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A TRANSPALATAL APPROACH ( PALATE SPLIT)
TO THE PARAPHARYNGEAL SPACE
N. Vaid t, S. Puntambekar 2, Mahesh Bora 3 A jay Kothadia 4
Key Words
: Pleomorphic adenoma, parapharyngeal space, transpalatal approach.
INTRODUCTION
The parapharyngeal space is a potential space located on
both sides of and parallel to the nasopharynx. It is filled
with loose connective tissue, arteries, veins, lymph glands,
nerves, muscles, tendons, glomus bodies and salivary
tissue. The space is like an inverted five sided pyramid
with its base towards the sphenoid bone and apex directed
inferiorly towards the minor horn of hyoid bone. Among
the various approaches to the parapharyngeal space, the
peroral approach is used sparingly due to the limited access
it provides. However, the transpalatal approach described
in this papaer allows good access to the whole length of
the parapharyngeal space.
CASE REPORT
A 20 year young boy came to K. E. M. Hospital, Pune in
ENT OPD which history of pain in the throat.
On examination, a smooth mass in the soft palate on the
left side was seen, mucosa over the mass was normal, no
ulceration seen over mass. The mass was non tender and
did not bleed on touch. Patient had no trismus no neck
swelling, no facial weakness or other cranial nerve
paralysis. On examination, a bulge was seen on the left
side of the soft palate, the mucosa over mass was normal.
Findings are as follows --
FNC of the lump perorally - pleomorphic adenoma.
CT Scan : Non enhancing 3.5 X 4 cms mass in left
parapharyngeal space.
- well encapsulated
- posterior displacement of parapharyngeal fat and mass
is separate from deep lobe of parotid gland.
OPERATIVE PROCEDURE
The patient was anaesthetised with a general anasthetic
and intubated. The oral cavity was exposed using a Boyles
Davis mouth gag.
An incision was taker~ about 0.5 cms around the mass
(Fig. I). Subperiosteal elevation done till the edges of the
mass were felt. Incision extended to enter through the
full - thickness of the soft palate. On dissection the tumor
was visualised. Using blunt dissection with forefinger and
guaze, the tumor was enucleated from the surrounding
structures and delivered unruptured into oral cavity. Pedicle
clamped cut and ligated. The repair was done primarily
using interrupted 3-0 vicryl sutures. Intraoperative blood
loss was around 50 ml.
POSTOPERATIVE
Th e patient was given IV antibiotics, anti inflammatory
drugs for seven days. Post operatively patient was on
Ryle's tube feeds for two days and then changed to oral
feeds on the third day.
No evidence of regurgitation, cough and aspiration and
nasal speech was noted postoperatively. Patient reviewed
Fig.
I : A
line drawing showing the full thickness palatal split incision
for access to the parpharyngeal space.
Hon. Consultant, ENT Department, 2ONCO Surgeon, ~Research Officer, ENT Deparment, 4 CR in ENT, KEM Hospital, Pune
308
A Transpalatal Approach ( Palate Split) to the Parapharyngeal Space
not extending to the syloid process. A peroral approach
with ligation of the ipsilateral external carotid artery
was used in the majority of patients.
More recently the peroral excision of small salivary
gland tumors of the anterior parapharyngeal space that
have been demonstrated to be separate from deep lobe
of parotid has been readvocated.
Fig. II : Mass seen in left parapharyngeal region.
at one week, two weeks and at one month postoperatively
revealed excellent healing of intraoral incision.
DISCUSSION
Parapharyngeal tumors are rare accounting for 0.5% of
all head and neck tumors.
The tumor may orginate from any of various types of
cells and tissue present within this space or by direct
extension from neighbouring structures. The group, of
salivary gland tumor being most prevalent
(50%) followed
by the neurogenic tumors. The majority of malignant
parapharyngeal tumors are in fact parapharyngeal
lymphnode metastases.
Pleomorphic adenoma is the most commonest of all benign
turnouts and is characterised by slow growth and a
clinically benign course. It is essentially an epithelial tumor
of complex morphology possessing epithelial and tumor
of complex morphology possessing epithelial and
myoepithelial elementsarranged in variety of paterns and
embedded in a mucopolysaccharides stroma. Its capsule
is the result of fibrosis of the surrounding salivary
parenchyma.
Access to tumors of the upper parapharyngeal space
provide a surgical challenge. There are six ways to
approach the parpharyngeal space.
I. Transoral
II. Transcervico sub maxillary
III. Transcervical
IV. Transmandibular
V. Transparotid
VI. Facial approach
A transoral approach offers direct route to tumors
presenting in the oropharynx, but provides no control of
the great vessels. This approach is only for small lesion
Thus, peroral approach allows direct access to the
parapharyngeal space and combined with palatal split it
gives excellent exposure.
Thus, transpalatal approach should be considered for
benign parapharyngeal tumors which have been
demonstrated on imaging to be extra - parotid and non
vascular. The approach does not provide adequate
exposure for removal of malignant tumors.
ACKNOWLEDGEMENT
Many thanks to Dr. Mrs. B. J. Coyaji, chief Medical
Officer, K. E. M. Hospital, Pune for allowing to publish
this paper.
REFERENCES
I. Batsakis J. (i, Neige N.(1989) : Parapharyngeal and
retropharyngea[ space disease. Annals of Otology, Rhinology
and Laryngology 98 : 320 - 323.
2. Bent J. E, Dinges D., Whitehouse A. (1992) : Pathology Quiz
Case 1. Minor salivary gland pleomorphic adenoma of the
parapharyngeal space. Archives of Otolaryngology, Head and
Neck Surgery 118 (6) : 664 - 666.
3. Carrau R. L., Myers E. N., Johnson J. T. (1990): Management
of tumors arising in the parapharyngeal space. Laryngoscope.
1990, 100 : 583 - 589.
4. Cross R. R., Shapiro M. D., Som E M. {1989) : MRI of the
parapharyngeal space. Radiology Clinics of North America.
27:353 - 358.
5. Goodwin W. L., Chandler J. R.,(1989) : Transoral excision of
lateral parapharyngeal space tumors presenting intraorally.
Larangyscope. 98 : 266-269.
6. Myatt H. M. (1997) : Transpalatal approach to the
parapharyngeal space. JLO 111 : 159 - 162.
7. Sore E M., Biller H. F., Lawson W. (1981) : Tumors of the
parapharyngeal space : preoperative evaluation, diagnosis and
surgical approaches. Annals of Otology, Rhinology and
Laryngology. 90 (suppl. 80/4) : 3-15.
8. Som R M., Braum t. E, Shapiro M. D.(1987) : Tumors of the
parapharyngeal space and upper neck. MRI characteristics.
Radiology 164 : 823- 829.
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 53 No. 4, October - December 2001
