1. Dr. Simple Patadia MS ENT Neuro-Otology
Benign Parapharyngeal Tumours: Surgical Intricacies by Trans-cervical Approach
Dr. Simple Patadia
MS ENT
Neuro-Otology

2. Introduction
Parapharngeal Space is one of the potential confined fascial planes of head and neck that can be involved by various pathological processes.
Constitute less than 0.5% of all head and neck tumours (80% benign).
Surgical removal of these tumours is the best treatment.

3. Anatomy

4. Tensor Veli Styloid Fascia

5. Differential Diagnosis
Pre-styloid Space
Post-styloid Space
Salivary gland neoplasm
Lipoma
Neurogenic tumours
Warthin’s tumour
Oncocytomas
Schwannoma
Paraganglioma
Neurofibroma

6. Approaches to PPS

7. Recent advances have considered the use of endoscopes, microdebriders, neuronavigation, and robotic surgery to felicitate better tumour removal.
The experience of PPST in our institiute via transcervical approach is highlighted in this study.

8. Materials and Methods Retrospective study 19 Cases
Study Period: January 2013 to January 2015
Surgery: Excision via Transcervical approach
The data obtained were reviewed on basis of patients clinical details, presenting symptoms, imaging characteristics, fine needle aspiration cytology, surgical approach, postoperative complications, and histological confirmation.

9. Post styloid tumours

10. Trans-Cervical Approach Incision and elevation of subplatysmal flap

11. Exposure and Control of Great vessels

12. Tumour Removal

13. Tumour Removal by blunt dissection

14. Specimen

15. Prestyloid Space Tumour

17. Rare Cases

18. Preop Mri (Axial + Coronal)

19. Cross Flow and Balloon Occlussion Test

20. Incision

21. Removal of SCM for exposure

22. Tumour Dissected from surrounding structures

23. Identification

24. Pleomorphic adenoma extending into PPS

25. Exposure

26. Identification of Facial Trunks

27. Facial Nerve Reconstruction

28. Tumour removed in 2 parts

29. Carotid Body Tumour

30. Localising tumour

31. Removing tumour from the carotid adventitia

32. After tumour removal

33. Tumour removed

34. Results
Most common presenting complaint was a unilateral neck mass (89.8%).
The mean age at presentation was 42.4 years (Range: years).
The study group had seven males (37%) and 12 females (63%).
FNAC (Fine Needle Aspiration Cytology) was done in all cases. Positive Predictive Value (PPV) of FNAC was 57.14%.

35. Results
All patients underwent tumour excision via transcervical approach.
Submandibular gland was removed to improve exposure in four cases and in one case it was retracted anteriorly.
SCM cut to improve exposure in 2 cases.
Extracapsular dissection was done in twelve (85.71%) cases, while intracapsular debulking was required in two cases (14.28%).
Complete tumour excision was done in all cases.

36. Complications
(Table 1). None of the patients developed wound infection or hematoma.

37. Histopathological Diagnosis
No cases have tumour recurrences till present

38. Schwannoma Subtypes

39. Discussion
Histologically and anatomically, the most common tumour of the parapharyngeal space is parotid pleomorphic adenoma.
The imaging modality of choice according to our study is MRI as it better delineates origin (prestyloid/poststyloid compartment), character (benign/malignant), vascularity, and also shows relation with the deep lobe of parotid and the great vessels.

40. Comparison In Angiogram

41. Schwannoma Vs CBT

42. Discussion
Transcervical approach not only gives excellent exposure both in pre-styloid and post-styloid spaces, but also prevents any undue injury to vessels and nerves.
The key to prevent any complications during surgery is to perform blunt dissection along the tumour capsule (extracapsular dissection) and avoid its rupture.
However in cases with large suspected schwannomas with difficult dissection superiorly and medially, internal enucleation and debulking of tumour is recommended by us to avoid mandibulotomy.
Functional preservation of peripheral nerves by intracapsular enucleation has been reported in literature

43. Conclusion
Tumours of parapharyngeal space are challenging and have important surgical considerations due to their close relation to neurovascular structures and deep lobe of parotid gland.
Imaging plays a crucial role to delineate origin, vascularity and relation with the great vessels.
The transcervical approach is a versatile approach for complete excision of tumours with excellent exposure and minimum morbidity. It can also be combined with excision of submandibular gland in order to improve exposure.
Intracapsular debulking is recommended in cases of schwannomas, which can provide better neural preservation rate.