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Transcervical Excision ofRanula
https://t.me/med1917
JohannesJ.Fagan andKevinG.Smith
21.1 Introduction
This chapter presents the transcervical approach to excise a
plunging ranula. Readers are referred to Chap. 20, “Intraoral
Excision of Ranula,” for the pathophysiology, clinical features, diagnosis, and investigations of ranula.
A ranula is a salivary pseudocyst, typically arising from
the sublingual salivary gland [1]. A “plunging ranula” occurs
when the mucous extravasation extends from the oor of the
mouth into the submandibular triangle (Level 1b) of the neck
through a defect in the mylohyoid muscle, or less commonly,
by passing behind the posterior edge of the muscle (Fig.21.1).
A ranula may also track posteriorly along tissue planes into
the parapharyngeal space [2].
Excision of the involved sublingual salivary gland is associated with the lowest recurrence rates [1, 3–5] and is the
authors’ treatment of choice. Some surgeons, however, elect
to use a transcervical approach to resect the pseudocyst (even
though it has no epithelial lining), with or without resecting
the sublingual salivary gland transorally. The success of surgeries in which the sublingual gland is preserved likely
occurs when scarring seals off the source of extravasation, so
it is less predictable.
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Fig. 21.1 CT scan demonstrates a plunging ranula: intraoral (a) and
cervical (b) components
21.2 Preoperative Checklist,
Considerations, andAnaesthesia
J. J. Fagan
Division of Otolaryngology, University of Cape Town, Groote
Schuur Hospital, Observatory, Cape Town, South Africa
e-mail: johannes.fagan@uct.ac.za
K. G. Smith (*)
Department of Otolaryngology - Head and Neck Surgery, North
Shore Hospital, Auckland, New Zealand
e-mail: kevin.smith2@waitematadhb.govt.nz
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_21
• Is it a ranula? The diagnosis is based on the history, clini-
cal appearance, and the nature of the aspirate, with imaging reserved for more complex cases.
• Which side? If a large ranula crosses the anterior oor of
the mouth, it is imperative to determine the side of origin.
Cross-sectional imaging is helpful in these cases.
• Perioperative antibiotics? Recommended, as both the oral
cavity and neck are entered, risking contamination of the
cervical wound with oral organisms.
• Consent? Caution the patient about the incision in the
anterior oor of the mouth, the cervical scar, and the
proximity and risk of injury to the lingual, hypoglossal,
and marginal mandibular nerves, as well as the submandibular salivary duct.
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J. J. Fagan and K. G. Smith
• Anaesthetic considerations? Surgery is performed under
general anaesthesia. The anaesthetist should avoid muscle
paralysis, as it is useful to monitor movement of the lower
lip and to minimise trauma to the marginal mandibular
nerve.
21.3 Indications
Excision may be done for a symptomatic plunging ranula.
21.4 Surgical Technique
1. Position the patient supine with neck extended, sterilise
the skin of the anterior neck and lower face, and drape to
leave the mouth and upper neck exposed.
2. Resect the sublingual salivary gland, as described in
Chap. 20.
3. Close the mucosa of the oor of the mouth with absorb-
able sutures to hasten healing and to seal the neck from
the oral cavity.
4. Proceed to the cervical dissection. Make a horizontal
incision, placed in a skin crease and at least 3cm below
the mandible or at the level of the hyoid bone, and
extending anteriorly from the anterior border of the sternocleidomastoid muscle, through skin, subcutaneous tissue, and platysma (Fig.21.2). The common facial and
anterior facial veins are identied and divided and
ligated if necessary for access.
5. The fascial capsule of the submandibular gland is incised
parallel to and just above the hyoid bone. While applying inferiorly-directed traction on the gland, a subcapsular dissection with exposure of the gland is performed
(Fig.21.3). Dissecting in this subcapsular plane protects
the marginal mandibular nerve. Contraction of the angle
of the mouth alerts the surgeon to the proximity of the
marginal mandibular nerve.
6. The plunging ranula should now come into view anterior
to the submandibular gland (Fig.21.4).
7. The mylohyoid muscle is identied deep and posterior
to the anterior belly of the digastric.
8. If the ranula extends medial to the submandibular salivary gland, it may be necessary to mobilise or resect the
submandibular gland to improve surgical exposure, taking care not to injure the lingual nerve (Fig.21.4).
