Case presented in National ENT conference in serena hotel, Islamabad in Dec. 2015
Author
Dr. Ghulam Saqulain HOD
Dr. Jawad Ahmed Assoc. surgeon
Dr. Zaimal Shahan PGT
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Pleomorphic adenoma of minor salivary gland revised
1. Dr. Zaimal Shahan
PGT
Capital Hospital,CDA
Islamabad
Pleomorphic Adenoma of Minor
Salivary Gland in
Parapharyngeal Space
2. Introduction
Most common Parapharyngeal space tumors are PLEOMOROHIC ADENOMAS.
Pleomorphic adenomas in the parapharyngeal space usually arise from deep lobe of the parotid,
however they very rarely develop denovo from displaced or abberant salivary gland tissue within
lymph node*.
We report a case of a large primary pleomorphic adenoma.
It arised de novo from a minor salivary tissue in the right parapharyngeal space and presented
with difficulty in breathing.
Tumor was removed by transoral transpalatal approach..
* H. Chijiwa, T. Mikhoki, B.Shir, et.al . Clinical Study of parapharyngeal space tumors. The journal of laryngology and otology. 2009; 123:100-103
3. Epidemiology
Parapharyngeal space tumors account for some 0.5% of head and neck neoplasms . 82%
being benign and 18% malignant.* Plemorphic adenomas being the most common benign
parapharyngeal tumors (34%) *.
On the other hand minor salivary gland neoplasms account for 22% of all salivary
neoplasms **, majority being malignant.
Pleomorphic adenoma is more common in females than in males (2:1 ratio).
When it originates from the minor salivary glands, the tumor most commonly involves
the palate followed by lip, buccal mucosa, floor of mouth, tongue, tonsil, pharynx,
retromolar area and nasal cavity **.
A comprehensive review of literature shows very few reports of peomorphic adenoma
arising "de novo" in the parapharyngeal space **
* Riffat F, Dwivedi R.C, Palme C, Fish B, Jani P. A systematic review of 1143 parapharyngeal space tumors reported over
20 years. Oral Oncology. 2014;50(5):421-430
** AH Hakeem, B Hazarika, SA Pradnan, R Knnan. Primary Pleomorphic adenoma of minor salivary gland in the parapharyngeal
space. World Journal of Surgical Oncology. 2009:7:85
*** Varghese BT, SebastianP, Abraham EK, Mathews A. A case report:"Pleomorphic adenoma of minor salivary gland in the
parapharyngeal space".World Journal Surgical Oncol. 2003,1:2
4. Diagnosis
The cornerstone for diagnostic evaluation is appropriate
radiologic investigation
1. Imaging studies
• CT scan
• MRI
1. Histopathology
• FNAC
5. Treatment
Surgical excision is the treatment of choice:
Transcervical approach
Transparotid approach
Extended transmandibular approaches
Transoral approach
9. History
• A 61 year old male presented in Otolaryngology outpatient department with
history of difficulty in breathing for 2 years associated with Headache off
and on, sore throat and difficulty in swallowing due to a mass in the
pharynx.
• On inquiry he complained of a painless slowly progressing swelling in the
nasopharynx on the right side for 7 years
• He was also advised surgery six months back but he left against medical
advice.
• There was no history of smoking or alcohol intake
• There was history of DM for last 5 years and HTN for the last 8 years
10. Examination
• Soft palatal and lateral
pharyngeal wall buldge
on Rt. Side extending
beyond midline and down
up to the tonsil.
• No swelling in neck.
• Normal nasal patency.
• Tympanic Membrane and
hearing was normal
11. CT Scan
CT SCAN NECK WITH CONTRAST (11.O1.13)
•Revealed a well defined soft tissue density mass centered in Right Parapharyngeal
space
•37 mm transverse x 28 mm AP diameter with craniocaudal length of 43 mm.
•Mass was oval in shape with surrounding smooth margins.
•It compressed base of tongue.
12.
13.
14.
15.
16.
17. MRI Scan
MRI SCAN NECK WITH CONTRAST (19th
Feb,2013)
• Revealed a well defined soft tissue mass in parapharyngeal space on the right
side.
• 42 mm transverse and 39 mm AP diamension with 52 mmm craniocaudal extent.
• It is causing midline shift and resultant narrowing of oropharynx and part of
nasopharynx.
• The mass is isointense on T1W1 while it is hypertintense on T2W1.
• There are few foci inside the mass which are hyperintense on T1 and few brighter
on T2
• Mass is pushing carotid space laterally but fat plane between the mass and carotid
space is
intact.
• No lymphadenopathy, bony involvement, intracranial extension noted
• D/D
Although MRI is known as the method of choice for imaging the parapharyngeal space. CT Scan is an important diagnostic tool in tumors of parapharyngeal space because it helps in determining the extent of disease, local spread, and to an extent determining the type of tumor. Contrast enhancement is seen in vascular and neurogenic tumors. Presence of intact fat plane helps in distinguishing benign tumors from malignant. Extension of tumors from the deep lobe of a parotid gland is distinguishable from tumor arising de novo in the parapharyngeal space by a fine lucent line representing the compressed layer of fibroadipose tissue between the tumor and the deep lobe of parotid
Fine needle aspiration cytology is the modality of choice for obtaining biopsy sample for diagnosis 9. It has an accuracy rate of 95%. Incision biopsy is no more advised due to seeding of tumor and subsequent multinodular recurrence
A number of approaches have been described in literature of which the three basic ones are transcervical, transparotid and mandibular swing. The selection of surgical approach should meet two criteria i.e, it should give wide intra operative visibility and it shuld have minimal functional and or cosmetic side effects.The most common approach used for excision is the transcervical appraoch (48%)
we used the transoral approach in our case along with palatal split with out any significant complication. The trans-oral approach was first described by Ehrlich in 1950
Name:Muhammad Ayub
Address:G-7/2, Islamabad
Age: 61
Sex:Male
Occupation: Admin officer in CDA
DOA:21st January 2013
DOD:4th February 2013
General Physical
Old age man well oriented in time, place and person sitting comfortably in bed
He is hypertensive, non febrile
Rest of GPE is normal.
No lymph nodes palpable
Cardio-Respiratory System:
S1 +S2 audible in all four areas.
Chest Clear with NVB
GIT:
NAD
No Scar
No Swelling
No Tenderness
CNS:
NAD
Loco motor System:
NAD