Parapharyngeal space

surgical anatomy and approaches

1. para-pharyngeal space Dr safika zaman, PGT, dept of ent & head neck surgery, rkmsp , vims

2. introduction understanding of the anatomy and relationship of the various neck spaces is valuable in diagnosing and treating diseases of the neck

3. Neck spaces

4. Para-pharyngeal space Inverted pyramid with floor at skull base, tip at hyoid, bounded by the pharyngeal wall medially and the mandible laterally Also known as-lateral pharyngeal space, pharyngomaxillary space, pterygomaxillary space, pterygopharyngeal space.

5. Boundaries of pps The space between the muscles of mastication and the muscles of deglutition. Superior:  base of skull. Inferior: greater cornu of the hyoid bone. Medial: middle layer of the deep cervical fascia covering the superior pharyngeal constrictor  levator   tensor veli palatini  muscles

6. Boundaries of pps lateral: superficial layer of the deep cervical fascia extending between styloid process and mandibular ramus, 1 anterior:  pterygomandibular raphe and superficial layer of the deep cervical fascia covering the medial pterygoid muscle

7. Cont …. posterior: an extension of tensor veli palatini muscle fascia termed the tensor-vascular-styloid fascia ; or an extension of the fascia of the  stylopharyngeus ,  styloglossus , and  levator veli palatini  muscles .

8. compartments aponeurosis of Zuckerkandl and Testut This fascia joining the styloid process to the tensor veli palatini

9. Pre-styloid compartment masticator space Fat Retromandibular parotid Lymph node Internal maxillary artery Inferior alveolar nerve Lingual nerve

10. Post-styloid compartment/ carotid space Internal carotid artery Jugular vein Sympathetic chain Cranial nerves ⅸ-ⅻ Lymph nodes

11. Prestyloid lesions Pleomorphic adenoma - medial extension of a deep lobe parotid tumour Salivary gland tumors Lipoma Neurogenic tumors like trigeminal schwanomma Abscess Cystic hygroma Second branchial cleft cyst

12. Presenting symptoms of prestyloid lesions Asymptomatic. Medial displacement of the lateral pharyngeal wall and tonsil is a hallmark of a parapharyngeal space infection . Trismus, drooling, dysphagia, and odynophagia are also commonly observed. Change in voice. Guruprasad Y, Chauhan DS. Deep lobe parotid gland pleomorphic adenoma involving the parapharyngeal space.Med J DY Patil Univ 2012;5:62-65

13. Prestyloid pps tumor presentation The Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery by Johan Fagan (Editor) [email protected] is licensed under a Creative Commons Attribution

14. Lesions of carotid space tumors paraganglioma schwannoma,  neurofibroma metastatic lymphadenopathy, lymphoma meningioma vascular lesions internal jugular deep vein thrombosis, carotid artery stenosis carotid artery dissection carotid artery pseudoaneurysm Carotidynia carotid fibromuscular dysplasia cellulitis/abscess

15. Tumour presentation of carotid space Asymptomatic Neck mass behind the mandible, which can be pulsatile. OSA Symptoms of ET dysfunction/ unilateral OME. Usually with a mass extending into upper lateral neck in the lareral oropharynx . Dysfunction of cranial nerve 9 th to 12 th . Horners syndrome.

16. Cont …

17. Carotid body tumour

18. Inflammatory lesions Odontogenic infection is most commonly the source of an inflammatory mass in the masticator space. Cellulitis or abscess may form as a complication of acute tonsillitis or sialoadenitis . Infection can spread to other neck spaces and to the mediastinum.

19. Pre operative evaluation Imaging should always be used prior to surgery. MR angiography (MRA) may be added for a more precise diagnosis. radiological staging of the patient is completed by using a hybrid of positron emission tomography(PET) and CT (PET/CT).

20. imaging CT- Bone erosion Calcification/hyperostosis MRI- Superior contrast resolution direct multiplanner imaging vascular imaging without contrast no bone artifacts Can show nerve involvement with perineural spread.

21. Radiological features

22. imaging Abnormality Origin and extend Vascularity Presence of fat in between planes Relationship to parotid gland Involvement of carotid Approach

23. Tissue diagnosis tissue diagnosis is sensitive to differences between benign and malignant Lesion. Fine needle aspiration (FNA) biopsy can be performed via ultrasound, but frequently CT-guided FNA, Exception: JNA Paraganglioma suspected vascular aneurysm. Zell Ballan appearance of paraganglioma , image source wiki

24. Other investigations plasma metanephrines or 24-hour urine collection for catecholamines and metanephrines . Routine blood investigations USG neck Xray to assess airway I/L or FOL to see vocal cord mobility.

25. Laturiya,R.Kasim,J.S.,Jankar,A.S., Mohiuddin,S.A .,(2016). Pleomorphic Adenoma of Minor Salivary Gland Arising de novo in the Parapharyngeal Space- A Rare Case Report ,  10 (3), ZD01-ZD03.

26. Approaches and indications © Springer Berlin Heidelberg 2016 D.M. Fliss , Z. Gil, Atlas of Surgical Approaches to Paranasal Sinuses and the Skull Base

27. Principle of surgery Pre-op airway assessment. Wide field exposure. Gentle dissection around the tumour to prevent rupture.

28. Trans-oral approach small benign neoplasms that originate in the PPS, The limitations are limited exposure, inability to visualize the great vessels, an increased risk of facial nerve injury and tumour rupture. for small benign salivary gland tumour combined with an external approach to mobilize lesions with a oropharyngeal component.

29. Transcervical approach Most preferred approach, Key structures: The cranial nerves, including the hypoglossal, vagus , and spinal accessory nerves,  distal facial artery and vein need to be ligated .

30. Transcervical-transparotid approach For tumours arising from the deep lobe of the parotid, the trans-cervical approach can be combined with a trans-parotid approach. Involves dissection of facial nerve and parotid, thus extensive.

31. Transcervical-transmandibuler approach when better exposure is required. Such situations include very large tumors , vascular tumors with superior PPS extension, mandibular involvement.

32. Transmastoid infratemporal fossa approach Indication- Paraganglioma post-styloid lesions intracranial extension.

33. complications Bleeding, Seroma,Wound infection Cranial nerve paralysis (spinal accessory palsy and shoulder dysfunction, hypoglossal, lingual, marginal mandibular branch of the facial nerve, vagus , phrenic, brachial plexus, sympathetic trunk) Anasthesia in the perioricular area. First-bite syndrome Frey’s syndrome.

34. Recent advances TORS

35. Tors 3 dimentional Better visualisation Gentle dissection Allows examination to space around tumour

36. The trans oral robotic approach is used for selected PPS tumors that are located anterior to the carotid artery.  radical tonsillectomy, and partial laryngectomy , tongue base neoplasms. Advantage: no disfiguring facial scar. no large external incisions to the patient’s neck. no malocclusion or malunion of the jaw. no possibility of a separate procedure for hardware, plate, and screw removal. less chance of infection.

37. TORS Disadvantage: The surgical procedure is technically challenging and necessitates the training of all levels of surgical personnel. Costly. Delicate microinstrument .

38. Thank you