Management of Tumors of the Parapharyngeal Space

This paper offers a very good overview of a large topic that encompassesa multitude of tumors, each with its own set of controversial issues interms of diagnosis and management. The authors discuss the various diagnosticand therapeutic options available for these tumors in a general sense,rather than concentrating on the specifics of each pathology. Althoughthis approach certainly provides a satisfactory overview, it does not delineatethe many diagnostic and therapeutic dilemmas that may confront the practicinghead and neck surgeon. However, given the space limitations for such apaper, a more detailed discussion probably was infeasible.

The authors offer a good summary of diagnostic testing. However, theydo not clearly state whether computed tomography (CT) or magnetic resonanceimaging (MRI) should be the screening modality of choice, or, as is mybelief, whether both should be ordered, as they tend to supply complimentaryinformation.

Although angiography has always been the standard diagnostic procedureto evaluate vascular tumors, with the increasing use of magnetic resonanceangiography (MRA), angiography can be avoided in many situations. I believethat most paragangliomas, other than carotid body tumors, require embolization.Therefore, I usually perform angiography on the day before surgery in conjunctionwith embolization.

Caveats Regarding Surgery

Although the article addresses all surgical therapeutic options, albeitbriefly, in my opinion intraoral resection should be condemned more strongly,particularly for the occasional surgeon. Inadequate excision and tumorseeding, not to mention uncontrollable hemorrhage from major vessel lacerationand nerve damage, are all potential consequences of such an approach.

The authors also mention techniques that increase exposure to both theparapharyngeal space and skull base. However, it should be stressed thatit is rare for mandibulotomy to be needed, except in extremely large orvery vascular tumors, or in cases where control of the distal internalcarotid artery is essential. In my experience, mandible dislocation doesnot offer any meaningful improvement in exposure.

Finally, it should be emphasized that resection of many of these benigntumors can result in cranial nerve palsies, which can have disastrous consequences,particularly in the elderly patient. Therefore, if vagal palsy is a possibility,patients should be well prepared regarding the potential consequences,including the effects on speech and swallowing. Failure to do so can leadto a very unhappy patient and a difficult rehabilitation. Therefore, thepros and cons of resection should be clearly discussed with the patientand family before a surgical procedure is performed. In many patients,particularly those who are elderly, watchful waiting is not an unreasonablealternative as long as one is sure that the lesion is benign.