Cephalometric evaluation of skeletal stability and pharyngeal airway changes after mandibular setback surgery: Bioabsorbable versus titanium plate and screw fixation.

Purpose: This study compared sequential changes in skeletal stability and the pharyngeal airway following mandibular setback surgery involving fixation with either a titanium or a bioabsorbable plate and screws. Materials and Methods: Twenty-eight patients with mandibular prognathism undergoing bilateral sagittal split osteotomy by titanium or bioabsorbable fixation were randomly selected in this study. Lateral cephalometric analysis was conducted preoperatively and at 1 week, 3-6 months, and 1 year postoperatively. Mandibular stability was assessed by examining horizontal (BX), vertical (BY), and angular measurements including the sella-nasion to point B angle and the mandibular plane angle (MPA). Pharyngeal airway changes were evaluated by analyzing the nasopharynx, uvula-pharynx, tongue-pharynx, and epiglottis-pharynx (EOP) distances. Mandibular and pharyngeal airway changes were examined sequentially. To evaluate postoperative changes within groups, the Wilcoxon signed-rank test was employed, while the Mann-Whitney U test was used for between-group comparisons. Immediate postoperative changes in the airway were correlated to surgical movements using the Spearman rank test. Results: Significant changes in the MPA were observed in both the titanium and bioabsorbable groups at 3-6 months post-surgery, with significance persisting in the bioabsorbable group at 1 year postoperatively (2.29°±2.28°; P<0.05). The bioabsorbable group also exhibited significant EOP changes (-1.21±1.54 mm; P<0.05) at 3-6 months, which gradually returned to non-significant levels by 1 year postoperatively. Conclusion: Osteofixation using bioabsorbable plates and screws is comparable to that achieved with titanium in long-term skeletal stability and maintaining pharyngeal airway dimensions. However, a tendency for relapse exists, especially regarding the MPA.

Management of Parapharyngeal Metastatic Medullary Thyroid Carcinoma Via a Combined Trans-Cervical and Trans-Oral Robotic Approach.

INTRODUCTION: Medullary thyroid carcinoma constitutes 5% to 10% of all thyroid cancers. Metastatic adenopathies may pose challenges in intricate anatomical locations, such as the parapharyngeal space. A rare case of metastatic medullary thyroid carcinoma in the parapharyngeal space has been treated in our unit using combined trans-cervical trans-oral robotic surgery. Our objective was to provide a detailed description of the surgery performed on this patient. METHOD: We reported a singular case report worth of interest. RESULT: A 42-year-old woman was addressed in our unit for the management of a medullary thyroid carcinoma adenopathy located in the right parapharyngeal space. A parapharyngeal 40.0 mm × 25.0 mm × 12.0 mm adenopathy was removed using a combined trans-cervical and trans-oral robotic approach without sacrifice or injury of vascular or nervous structure. Neither the tracheostomy nor the feeding tube was implemented. Feeding was resumed on postoperative day 1 and hospitalization spanned 7 days. CONCLUSION: An innovative combined trans-cervical and trans-oral robotic surgery approach was conducted to address a metastatic medullary thyroid carcinoma in the parapharyngeal space. This surgical technique allowed us to circumvent the need for a trans-mandibular approach, tracheostomy, and feeding tube and enabling successful tumor removal without fragmentation. Postoperative care was significantly eased. The sole complication observed was dysphonia, likely resulting from intra-operative stretching of the vagus nerve during the dissection of the carotid artery.

Surgical Dilemma in Approaching Parapharyngeal Space Pleomorphic adenoma- Transcervical or Transoral Route - A Case Report.

A case of pleomorphic adenoma of deep lobe of parotid in parapharyngeal space presented as intra oral swelling. FNAC showed features of pleomorphic adenoma. Surgery done through transcervical route. HPE of excised mass confirmed pleomorphic adenoma.

Parapharyngeal Nodal Metastasis in Papillary Thyroid Carcinoma: Catching Early.

Background: Metastasis to parapharyngeal space in papillary carcinoma of the thyroid is rare and often missed in routine clinical and radiological investigations. Although contrast CT /MRI can be done to locate the parapharyngeal lesion, the diagnosis of metastasis mostly deepened upon aspiration cytology, which is a challenge in difficult anatomical locations. Here, we have emphasized the management dilemma of parapharyngeal metastasis in papillary carcinoma of the thyroid. Case Report: A 30-year-old female presented with multiple right-side neck swelling for two months. Ultrasonography of right thyroid showed TIRAD V and left thyroid showed TIRAD II. Aspiration cytology of the right thyroid showed Bethesda III and aspiration cytology revealed thyroid follicles. Due to the diagnostic ambiguity, contrast-enhanced CT scan was advised. It revealed a hypervascular lymph node in the parapharyngeal space besides multiple right cervical lymph nodes and later changed the treatment plan. Conclusion: - Metastasis to parapharyngeal space in Papillary carcinoma of the thyroid is rare and often missed on routine evaluation. Contrast-enhanced CT/MRI can be added as a primary investigation in challenging cases of suspicious malignancy of the thyroid.

