J Oral Maxillofac Surg

67:1239-1244, 2009

Management of
Parapharyngeal-Space Tumors
Keqian Zhi, DDS, MD,* Wenhao Ren, DDS,† Hong Zhou, DDS,‡
Yumin Wen, DDS,§ and Yincheng Zhang, DDS㛳

Purpose: This study evaluated parapharyngeal-space (PPS) tumors in regard to clinical pathological
features, preoperative assessment, surgical approaches, perioperative complications, and patterns of
recurrence.
Patients and Methods: We performed a retrospective review of patients with PPS tumors referred to
the stomatological hospitals of Sichuan University and Xi’an Jiaotong University between 1990 and 2004.
Results: Beginning in 1990 and ending in 2004, 162 patients with PPS tumors were evaluated in our
unit. The gender distribution was 94 (58.08%) males and 68 (41.98%) females. The median age was 36.4
years. The main presenting symptom was neck swelling. All cases were evaluated with at least a
computed tomography scan. The most common class of lesion was salivary-gland neoplasm, accounting
for 74 cases (45.68%). The next most common group of tumors was neurogenic, representing 68 cases
(41.98%). Only 22 patients (13.58%) presented with malignant disease. Three surgical approaches were
commonly used in the management of these lesions: transcervical-transparotid in 93 patients (57.41%),
transcervical in 51 patients (31.48%), and transcervical-transmandibular in 18 patients (11.11%). Twenty
patients with malignant disease underwent adjuvant chemotherapy and/or radiotherapy. All cases were
followed for a mean of 36 months. There was no perioperative mortality. Two patients suffered local
failure, and 4 patients developed distant metastasis during the observation period.
Conclusions: Surgery is the mainstay treatment for PPS tumors. Surgical approaches were dictated by
size of the tumor, its location, its relationship to the great vessels, and suspicion of malignancy. The most
common approach was transcervical-transparotid for benign tumors.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1239-1244, 2009

The parapharyngeal space (PPS) is one of several
potential fascial planes of the head and neck which
may become involved in various inflammatory and
neoplastic processes, the latter of which represents
less than 1% of all head and neck tumors.1
The PPS assumes the shape of an inverted pyramid
on a pedestal. The base is formed by the greater wing
of the sphenoid at the skull base. The apex is at the
level of the greater cornu of the hyoid bone. This
space is further divided into prestyloid and post-
styloid compartments by the styloid process and its
attached muscles and fascia.2 Neoplasms of this
space tend to have a similar presentation, and are
asymptomatic in 50% of patients.3 This study re-
viewed our experience with the treatment of PPS
tumors at the stomatological hospitals of Sichuan
University and Xi’an Jiaotong University, with par-
ticular attention to the clinical-pathological features
of these lesions, their preoperative assessment, sur-
gical approaches to their extirpation, and the inci-
dence and characteristics of perioperative compli-
cations.

*Assistant Professor, Department of Oral and Maxillofacial Surgery/
Oncologic Head and Neck Surgery, Stomatological Hospital, School of
Medicine, Xi’an Jiaotong University, Xi’an, Shaan Xi, China.
†Resident, Department of Oral and Maxillofacial Surgery/Onco-
logic Head and Neck Surgery, Stomatological Hospital, School of
Medicine, Xi’an Jiaotong University, Xi’an, Shaan Xi, China.
‡Professor, Department of Orthodontics, College of Stomatology,
Xi’an Jiaotong University, Xi’an, Shaan Xi, China.
§Professor, Department of Oral and Maxillofacial Surgery, West China
College of Stomatology, Sichuan University, Chengdu, Sichuan, China.
㛳Professor, Department of Oral and Maxillofacial Surgery/Onco-
logic Head and Neck Surgery, Stomatological Hospital, School of
Medicine, Xi’an Jiaotong University, Xi’an, Shaan Xi, China.
This research received scientific funds from Xi’an City
(SF08008-4) and educational funds of Stomatological Hospital in
Xi’an Jiaotong University (2008-5).
Address correspondence and reprint requests to Dr Zhi: Depart-
ment of Oral and Maxillofacial Surgery/Oncologic Head and Neck
Surgery, College of Stomatology, Xi’an Jiaotong University, No. 98
Xiwu Road, Xi’an, Shaan Xi 710004, China; e-mail: zhikeqian@
sina.com
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6706-0014$36.00/0
doi:10.1016/j.joms.2008.09.003

