Transoral robotic surgery for adult parapharyngeal lymphangioma:A case report

BACKGROUND Lymphangiomas are a group of benign swellings which are commonly seen in children.The most common sites of presentation is the head and neck region,less commonly seen in axilla,chest,liver,spleen,etc.The ideal modality of treatment has always been surgical excision irrespective of the site and age group.But with the advent of minimally invasive surgical techniques,it is now possible to perform excision of parapharyngeal space lesions with minimal morbidity and good clearance.CASE SUMMARY A 42-year-old male patient who presented with difficulty in swallowing and had undergone surgery twice outside,where Transcervical approach was attempted to remove the parapharyngeal mass,but failed.Magnetic resonance imaging scan demonstrated a 6 cm x 5 cm x 4 cm left parapharyngeal mass.He underwent transoral robotic surgery for the excision of the parapharyngeal lesion and had an uneventful post-operative recovery.CONCLUSION Lymphangiomas are hamartomatous swellings which are benign in nature.The symptoms of the patient with large parapharyngeal mass include dysphagia,dyspnoea and neck swelling.Clinicoradiological evaluation is of utmost importance to determine the adjacent vital structures and the approach to the tumor.With the advent of robotics in oncology,transoral robotic excision is one of the best approaches to perform such a surgery.

THE RELATIONSHIP BETWEEN THE INVASION OF PARAPHARYNGEAL SPACES AND THE INVOLVEMENT OF CERVICAL NODES AND POSTERIOR GROUP CRANIAL NERVES IN NASOPHARYNGEAL CARCINOMA

Two hundred cates of nasopharyngeal carcinoma (NPC) admitted to this department from Feb. 1985 to May. 1988 were analysed according to the CT scanning and clinical findings of the primary lesions prior to radiotherapy. The results showed that involvement of parapharyngeal space was very common in NPC, about 80% (160/200 cases) ; particularly unilateral or bilateral retro-styloid spaces, about 69.5% (139/200 cases). It was proposed that patients with NPC had a high Incidence of ipsilateral cervical node metastasis. Contralateral cervical node metastasis was rare. The development of cervical node metastasto in NPC has two modes: one Is direct Infiltration of the retro-stylold space by the lesion; the other Is along the nasopharyngeal lymphatic rete. The data also showed that patients with NPC who presented symptoms of Ⅸ- Ⅲ cranial nerve paralyses always had ipsilateral or bilateral retro- styloid space Infiltrations.

Dumbbell-shaped solitary fibrous tumor in the parapharyngeal space:A case report

BACKGROUND Solitary fibrous tumors(SFTs)occurring in the parapharyngeal space are rare,and their final diagnosis depends on pathological and immunohistochemical analyses.Once the tumor is diagnosed,complete resection and regular postoperative follow-up are required.CASE SUMMARY A 40-year-old male patient with a right parotid gland mass discovered 8 years ago was admitted to hospital.The mass showed no tenderness or local skin redness.Imaging was carried out as the patient had stable vital signs and showed that the mass was a dumbbell-shaped tumor comprising a superficial tumor approximately 5 cm long and 3 cm wide in size that compressed the right parotid gland and a deep tumor located in the right parapharyngeal space approximately 4.5 cm long and 2.5 cm wide in size.Both tumors were connected in the middle.Prior to surgery,the tumors were considered to be parapharyngeal schwannomas.During surgical dissection,the tumors were found to be smooth and tough,without obvious adhesion to the surrounding tissues.The tumors were revealed to be a SFT following postoperative pathological analysis.CONCLUSION SFTs in the parapharyngeal space are rarely reported,and complete resection of such tumor is recommended.Adjuvant chemoradiotherapy is used in patients with extensive tumor invasion to lower the recurrence rate.Postoperative longterm follow-up is required.