[An anatomical road map of the parapharyngeal internal carotid artery in lateral and endoscopic ventral approaches].

Objective:To describe the road map of the lateral and endoscopic ventral approaches for the pharyngeal segment of the internal carotid artery, propose a sub-segmentation scheme, systematically and comprehensively understand its anatomical details and relationships with the surrounding structures. Methods:Five fresh cadaveric head specimens（10 sides in total） were dissected through lateral and endoscopic ventral approaches to evaluate the anatomical details of the parapharyngeal internal carotid artery and its relationship with the surrounding structures. Results:From the bifurcation of the common carotid artery to the vertical part of the internal carotid artery, alongside the direction of blood flow, the parapharyngeal internal carotid artery passes through four distinct anatomical tissues. Based on this, the parapharyngeal internal carotid artery can be divided into four sub-segments: nerve, muscle, fascia and osseous sub-segments. The boundaries and important adjacent structures of each segment are described in detail. Conclusion:The anatomical road map of the parapharyngeal internal carotid artery and the sub-segmentation scheme serving as a practical guide to navigate modular endoscopic skull base surgery of the parapharyngeal space while reduce the risk of internal carotid artery injury.

[Research progress in the anatomy and surgical approach of the parapharyngeal space].

The parapharyngeal space, a complex fascial compartment within the head and neck region, encompasses crucial anatomical structures including blood vessels and nerves. Tumors occurring within this space are rare, with the majority being benign in nature. Surgical intervention remains the primary treatment modality; however, managing parapharyngeal space tumors poses significant challenges due to their intricate anatomical configuration. Conventional open surgical approaches have been associated with significant tissue damage and a high prevalence of postoperative complications. Recently, advancements in anatomical studies and surgical techniques have led to significant progress in understanding parapharyngeal space anatomy and improving surgical management. This article aims to provide a comprehensive overview of these developments.

Parotidectomy for deep lobe pleomorphic adenomas is associated with higher rates of complications and recurrence.

BACKGROUND: Pleomorphic adenoma (PA) is a common parotid tumor, yet due to the relative rarity of deep lobe PA (DLPA), there is a paucity of information about its clinical presentation and surgical outcomes. METHODS: We reviewed the charts of patients with previously untreated parotid PA between the years 1990 and 2015. Clinical parameters and surgical outcomes were compared between superficial lobe PA (SLPA) and DLPA. RESULTS: The cohort comprised 147 cases of DLPA and 222 cases of SLPA. DLPA were larger (median 2.6 cm vs. 2.0 cm, p < 0.001), more often discovered incidentally on imaging (33%, n = 48) and had unique presentations (pharyngeal mass, dysphagia, otalgia). Postsurgical complications were more frequently observed in DLPA (41% vs. 30% in SLPA, p = 0.025), mainly transient facial nerve weakness. DLPA also showed higher recurrence rates (n = 6, 4.1% vs. n = 1, 0.4%, p = 0.016). CONCLUSIONS: Parotidectomy for DLPA carries a higher risk of complications and recurrence compared to SLPA.

Meningocele in the Parapharyngeal Space: A Case Report and Review of the Literature.

The parapharyngeal space has been described as an inverted pyramid shape with the base of the skull and the great cornu of the hyoid bone at the top. Tumors of the parapharyngeal space account for 0.5% of head and neck tumors and a wide range of tumor types can occur in this area, 80% of which are benign, the most common being pleomorphic adenomas of the salivary glands and neurogenic tumors. We present a 39-year-old woman who was hospitalized due to left-sided neck pain with a feeling of blockage in the left ear and hearing loss for 10 months. Imaging showed that the mass was not connected to the cranium and the patient underwent surgical resection via a transoral approach, where the contents of the mass were found to be cerebrospinal fluid, and meningocele in the parapharyngeal space is a rare occurrence. The patient presented mainly with painful symptoms, which were eventually relieved by nerve block therapy.

Parotid Gland Cancer With First Bite Syndrome Detected via CT-Guided Fine Needle Aspiration Cytology.