1239
1240 MANAGEMENT OF PARAPHARYNGEAL-SPACE TUMORS

Patients and Methods

From 1990 to 2004, we evaluated 162 patients with
PPS tumors in the Oral and Maxillofacial Surgery Units
at the stomatological hospitals of Sichuan University
and Xi’an Jiaotong University. Patients underwent a
preoperative history and physical examination, with
special attention to presenting symptoms and a clini-
cal examination of the primary lesion and neck status.
Computed tomography (CT) was performed in all
patients. Magnetic resonance imaging (MRI) was used
selectively in cases of suspected malignancy and
where a clear delineation of surrounding vital struc-
tures, such as the carotid artery, was not evident on
CT scanning. Magnetic resonance angiography was
performed in patients with pulsatile masses. Fine- FIGURE 2. Basal-cell adenoma and partial deep-lobe parotidec-
needle aspiration cytology (FNAC) was attempted tomy were performed using a cervical approach.
whenever possible. Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
The surgical approach chosen by the operating Maxillofac Surg 2009.
surgeon was dictated by the size of the tumor, its
location, its relationship to the great vessels, and
nerve, which are reflected superiorly. Division of the
suspicion of malignancy. The following surgical ap-
stylohyoid ligament allows improved access to the
proaches were used.
PPS (Figs 1, 2). The submandibular gland can be re-
TRANSCERVICAL APPROACH tracted anteriorly for exposure, or it can be removed if
necessary. Dissection is then easily accomplished under
The transcervical approach was the method most
direct vision, offering excellent control of vital struc-
commonly chosen for the removal of most poststyloid
tures such as the common carotid artery and internal
and some prestyloid PPS tumors. In this approach, a
jugular vein. Generally, this approach was applied to
transverse, curvilinear incision is placed in a skinfold,
benign tumors less than 5 cm in diameter.
2 finger breadths’ below and behind the angle and
ramus of the mandible. This incision is designed to TRANSCERVICAL-TRANSPAROTID APPROACH
permit easy conversion to a more extensive opera-
For larger lesions arising from the deep lobe of the
tion, should unanticipated findings be encountered,
parotid gland with involvement in the PPS, the
such as malignancy necessitating lymphadenectomy.
transcervical approach can be combined with a
Subplatysmal flaps are elevated, with preservation of
transparotid approach by extending the incision su-
the submandibular gland and marginal mandibular
periorly, as for a parotidectomy. The facial nerve is
identified and dissected, and a superficial parotidec-
tomy is performed. The deep-lobe portion of the
tumor is identified. The tumor is then mobilized in a
3-dimensional manner from the parotidectomy
wound to the submandibular space, and then re-
moved (Figs 3, 4).

FIGURE 1. Axial CT scan of basal-cell adenoma in the deep lobe
of the parotid gland.
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.
TRANSCERVICAL-TRANSMANDIBULAR APPROACH
Transmandibular access is gained by the creation of
an osteotomy in the region of the angle of the man-
dible, after the masseter muscle has been cut from the
mandible and retracted superiorly. The osteotomy
necessarily transects the inferior alveolar nerve. The
mandibular segments are distracted, and often part of
the medial pterygoid muscle must be separated, to
increase exposure. After severing the attachment of
the stylomandibular ligament to the posterior border
of the mandible, the tumor can be easily dissected,
with control of the major neurovascular structures.
This technique was used for very large tumors, vas-
ZHI ET AL
FIGURE 3. Axial MRI indicates adenocarcinoma of the parotid
gland, with involvement of the deep lobe.
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.
cular tumors with superior PPS extension, malignant
tumors requiring radical resection, and cases in which
distal control of the carotid at the skull base was
required (Figs 5-8).
Histopathological examination of surgical specimens
was carefully reported and reviewed, with particular
attention to the attainment of clear margins and lymph-
node involvement. Morbidity, mortality, patterns of
recurrence, and functional results of surgery were
reported and evaluated for 36 months. Adjuvant che-
motherapy and radiotherapy were offered, based on the
histology and clinical behavior of malignant disease.
FIGURE 4. Excision of adenocarcinoma involves deep lobe of the
parotid gland, with facial-nerve sacrifice via the transcervical-
transparotid approach.
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.
1241
FIGURE 5. Coronal MRI shows large pleomorphic adenoma of the
left parotid gland.
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.
Results
Our sample consisted of 162 patients with tumors of
the PPS. There were 94 (58.08%) males and 68 (41.98%)
females. In male patients, 81 had benign lesions, and 13
had malignant disease. In female patients, 58 presented
with a benign tumor, and 10 presented with malignan-
cies. The median age for all patients was 36.4 years.
Table 1 summarizes the main presenting symptoms. The
most common presenting symptoms were painless
neck, parotid, and oral masses.
Surgery was the mainstay of treatment for tumors of
the PPS. Table 2 lists the different surgical approaches
FIGURE 6. Pleomorphic adenoma of left parotid gland removed
by transcervical-transmandibular approach, with preservation of
the facial nerve.
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.
1242 MANAGEMENT OF PARAPHARYNGEAL-SPACE TUMORS

