Mandibulotomy for access to benign deep lobe parotid tumors with parapharyngeal extension: report of four cases

Management of a Giant Para-Pharyngeal Space Pleomorphic Adenoma of Deep Lobe of Parotid Gland Without Mandibular Swing Approach in a 17-Year Old Patient: Rare Case Report

Pleomorphic adenomas comprise of 0.5% of all head and neck tumors. Pleomorphic adenoma affects patients from 4th to 6th decades. 10-12% of Pleomorphic adenomas arise from deep lobe of parotid gland that grow medially and involve the parapharyngeal space. Investigations play a role of paramount importance in treatment of para-pharyngeal tumors. CT scanning aids in evaluating the bone structures and possible calcification of the tumors. MRI provides precise tumor margins and the relationship of the tumor with its adjacent vital structures. The most common approaches to access these masses are the trans-oral, trans-mandibular, transcervical and trans-parotid trans-cervical approaches. Complete surgical excision of the lesion is the treatment of choice for such PPS tumors. The choice of surgical approach should enable the surgeon to maximize exposure for complete resection of the tumor while minimize functional and cosmetic morbidity. The various mandibulotomies are median mandibulotomy, para-symphyseal osteotomy, horizontal osteotomy, inverted 'L' osteotomy and double mandibular osteotomy. We report a rare case of giant pleomorphic adenoma arising from the deep lobe of parotid gland of the parapharyngeal space in a young patient. The excision was done in to without the mandibular swing approach making it one of the rare case reports.

Mandibular access osteotomy: Gate way to parapharyngeal space - A case report

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Parapharyngeal space is an anatomically complex and difficult to access terrain for surgical interventions.

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Tumours originating from or extending into the parapharyngeal space are rare and literatures are suggestive of the occurrence of only 0.5% among all head and neck tumours.

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The aims of choosing the right approach should be complete removal of lesion, maintenance of occlusion and good temporomandibular function and preservation of inferior alveolar nerve.

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Performing the osteotomy anterior to mental foramen preserves the inferior alveolar nerve and the osteotomy between the teeth avoids the need of tooth removal.

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Out of the numerous techniques mandibular swing approach is a good option for skull base tumors because of the ease of technique even in inexperienced hands.

Introduction

Para pharyngeal tumors often pose a challenge to surgeons for surgical interventions. Maxillofacial access osteotomies offer excellent visualization and permit unhindered surgical manipulation. Access osteotomy allows the surgeon an adequate access of the surgical field to resect the tumor completely and to preserve vital structures. Though numerous techniques exist, selection of the proper technique is the key factor in reestablishing the function and cosmesis. This article describes our experience with mandibular swing approach that has facilitated complete removal of a parapharyngeal space tumor.

Case presentation

35years old female complained of deviation of tongue to one side and swallowing difficulty. Clinical and radiographic examinations were suggestive of a skull base lesion involving the hypoglossal nerve. After evaluation the tumor was excised through a mandibulotomy approach. Post operatively the patient was relieved completely of the symptoms and without any postoperative sequalae.

Clinical discussion

Accessibility is the main concern while dealing with skull base lesions. But the success of surgery lies on the selection of right approach. Paramedian mandibular swing approach has its own advantages over various other facial osteotomies. The swinging of the mandible gives advantage of accessing neck and skull base together, which is not possible with other facial osteotomies.

Conclusion

Management of skull base tumors involve a multidisciplinary approach. Choosing the right approach is often a major dilemma. Access osteotomies of facial skeleton is a hatchway to the skull base lesions. Of which mandibular swing approach is a good option for skull base tumors because of the ease of surgical technique even in inexperienced hands.

A Transoral Excision of a Deep Parotid Lobe Lesion Using Ultrasound-Guided Wire Localization: A Multi-disciplinary Team Approach

Purpose

Removing deep parotid lobe lesions often requires a mandibulotomy procedure which carries with it a risk of significant morbidity. A transoral approach may help mitigate against complications but is technically demanding due to limited access in an area with a close relation to the internal carotid artery.

Methods

We describe a multi-disciplinary approach with the use of intraoral ultrasound-guided wire localization of a low-grade acinic cell carcinoma located in the deep lobe of the right parotid gland.

Results

Our multi-disciplinary approach facilitated the complete removal of this deep lobe parotid lesion via a transoral approach with minimal post-operative sequelae or complications.

Conclusion

In selected cases, with appropriate expertise, this dynamic approach can potentially be used even for malignant disease to limit post-operative morbidity when managing small deep parotid lobe lesions.