Lymphoepithelioma-Like Carcinoma of Parapharyngeal Space—A Case Report with Review of Literature

Extra-nasopharyngeal lymphoepithelioma-like carcinomas (LELC) are uncommon epithelial tumors. A few isolated case reports and series are available in literature involving the larynx, pharynx, salivary gland, lung etc., but involvement in the parapharyngeal space has not yet been reported. We aim to highlight one such case that has a clinical and radiological characteristic of a benign lesion whilst the histopathology reveals an infiltrating neoplasm. The typical clinical aggressiveness of a classical LELC of extra-nasopharyngeal lesion as described in literature is not present in our case. Also seen is an uncommon finding of abnormal branching of left external carotid artery. There is no standard treatment protocol for such a tumor;however, wide excision of this tumor in the parapharyngeal space via trans-cervical, trans-mandibular, trans-palatal approach has shown good and satisfactory tumor control of the primary site so far.

Transoral endoscopic excision of a giant parapharyngeal space tumour:A case report

Most of the parapharyngeal space tumours are benign.The primary treatment is complete resection of the tumour.Due to its location in the deep neck space,a pre-styloid tumour can be resected via the transoral approach.However,the surgical field is limited by the small oral cavity.With the use of rigid endoscopes,removing benign tumours through transoral approach in the parapharyngeal space is possible as they provide a broad and enlarged view of the confined space.Here,we report a case of a 64-year-old male with a giant pre-styloid parapharyngeal space tumour,who successfully underwent transoral endoscopic excision.Postoperatively,the patient had short hospital stay of total 3 days.His chewing and swallowing were not affected,and he resumed oral feeding prior to discharge.

Endoscopy-assisted transoral approach for parapharyngeal space tumors:Our experience and a systematic review of the literature

Background:Several approaches have been described for the excision of parapharyngeal space tumors(PPSTs).Advances in endoscopy gave a further stimulus to the use of the transoral route.Aims:We present our experience with the endoscopy-assisted transoral approach(EATA)in this regard and a review of the most recent literature about EATA for PPSTs excision.Materials and Methods:We retrospectively analyzed our experience and systematically reviewed the literature about the outcomes of this technique.Results:Seven PPSTs were completely excised,with three of them requiring a combined transcervical approach.Only one case of postoperative wound dehiscence was registered,and the mean length of stay was 3.9 days.Final histopathological examination confirmed the results obtained with preoperative fine-needle aspiration biopsy in all cases and no recurrences were apparent after a mean follow-up of 28.1 months.Discussion:Magnetic resonance imaging,the modified Mallampati score and the 8 Ts criteria are useful instruments for the choice of the most appropriate surgical approach.Conclusion:In light of our experience and following other published series in the literature,we believe that EATA may represent a safe and effective approach for the treatment of the majority of PPSTs.

Surgical management of parapharyngeal lymph node metastasis of thyroid carcinoma： a retrospective study of 25 patients

Background Parapharyngeal lymph node （PPLN） metastasis from thyroid carcinoma is rare. We describe the clinical features, diagnosis, and surgical treatment of this condition. Methods Twenty-five patients with PPLN metastasis from thyroid carcinoma were treated at our institution from January 1999 to December 2010, including 22 patients with papillary carcinoma, two with medullary carcinoma, and one with follicular carcinoma. Of these, 16 had a history of surgical treatment prior to PPLN metastasis. Of the nine patients without a history of surgical treatment, five had widespread cervical lymph node metastases and four had occult papillary thyroid carcinoma. PPLN metastasis was diagnosed by enhanced computed tomography in 22 cases. Results Resection of metastases was performed via a transcervical approach in 23 patients and a transmandibular approach in two patients. After a median follow-up time of 31 months （range： 6-130 months）, nine patients developed distant metastases, and six of these died of their disease. The 5-year survival rate was 63.8%. Conclusions PPLN metastasis from thyroid carcinoma may occur in patients： with previous neck dissection, with widespread metastases to cervical lymph nodes prior to initial treatment, and with occult thyroid carcinoma. Enhanced computed tomography is helpful for diagnosis in the first two presentations. Surgical resection remains the mainstay of treatment for this disease. PPLN metastasis has a tendency to be associated with distant metastases and a poor prognosis.