BACKGROUND/AIM: First bite syndrome (FBS) is a symptom of severe pain at the beginning of a meal that lessens as the meal progresses. It is a common postoperative complication of parapharyngeal space tumors and is rarely reported as the first symptom of parotid carcinoma. The parapharyngeal space is considered a difficult area for approach; hence, preoperative histopathology is often challenging. However, there are hardly any reports on the approach of performing biopsies under computerized tomography (CT) guidance. CASE REPORT: A 28-year-old woman presented to our hospital with the chief complaint of pain in the left parotid region since the past year. Contrast-enhanced magnetic resonance imaging of the parotid gland revealed a 10-mm high-signal area on T2-weighted images extending from the deep lobe of the left parotid gland to the parapharyngeal space, which could not be visualized on ultrasound. She was suspected to have a malignant tumor because of the presence of a parotid tumor with FBS. Therefore, she underwent CT-guided fine-needle aspiration cytology (FNAC) and was diagnosed with adenoid cystic carcinoma. The patient underwent left parotid tumor resection and left cervical dissection, and her pain during feeding improved postoperatively. CONCLUSION: In a patient with parotid tumor extending into the parapharyngeal space with FBS as the initial symptom, CT-guided FNAC was successfully used to diagnose parotid carcinoma. Symptoms of pain, including FBS, should be considered in cases of malignancy. CT-guided FNAC is effective for lesions that cannot be visualized by ultrasound, such as those in the parapharyngeal space.

[Efficacy analysis of 23 cases of parapharyngeal space tumors removed by oral approach assisted by plasma and high-definition endoscopic system].

Objective:To explore the selection, efficacy and application of indications for parapharyngeal space tumor resection assisted by plasma and HD endoscopic system through oral approach. Methods:The clinical data of 23 patients with parapharyngeal space tumor resection assisted by plasma and HD endoscopic system were retrospectively analyzed in Department of Otolaryngology Head and Neck Surgery, the First Affiliated Hospital of Bengbu Medical University from January 2013 to June 2023. All cases were examined by high-resolution CT and MRI before operation, and some cases were examined by CTA or DSA. During the operation, the high definition nasal endoscopic recording system was assisted, and low temperature plasma knife was used in some cases. The follow-up time was from 3 to 115 months, and the median follow-up time was 45 months. Results:There were no deaths in this group. All patients had complete tumor resection. The maximum tumor diameter was as follows: （5.20±1.00） cm, the operation time was（128.70±46.67） min, and the average blood loss was（80.87±32.74） mL. One case of vascular smooth muscle tumor had more bleeding during the operation and was assisted by tracheotomy after operation. One case of nourishing vascular bleeding after operation of giant Schwannoma was investigated and hemostasis + external carotid artery ligation. Bleeding in the remaining cases was below 120 mL. Postoperative pathologies were all benign tumors, including 11 pleomorphic adenoma, 4 schwannoma, 2 base cell adenoma, 1 epidermoid cyst, 1 lymphatic cyst with infection, 1 angiomyoma, 1 solitary fibroma, 1 salivary gland cyst, and 1 tendon giant cell tumor. All patients were followed up. One patient originating from vagal schwannoma had 2-month vocal cord paralysis and 1 recurrence（recurrence of the skull base of schwannoma）. Conclusion:Oral approach assisted by plasma and high-definition endoscopic system is suitable for partial selective resection of benign tumors in parapharyngeal space, which has the advantages of less trauma and rapid recovery. When the tumor is blood-rich, suspected to be malignant, the top of the tumor is deep into the cranial base nerve canal,located outside the internal carotid artery, and larger than 6.0 cm considering pleomorphic adenoma, it is recommended to conduct an external open or auxiliary cervical small incision approach.

Delayed Surgical Intervention in Cranio-Maxillofacial Splinter Injury: Report of a Case and A Literature Review.

Introduction: In the context of Indian combat scenario, maxillofacial injuries from gunshots are uncommon. Methods: The first section of this study is a case report of a rare instance of metal foreign bodies that were lodged in the parapharyngeal space, deeper to the deep lobe of the parotid right next to the carotid space in the neck. The second section focusses on the unique treatment for blast injuries as well as the variety of imaging procedures that are readily available to assist with surgery, such as plain film, CT, angiography, and occasionally MR imaging. Result and Conclusion: According to the study, understanding the pertinent anatomy, precise imaging of the penetrating object in relation to vital structures, meticulously planned and conducted surgical removal of the foreign body, and repair of damaged structures are the key elements of a successful treatment.

