Materials and Methods

During the past 5 years, 13 patients have been treated surgically for primary PPS tumors. This study was limited to patients with primary PPS tumors, while patients with tumors originating elsewhere and extending into the PPS were not included. 6 patients were excluded who were surgically treated during the same period for primarily oropharyngeal and parotid carcinomas extending into the PPS. None of the patients included in this study had previously received therapy (surgery, radiotherapy or other) for their PPS tumor.

The following data were collected for each patient: gender, age, symptoms and clinical examination findings, size of the tumor, surgical approach, histological diagnosis, additional therapy, complications, follow-up time and outcome. All patients underwent full laboratory examinations. Computed tomography (CT scan) and/or magnetic resonance imaging (MRI) were used to define the exact location and the size of the tumor. In one case, in which high vascularity was presumed from the MRI, a digital angiography was performed. Preoperative fine needle aspiration (FNA) biopsies (CT-guided or not) or open intraoral biopsies were performed in 12 patients, in whom the nature of the tumor (not very vascular) allowed these procedures, in order to determine if the lesion was malignant or benign.

All 13 patients were treated with surgical removal of the PPS tumor. For every patient an individualized surgical approach was selected, depending on the suspicion of malignancy (on clinical, imaging, and, if available, FNA or open biopsy ground), the size of the tumor, its exact location and its relation to the neck great vessels. Intraoral, transcervical and transmandibular approaches were used.

The intraoral approach was used when the patient’s history, clinical and imaging findings, or FNA results indicated that the PPS lesions were benign. In addition, the tumors were small (up to 2 cm), the patient’s main symptom was a pharyngeal mass and the tumor projected into the oropharynx causing soft palate displacement.

The transcervical approach was used for presumably benign tumors of large size (>2 but <4 cm), when the patient’s main symptom was a neck mass. The tumor was located in the poststyloid PPS compartment in all cases. During the transcervical approach the submandibular salivary gland was retracted and preserved, and the neurovascular bundle of the neck was identified, dissected and protected.

For the transmandibular approach, the authors defined surgical procedures that included one or more osteotomies of the mandible, after a submandibular incision. In cases where very wide access was needed, an inferior lip-split was added to the submandibular incision.

The types of mandible osteotomies used in the patients in the study were: paramedian (PMO) and vertical subsigmoid (VSSO) with or without a coronoidectomy (COR). The type of the osteotomy was selected depending on the width of the access required. The VSSO alone was used only in one case, where the tumor was very close to the ramus of the mandible. As the PMO provides wider access than the VSSO, in cases of tumors of larger size and deeper location this osteotomy was preferred. In cases where even wider access was needed, a combination of osteotomies was adopted. In all cases where a transmandibular approach was used, the neurovascular bundle of the neck was identified, dissected and protected before mandible osteotomy. In every case where a PMO was used, a paralingual incision was made up to the posterior floor of the mouth, to help the surgeons perform the mandibular swing and expose the PPS widely.

The transmandibular approach was adopted in cases in which the patient’s preoperational data (history, clinical and imaging findings or FNA results) indicated a benign PPS tumor of large size (>4 times 4 cm). In one case, preoperative imaging findings showed a very vascular tumor. 4 days before surgery a preoperative embolisation was performed in order to reduce intra-operative blood loss and the surgical procedure was a transmandibular approach with a lip-split for a wider access.

The transmandibular approach was used in cases in which the patient’s history, clinical and imaging findings, FNA or open biopsy results favoured a malignant diagnosis. It was used in one case with a preoperative FNA diagnosis of adenocarcinoma (the postoperative final histopathological diagnosis was a synovial sarcoma) and in another case with a preoperative diagnosis of adenocarcinoma on the basis of an intraoral open biopsy. In these two cases a transmandibular approach with a lip-split was performed for wider access in order to obtain clear margins.

In cases in which a very wide approach was adopted (transmandibular approach with an additional lip-split) a prophylactic tracheotomy was performed and was abolished 4 days postoperatively.

Follow-up for patients with benign tumors included clinical examination after 1, 3, 6, 12 and 24 months and a head and neck MRI 6 months postoperatively, in order to detect possible recurrence of the disease. Every patient with a malignant tumor was examined once a month for the first year, once every 3 months for the second year and once every 6 months for 5 years after treatment. Additionally, these patients underwent a head and neck CT and/or MRI every 6 months for the same period. These patients will remain under observation until the authors are able to reach to conclusions about their disease course and the 5-year-survival.

