07-91 41

Pictorial Essay -- Parapharyngeal Space Lesion

S BISWAS, S SAHA, A SADHU
Ind J Radiol Imag 2005 15:1:41-46
Keywords: Parapharyngeal space - neck masses
P
arapharyngeal space is a fascial space that
extendsfromskullbasetohyoidbone,andforms
theneurovascularconduittohead.Tumorsmay
arisefromtheindividualcomponentsofthespaceormay
invade from the surrounding structures. In the era of
antibiotics,infectionandabscessformationinthespace
hassignificantlycomedown.
EPIDEMIOLOGY--
World literature suggests that parapharyngeal space
lesionaccountsforaround0.5%ofallhead&necktumors
[1].Ofthesepleomorphicadenomaisthecommonest
pathology [2]. For carotid body tumors there is slight
femalepredominance.Parapharyngealspaceinfectionis
now a less common entity. With advent of modern
antibiotics it now accounts for only 30% of deep neck
infections[3].
2. Enhancing Hyperdense Carotid Body Tumor
1. Enhancing Hyperdense Lesion Involving The Superficial
And Deep Lobe Of Parotid - Pleomorphic Adenoma.
3. Paraganglioma Showing Intense Homogenous
Enhancement
From the Department Of Ent. Department Of Ct & Mri Medical College, Kolkata, 88, College Street, Kolkata- 700073.
Request for Reprints: Dr. Somnath Saha. SundaramApartment, 91, Sarat Chatterjee Road Borat, Lake Town Kolkata-700089.
Received 3 July 2004;Accepted 25 October 2004

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42 S Biswas et al
ANATOMY-
The parapharyngeal space is divided in three main
compartments,beingprestyloid,poststyloid(comprising
carotidspace)andretropharyngealspace.Deeplobeof
parotidglandcomesinlateralrelationofthespaceand
frequentlyitstumormayinvadethespace (Fig-1).
Carotidspaceiscomprisedofcarotidartery,IXth,Xth&
XIIthnerves,cervicalsympatheticchain.Retropharyngeal
spacecontainslymphnodethatispresentmainlyduring
childhood.Withincarotidspace,carotidbodymeasuring
3-6mm,ovoidinshapeandlocatedontoposteromedial
aspectofcommoncarotidarterynearbifurcation,isseat
toatypeofparagangliomascalledcarotidbodytumor
(Fig-2).
PATHOLOGY--
Commonesttypeoftumorinparapharyngealspaceis
pleomorphicadenomathatmayriseeitherfromminor
salivaryglandorfromdeeplobeofparotid.Nextisthe
neurogenic tumors accounting for 17% to 25% of
parapharyngealtumors[2].Whereasneurofibromamay
disturbnervefunction,bypressingonit,schwanomas
areusuallyfreeofneurogeniceffect.Paragangliomasare
spindleshapedwellcapsulated,brownishtumorthatmay
arise from vagus, hypoglossal and carotid body and
occupiesthespace(Fig-3).Occasionallytheymayextend
upthroughskullbase,andhaveintracranialextension
(Fig-4)[2].Aneurysmfromcarotidvesselisalsopossible.
Metastatic tumor (Fig-5) and lymphomas are other
possiblemalignantlesionsoftheregion.
4. Vagal Paraganglioma With Intracranial Extension.
IJRI, 15:1, February 2005
5.MetastaticTumorInParapharyngealSpaceExtendingFrom
SkullBase.ThePatientHadMultipleCranialNerveParalysis.
HISTOLOGY-
Paragangliomas may contain cluster cells of epithelial
cellsofZellballeninhighlyvascularstroma.Theymay
secretecatecholamine.Inschwanoma,nervecoverings
undergo neoplastic transformation. Antoni type A
arrangementsofnucleiandVerucaybodiesarefound
here.
Incaseofinfectionofthisregion,polymicrobialinfection,
usuallytheoropharyngealfloraiscommonlyfound.Only
in cases of immunocompromised patients, unusual
organismsarediscovered[4]
CLINICAL PRESENTATION-
Patientswithparapharyngealspaceinfectionpresentwith
fever,trismus,perimandibularedema.Tumorsoftheregion
aremostlyslowgrowing,presentingwithcervicalswelling
andmuffledvoice.Parotidswellingswerepresentincases
ofparotidpathology.Tonsilbulgeiscommonlyfoundon
patientexamination.
TREATMENT-
Treatment is mostly surgical. In cases of malignancy,
afterresectionofprimarytumor,combinedtherapyisused
totreatresidualdisease.Parapharyngealspaceinfection
istreatedconservativelyandabscessdrainedbyexternal
submandibularapproach.Retropharyngealabscessmay
bedrainedinRosepositiontransorally,or,ifrespiratory
obstructionorsignificantinferiorextensionpresent,then
byanteriorcervicalapproachasdescribedbyDean,is
preferred[5].
