Author's Accepted Manuscript

Imaging of the parapharyngeal space

Dan Paz MD, Ayelet Eran MD.

PII: S1043-1810(14)00025-6 www.techgiendoscopy.com

DOI: http://dx.doi.org/10.1016/j.otot.2014.04.002
Reference: YOTOT630

To appear in: Operative Techniques in Otolaryngology

Cite this article as: Dan Paz MD, Ayelet Eran MD., Imaging of the parapharyngeal space,
Operative Techniques in Otolaryngology, http://dx.doi.org/10.1016/j.otot.2014.04.002

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Imaging of the parapharyngeal space

Dan Paz MD, Ayelet Eran MD.

Affiliations:

Dan Paz – Radiology resident, from: Rambam Health Care Campus, Department of

Radiology, Haifa, Israel.

Ayelet Eran Attending Neuroradiologist, Rambam Health Care Campus, Department of

Radiology, Haifa, Israel.

From: Rambam Health Care Campus, Department of Radiology, Haifa, Israel.

Corresponding author:

Ayelet Eran

Rambam Health Care Campus

Radiology Department

P.O.B 9602

Haifa 31096, Israel

Phone number: 972-4-8543682

Fax: 972-4-8452690

E mail: a_eran@rambam.health.gov.il
 

Abstract:

The parapharyngeal space is a deep fascial space in the suprahyoid neck,

shaped like an inverted cone. The tensor vascular styloid fascia divides it into

prestyloid compartment that mainly contains fat, and retrostyloid compartment

that contains the carotid sheath and its content.

Most lesions in the prestyloid parapharyngeal space either bulge into it from

adjacent neck spaces or push it. The pattern of parapharyngeal fat displacement

is used for localization of lesions in the deep neck. Primary lesions of the

prestyloid parapharyngeal space are rare and mostly benign. Tumors of the

retrostyloid compartment usually grow from the carotid sheath content and are

mostly of neurogenic origin. Due to the central location of the space it may serve

as a critical path of tumoral or infectious spread from one neck space to another.

In this review we describe the basic anatomy of the parapharyngeal space and

present the radiological approach to lesions involving it.

Anatomy:

The parapharyngeal space (pps) is a fascial space in the suprahyoid neck,

shaped like an inverted cone and extends from the skull base down to the level

of the hyoid bone from both sides of the pharynx (1, 2) (fig 1).
The Superior border (Base) is a portion of the temporal bone lateral to the

attachment of the pharyngobasilar fascia and medial to foramen ovale and

spinosum. It has three bony landmarks: (I) Scaphoid fossa-origin of the tensor

velli palatine, (II) Spine of the sphenoid bone, and (III) Styloid process. None of

the skull base foramina is included in the roof of the pps (3, 4).

The inferior border (Apex) is described at the junction of the posterior belly of

the digastric muscle and greater cornu of the hyoid bone (5). Practically, facial

planes and muscle sheaths at the level of the mandibular angle obstruct the

space at this level (6).

The medial border is formed by the buccopharyngeal fascia over the

pharyngobasilar fascia and the pharyngeal constrictor muscles (3).

The lateral border is formed by the superficial layer of the deep cervical fascia

over the masticator space and the deep lobe of the parotis (3). The deep lobe of

the parotid gland bulges towards the lateral aspect of the prestyloid pps through

the stylomandibular tunnel anterior to the styloid process and the styloid muscles

(6).

The anterior border is usually considered to be the pterygomandibular raphe

which is a soft tissue condensation that extends from the hamulus of the medial

pterygoid plate to the lingual surface of the mandible, posterior to the myelohyoid

line (4).

The posterior border is the prevertebral fascia that covers the spinal column

and paraspinal muscles (3).

The tensor vascular styloid fascia is a fascial layer that divides the pps into

prestyloid and retrostyloid compartments. It extends between the pterygoid plate,

the tensor veli palatini and the skull base at the level of the styloid process and

its associated musculatures (6). This fascial plane is used as a surgical landmark

with the major vessels and cranial nerve laying deep to it.

The prestyloid pps mainly contains fat and connective tissue. Additionally,

branches of the internal maxillary artery and veins, branches of cranial nerve V,

and minor salivary gland rests are present (6).