Table 1. INITIAL SYMPTOMS

Symptoms No. of Patients Percentage

Neck swelling 118 72.84

Parotid swelling 56 34.57
Oral swelling 45 27.78
Dysphagia 11 6.79
Nasal obstruction 6 3.70
Facial-nerve paralysis 6 3.70
More than one symptom may be present in the same
patient.
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.

no perioperative mortality. Postoperative pathologi-

FIGURE 7. Closure involved restoration of pterygo-masseteric
sling. This image is of a typical superficial parotidectomy defect,
with preservation of the facial nerve.
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.
applied. The transcervical-transparotid approach was
the most common, and was used in 93 patients. A
simple transcervical route was chosen in 51 cases
(31.48%), whereas the more extensive transcervical-
transmandibular approach was used in 18 (11.11%).
Neck dissection was performed in 8 patients (3 pa-
tients with neurofibrosarcoma, 1 patient with squa-
mous-cell carcinoma, 2 patients with mucoepider-
moid carcinoma, 1 patient with adenocarcinoma, and
1 patient with adenoid cystic carcinoma). There was
cal results are shown in Table 3. Parotid-gland tumors
and neurogenic tumors were the commonest. Postoper-
ative radiotherapy was given to 16 patients with malig-
nant tumors, and chemotherapy was given to 4 patients
diagnosed with lymphoma. Two patients refused the
recommended radiotherapy and chemotherapy.
The follow-up period for all patients ranged from
30 to 50 months, with a mean of 36 months. Two
patients suffered local failure, and 4 patients devel-
oped distant metastases. The 2 patients with local
failure had neurofibrosarcoma with positive surgical
margins. Distant metastases were observed in 2 pa-
tients with adenoid cystic carcinoma: 1 patient with
mucoepidermoid carcinoma, and 1 patient with neu-
rofibrosarcoma.
Postoperative complications were encountered in 17
patients. Eight patients experienced hoarseness (5 with
neurofibroma, and 3 schwannomas), and 5 developed
Horner’s syndrome (2 with paraganglioma, 2 with ma-
lignant paraganglioma, and 1 with neurofibrosarcoma).
The facial nerve was completely sacrificed in 5 patients
with a malignant parotid tumor, and the lower trunk
was sacrificed in 2 others with a malignant parotid
tumor because of evidence of involvement by the tu-
mor. The incidence of postoperative cranial nerve defi-
cits was reported to range from 0% to 57%, with high
incidence in malignant or neurogenic lesions.4-6

Table 2. SURGICAL APPROACHES

Approach No. of Patients Percentage

Transcervical 51 31.48
Transcervical-transparotid 93 57.41
Transcervical-transmandibular 18 11.11
FIGURE 8. Postoperative specimen. Total 162 100
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009. Maxillofac Surg 2009.
ZHI ET AL 1243