Transoral Robotic Surgery for a Rare Case of Venolymphatic Malformation in Parapharyngeal Space.

Venous malformations are low flow endothelial malformations with aberrant and ectatic venous channels. They are defects in vascular growth which causes functional and cosmetic impairment. Gradual growth in size of the lesion occurs due to venous congestion or thrombosis. Venous malformations in parapharyngeal space are a rare entity and are difficult to diagnose. Case Report. 13 year old boy presented with a history of hyposmia and progressive difficulty in breathing for a duration of 2.5 years. MRI face and neck with contrast showed a 4.5 × 4.3x3.6 cm lesion in the left parapharyngeal space. CT angiogram of brain and neck demonstrated a heterogeneously enhancing mass in the left parapharyngeal region. PET scan illustrated an ill-defined mass in the left pre styloid parapharyngeal space. Biopsy from the lesion showed features consistent with venolymphatic malformation. Flexible laryngoscopy showed a bulge over the left soft palate region with narrowing of nasopharyngeal lumen. Patient underwent transoral robotic surgery for complete excision of the mass. Post-operative period was uneventful. He has been on follow up for the past 1 year with no evidence of any residual or recurrent disease. Venolymphatic malformation is a rare lesion in the parapharyngeal space which is difficult to diagnose pre operatively. Surgical excision is the preferred modality of treatment for deep seated lesions in the parapharyngeal space. The advent of transoral robotic surgery have reduced the morbidity and improved clearance for such cases.

Solitary fibrous tumor of the parapharyngeal space: report of 2 cases and a literature review.

The solitary fibrous tumor (SFT) is usually described as a lesion arising from the pleura. Rarely, it has been described in the parapharyngeal space (PS). This study aims to report two cases of SFT in the PS and to perform a literature review on this topic. Two patients undergoing surgical resection of a SFT in the PS, were reported. A literature review on SFT of the PS, was also performed. Two patients were analyzed. Both patients underwent surgical resection, followed by adjuvant radiotherapy, for SFT arising from the PS. The postoperative course was uneventful and both patients recovered well after the procedure. No recurrences were diagnosed during the followup. SFT of the PS is an infrequent entity. Surgical resection is the most used treatment, and adjuvant radiation should be considered in patients with recurrence risk factors or distant metastases.

Osteoma of the stylohyoid chain: A rare presentation in a CBCT study.

A 54-year-old male patient presented for a periodic check-up at the dental clinic. A panoramic radiograph showed bilateral ossification of the stylohyoid ligament with an oval radiopacity on the right side. Cone-beam computed tomography revealed a well-defined, homogenous hyperdense entity from the lower third of the ossified stylohyoid ligament on the right side. The differential diagnosis of osteoma on the stylohyoid chain includes Eagle syndrome and benign tumors of the stylohyoid chain and adjacent structures. Osteoma rarely manifests in the neck. Even more infrequent are tumors originating from the stylohyoid chain, with only a single documented case of osteoma reported in the literature in 1993. Due to the asymptomatic status, no surgical intervention was advised, and the case would be monitored periodically. This case report describes the details of an osteoma that emerged from the stylohyoid chain, marking it as the second recorded occurrence of this highly rare condition.

Novel insights into the classification of Shamblin III carotid body tumors from a neurosurgical perspective.

BACKGROUND AND PURPOSE: The classic Shamblin system fails to provide valuable guidance in many Shamblin's III carotid body tumors (III-CBTs) due to the variable forms of carotid arteries and the complex anatomic relationships in parapharyngeal space. We proposed a modified classification to separately divide III-CBTs into different subgroups on the basis of arterial relevant features and anatomical relevant features. MATERIALS AND METHODS: From 2020 to 2023, a total of 129 III-CBTs at a single institution were retrospectively analyzed. All cases were independently classified as arterial-relevant and anatomical-relevant subgroups. The pre-, peri- and postoperative data were summarized and compared accordingly. RESULTS: Among the 129 cases, 69 cases were identified as "Classical type", 23 cases as "Medial type", 27 cases as "Lateral type" and 10 cases as "Enveloped type" according to arterial morphologies. Besides, 76 cases were identified as "Common type", 15 cases as "Pharynx- invasion type", 18 cases as "Skull base-invasion type" and 20 cases as "Mixed type" according to anatomical relationships. "Enveloped type" of tumors in arterial-relevant classification and "Mixed type" of tumors in anatomical-relevant classification are the most challenging cases for surgeons with the lowest resection rate, highest incidence of carotid arteries injury and postoperative stroke. CONCLUSION: The modified classifications provide comprehensive understanding of different III-CBTs which are applicable for individualized treatment in clinical practice.