Pre-mental foramen mandibulotomy for resecting tumors of tongue base and parapharyngeal space

Background Resection of tumors arising from the tongue base and the parapharyngeal space is difficult for exposure and manipulation because of their obscure location. The aim of this study was to evaluate the surgical approach of the pre-mental foramen mandibulotomy for resecting the tumors of tongue base and parapharyngeal space. Methods Fifty-one patients with tumors of tongue base and parapharyngeal space were treated using the mandibulotomy approach on the pre-mental foramen. In the present study, this technique was described in detail. The patients were followed up for three months to six years with a mean of 26 months. Results The tumors of tongue base and parapharyngeal space could be exposed clearly and be resected radically by surgical approach of pre-mental foramen mandibulotomy. The surgical complications were reduced. Conclusions Compared to other surgical approaches, such as lateral mandibulotomy, midline mandibulotomy, the suprahyoid parapharyngeal approach, and paramedian mandibulotomy, we found that the pre-mental foramen mandibulotomy is the ideal choice for resecting the tumors of tongue base and parapharyngeal space.

内镜辅助治疗咽旁间隙肿瘤研究进展

咽旁间隙是颈侧上部潜在的组织间隙,其组织多形性和解剖位置深在使得咽旁间隙肿瘤的临床治疗较为困难。作为咽旁间隙最常用的术式,颈侧入路及其变式已在长期的临床应用得到巩固,但此入路创伤大,并发症多也是临床上不可回避的问题。近年来,内镜系统的发展既打开了传统入路的局面,也开拓了崭新的手术入路。本文针对咽旁间隙肿瘤切除术的内镜辅助入路进行概述,旨在为临床上治疗难治性咽旁间隙肿瘤提供诊疗思路。

咽旁间隙Castleman病1例

Castleman病是一种少见的淋巴组织增殖性疾病,又名血管滤泡性淋巴组织增生或者巨大淋巴结病。临床根据肿大淋巴结的分布和器官受累情况分为单中心型和多中心型;病理可分为透明血管型、浆细胞型和混合型。我科收治1例咽旁间隙单中心型Castleman病患者,现报道如下。1临床资料患者,女,59岁。

甲状腺乳头状癌转移至咽旁间隙1例

1 临床资料患者,女,34岁,以"体检发现咽旁间隙肿物1周"为主诉入院。缘于入院前1周因偶有吞咽梗阻感就诊外院,查颈部CT示"咽旁间隙肿物",无咳血、吞咽疼痛、困难,无咳嗽、咳痰,无发热、畏寒等不适,建议其转上级医院治疗,故转诊我院。门诊查体后拟"咽旁间隙肿瘤(右)"收住院,自发病以来,患者精神、食欲、睡眠可,体重无明显变化。

Solitary Intraparotid Facial Nerve Plexiform Neurofibroma

Solitary intraparotid facial nerve plexiform neurofibromas are extremely rare. These tumors arise from Schwann cells. The plexiform variant is recognized by tortuous and multinodular gross and microscopic lesions. It has a high risk of malignant transformation. We report a case of a solitary plexiform neurofibroma in a 5-year-old Italian male, who initially presented a right parotid mass of four-month duration. He had not pain, trismus, facial weakness or previous trauma. There was not familiar history of Von Recklinghausen’s disease. TC and MRI scans revealed a mass in the superficial lobe of the parotid gland. A partial parotidectomy was performed. Histopatological examination indicated plexiform neurofibroma. The incidence, presentation, diagnosis and surgical treatment of this lesion are discussed. In our case, the tumor could be readily separated from the main trunk, and facial movement was completely preserved owing to the rich neural network around the mass.

Acquired Hemophilia A Simulating Retropharyngeal Abscess: Importance of Differential Diagnosis of Neck Masses before Surgery

The coexistence of acquired hemophilia A with a secondary retropharyngeal hematoma is an extremely unusual condition with important clinical implications. The purpose of this paper is to present a case involving a patient whose first clinical manifestation, namely dysphagia, along with specific clinical examination and imaging findings, led to an incorrect initial diagnosis of a retropharyngeal abscess. However, performance of a more thorough clinical examination led to the correct diagnosis of a hematoma secondary to acquired hemophilia A. This allowed surgery to be avoided in a patient at a high risk of bleeding. Conclusions: Acute neck masses require meticulous differential diagnosis assessing the possible presence of various causative systemic diseases before the most appropriate therapy can be determined.