Table 3. POSTOPERATIVE
and paragangliomas (8 cases; 4.94%). The remaining
PATHOLOGICAL DIAGNOSES 20% of cases comprised a wide variety of entities
including hemangiomas, branchial cleft cysts, carotid
No. of aneurysms, and chondrosarcomas. Johnson et al10 re-
Diagnosis Patients Percentage
ported that schwannomas accounted for 20% of all
Salivary-gland neoplasm 74 45.68 PPS tumors, and were the most common enhancing
Pleomorphic adenoma 57 35.19 extraparotid tumors. Carrau et al3 reported that neu-
Basal-cell adenoma 5 3.08
Warthin’s tumor 3 1.85
rogenic tumors occurred in 31 out of 54 patients
Mucoepidermoid carcinoma 3 1.85 (57.41%). Twenty-six patients (83%) had benign tu-
Adenoid cystic carcinoma 2 1.23 mors, whereas 5 (17%) had malignant tumors.
Adenocarcinoma 2 1.23 In our study, the presence of a mass in the neck or
Acinic-cell carcinoma 1 0.62 parotid gland was the most commonly encountered
Squamous-cell carcinoma 1 0.62
Neurogenic neoplasm 68 41.98 symptom (72.84% and 30.86%, respectively), fol-
Schwannoma 36 22.22 lowed by oral swelling (27.78%) and dysphagia
Neurofibroma 18 11.11 (6.79%). Facial-nerve paralysis was rare, presenting in
Paraganglioma 8 4.94 only 3.70% of patients, and in every case was associ-
Malignant paraganglioma 3 1.85
Neurofibrosarcoma 3 1.85
ated with a malignant tumor. Kenneth et al,9 echoing
Other lesions 20 12.35 our findings, found that most of their 172 patients had
Hemangioma 5 3.09 only vague symptoms, ie, ear pressure or pain (36%),
Branchial cleft cyst 4 2.47 dysphagia (12.8%), hearing loss (11%), hoarseness
Carotid aneurysm 4 1.85 (10.5%), and facial or jaw pain (6.4%).
Chondrosarcoma 3 2.47
Lymphoma 4 2.47 In our series, 70 patients underwent FNAC, and 21
patients had previously undergone a biopsy before
Zhi et al. Management of Parapharyngeal-Space Tumors. J Oral
Maxillofac Surg 2009.
presenting at our hospital. The FNAC was selectively
applied where fascial planes were obscured by tu-
moral growth, raising the possibility of malignancy.
Discussion Fine-needle aspiration was performed in 40.5% of all
patients, and correctly provided the diagnosis in 88%.
This review included 162 patients with PPS tumors.
All patients underwent resection with frozen-section
All were primary cases. The male-to-female ratio was
analysis of their tumor to facilitate intraoperative deci-
1.4:1. This demonstrates a slight male preponderance,
sion-making in regard to the extent of surgery and the
compared with similar series where ratios ranged
from 2:3 to 3:5 to 5:6.3,7,8 The mean age of our cohort need for adjunctive procedures such as lymphadenec-
was 36.4 years (slightly younger than in the series of tomy. If imaging studies were suggestive of a vascular
Kenneth et al,9 where the mean age of 172 cases was tumor such as a paraganglioma, fine-needle aspiration
50.1 years). was not performed because of the risk involved and the
The histopathology of tumors of the PPS is diverse. low likelihood of gaining incremental information.
Batsakis and Sneige1 found that neoplasms of salivary- Initial radiographic evaluations of PPS tumors con-
gland origin accounted for 40% to 50% of PPS tumors, sisted mainly of CT scanning as a practical first choice.
and were located on the prestyloid compartment of Magnetic resonance imaging was used selectively
the PPS. In aggregate, salivary-gland tumors (of pri- where superior soft-tissue delineation was felt neces-
mary parotid origin), neurogenic tumors, paragangli- sary, and in cases where skull-base involvement was
omas, and lymphomas comprised nearly 80% of PPS suspected. Magnetic resonance imaging is also supe-
masses.1,10 Our findings were in accordance with rior in defining the boundaries and extent of tumoral
these previous observations. Benign salivary-gland involvement of the great vessels, whereas CT scan-
neoplasms predominated, with 65 cases (40.12%) ning is superior to MRI in demonstrating the presence
including 57 pleomorphic adenomas (35.19%), 5 of calcifications and bony involvement.
basal-cell adenomas (3.08%), and 3 Warthin’s tumors Tumors arising in the PPS represent a challenge to
(1.85%). Because most of these salivary lesions were the head and neck surgeon, not only because they are
prestyloid in location, they tended to displace the rare, but also because of the wide variety of histological
contents of the carotid sheath posteriorly. types in this site. Anatomic knowledge is mandatory
The next commonest group of tumors was neuro- because of the presence of important structures such as
genic, with 68 cases (41.98%). The majority of these the carotid and jugular vessels and cranial nerves V, VII,