Extension of Multinodular Goiter to the Parapharyngeal Space - a Case Report.

parapharyngeal space can have a mass of thyroid origin following metastasis from the thyroid or ectopic thyroid tissue. The extension of multinodular goiter into the parapharyngeal space is rare. A 54-year-old female presented with a 5-month history of neck mass and dyspnea. On examination, a large mass was seen on the right side of the neck which was bulging into the right parapharngeal. In the sonography, a large 50 × 57 mm cyst seen at the upper end of the right lobe of the thyroid. Computed tomography (CT) identified a 46 × 56 mm lesion medial to the right carotid sheath with a mass effect on the parapharyngeal space from the posterolateral aspect and appeared to be an exophytic cystic nodule arising from the upper pole of the right thyroidal lobe. The patient underwent total thyroidectomy, and the final pathology of multinodular goiter was reported. The spread of masses of the thyroid origin to the parapharyngeal space should be considered one of the differential diagnoses of these space masses.

Functional vagal paraganglioma developing 15 years after resection of a retroperitoneal paraganglioma.

The patient, a 40-year-old woman, was diagnosed as having a functional right vagal paraganglioma (PGL) 15 years after undergoing resection for a retroperitoneal PGL. 123I-MIBG scintigraphy showed no accumulation, but as the blood noradrenaline and urinary normetanephrine concentrations were elevated, the tumor was judged as being functional, and surgery was scheduled. The patient was started on doxazosin infusion and embolization of the tumor feeding vessel was performed before the surgery. Intraoperative examination showed that the tumor was contiguous with the vagal nerve, necessitating combined resection of the vagal nerve with the tumor. Postoperatively, the catecholamine levels returned to normal range. Histopathologically, the tumor was diagnosed as a moderately differentiated, intermediate-malignant-grade PGL, with a GAPP score of 4 to 6. No non-chromaffin tissue was observed in the tumor background, so that the functional vagal PGL was considered as a sporadic metachronous tumor rather than as a metastasis from the retroperitoneal PGL. More than half of head and neck paragangliomas (HNPGLs) are reported to arise in the carotid body, and about 5% from the vagal nerve. In addition, HNPGLs rarely produce catecholamines. Herein, we consider the relationship with the previously resected retroperitoneal PGL based on a review of the literature.

Cervical approach for prestyloid parapharyngeal pleomorphic adenoma resection.

OBJECTIVE: To describe the key points of cervical resection for prestyloid parapharyngeal pleomorphic adenoma and to discuss the role of modern imaging. OBSERVATION: Retrospective case series of 10 patients (4 women and 6 men, age 29-63 years) with prestyloid parapharyngeal pleomorphic adenoma with 2 to 8cm largest diameter on MRI, consecutively resected via a cervical approach between 2000 and 2020 in a French tertiary university referral care center. Seven patients had a minimum 10 years' follow-up, and one was lost to follow-up before the fifth postoperative year. Peri- and postoperative complications comprised great auricular nerve transection without subsequent symptomatic neuroma (2 patients), associated transoral approach to free the upper pole of the adenoma (2 patients), capsule effraction (3 patients), and hematoma (1 patient). There were no cases of facial paresis or palsy, other cranial nerve impairment, trismus, auriculotemporal or first-bite syndrome. One of the three patients with capsule effraction showed local recurrence at month 17. CONCLUSION: In agreement with previous reports, the present case series confirmed the role of the cervical approach to resect prestyloid parapharyngeal pleomorphic adenoma, and hence the need to continue teaching it.

Diagnostic and management challenge of concurrent tongue squamous cell carcinoma with an unknown parapharyngeal mass.

There are very few case reports of the diagnosis and management of concurrent oral cavity and parapharyngeal space tumors. We present a case involving a 49-year-old female who presented with oral cavity squamous cell carcinoma confirmed by biopsy. Initial diagnostic workup revealed a concurrent parapharyngeal mass. Diagnostic studies and surgical therapy were tailored to account for both pathological entities. The patient was treated with a combination of surgery and adjuvant therapy. The surgical strategy was designed to address both lesions simultaneously. One year post-surgery, the patient had good response to therapy with no evidence of persistent or recurrent disease. This report discusses the outcome and treatment of a rare case of concurrent squamous cell carcinoma with a complicating parapharyngeal space tumor. It explores the diagnostic process, comprehensive workup, and the surgical management.