Fig. 21.2 Placement of incision
Fig. 21.3 Subcapsular dissection of the submandibular gland to avoid injury to the marginal mandibular nerve
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Fig. 21.4 Ranula passing medial to the submandibular salivary gland, which is being resected for access
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Fig. 21.5 Ranula identied in the anterior submandibular triangle
9. The ranula is mobilised with sharp and blunt dissection
from the surrounding tissues (Figs.21.5 and 21.6).
10. By retracting the mylohyoid posteriorly and using careful
blunt dissection, the lingual nerve, submandibular ganglion, and submandibular duct come into view (Fig.21.7).
11. Excise the cervical extension of the plunging ranula by
tracking it to where it passes into the oor of the mouth
through a dehiscence in the mylohyoid muscle or, less
commonly, behind the mylohyoid.
12. Irrigate the wound with sterile water or saline, and close
it in layers with Vicryl to the platysma and a subcuticular
suture to skin. A suction drain is left in situ.
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Fig. 21.6 Exposing the posterior part of the mylohyoid muscle
J. J. Fagan and K. G. Smith
Fig. 21.7 Retracting the mylohyoid brings into view the lingual nerve, hypoglossal nerve (XII n.), and submandibular (SM) duct
21.5 Postoperative Care
The patient receives broad-spectrum antibiotics for 24 h,
with simple analgesia. An oral liquid or soft diet can commence on the day of surgery.
References
1. Harrison JD.Modern management and pathophysiology of ranula:
literature review. Head Neck. 2010;32:1310–20.
2. Fagan JJ. Ranula and sublingual salivary gland excision. In:
Open access atlas of otolaryngology, head & neck operative surgery. https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-
48e5-81be-586fbaeba29d/Ranula%20and%20sublingual%20
salivary%20gland%20excision.pdf. Accessed 1 Nov 2018.
3. Samant S, Morton RP, Ahmad Z.Surgery for plunging ranula: the lesson not yet learned? Eur Arch Otorhinolaryngol. 2011;268:1513–8.
4. Huang SF, Liao CT, Chin SC, Chen IH.Transoral approach for plunging ranula—10-year experience. Laryngoscope. 2010;120:53–7.
5. Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical review of 580
ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2004;98:281–7.
Parapharyngeal Space Tumour Excision
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JohannesA.Rijken, CarstenE.Palme,
andC.RenéLeemans
22
22.1 Introduction
The parapharyngeal space (PPS) is a triangular, fat-lled
compartment of the suprahyoid neck, lateral to the pharynx.
The PPS has also been termed the peripharyngeal space,
pterygopharyngeal space, pterygomandibular space, pterygomaxillary space, pharyngomaxillary space, or the lateral
pharyngeal space, but currently, these terms have been dis-
carded in favour of the term parapharyngeal space. The PPS
is described as an inverted pyramid with the oor of the pyramid at the skull base and the apex at the level of the greater
cornu of the hyoid bone [1–5]. The styloid process, along
with the attaching muscles and tensor veli palatini fascia,
divides the PPS into prestyloid and poststyloid compartments. The prestyloid space contains the deep lobe of the
parotid, minor salivary glands, and fat. The poststyloid space
contains the ninth, tenth, eleventh, and twelfth cranial nerves,
the cervical sympathetic chain, the internal jugular vein, the
internal carotid artery, and lymph nodes (Fig.22.1).
This complex anatomy is responsible for a wide variety of
pathologies arising within the PPS [1, 6]. Tumours are generally rare; they account for only 0.5–1.5% of all head and
neck tumours [2, 7]. The majority are diagnosed in adults
and include primary neoplasms, direct extension from adjacent regions, and metastatic disease. Approximately 80% of
J. A. Rijken (*)
Department of Head and Neck Surgical Oncology,
University Medical Center Utrecht, Utrecht, the Netherlands
e-mail: j.a.rijken-3@umcutrecht.nl
C. E. Palme
Department of Head and Neck Surgery, Crown Princess Mary
Cancer Centre, Westmead Hospital, Westmead, NSW, Australia
e-mail: carsten.palme@sydney.edu.au
C. R. Leemans
Department of Otolaryngology–Head and Neck Surgery,
Amsterdam University Medical Centres, Cancer Center
Amsterdam, VU University, Amsterdam, the Netherlands
e-mail: cr.leemans@amsterdamumc.nl
these neoplasms are benign and of salivary gland origin [2, 5,
7–11]. They most commonly include pleomorphic adenomas
arising within the prestyloid PPS. The next most common
are neurogenic tumours, which are generally found within
the poststyloid compartment [5, 10–12]. Neurobroma, neurilemmoma, and paraganglioma are the neurogenic tumours
most often encountered. Neoplastic proliferation of the various tissues that exist in the PPS may result in a wide variety
of unusual benign tumours, such as lipoma, and rarely a
branchial cyst is found in this region, as well as malignant
tumours such as liposarcoma, chondrosarcoma, lymphoma,
meningioma, and rhabdomyosarcoma. The most frequent
primary malignancy occurring within the PPS is of salivary
gland origin [3, 5, 7, 10].
