Management of Parapharyngeal Space Tumor Using Transoral Robotic Surgery: The Tonsillar Fossa Battlefield

Abstract

Introduction: The management of parapharyngeal space (PPS) tumors is surgical, but the approach remains a challenge. Attention should be paid to avoid intra-operative bleeding, cranial nerves damage, and external scars. Presentation of Case: The authors report a case of a 23-year-old female, with complaint of progressive, painless swelling just below the right angle of the mandible of 6-month's duration. Magnetic resonance imaging images reported the presence of an oval-shaped expansive lesion (maximum diameter 3 cm), from the lower polar region of the parotid gland while fine needle aspiration cytology (FNAC) was not diagnostic. We performed a Trans Oral Robotic surgical excision of the tumors with Da Vinci Robot. Discussion: Thanks to a detailed magnification, the authors were able to reach the PPS region through the tonsillar fossa saving the palatine tonsil without any significant bleeding or nerve lesions. The histological examination confirmed the diagnosis of pleomorphic adenoma of parotid gland. The decision on which surgical approach to be used is determined by site, size vascularity, histology of the tumor, and knowledge of radiological images. Conclusion: There is not only 1 surgical approach for PPS tumors but the surgeon must know all the different options and possible outcomes. Transoral Robotic Surgery approach with Da Vinci could represent a valid option with a good knowledge of Robot surgical instruments and a detailed preoperative plan.

Trans-Oral Robotic Surgery: 14 Cases of Pleomorphic Adenoma of the Parapharyngeal Space

“…Most PAs originate from the superficial lobe of the parotid gland, although, in rare cases, they may arise from the deep lobe of the parotid gland and extend into the PPS or, alternatively, arise de novo from aberrant minor salivary glands located in the PPS. 4–9…”

“…Most PAs originate from the superficial lobe of the parotid gland, although, in rare cases, they may arise from the deep lobe of the parotid gland and extend into the PPS or, alternatively, arise de novo from aberrant minor salivary glands located in the PPS. [4][5][6][7][8][9] Regardless of the tumor origin, they become symptomatic when they reach more than 3 cm in diameter, manifesting as masses in the oropharynx or in the upper neck region, which may displace the lateral pharyngeal wall, often associated with dysphonia, dysphagia, Eustachian tube obstruction and alterations of the voice. However, PPS tumors are usually asymptomatic and are discovered by chance during imaging examinations carried out for other reasons.…”

Surgical Treatment of Parapharyngeal Space Salivary Gland Tumor

“…Since it is difficult to identify parapharyngeal space tumors by physical examination, imaging tests, such as CT or MRI, are important for confirming the location of the lesion and the relationship with the surrounding structures. 1,4,7,8 Generally, parapharyngeal space tumors in the prestyloid compartment tend to cause posterior displacement of the internal carotid artery. 1,4,8 Parapharyngeal space salivary gland tumors can arise from the deep lobe of parotid or minor salivary gland.…”

A Retrospective Analysis on the Effects and Complications of Endoscope-Assisted Transoral Approach and Lateral Cervical Approach in the Resection of Parapharyngeal Space Tumors

“…Parapharyngeal space (PSS) tumors account for about 0.5% of head and neck tumors and generally occur in adults, 30-50 years old account for about 50%, occur in childhood is very rare, female incidence is more than male [1]. ere are many kinds of tumors in PSS, with more than 70 kinds, but benign tumors account for 70-80%, malignant tumors account for 20-30%, including primary tumors, direct spread tumors, and distant metastatic tumors.…”