Giant Parapharyngeal Space Pleomorphic Adenoma of the Deep Lobe of Parotid Presenting as Obstructive Sleep Apnoea: A Case Report & Review of the Diagnostic and Therapeutic Approaches

INTRODUCTION

Salivary gland tumours constitute about less than 4 % of all head and neck tumours. Pleomorphic adenoma, also called benign mixed tumour, is the most common tumour of the salivary glands. About 80-90 % of these tumours occur in the major salivary gland mainly parotid gland and 10 % of them occur in the minor salivary glands.

AIMS AND METHODS

Aim of this case report is to discuss the unique case of giant parotid pleomorphic adenomas arising in the deep lobe involving the parapharyngeal space and difficulty in respiration at sleep during nights repoted at this institute. The patient was undergoing treatment for obstructive sleep apnea syndrome when she reported at this institute for disturbed sleep. Diagnosis was based on computed tomography scan and magnetic resonance imaging and cytology by means of fine needle aspiration biopsy.

CONCLUSION

An exhaustive pre-operative diagnostic algorithm is mandatory before approaching such lesions involving parapharyngeal space. Fine needle aspiration biopsy is, in our opinion, mandatory to avoid histological surprises. The surgical approach varies according to the location of the tumour and should provide excellent visibility with wide surgical exposure to secure local neurovascular structures.

Skull base tumors: a kaleidoscope of challenge

Resection of skull base lesions has always been riddled with problems like inadequate access, proximity to major vessels, dural tears, cranial nerve damage, and infection. Understanding the modular concept of the facial skeleton has led to the development of transfacial swing osteotomies that facilitates resection in a difficult area with minimal morbidity and excellent cosmetic results. In spite of the current trend toward endonasal endoscopic management of skull base tumors, our series presents nine cases of diverse extensive skull base lesions, 33% of which were recurrent. These cases were approached through different transfacial swing osteotomies through the mandible, a midfacial swing, or a zygomaticotemporal osteotomy as dictated by the three-dimensional spatial location of the lesion, and its extent and proximity to vital structures. Access osteotomies ensured complete removal and good results through the most direct and safe route and good vascular control. This reiterated the fact that transfacial approaches still hold a special place in the management of extensive skull base lesions.

Trigeminal schwannoma extending into the parapharyngeal space

Parapharyngeal space tumors are very rarely seen, and surgical approach to these tumors has not been well established. Most of these tumors are benign and originated from salivary glands and neurogenic in nature. In this case, we report a patient who has a trigeminal schwannoma extending into the deep parapharyngeal space and explain our surgical approach.

Single, subcondylar mandibular osteotomy: a new access route for extensive, benign parapharyngeal neoplasms

Objective:

We report a new approach to benign parapharyngeal space tumours: a single, subcondylar mandibular osteotomy.

Method:

Case report and review of the world literature concerning parapharyngeal space access and the various types of mandibular osteotomy.

Results:

The use of a single, subcondylar mandibular osteotomy achieves good exposure and satisfactory aesthetic and functional results, using a simple, easily performed technique that is fast and has minimal morbidity. In addition, this technique preserves the submandibular gland and avoids lip-splitting and post-operative intermaxillary fixation.

Conclusion:

To our knowledge, this is the first report of this approach to the parapharyngeal space. We propose this approach as the first choice for resection of benign neoplasms of the parapharyngeal space.

[Lateral transmandibular route for deep-lobe parotid tumor excision]

The parapharyngeal space may be a site for tumors, especially for those developed in the deep parotid lobe. The surgical route to parapharyngeal space tumors is a challenge because of neighbor anatomic structures and the specific risk of mandibular nerve damage. The aim of this study was to describe an original lateral transmandibular route, setting aside the mandible angle and preserving the mandibular nerve.

[Parapharyngeal tumors: diagnosis and treatment]

OBJECTIVES

Parapharyngeal space tumors are rare and usually benign. Their treatment is surgical and many approaches have been described. We report our experience in managing these neoplasms. Two points are developed more fully: the correlation between imaging and surgical observation and the reliability of the cervical approach.

MATERIAL AND METHODS

A retrospective review of primary parapharyngeal space tumors treated at the Rennes University Hospital between 1992 and 2004 is presented. Nine patients were included, all treated surgically with a cervical approach without parotidectomy.

RESULTS

Eight MR imaging and seven CT scans were done. Two retrostyloid tumors and six prestyloid tumors, all independent of the deep lobe of the parotid gland, were found. They were benign in all cases (five salivary tumors and four schwannomas). Two patients treated for a pleomorphic adenoma presented recurrence and were reoperated successfully. The average follow-up was 66 months. None of the patients died. Definitive postoperative complications occurred only for neurogenic tumors.

CONCLUSION

The cervical approach is safe and allows the surgical excision of retrostyloid and prestyloid tumors, independent of the deep lobe of the parotid gland. Large tumor (8cm in our study) excision can be done with few complications. An attentive study of preoperative imaging is necessary to choose the best surgical approach.