Tumours in the PPS are often asymptomatic and therefore
can stay undetected for a long time. Symptoms generally
occur when the size of the lesion exceeds 2.5–3cm and may
also depend on its histology and its specic location [8, 10].
Patients may present with upper aerodigestive tract disturbance due to simple mass effect or due to cranial nerve decits (9th, 10th, or 11th cranial nerves), including airway
obstruction, dysphonia, dysarthria, and dysphagia. Hearing
loss may be the result of Eustachian tube compression.
Pulsatile tinnitus may suggest a vascular lesion. Pain is generally uncommon and may be indicative of an inltrative and
malignant process. It may be present during swallowing,
may lead to trismus, or may be referred to the ear. Sleep
apnoea has been described as a presenting symptom of large
lesions that lead to signicant upper airway obstruction [13].
Functional symptoms of palpitations, profuse sweating, and
acute hypertension may be seen in secreting tumours such as
paragangliomas. Clinically, patients often present with a
medialized tonsil and a submucosal soft palate bulge leading
to narrowing of the oropharyngeal inlet. Other signs may
include trismus, middle ear effusion with conductive hearing
loss, or the result of cranial nerve decits (9th, 10th, 11th, or
12th).
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_22
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208
a
b
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Fig. 22.1 (a) Axial section
of the parapharyngeal space at
the level of the nasopharynx.
1=fascial layer from the
tensor veli palatine muscle to
the styloid process;
2=medial pterygoid fascia.
(b) Lower axial section of the
parapharyngeal space. The
parotid gland is seen
protruding into the prestyloid
compartment. 1=tensor veli
palatine fascia; 2=medial
pterygoid fascia
J. A. Rijken et al.
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22.2 Preoperative Considerations
Imaging, including MRI and contrast CT scans, is crucial for
the diagnosis and management of PPS tumours. Formal
angiography is required for vascular lesions and may allow
preoperative embolization. CT scans are simple, easily available, and an excellent screening tool for evaluation of the
primary lesion, regional lymphatics, and distant sites. It is
particularly valuable when assessing the surrounding bony
skeleton (the skull base and the mandible). The preferred
modality, however, is MRI, which is superior to CT in precise
localization of the tumour and its possible extension and soft
tissue delineation. It allows imaging of the major vasculature
and evaluation of possible perineural and intracranial
involvement. The classic appearance on T1-weighted MRI
shows a sliver of fat around the tumour: The tumour literally
‘oats’ within the parapharyngeal space. This appearance
lends a level of comfort, knowing that the tumour is not inltrative and has a good chance of being safely delivered via
blunt manipulation through the neck. A tumour arising from
the prestyloid compartment generally displaces the parapharyngeal fat pad posteriorly on imaging, whereas a poststyloid
tumour pushes fat anteriorly [14]. Figure 22.2 shows MR
imaging of a pleomorphic adenoma located in the
PPS.Careful and appropriate imaging is also very important
when planning the operative approach, and it may facilitate
preoperative embolization should this be needed for a vascular lesion such as a paraganglioma.
Fine-needle biopsy, either via a transoral approach or with
image guidance, is the biopsy technique of choice. It is safe,
simple, readily available, and yields good diagnostic success
in experienced units. Incisional biopsy is unnecessary in the
vast majority of cases and should be avoided. It is associated
with unacceptable risks such as severe bleeding and the
potential for seeding tumours such as pleomorphic adenomas. Open biopsy may be indicated only in the event of a
possible diagnosis of lymphoma or unresectable malignancy
[15].
22.3 Choice ofSurgical Approach
Surgery is the mainstay of treatment for PPS neoplasms. A
variety of surgical approaches to the PPS have been
described, depending primarily on the size of the tumour, its
position in either the prestyloid or poststyloid compartment,
the potential pathology, and the individual preference of the
head and neck surgeon. The most important feature is the
ability to provide enough exposure to safely excise the
tumour. The risk of tumour spill and losing control of the
vasculature is greater if the access is limited and the tumour
is large. The classic approaches are transcervical, transparotid via mandibulotomy, or a combination of these. Formal
identication and dissection of the facial nerve may be indicated to avoid inadvertent injury and tumour spill, especially
if the lesion appears to arise from within the deep lobe of the
parotid gland [1]. Supplementary procedures for better
access have been described, such as division of the stylomandibular ligament, removal or mobilization of the submandibular gland, excision of the lateral lobe of the parotid
gland, extirpation of the styloid process, and separation of
the posterior belly of the digastric muscle from the hyoid.