Results

This series consisted of 13 patients surgically treated for primary PPS tumors and included 7 women (54%) and 6 men (46%) with a mean age of 46.3 years (range 22–72 years). The patients’ most common main symptoms were awareness of an intraoral/pharyngeal or a neck mass (92%) and dysphagia (31%), two patients suffered from dysarthria (15%) and one from hoarseness (8%). Pain was present only in the two cases of malignant neoplasms (15%). The most common findings on clinical examinations were the presence of a palpable neck mass posterior to the mandibular angle (77%) or an intraoral/pharyngeal mass (62%) causing a swelling of the lateral pharyngeal wall and the displacement of the soft palate and/or the tonsil. Five patients (39%) had an intraoral/pharyngeal and a palpable neck mass. Three patients (23%) had developed a XII deficit, two patients presented an IX deficit, while only one patient had true vocal cord palsy and was referred with hoarseness ( Table 1 ).

Table 1

Patient data.

Gender	Age	Main symptoms	Clinical examination findings	Size (in cm)	Surgical approach	Histological diagnosis	Additional therapy	Complications	Follow-up time (months)	Outcome
Male	38	Neck mass Dysphagia	Neck mass	4.5X3X2	Transmandibular (PMO)	Pleomorphic adenoma	–	Hematoma	50	NED
			Phar. mass
Male	48	Pain	Neck mass	4X3.5X3	Transmandibular (PMO)+LS	Synovial sarcoma	Postoperative	–	14	Brain metasta-sis
		Neck mass	XII deficit				Radiotherapy
							Chemotherapy
Female	72	Phar. mass	Phar. mass	2X2X2	Intraoral	Pleomorphic adenoma	–	–	6	NED
Female	37	Neck mass	Neck mass	3X3X2.5	Trancervical	Branchial cleft cyst	–	–	63	NED
Male	42	Neck mass	Neck mass	4.5X3X2	Transmandibular (VSSO)	Pleomorphic adenoma	–	–	58	NED
			Phar. mass
Female	72	Dysphagia Dysarthria Hoarseness	Phar. mass	6X4X3.5	Transmandibular (PMO)+LS	Vagal para-ganglioma	Preoperative Embolisation	Temporary MMB neuropathy	16	NED
			True vocal fold palsy
			IX deficit
			XII deficit
Female	39	Phar. mass	Phar. mass	2X2X1.5	Intraoral	Pleomorphic adenoma	–	–	38	NED
Male	22	Neck mass	Neck mass Phar. mass	5X3.5X3	Transmandibular (VSSO+PMO+COR)	Pleomorphic adenoma	–	–	5	NED
Female	47	Pain	Neck mass	4.5X3X3	Transmandibular (PMO+COR)+LS	Adenocarci-noma	Postoperative	Temporary MMB neuropathy	54	NED
		Neck mass Phar. mass	Phar. mass				Radiotherapy
		Dysphagia Dysarthria	Parotid mass IX deficit
			XII deficit
Male	44	Neck mass Dysphagia	Neck mass	5X3.5X3	Transmandibular	Neurofibroma	–	Temporary	48	NED
			Phar. mass		(PMO+COR)			XII neuropathy
Male	49	Neck mass	Neck mass	3X3X2	Trancervical	Pleomorphic adenoma	–	–	26	NED
Female	41	Neck mass	Neck mass	3.5X3X2	Trancervical	Pleomorphic adenoma	–	–	19	NED
Female	52	Neck mass	Neck mass	3X2.5X2	Trancervical	Pleomorphic adenoma	–	–	29	NED

LS, lip-split; PMO, paramedian mandibular osteotomy; VSSO, vertical subsigmoid osteotomy; COR, coronoidectomy; MMB, marginal mandibular branch of the facial nerve; NED, no evidence of the disease; Phar., pharyngeal.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Clinical use of botulinum toxins in oral and maxillofacial surgery
2. Incidence of venous thromboembolism in oral and maxillofacial surgery: a retrospective analysis
3. Distribution of Small Integrin-Binding LIgand, N-linked Glycoproteins (SIBLING) in the condylar cartilage of rat mandible
4. Intraoral vertical ramus osteotomy: a simple method to prevent medial trapping of the proximal fragment
5. Reply to a letter to the editor regarding article “Traumatic neuroma of mental nerve following chin augmentation”
6. Mandibular osteoblastic metastasis of poorly differentiated carcinoma of the thyroid gland

Stay updated, free dental videos. Join our Telegram channel

Join