One-stage zygomaticomandibular approach for improved access to the hemimaxilla and the middle base of the skull

In this report, we describe a 1-stage zygomaticomandibular composite flap for improved access to the retromaxillary space and the base of the skull. The zygoma and the mandible were not detached from the facial musculature or from its overlying tissues, maintaining an optimum bone-soft tissue relationship. The advantage of this approach was the enhanced exposure of the deep lesion, which provided a shorter and wider view to the maxilla, the retromaxillary space, and the base of the skull. Restoration of the skeletal symmetry and the three-dimensional contour of the maxilla was greatly enhanced by using preadapted plates and a stereolithographic model. To the best of our knowledge, no references were found in the literature regarding the use of the same technique for treating defects of similar nature to those described in this article. The deep circumflex iliac artery flap was used to reconstruct the midfacial defect and the base of the skull. The use of the flap provided optimum results because the defect was closed with the muscle that became epithelialized with minimal bulk.

An extraoral parapharyngeal space approach via vertical ramus osteotomy

BACKGROUND

Numerous approaches to access the parapharyngeal space have been described, each with associated morbidities.

SURGICAL TECHNIQUE

We describe the use of vertical ramus osteotomy to increase exposure of the parapharyngeal space.

RESULTS

We have been using this approach over the past 5 years and have found it to be the preferred approach to the parapharyngeal space.

CONCLUSION

This approach provides excellent exposure with low risk to the facial nerve while allowing for adequate tumor resection. It also avoids facial scarring and oral contamination of the cervical wound.

Treatment of lesions involving both the infratemporal fossa and middle skull base

BACKGROUND

Communicating occupying lesions of the intratemporal fossa and mid-cranial fossa represent challenges for neurosurgeons and maxillofacial surgeons. Lesions of the skull base, with complex anatomy, are extremely varied in their histopathology. They often spread via normal anatomic pathways or bony destruction to involve adjacent structures, especially in the case of malignant neoplasms. However, with the development of operative skills and reconstruction techniques, total or near total resection of many such lesions can be accomplished with a low morbidity rate.

METHODS

The combined frontotemporal-preauricular infratemporal approach, frontotemporal-orbitozygomatic approach, combined frontotemporal and transmandibular approach, transmandibular approach, and transmaxillary approach were used to resect the lesions using microsurgical skills. The plastic reconstruction included reconstruction of the dura defects, osteosynthesis, and obliteration of the operative cavity.

RESULTS

Thirty-three patients with communicating lesions invading both the infratemporal fossa and the middle skull base underwent microsurgery. Among them, lesions were totally resected in 23, subtotally resected in 6, and partially resected in 4. In 29 patients, clinical status improved significantly. Complications were encountered in 7 cases, and morbidity was not remarkable.

CONCLUSION

The surgical approach should be selected depending on the size, location, histopathology, and invading extension of the lesion, which can provide excellent visualization and allow for an aggressive and safe resection of lesions involving this region. Familiarity with skull base anatomy, careful microsurgical manipulation, protection of vital structures, reliable plastic reconstruction, intraoperative nerve monitoring, as well as consideration of functional and esthetic outcomes, will all contribute to successful surgery and satisfactory results.

Vertical ramus osteotomy combined with a parasymphyseal mandibulotomy for improved access to the parapharyngeal space

BACKGROUND

A number of procedures have been described that facilitate access to the parapharyngeal space. Their use may be limited because of restricted access or postoperative morbidity.

METHODS

We describe the use of two mandibular osteotomies to greatly enhance the exposure of the parapharyngeal space, with possible access up to the skull base.

RESULTS

We have performed this procedure in three cases with minimal postoperative morbidity and no neurologic deficit or occlusal disturbances.

CONCLUSIONS

We have found that the osteotomies described provide far better exposure to this area than a single mandibular osteotomy alone. Furthermore, it avoids a facial scar.

Stylomandibular tenotomy in the transcervical removal of large benign parapharyngeal tumours

We used a simple modification of the transcervical approach in a selected group of nine patients with large benign parapharyngeal space tumours, all of whom met the following inclusion criteria: The tumour was benign on fine needle aspiration, the encapsulated tumour was not attached to skull base or great vessels in the parapharyngeal space on imaging. Adequate exposure was achieved by just dividing the stylomandibular ligament and retracting the mandible anteriorly. It was possible to remove the tumours successfully and safely in all nine patients without the need for mandibulotomy or superficial parotidectomy. In seven cases, the tumour crossed the midline. There were no major perioperative neurological or vascular complications. On subsequent follow up, there were no clinical or radiological signs of residual or recurrent tumour.