Transoral approaches have been discouraged in the past
because of lack of vascular control and increased risk of
recurrence, but with the emergence of the Da Vinci Robot,
they have found some enthusiasm. This approach should be
considered only in highly selective cases, however, in highvolume, experienced head and neck centres [1, 7, 8].
Fig. 22.2 Axial T1-weighted MR image of a pleomorphic adenoma
extending from the deep lobe of the left parotid
22.3.1 Prestyloid Parapharyngeal Space
Surgical Approaches
Tumours in the prestyloid PPS are most commonly well
dened, benign, and surrounded by fatty tissue. In contrast to
tumours of the poststyloid space, these tumours are generally
not tethered to important structures such as major nerves and
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J. A. Rijken et al.
vessels. Tumours in the prestyloid space are situated between
the hyoid bone and the skull base, on the medial aspect of the
medial pterygoid muscle, but usually they do not extend
above the level of the hard palate or pterygoid plates.
Therefore, these tumours generally can be removed by
meticulous blunt dissection along the capsule of the tumour
via a transcervical-submandibular approach. A large tumour
arising from the deep lobe of the parotid may require a combined transparotid-cervical approach.
22.3.2 Poststyloid Parapharyngeal Space
Surgical Approaches
Several important anatomical structures run through the
poststyloid PPS: the internal carotid artery, the internal jugular vein, and the lower cranial and sympathetic nerves.
Therefore, surgical approaches to this space are mainly
focused on avoiding injury to these structures (see Fig.22.1).
Surgical access is limited by the skull base, the ramus of the
mandible, the parotid gland, the facial nerve, and the styloid
process, with its muscular and ligamentous attachments.
Resection requires good exposure of the mass and of the
major vessels and nerves via a transcervical and/or transparotid approach. In selected cases, a mandibulotomy is required
for additional exposure, especially when dealing with very
vascular or malignant lesions, when maximum control of the
internal carotid artery is required. Rarely, a lateral skull base
type of approach (i.e., Fisch) is required in order to gain the
best exposure and control of the jugular foramen and the
intratemporal carotid artery. In the surgical planning for a
vascular lesion such as a paraganglioma located in the poststyloid PPS, preoperative angiographic studies should be
performed to demonstrate the feeding vessels, and preoperative embolization should be considered, ideally within 24h
before the surgical procedure.
22.4 Surgical Technique
22.4.1 Position ofthePatient During Surgery
The patient is positioned supine on the operating table,
anaesthetized and nasally intubated. Having the mouth
closed increases the space between the posterior aspect of
the ascending mandibular ramus and the mastoid. Also, it
allows gentle anterior subluxation of the mandible to further
increase access once the stylomandibular ligament has been
divided. The head is turned to the opposite side and is hyperextended with a towel or pad placed under the shoulders of
the patient. Monitoring of the facial nerve and the vagus
nerve should be considered, especially when using a
transparotid- transcervical approach.
22.4.2 Transcervical Approach
This is the approach used for the majority of tumours located
within either the prestyloid or poststyloid compartments.
Consideration should be given to combining this with either
a mandibulotomy or a lateral skull base approach, especially
for vascular or malignant poststyloid tumours. A transverse
incision is made in a natural skin crease, two ngerbreadths
below the mandible, allowing extension into a modied Blair
incision should formal parotidectomy and facial nerve dissection be required. Subplatysmal aps are elevated, carefully preserving the ramus mandibularis of the facial nerve.