Parapharygeal Space Tumours—Surgical Approach and Role of Tumour Markers

Both benign and malignant tumors may arise from any of the structures contained within the parapharyngeal space. Parapharyngeal space is difficult to reach and formidable area to approach by any surgeon. Due to its deep placement and approximation to vital structures, not only is tumour involving this space a difficult task to manage for the surgeon, but even its diagnosis may elude the doctor. Even the battery of clinical, biochemical or radiological tests diagnosis remains a difficult objective. We aim to provide an adjunct mode of aiding the diagnosis in the form of tumour markers. Though tumour markers alone are not sufficient, with the help of other tests, the diagnosis can be reached in a fairly accurate measure.

Safe surgical zone during TORS radical tonsillectomy:An anatomical and radiological study

Objective:Parapharyngeal space contains intricate vascular anatomy(external and internal carotid arteries)that might be inadvertently injured during the dissection in this plane.None of the bony landmarks can be used during the transoral robotic surgery(TORS)radical tonsillectomy as these landmarks lie lateral to the internal carotid artery(ICA)and external carotid artery(ECA)in transoral approach.Our study aims to identify the safe surgical limits during the dissection of parapharyneal space in TORS radical tonsillectomy and to correlate the same with radiological study.Material and methods:Fifteen cadavers(30 head and neck regions)and 50 CT-Angiogram of neck(100 head and neck regions)were included in the anatomical and radiological study respectively.The vertical midpoint of anterior tonsillar pillar(palatoglossus muscle)was taken as the reference point and all the measurements were done at the level of reference point both for anatomical and radiological study.Distance between tonsillar fossa and ECA,distance between tonsillar fossa and ICA,relation between ECA and styloglossus and relation between ICA and stylopharyngeus at reference level were studied.Results:The mean distance of ECA from the tonsillar fossa at the reference point was 18.2 mm in the anatomical study and 16.2 mm in the radiological study.The mean distance of ICA from the tonsillar fossa was 23.4 mm and 23.3 mm in the anatomical study and radiological study.There was no significant difference between the anatomical and radiological findings for both the mean distance between ECA and ICA to the tonsillar fossa(p value was 0.45 and 0.30 respectively).ECA was located posterolateral to styloglossus in 24 cases(80.0%)and 79 cases(79.0%)in the anatomical and radiological study respectively.ICA was found posterolateral to stylopharyngeus in 21 cases(70.0%)and 69 cases(69.0%)in the anatomical and radiological study respectively.Conclusion:The muscular plane between styloglossus and stylopharyngeus can be used as an envelope to locate the ECA and ICA that lie medial to these critical vascular structures during TORS.We propose to divide the parapharyngeal space into two compartments(anterior and posterior)based on the surgical perspective of inside-out anatomy.The anterior compartment houses styloglossus muscle with ECA posterolateral to it and the posterior compartment has stylopharyngeus and ICA posterolateral to it.

Management of pediatric peritonsillar and deep neck infections-cross-sectional retrospective analysis

Objective:Deep neck infections(DNI)are responsible for significant morbidity in children and healthcare expenditures.Few studies exist specifically addressing the clinical and epidemiologic characterization and management of DNI's in the pediatric population.Our goal was to analyse the demographic characteristics,clinical presentation,diagnostic and therapeutic approaches of peritonsillar and DNI in pediatric patients.Methods:The medical records of patients,aged up to 18 years,admitted for peritonsillar and DNI at our department,from 2011 to 2016,were retrospectively reviewed and compared with the literature available.Ninety-eight patients were enrolled.Results:The mean age was higher in patients with peritonsillar abscess and lower in patients with retropharyngeal and parapharyngeal infections.Admissions have significantly increased from 2011.There was a seasonal variation for DNI incidence,with a peak incidence in Summer and Spring.All patients included were treated as inpatient and received empirical intravenous antibiotic therapy and steroids regardless of drainage procedures.Incision and drainage was performed in 72 patients.The hospital length of stay was higher among patients with retropharyngeal abscess and in the group with complications.Only 2 patients developed complications during hospital stay.The most common microbiological pattern was monomicrobial and the most commonly isolated pathogens were Streptococcus Pyogenes,Streptococcus Mitisand anaerobic bacteria.Conclusions:Surgical incision and drainage followed by intravenous antibiotic and steroids proved to be successfull with low morbidity related to surgical approach.However,in selected cases,medical therapy may be an alternative to surgical management in uncomplicated infections.