RADIOGRAPHIC FEATURES-
Parapharyngeal pathologies are less identified by
43
IJRI, 15:1, February 2005
conventional radiology. Though before advent of CT
ScanningandMRimages,conventionalradiographyand
angiographywereprimarytoolsindiagnosis.
RETROPHARYNGEAL ABSCESS-
Collection in retropharyngeal space could easily be
identifiedbyconventionalradiographyandformsbasis
before drainage. Wholey and colleagues have
demonstratedRetropharyngealspaceexceeding7mm
inbothadultsandchildrenorincreaseinretrotracheal
spacetomorethan22mminadultsand14mminchildren
[6]asalsolossofcervicallordosisisvirtuallydiagnostic
for retropharyngeal abscess (Fig-6). Occasionally a
horizontalfluidlevelisidentified,suggestingofpresence
of pus and gas in the enclosed space. Source of gas
may be due to esophageal rupture due to iatrogenic
traumaorforeignbody,butalsomaybeduetogasforming
organism, or both. When pus that has accumulated
betweenbuccopharyngealfasciaandalarfasciaruptures
into prevertebral space (named dangerous space by
Grodinsky), it may easily pass down onto posterior
mediastinumcausingmediastinitis.CTScanisequally
efficienttoidentifytheselesions(Fig-7).Fortunatelywith
development of antibiotics these infection have come
down.
6. X-ray Showing Retropharyngeal Abscess With Air Fluid
Level.
Parapharyngeal Space Lesion 43
7. Ct Scan Showing Retropharyngeal Abscess
PARAPHARYNGEAL SPACE INFECTION-
Abscessofparapharyngealspacemayresultfromlateral
spreadofanadvancedtonsillarinfectionorfrommedial
extensionofanodontogenicinfectionarisinginmasticator
space.Thoughconventionalradiographymaynotidentify
theinvolvement,CTwithcontrastmayevaluatetheextent
ofpathology(Fig-8).Carotidspaceformsmainconduit
forspreadofinfectiontoandfrommediastinum,andhas
beennamed"Mosher--LincolnHighwayoftheneck[7]."
8. Ct Scan Of Parapharyngeal Abscess In A Patient With
Complicated Chronic Mastoiditis.
MASSES OF PARAPHARYNGEAL SPACE & CT
EVALUATION:---
PRESTYLOID COMPARTMENT
Localizingamasstotheparapharnygealspacemaybe
difficult.Primaryparapharyngealprestyloidmassusually
displacedeeplobeofparotidglandlaterally,anddoes
notextendintodeeplobeofparotidgland.Thesemasses
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44 S Biswas et al
areunifocalwhereasparotidmassesmaybemultifocal
[8].Thesemassesmayalsobedifficulttoseparatefrom
deepextensionofprimarymasticatorspacelesion.They
are seperated from their relation to medial pterygoid
muscle,withparapharyngealmasslyingmedialtoit.
Primaryprestyloidparapharyngealmassesmaybe-
Minorsalivaryglandtumor,atypicaltypeIIfirstbranchial
cleftanomalyandlipoma.Secondarymassesmaybe,
deepspreadofmalignanttumorfromadjacentspaces
(Fig-9),squamouscellcarcinomafromvisceralspaces.
Sarcomafrommasticatorandextensionoftumorfrom
parotid space. Most common lesions results from
secondaryextensionofpathologicprocessarisingfrom
adjacent spaces. Of these most common is deep
extensionofsquamouscellcarcinomaarisingintonsillar
region (Fig-10). Spread into parapharyngeal space is
importanttosurgeonsasitcontraindicatesresectionof
tonsillarcarcinomawithwidelocalextension,throughan
intraoralapproach.
9. Metastatic Cervical Lymphadenopathy From Adjacent
Nasopharyngeal Carcinoma.
10. Metastatic Cervical Lymphadenopathy From Adjacent
Tonsillar Carcinoma.
IJRI, 15:1, February 2005
CAROTID SPACE-
Itispoststyloidcompartmentofparapharyngealspace.
It contains internal carotid artery, internal jugular vein,
sympathetic chain, cranial nerves IX to XII and lymph
nodes.Itextendsfromjugularforamentoaorticarch
Lesions that could be expected in this region are as
follows--
CAROTID ARTERY-- Ectasia, Aneurysm, Dissection,
Encasementbydirectsquamouscellcarcinoma.
JUGULAR VEIN-Asymmetricenlargement,Thrombosis,
Thrombophlebitis,Meningioma(fromjugularforamen)
CRANIAL NERVES AND SYMPATHETIC CHAIN --
NeurogenicTumor,Neuroblastoma,Paraganglioma
LYMPH NODE-- Metastatic cervical adenopathy,
Lymphoma.
