APPROACH TO

PARAPHARYNGEAL SPACE
Prepared by: dr Mustafa jabbar
Supervised by Dr Thamer Muhsin
al rubaye
 PARAPHARYNGEAL SPACE
• It is a potential space filled with fat and
areolar tissue, inverted pyramidal in shape
with base at skull base [sphenoid and
temporal bone} and apex at greater cornu of
hyoid bone.
• It is also called pterygopharyngeal ,
pterygomaxillary , pharyngomaxillary , lateral
pharyngeal space.
It has 3 sides :medial, lateral, posterior and anterior
leading edge which is pterygomandibular raphe
The medial surface is distensible and comprise superior
pharyngeal constrictor and bucopharyngeal membrane
.and pharynx
The lateral surface comprise medial pterygoid , the
.ramus of mandible and deep lobe of parotid gland
It has a posterior surface which is part of prevertebral
fascia : posterolaterally is the carotid sheath and
.posteromedially is the retropharyngeal space
• There are 2 fascial condensation of surgical
importance:
• A- aponeurosis of zukerkendle and testut joining the
styloid process to tensor veli palatini devides the
parapharyngeal space to prestyloid and post styloid
compartement.
• B- stylomandibular ligament forming a tunnel which
give the dumbell shape of tumour.
• We should note the medial wall unlike the lateral wall
is distensable.
 history
• The most common presentation is asymptomatic due to sore
throat or non fitting denture or small swelling near the angle
of mandible.
The patient may complain of general or local symptoms in case
of parapharyngeal lesion.
high grade fever drooling of saliva trismus with history of
tonsillitis should suspect parapharyngeal abscess .Patient with
fever and night sweat and weight loss in case of lymphoma.
Patient with labile hypertension and flushing attack in case of
paraganglioma {3% of paraganglioma are actively secrete
catecholamines}.
• Patient might complain of trismus in case of
involvement of medial pterygoid muscle or
pressure on it.
• Xerostomia may be the leading symptom in
case of parotid gland involvement
• Unilateral hearing impairment in case of
eustachian tube dysfunction due to invasion of
fossa of rosenmuller
• Dysarthria and disruption of oral phase of swallowing in
case of hypoglossal nerve palsy which could be due to
paraganglioma ,shwanoma of12th nerve or direct invasion
by malignant tumour.
• Frequent choking and aspiration in case of superior
laryngeal nerve invasion in pyriform area .which lead to
positive Chevalier Jackson sign {pooling of saliva}
• Hoarseness and shortness of breath in case of vagus nerve
palsy [one-third of paraganglioma presented with palsy]
which lead to immobile atrophic and sagging vocal cord.
• Torticollis and inability to shrug the shoulder in
case of accessory nerve involvement.
• Inability to close the eye and deviation of the
mouth in case of fascial nerve involvement duo
to perineural invasion of adenoid cystic
carcinoma of parotid{careful examination of
parotid should be done in 7th palsy to not to
miss a small adenocystic carcinoma with early
perineural invasion}.
• Horner syndrome {enophtalmus , miosis and
anhidrosis} in case of sympathetic involvement}
• Patient with unilateral cystic swelling that
aggravated by upper respiratory tract infection
near upper part of sternocleidomastoid is
suggestive of branchial cyst.
• Patient with bilateral swelling near the angle of
mandible that increase with URTI is suggestive
of warthin tumour.
 EXAMINATION
• The most common finding is medial push of
tonsil to the midline or palpable mass near the
angle of mandible. Other finding:
• Curtain sign : in 9th cranial nerve palsy
• Gag reflex lost : in 10th cranial palsy
• Unilateral atrophy and fasiculation of the
tongue and deviation toward the affected
side: in 12th cranial nerve palsy
• Chevalier Jackson sign : pooling of saliva in
superior laryngeal palsy
• Fountaine sign : carotid body swelling that is
mobile horizontally but not vertically
• Vocal cord palsy : the vocal cord become
atrophic and sagging and in paramedian
position in nerve palsy unlike withdrawal due
to mass.
 RADIOLOGY
• Accurate imaging of parapharyngeal space is essential
for planning for surgical resection.
• Multiplanar imaging using fine slice CT and MRI
provides the detail required.
• Further information regarding vascularity can be
obtained using MR angiography and carotid
angiography.
• Therapeutic intervention such as preoperative
embolization or balloon occlusion can be done at the
same time.
• How can we differentiate pre-styloid from post-
styloid lesion?
• How can we differentiate a true parapharyngeal
tumour from extension of deep lobe of parotid ?
• What is the difference between shwanoma and
paraganglioma radiologicaly ?
• What is lyre sign ? And pathognomonic of
what ?
• In pre- styloid lesion:
• Carotid sheath displaced posterolaterally
• Fat pad displaced anteromedially
• In post- styloid lesion:
• Carotid sheath displaced anteromedially
• Fat pad will be displaced anterolaterally
• A true parapharyngeal tumour can be
differentiated from extension of deep lobe of
parotid by a thin plane of fat separate the
deep lobe from para -pharyngeal space
• Shwanoma are fusiform ,sharply circumscribed
masses seen on CT as soft tissue density
masses with a few cystic area within. They
show uniform enhancement on post contrast
study. On MRI they appear heterogenously
hyper intense on T2 image . There are no flow
void within them which help to differentiate
from paraganglioma give them characteristic
salt and pepper appearance on MRI .
• LYRE SIGN : is widening of the angle between
internal and external carotid artery.
• Pathognomonic of carotid body tumour.
 TREATMENT
• Lesion of parapharyngeal space predominantly treated
by surgery
• Frozen section is important for definitive diagnosis.
• Radiotherapy : for high surgical risk or unrespectable
tumors.
• Adjuvant radiotherapy : for malignant lesion or recurrent
benign lesion with high risk of recidivism.
• Chemotherapy : need specific histology.
• The aim of surgery to remove the lesion with minimum
morbidity.
 TRANSCERVICAL APPROACH
• Used in 46% of cases
• Ideal for small benign tumors independent of deep lobe of parotid
gland.
• A transverse skin crease 5 cm below the mandible to spare the
marginal mandibular nerve. The platysma is divided and the
superficial fascia of submandibular gland raised with the superior
flap. Submandibular gland mobilized and displaced anteriorly to get
greater access . The stylomandibular ligament is identified and
divided and the mandible is distracted anteriorly. The parapharyngeal
space is lcated between the digastric and periostium of the mandible
and attachment of medial pterygoid to the mandible, the external
carotid may need to ligated to access to remove large tumour.
 Transcervical - transparotid approach

• Used in 27% of cases.

• It is well suited for:
• A:lesion arising from deep lobe of parotid.
• B: vascular tumour
• C: malignant lesion
• Done using modified blair incision and slight
anterior extension for cervical incision.
 MANDIBULOTOMY
• Used in 9% of cases
• Used for:
• A- Infiltrating malignancy
• B- multifocal recurrent benign
• Can be performed as standard Para median or laterally
with defense of inferior alveolar nerve using inverted L
or double osteotomy above the lingula of mental
foramen.
• They may need tracheostomy or overnight endotracheal
intubation.
 TORS
• Disadvantage
• A-risk vital neurovascular structures
• B-risk of tumour spillage
• Advantage
• A-3D high resolution image
• B-tremor filtration and motion scaling
• Indication
• 1-benign prestyloid salivary tumors
• 2-shwaoma not deforming the carotid
• 3- cystic lesion such as branchial cleft cyst
• Absolute contraindication tumour that is
adherent or involving the carotid artery.
Thank you