Parapharyngeal pleomorphic adenoma as a cause of severe obstructive sleep apnoea

Abstract

A 26-year-old man presented with severe obstructive sleep apnoea that had progressively worsened over a 3-year period. His main complaints were heavy snoring, daytime somnolence, dysphagia and dysphonia. He reported no trismus, fever or other constitutional symptoms. Medical background included gastroesophageal reflux and smoking.Oral examination revealed a large, firm, non-tender swelling of the right peritonsillar/soft palatal region, causing deviation of the uvula to the contralateral side. On flexible nasoendoscopy, there was a significant right-sided unilateral narrowing of the oropharynx and hypopharynx. There was no lymphadenopathy on neck palpation and cranial nerve examination was normal.Contrast computed tomography (CT) imaging of the neck demonstrated an ovoid mass in the right parapharyngeal space (Fig. 1). The mass appeared to abut the right medial pterygoid, with no clear plane between muscle and mass. There was significant oropharyngeal airway compression and narrowing. Incision biopsy of the right parapharyngeal mass was performed in theatre. Histopathology was suggestive of a pleomorphic adenoma.Total resection of the right parapharyngeal tumour was performed via a transcervical approach (Fig. 2). The submandibular gland was resected for surgical access to the parapharyngeal space, while the lingual and hypoglossal nerves were preserved. Digastric, stylohyoid, stylopharyngeus and the styloid process were all divided. The whole tumour capsule was mobilized without rupture. The tumour appeared to arise from the deep lobe of the parotid gland.Histological examination of the mass revealed cellular areas alternating with loose, myxoid and chondromyxoid stroma, consistent with pleomorphic adenoma. There was no evidence of malignancy, and the soft tissue plane of surgical excision was free from tumour. He made an unremarkable post-operative recovery with complete resolution of obstructive sleep apnoea symptoms.Pleomorphic adenomas are the most common tumours of salivary glands. While the most common site in which they occur is the parotid, pleomorphic adenomas are seen in all major and minor salivary glands.Parapharyngeal space tumours are relatively rare, equivalent to about 0.5% of all head and neck tumours. 1 Within the parapharyngeal space, approximately 80% of tumours are benign. The three main groups of primary tumours of the parapharyngeal space are salivary gland tumours, neurogenic tumours and paragangliomas. The most common of the three is the salivary gland tumour group, most frequently arising from the deep lobe of the parotid gland. 2 Less common differentials of parapharyngeal space mass include haemangiomas, metastases, aneurysms, branchial cysts, chordomas, meningiomas and sarcomas.Parapharyngeal pleomorphic adenomas can be undetected for long periods of time due to their slow growth. Symptoms usually only appear when the tumour is greater than 2.5-3.0 cm. 3 Clinical manifestations include a mass in the oropharynx, trismus, otological symptoms due to obstruction of the Eustachian tube, a...

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