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Minimally Invasive Surgery

Transoral Robotic Surgery for a Parapharyngeal Space Tumor

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Otolaryngology–Head & Neck Surgery

Published Online: May 18, 2023

Clinical Challenge

Article Information and Disclosures

Jessa E. Miller, MD¹;

Dipti P. Sajed, MD, PhD²;

Abie H. Mendelsohn, MD¹

Author Affiliations

¹Department of Head and Neck Surgery, University of California, Los Angeles
²Department of Pathology and Laboratory Medicine, University of California, Los Angeles

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A 71-year-old woman presented to the otolaryngology clinic for evaluation of a parapharyngeal space (PPS) mass that was incidentally found on magnetic resonance imaging (MRI) of the face. The patient experienced left jaw tightness, aural fullness, and facial discomfort. The MRI results demonstrated a well-circumscribed, ovoid mass in the left prestyloid PPS that measured 12 × 15 × 22 mm. The lesion was isointense on T1-weighted imaging, was hyperintense on T2-weighted imaging, and demonstrated heterogeneous enhancement following gadolinium administration (Figure 1). A computed tomography–guided fine-needle aspiration was performed, which demonstrated blood, fibrin, and rare mesenchymal cells. Given her ongoing symptoms, the patient requested surgical resection. The patient underwent transoral robotic surgery for resection of her PPS mass to achieve definitive diagnosis and treatment. Histopathologic evaluation demonstrated a well-circumscribed, 12-mm mass.

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B. Venous malformation

The PPS is often described as an inverted pyramid, with the base centered at the skull base and the apex at the greater cornu of the hyoid bone. Tumors of the PPS account for approximately 0.5% of head and neck neoplasms, and 80% are benign.¹ The PPS is separated into prestyloid and poststyloid compartments by the tensor veli palatini muscle and the styloid process.¹ Tumors in the PPS arise from structures that normally occupy the prestyloid and poststyloid compartments. The prestyloid space is composed of lymph nodes, adipose tissue, and a portion of the deep lobe of the parotid gland. Consequently, salivary gland neoplasms are the most common tumors found in the prestyloid PPS.² The poststyloid PPS contains the internal carotid artery, the internal jugular vein, cranial nerves IX to XII, lymph nodes, and the sympathetic chain. As such, neurogenic tumors are the most commonly identified tumors in this compartment.²

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Article Information

Corresponding Author: Abie H. Mendelsohn, MD, Department of Head and Neck Surgery, University of California, Los Angeles, 10833 Le Conte Ave, Center for the Health Sciences 62-235, Los Angeles, CA 90095-1624 (amendelsohn@mednet.ucla.edu).

Published Online: May 18, 2023. doi:10.1001/jamaoto.2023.0904

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.