treatment proposal. Cancer. 2000;88:2811-2816. [EBM level 4] 

Basic Science

Learning Objectives 

Outline the heredity of multiple paraganglioma.

References 
  1. Baysal BE, Ferrell RE, Willett-Brozick JE, et al. Mutations in SDHD, a mitochondrial complex II gene, in hereditary paraganglioma. Science. 2000;287:848-851. [EBM level 2]

Incidence

Learning Objectives 

List the most common tumors encountered in the parapharyngeal space.

References 
  1. Riffat F, Dwivedi RC, Palme C, et al. A systematic review of 1143 parapharyngeal space tumors reported over 20 years. Oral Oncol. 2014;50:421-430. [EBM level 2]

Patient Evaluation

Learning Objectives 
  2. Describe indications for imaging.
  3. Understand indications for angiography and selective embolization.
References 
  1. Eisele DW, Richmon JD. Contemporary evaluation and management of parapharyngeal space neoplasms. J Laryngol Otol. 2013;127:550-555 [EBM level 5]
  2. Jackson RS, Myhill JA, Padhya TA, et al. The Effects of Preoperative Embolization on Carotid Body Paraganglioma Surgery: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2015;153:943-950 [EBM level 2]

Imaging

Learning Objectives 
  1. Describe radiographic landmarks that distinguish the pre- from poststyloid parapharyngeal space.
  2. Understand radiographic characteristics of neuromas, paragangliomas, and mixed tumors.
References 
  1. Gupta A, Chazen JL, Phillips CD. Imaging evaluation of the parapharyngeal space. Otolaryngol Clin North Am. 2012;45:1223-1232 [EBM level 5]

Pathology

Learning Objectives 

Know the kinds of tumors that may be encountered in either the pre- or poststyloid parapharyngeal space.

References 
  1. Riffat F, Dwivedi RC, Palme C, et al. A systematic review of 1143 parapharyngeal space tumors reported over 20 years. Oral Oncol. 2014;50:421-430 [EBM level 2]

Treatment

Learning Objectives 

What are criteria for observation of parapharyngeal space masses.

References 
  1. Moore MG, Netterville JL, Mendenhall WM, et al. Head and Neck Paragangliomas: An Update on Evaluation and Management. Otolaryngol Head Neck Sur. 2016;154:597-605. [EBM level 4]
  2. Langerman A, Athavale SM, Rangarajan SV, et al. Natural history of cervical paragangliomas: outcomes of observation of 43 patients. Arch Otolaryngol Head Neck Surg. 2012;138:341-345. [EBM level 4]

Medical Therapies

Learning Objectives 

Know potential uses of radiotherapy for pharyngeal space masses.

References 
  1. Gilbo P, Morris CG, Amdur RJ, et al. Radiotherapy for benign head and neck paragangliomas: a 45-year experience. Cancer. 2014;120:3738-3743. [EBM level 4]

Surgical Therapies

Learning Objectives 
  1. Understand surgical approaches to the prestyloid parapharyngeal space.
  2. Describe surgical approaches to the poststyloid parapharyngeal space.
  3. Indicate the advantages and disadvantages of preoperative embolization.
  4. Describe function-sparing enucleation of neurogenic tumors.
  5. Describe minimally invasive approaches to the parapharyngeal space.
References 
  1. Carrau RL, Johnson JT, Myers EN. Management of tumors of the parapharyngeal space. Oncology. 1997;11:633-42.
  2. Cohen SM, Burkey BB, Netterville JL. Surgical management of parapharyngeal spaces masses. Head Neck. 2005;27(8):669-75.
  3. Eisele DE, Netterville JL, Hoffman HT, et al. Parapharyngeal space masses. Head Neck. 1999;21:154-159. [EBM level 5]
  4. Beswick DM, Vaezi A, Caicedo-Granados E, et al. Minimally invasive surgery for parapharyngeal space tumors. Laryngoscope. 2012;122:1072-1078. [EBM level 4]
  5. Langerman A, Athavale SM, Rangarajan SV, et al. Natural history of cervical paragangliomas: outcomes of observation of 43 patients. Arch Otolaryngol Head Neck Surg. 2012;138:341-345. [EBM level 4]
  6. Netterville JL, Reilly KM, Robertson D, et al. Carotid body tumors: A review of 30 patients with 46 tumors. Laryngoscope. 1995;105:115-26.
  7. Carrau RL, Myers EN, Johnson JT. Management of tumors arising in the parapharyngeal space. Laryngoscope. 1990;100:583-589 [EBM level 4]

Complications

Learning Objectives 
  1. List the complications associated with treatment of tumors of the parapharyngeal space.
  2. Indicate risk of cerebral vascular injury during carotid paraganglioma resection. 
  3. Understand the risk of vagus nerve injury when resecting vagal paraganglioma. 
  4. List the complications associated with treatment of paragangliomas of the vagus nerve. 5. Describe voice rehabilitation following vagus nerve in jury or resection. 
  5. Indicate strategies for swallow rehabilitation following multiple cranial nerve injury. 
References 
  1. Netterville JL, Jackson CG, Civantos F. Thyroplasty in the functional rehabilitation of neurotologic skull base surgery patients. Am J Otolaryngol. 1993;14:460-4. [EBM level 4]
  2. Chiu AG, Cohen JI, Burningham AR, et al. First bite syndrome: a complication of surgery involving the parapharyngeal space. Head Neck. 2002; 24:996-999. [EBM level 4]

Review

Review Questions 
  1. What is the differential diagnosis of a parapharyngeal space mass? 
  2. How can parapharyngeal space masses be differentiated on imaging? 
  3. What is the natural history and average growth rate of paragangliomas? 
  4. What are indications for observation of asymptomatic neurogenic parapharyngeal space masses? What are indications for surgical excision? 
     
Resources 

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  1. Rhoton Collection Lecture on Head and Neck Anatomy for Neurosurgeons, includes excellent video and anatomy of parapharyngeal space at 24-minute mark. 
  2. Radiopaedia: Interactive parapharyngeal anatomy based on MRI scan. 
  3. Video of Transoral Robotic Excision of Parapharyngeal Space Mass by Dr Jeremy Richmon at Johns Hopkins University.
  4. Podcast: ENT Expert Opinion Glomus Tumors (Paragangliomas): Dr Sean Flannagan discusses head and neck paraganglionomas in 22 minute video. Available to download for free in iTunes. .