The retrostyloid compartment (carotid space) contains the carotid sheath with

the intranal carotid artery (ica) and internal jugular vein (ijv), cranial nerves IX

through XII, sympathetic chain and lymph nodes.

Radiographic approach to the parapharyngeal space:

Due to the deep location of the pps in the neck, lesions may grow considerably in

it before causing any symptoms or signs. Radiology has an important rule in the

diagnosis and treatment planning of such lesions. Which imaging modality to use

either CT or MRI depends on local factors such as availability and experience

and specific differential diagnostic considerations. MRI has the advantage of

better tissue characterization and better definition of tumor margins (6), on CT

bony details and landmarks are better seen. Both modalities can be used for

vascular mapping (by using CT or MR angiography) and in specific indications

such as hypervascular paragangliomas, catheter angiography can be employed

for diagnosis and treatment. Perfusion imaging may further increase the

diagnostic accuracy.

The prestyloid pps is located centrally in the suprahyoid neck; it's surrounded

by the pharyngeal mucosal space, submandibular space, masticator space,

carotid space, parotid space, retropharyngeal space, danger space and the

prevertebral space (fig 2). Primary lesions of the prestyloid pps are rare, however

a lesion in a space adjacent to the pps will many times compress or obstruct the

fat in the pps, the displacement pattern can be used to identify the origin of a

mass. For example, a lesion in the parotid gland will obstruct the fat plane

between the deep lobe of the parotid gland and the pps and will push the fat

anteromedialy (fig 3, 4). Table 1 summarizes the pattern of prestyloid pps fat

displacement according to the neck space from which the mass has originated. A

lesion originating from the prestyloid pps will typically be surrounded by fat from

all directions. As the lesion grows, fat effacement becomes more considerable

and the fat displacement pattern becomes less reliable.

In the retrostyloid pps the direction of ICA displacement either anterior or

posterior may assist in tumor localization and limit the differential diagnosis.

Lesions of the prestyloid pps will always displace the ica posteriorly (3, 7).

Schwannomas can displace the ica either anterior or posterior depending on the

nerve of origin. Hypoglossal origin will always cause anterior ica dislocation and

sympathetic chain or vagal origin can displace it in either anterior or posterior

direction (7).
Splaying of the ica and external carotid arteries is typical for carotid body tumor

(paraganglioma) (6) and vagal schwannomas will separate the ica from the ijv

(3).

Signs of frank malignancy comprise of extra-capsular spread, perineural spread

skull base extension with permeative bone destruction and enlarged draining

lymph nodes. Those signs are rare, as most pps lesions are benign, but should

be searched for in each lesion as they alter the treatment plan considerably.

The radiological appearance of different pps tumors is discussed later.

Preoperative needle sampling of pps lesions

With the use of preoperative CT and MRI, diagnostic accuracy may reach 90-

95%. The use of preoperative FNA is controversial as diagnostic accuracy vary

(40-90%) (3), lesions are in close proximity to major neck vessels and cranial

nerves and there is high likelihood of benign pathology. Nevertheless, depending

on local factors (accuracy of cytology diagnosis and experience of the

radiologist), surgeons may apt to preoperative needle sampling. Those

procedures are always performed under CT guidance, and can exploit different

approaches depending on lesion location (8):

Subzygomatic approach: The needle passes under the zygomatic arch and

between the coronoid process and the mandibular condyle.

Retromandibular approach: The needle pass is between the mandible and the

mastoid process and through the parotid gland.

Paramaxillary approach: The needle passes through the buccal space and

under the zygomatic process of the maxilla, between the maxilla and the

mandible.

Submastoid approach: The needle passes under the mastoid process and

through the sternocleidomastoid muscle.

Imaging appearance of pps lesions:

Tumors of the pps are uncommon, comprising 0.5- 1% of all head and neck

neoplasms (9) and may arise from any structure contained within the pps. Most

pps tumors are benign (70-80%) and the most common pathology is salivary

gland tumors, neurogenic tumors and lymphoreticular. The remainder includes a

wide variety of mesenchymal lesions, such as lipoma, liposarcoma,

hemangioma, heamangiopericytoma and metastatic lesions(6). The imaging

appearance of the most common pps malignancies is detailed.

Salivary gland tumors:

Primary Salivary gland tumors of the pps originate from minor salivary rests.