The sternocleidomastoid muscle is retracted posteriorly, and
the posterior belly of the digastric muscle is identied. This
structure is vital for a safe approach to the PPS and should be
widely skeletonized on its lateral aspect, from its tendon to
the mastoid process. The posterior belly of the digastric is
key in the safe identication of all the important neurovascular structures encountered during this approach, namely, the
spinal accessory, vagus, and hypoglossal nerves and the
carotid sheath. In the event of a tumour arising from the deep
lobe of the parotid gland or one located within the poststyloid space, formal identication of the facial nerve and parotidectomy may become necessary. The internal carotid artery
is identied and carefully dissected as far superiorly as safely
possible, up to the level of the skull base, in order to mobilize
this structure away from the tumour. The posterior belly of
the digastric and the external carotid artery and/or its
branches may need to be divided in order to gain greater
access. The angle of the mandible is retracted anteriorly, taking care to avoid excessive tension on the inferior division of
the facial nerve. Greater mobility may be achieved by dividing the stylomandibular ligament. The medial pterygoid
muscle can then be used as a guide to the tumour. The styloid
apparatus, which often lies lateral to the tumour, and possibly the styloid process may need to be divided or removed.
The submandibular gland may need to be removed to allow
improved mobilization and greater access, especially for
very large tumours. Meticulous blunt dissection is used to
carefully detach the tumour from the surrounding tissues. To
avoid spillage or bleeding, it is important to avoid aggressive
handling of the tumour or placing unnecessary traction on
the surrounding capsule. Vigorous nger dissection is to be
avoided. A Crile forceps may be placed on the surrounding
fascia attached to the tumour, and used for gentle traction. A
half-inch vascular gauze and/or cotton peanuts attached to a
Crile and soaked in 1:10,000 adrenaline can be utilized to
gently break adhesions between the tumour and PPS fat. It is
important to be patient and gentle, moving from place to
place to circumferentially mobilize the lesion. The transcervical approach allows safe delivery of the tumour in most
cases involving the prestyloid or poststyloid compartment.
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22.4.3 Transparotid-Transcervical Approach
For excision of parapharyngeal tumours situated close to the
skull base or arising from within the deep lobe of the parotid
gland, a transparotid-transcervical approach, including dissection of the facial nerve, is required. This approach starts
with a standard modied Blair or face-lift type of incision,
which provides direct access to the lateral aspect of the
tumour (Fig.22.3). A supercial parotidectomy is performed,
and the facial nerve is completely mobilized off the deep
lobe. Consideration should be given to routine use of facial
nerve monitoring. The lateral aspect of the tumour may be
adherent to either the main trunk or branches of the facial
nerve, requiring meticulous dissection, often with the use of
micro forceps and vascular loops. It is vital to avoid rupture
of the tumour at this point. The external carotid artery, its
branches, and the retromandibular vein will need to be
divided to complete the access. Care must be taken, as
uncontrolled bleeding can occur and can become a major airway problem in the immediate postoperative period. The styloid process must be identied in all poststyloid tumours. It
will need to be excised with bone-cutting instruments, taking
care to avoid the internal carotid artery, which is immediately deep to this structure.
A lateral skull base approach may rarely be necessary in
order to gain greater access to the jugular foramen, the intratemporal internal carotid artery, and the skull base. This
technique was described by Fisch and requires a mastoidectomy, removal of the mastoid tip, and mobilization of the
facial nerve to the second genu. Once the facial nerve and the
vascular structures have been freed, mobilization of the rest
of the tumour can proceed. Smaller tumours may be able to
be removed from around the branches of the facial nerve, or
transcervical removal can proceed as described above.
22.4.4 Transmandibular Approach
Malignant, vascular, recurrent, or very large tumours arising
from within the PPS may require a mandibulotomy for safe
and oncologic removal. This can be achieved via a lip split or
visor ap type of approach and often requires removal of the
submandibular gland. The most common osteotomies used
are midline, paramedian, or lateral in position and should be
pre-plated to ensure normal postoperative dental occlusion.
Dissection requires an incision along the oor of the mouth,
leaving at least 10mm of lateral mucosa for closure. The
mylohyoid muscle is detached at its insertion into the mandible to allow it to swing laterally. The lingual nerve traverses the line of dissection and can often be preserved. The
hypoglossal nerve travels inferior and medial and can easily
be avoided. The incision is then extended up along the anterior tonsillar pillar. The superior constrictor muscle is divided
to gain direct access to the PPS.It is important to dissect the
internal carotid artery from the neck to its entry within the
skull base to avoid inadvertent injury. The styloid apparatus
may need to be disconnected, and the glossopharyngeal
nerve, which travels between the internal and external carotid
arteries, may need to be sacriced. Safe tumour handling and
removal can then proceed in a fashion similar to that
described for the transcervical approach. At the end of the
procedure, the mucosal incision is closed with 3/0 Vicryl
Fig. 22.3 Intra-operative image of removal of a pleomorphic adenoma
extending from the deep lobe of the left parotid, through a transparotidtranscervical approach. The stylomandibular ligament was cut to allow
delivery of the tumour through the neck. The supercial lobe was repositioned after mobilization for access
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repair may be necessary in the uncommon event of signicant tissue loss or inadequate soft tissue cover over the
carotid sheath, with potential concern for vascular exposure
in the event of subsequent mucosal loss. A tracheostomy
should always be performed due to signicant tissue oedema
and the potential for airway obstruction in the postoperative
period. Nasogastric tube insertion and a period of enteral
feeding are routine. This approach should be considered only
in highly selective cases in high-volume, experienced head
and neck centres.