were benign (in 62 cases), compared with only 6 IX, X, and XII. Surgery is the mainstay of treatment for
malignancies. Benign tumors included schwannomas PPS tumors. In our experience, there are three surgical
(36 cases; 22.22%), neurofibromas (18 cases; 11.11%), approaches, guided basically by tumor size, histological
1244
type, and position of the tumor with respect to the
major vessels and styloid process.
The transcervical-transparotid approach was the
commonest approach in 93 patients, followed by
transcervical approaches, used in 51 patients. The
transcervical-transparotid approach provides excel-
lent access to the PPS, allowing dissection of the main
trunk of the facial nerve and adequate vascular con-
trol. If necessary, the submandibular gland may be
removed, and the stylomandibular ligament may be
transected for better exposure of the operative field.
This approach was used extensively by Carrau et al,3
with success for lesions of large size arising from the
deep lobe of the parotid gland, with involvement in
the PPS. This approach was often used after convert-
ing from a transcervical approach by extending the
incision that would be used for a parotidectomy.
Some authors have referred to this as the “transpar-
otid submandibular approach.”1
Transcervical-transmandibular approaches were
used for very large tumors and malignant tumors, and
always as part of a composite resection. We preferred
to perform mandibulotomy in the region of the angle
of the mandible, to achieve adequate exposure. Os-
teotomy necessarily transects the inferior alveolar
nerve in this region. Tracheostomy is not required for
respiratory problems during postoperative recovery.
Osteosynthesis was performed using a miniplate, thus
avoiding the need for prolonged intermaxillary fixa-
tion. Combinations of this technique with the transpa-
rotid approach are also possible in large, deep-lobe
tumors. We used this approach in 18 patients (12 with
malignant tumors, and 6 with large benign tumors).
Several variations of mandibulotomy have been advo-
cated. The inverted L-osteotomy or C-shaped osteotomy
just posterior to the mandibular foramen was advocated,
to avoid damage to the inferior alveolar nerve,8 but
these do not afford the same access to the PPS.
Beyond the 3 approaches used in our study, 2 other
approaches were described in literature. They include
the transoral approach11 and the infratemporal fossa
approach.12 The transoral approach is no longer rec-
ommended, for a variety of reasons. This approach
incorporates a lip-splitting incision and mandibu-
lotomy through the tooth-bearing portion of the man-
dible. This makes for relatively high morbidity, with
high rates of soft-tissue complications and nonunions,
especially in patients undergoing adjuvant radiother-
apy. Furthermore, the lip-splitting scar is quite unes-
thetic. The more limited access of this approach
makes oncologically safe resections more difficult,
and thereby increases the possibility of tumor spillage
and incomplete removal. The more limited access also
increases the risk of vascular and facial-nerve injury
when a blind approach toward the trunk is applied.
Lastly, by violating the oral cavity and pharyngeal mu-
MANAGEMENT OF PARAPHARYNGEAL-SPACE TUMORS
cosa, the neck is exposed to salivary contamination and
an increased risk of infection. The infratemporal fossa
approach is recommended for malignant tumors involv-
ing the skull base or jugular foramen, where improved
cephalad tumor control is required.
In our series, there were no perioperative deaths
and complications were rare (encountered in only 17
patients), a testament to the safety of this approach.
In conclusion, surgery is the mainstay treatment for
PPS tumors. Because most of these tumors are benign,
the approach chosen should minimize surgical mor-
bidity, as well as the risk of surgical recurrence. Ex-
ternal approaches to the PPS are preferred because
they afford excellent visualization and control of vital
structures. They also offer the potential for incremen-
tal surgical exposure. One may begin with the most
conservative incision and expand upon it, based on
intraoperative findings of tumor size and histology.
For example, a transcervical approach is easily con-
verted to a transcervical-transparotid approach.
Intraoral approaches are to be discouraged because
they do not offer the same control over vital structures,
and add salivary contamination to the wound and in-
crease the risk of wound infection.
Acknowledgment
We thank Dr Sean Edwards at the Department of Oral and
Maxillofacial Surgery, University of Michigan (Ann Arbor, MI), for
assistance in preparation of the manuscript.
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