Pleomorphic adenoma (Benign mixed tumor) (fig 3) is the most common tumor

type (10). It appears as a well defined rounded mass with smooth non-infiltrating

margins. On CT, small lesions are usually hyperdense and enhancing. When

larger than 2 cm it may have cystic or necrotic areas. On MRI, it has isointense to

Intermediate T1 signal and typically high T2 signal, with enhancement on post

contrast studies (11). Pleomorphic adenoma of the deep lobe of the parotid gland
that bulges towards the pps will be seen as a dumbbell shaped mass with waist

at stylomandibular tunnel (fig 5).

Neurogenic tumors:

Schwannomas (fig 4) most commonly involve the vagus nerve with the cervical

sympathetic chain being the next most common source (12). On CT

schwannomas are fusiform, sharply circumscribed masses with soft tissue

density. Large lesions (>3cm) can show benign degenerative changes consisting

of intratumoral cystic areas or areas of hemorrhage with fluid-fluid levels and

calcifications. On MRI they appear heterogeneously hyperintense on T2 and

isointense to hypointense on T1 with post contrast enhancement. As discussed

earlier, the direction of ica dislocation can be used to predict the nerve of origin of

carotid space schwannomas (7). Schwannomas may rarely originate in the

prestyloid pps from brunches of the trigeminal nerve.

Paragangliomas (fig 6) represent 10-15% of all lesions in the pps. Three

variations are seen in the PPS depending on its site of origin:

• Glomus vagale is the most common type, originating from the carotid

bodies located in the ganglion of the vagus.

• Glomus jugulare arises from the paraganglionic cells around the jugular

ganglion.

• Carotid body tumor originates from the carotid body cells near the carotid

bifurcation.
On CT the paraganglioma which extend into/through skull base foramen will

cause irregular bony erosions. On MRI paraganglioma appears as a smoothly

contoured, ovoid mass with multiple vascular flow voids giving it the typical "Salt

and pepper" appearance. Dynamic contrast enhanced MRI/MRA will show a

hypervascular curve with sharp early filling peak and a rapid washout phase.

When trying to differentiate a paraganglioma from schwannoma; the

hypervascularity and the pattern of bone erosion (permeative in paraganglioma

vs. pressure erosion in schwannoma), are radiological clues to the correct

pathology (4).

Conclusion:

PPS tumors are rare and mostly benign. Imaging plays an important role in

deriving the appropriate differential diagnosis and directing surgical intervention.

Table 1: Displacement pattern of the prestyloid pps fat according to the neck

space of origin:

Neck space Direction of fat displacement

Masticator space Posteromedially

Parotid space Anteromedially

Retropharyngeal space Anterolaterally

Pharyngeal space Posterolaterally

Table 1: The table lists neck spaces surrounding the pps and the direction to

which a mass within them will displace the prestyloid pps fat.

Figures & legends:

Fig 1: A schematic drawing showing the pps as an inverted cone that extends

from the skull base to the mandibular angle.

Fig 2: A schematic drawing in the axial plane showing the pps and adjacent neck

spaces.

Fig 3: Pleomorphic adenoma of the deep parotid lobe (asterisks) bulging to the

prestyloid pps. Note anteromedial displacement of the pps fat on CT and coronal

views (A, C arrows). The mass has mostly T2 signal (B), and undergoes partial

enhancement (D).

Fig 4: Retropharyngeal schwannoma. The mass displace the ica laterally and

there is effacement of the fat plane between the mass and the longus colli

muscle (arrows, A, C). Note anterior displacement of the pps fat (asterisks, A, C).

The mass has cystic changes (A) and undergoes homogenous enhancement

(D), typical for schwannoma.

Fig 5: Dumbbell shaped pleomorphic adenoma (asterisks) bulging from the

superficial lobe of the parotis to the pps with waist at the stylomandibular tunnel

(arrows).

Fig 6: Paraganglioma of the retrostyloid pps. The mass separates the ica from

the ijv (arrows, A), and undergoes avid early enhancement on dynamic MRA (D).

Note the black dots on T2 and contrasted T1 images (B, D), compatible with flow

voids.

The authors report no proprietary or commercial interest in any product

mentioned or concept discussed in this article.

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