22.4.5 Transoral Robotic Surgery
Transoral robotic surgery (TORS) appears to be a feasible
alternative approach to selected PPS neoplasms with minimal surgical morbidity. Magnied three-dimensional visualization allows en bloc resection of the tumour, close to vital
structures. Signicant experience with TORS and detailed
anatomic knowledge of the PPS is essential for success with
this approach. Limitations of TORS approaches are limited
vascular control and tumours on the far lateral and superior
areas of the PPS, which required combined transcervical
assistance. Further long-term evaluation is needed to dene
patient selection and the role of TORS for PPS neoplasms
[16–18].
J. A. Rijken et al.
Table 22.1 Complications of parapharyngeal space (PPS) surgery
Time period Complications
Intraoperative Vascular, neural, tumour spill
Early
postoperative
Late
postoperative
a
Facial pain characterized by a severe cramping or spasm in the parotid
region with the rst bite of each meal that diminishes over the next
several bites
Table 22.2 Short-term postoperative complications of PPS surgery
[20]
a
Grade
Grade I Facial nerve palsy 21.8
Grade II Wound infection 10.9
Grade III Haemorrhage 3.6
a
According to Clavien-Dindo classication
Airway obstruction, dysphagia (aspiration), facial
nerve palsy (including eye), infection,
haemorrhage, related to osteotomy
First bite syndromea, Frey’s syndrome,
complications relating to neural injury (IX–XII),
related to osteotomy
Complication Incidence (%)
Informing the patient about possible neurological complications prior to the operation will improve compliance with
the rehabilitation program; speech and swallowing therapy
may be necessary during postoperative rehabilitation of
patients with paralysis of the 9th, 10th, or 11th cranial nerve.
Because most of these tumours are benign and grow slowly,
the morbidity that would be caused by cranial nerve sacrice
should be taken into consideration when deciding on surgical
treatment, especially for older patients.
22.4.6 Other Approaches
Infratemporal fossa dissection and craniofacial approaches
are reserved for malignant tumours, tumours involving the
skull base, vascular lesions, or tumours with intracranial
extension.
22.5 Complications andPostoperativeCare
Perioperative risks should always be discussed with the
patient. The most serious complications of PPS surgery are
vascular and lower cranial nerve injury, as well as sympathetic trunk injury causing Horner’s syndrome or ‘rst bite’
syndrome [19]. Complications of PPS surgery can be classied as intraoperative, early postoperative, and late postoperative (Table22.1).
In a large, single-centre report on PPS tumours, shortterm postoperative complications according to the Clavien–
Dindo classication were facial nerve palsy, wound infection,
and haemorrhage (Table22.2). The most frequently encountered long-term post-operative complications were rst bite
syndrome (16.4%) and Frey’s syndrome (7.3%) [20].
22.6 Conclusions
Parapharyngeal tumours are rare lesions that are challenging
because of the complex anatomy of the PPS.There are several important anatomical structures running through the
PPS, resulting in a variety of pathologic entities. Clear
understanding of this complex anatomy is essential for optimal surgical management strategies.
References
1. Bradley PJ, Bradley PT, Olsen K.Update on the management of parapharyngeal tumours. Otolaryngol Head Neck Surg. 2011;19:92–8.
2. Carrau R, Meyers E, Johnson J.Management of tumors arising in
the parapharyngeal space. Laryngoscope. 1990;100:583–9.
3. Olsen K. Tumors and surgery of the parapharyngeal space.
Laryngoscope. 1994;104:1–28.
4. Stambuk H, Patel S. Imaging of the parapharyngeal space.
Otolaryngol Clin North Am. 2008;41:77–101.
5. Batsakis J, Sneige N. Parapharyngeal and retropharyngeal space
diseases. Ann Otol Rhinol Laryngol. 1989;98:320–1.
6. Starek I, Mihal V, Novak Z, Pospisilova D, Vomacka J, Vokurka
J. Pediatric tumors of the parapharyngeal space. Three case
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