Majority of masses that involve the carotid sheath are
lesionsthatoriginateprimarilywithinthisspace.Masses
involvingcarotidarteryorjugularveinareeasilyidentified
by contrast enhanced CT scan. Paragangliomas and
neurogenictumorsmayariseinsimilarlocation.Presence
ofinternaltumorsmayariseinsimilarlocation.Presence
ofinternalflowvoidsonMRImaginginamassthatis
greaterthan2cmissuggestiveofparaganglioma,rather
than Schwanoma. Flow voids are not helpful in
distinguishingbetweenthesetwolesionswhentheirmean
diameterislessthan2cm.Enlargedlymphnodesare
most common pathology of carotid sheath. Enlarged
nodeswithareasofdecreasedcentralattenuationmay
be either due to neoplastic or inflammatory cause.
Enlargedlymphnodethatappearveryvascularorcystic
aresuggestiveofmetastasisfromthyroidcarcinoma(Fig-
11).
11. Metastatic Enhancing Lymphadenopathy In Carotid
Sheath.
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IJRI, 15:1, February 2005
Forsuspectedcarotidbodyandvagalparaganglioma,thin
sectionCTscanning(Fig-2&3)isperformed,withthe
useofcontrastmaterialfromskullbasetothoracicinlet
at2.5-3mmintervalsintheaxialplane.Coronalscan
maybeobtainedindirectlywithreformationofaxialdata.
Boneorsofttissuealgorithmsmaybereconstructedfrom
theoriginaldata.CTScanningisusefultodemonstrate
theintegrityofassociatedsofttissueandthedetection
ofmultiplelesions[9].SplayingofInternalandExternal
carotidsandLyre'ssignsuggeststhediagnosisofcarotid
bodytumor.[10]
MAGNETIC RESONANCE IMAGING-
TheroleofMRImagining(Fig-12)inthediagnosisand
preoperativeassessmentofparagangliomashasbeen
established.[11.12]MRIallowsevaluationoftheselesions
andadjacentsofttissueandvascularstructurewithout
use of ionizing radiation. Imaging characteristics of all
paragangliomasaresimilar.Awell-definedhypointense
masswithareasofsignalvoidisseenonT1weighed
images.LongTR/TEimagesalsodemonstrateawell-
definedmass,whichisheterogeneouslyhyperintense.
Punctateflowvoidsareseenandarebelievedtorepresent
hypervascularnatureofthetumor.Oslenetaldescribed
chronic appearance of paraganglioma, that is, a salt
pepper appearance in all lesions larger than 2 cm in
diameter[13].PatternmorecommonlyisseeninT2WI,
and the dark and bright appearances in the lesion
representsthehighvascularityinthemasswithassociated
areasofhaemorrhage,slowflowingbloodandtumorcells.
AdropoutsignhasbeendescribedbyVogletal[14]for
skullbaseparagangliomas.Thiseffectwasseenaftera
large bolus of IV Contrast was infused, where by
susceptibilityeffectsfromthecontrastledtoanabrupt
dropoffinsignalintensityongradientechoMRI24-42
secondsafterthebolus,independentoflocation,size,or
classification of glomus tumor. With time susceptibility
effectdiminishesandincreasedsignalintensitycouldbe
seen.
Parapharyngeal Space Lesion 45
ULTRASOUND AND CAROTID BODY TUMOR
Thismodalityisusefulintheevaluationandfollowupof
carotidbodytumors.Vagalparagangliomaifpalpatedin
lowerneckcouldbeimagedwithultrasound.Grayscale
ultrasoundisusedfordelineationoftumormargins(Fig-
13),sizeandlocation.ColorDopplerflowimagingisuseful
toshowhypervascularnature(Fig-14).USGmayalso
differentiateCarotidbodytumorfromvascularanomalies
andpseudoaneurysm[15].USGcandifferentiatevagal
paragangliomasfromotherlesionsofneck,suchaslymph
nodes,metastasisandvascularabnormality.
13. Gray Scale Delineation Of Carotid Body Tumor.
14. Color Doppler Explaining Relationship Of Carotid Body
Tumor With Carotid.
12.T1wAxialMrSectionOfCarotidBodyTumor.
15. Skeletal Scintiscan Of Parapharyngeal Plasmacytoma
Showing Multiple Hot Spots.
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46 S Biswas et al
RADIONUCLIDE TECHNIQUE--
Radiolabelledcompoundsthatbindtoreceptorsintumors
formthebasisofreceptorimaging(Fig-15).Pentetreotide
is an octreotide that, when used for imaging gives
information about number and distribution of
paragangliomas.
ANGIOGRAPHY
Non-invasiveimagingCTAngiogramandMRAngiogram
(Fig-16)havealmostcompletelyreplacedangiography
as primary radiographic tool in the diagnosis of
paraganglioma.[16,17]Accurateassessmentandsafe
embolisation of these lesions require an extensive
knowledge of normal vascular anatomy, collateral
circulation,congenitalvariationsandvascularphysiology.
16. MrAngiogram Showing Vascular LesionAt Bifurcation Of
Common Carotid.
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