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Head & Neck Surgery Course
Dr Pierfrancesco PELLICCIA
Pr Benjamin LALLEMANT
Service ORL et CMF
CHU de Nîmes
CH de Arles
Parapharyngeal space: surgical anatomy
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Introduction
• Potential deep neck space
• Shaped as an inverted pyramid
• Base of the pyramid: skull base
• Apex of the pyramid: greater cornu of the hyoid bone
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Introduction
• 2 compartments
– Prestyloid
– Poststyloid
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Anatomy: boundaries
• Superior: small portion of temporal bone
• Inferior: junction of the posterior belly of the digastric and the hyoid bone
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Anatomy: boundaries
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• Posterior: deep fascia and paravertebral muscle
• Anterior: pterygomandibular raphe and medial pterygoid muscle fascia
Anatomy: boundaries
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• Medial: pharynx (pharyngobasilar fascia, pharyngeal wall,
buccopharyngeal fascia)
• Lateral: superficial layer of deep fascia • Medial pterygoid muscle fascia
• Mandibular ramus
• Retromandibular portion of the deep lobe of the parotid gland
• Posterior belly of digastric muscle
• 2 ligaments
– Sphenomandibular ligament
– Stylomandibular ligament
Anatomy: boundaries
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Aponeurosis and ligaments
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• Stylopharyngeal aponeurosis: separates parapharyngeal spaces to two compartments:
– Prestyloid
– Poststyloid
• Cloison sagittale: separates parapharyngeal and retropharyngeal space
Aponeurosis and ligaments
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Stylopharyngeal aponeurosis
Aponeurosis and ligaments
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stylohyoidien Stylopharyngeal , And styloglossus muscles
Muscles
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Prestyloid compartment
Contents: – Retromandibular portion of the
deep lobe of the parotid gland
– Minor or ectopic salivary gland
– CN V branch to tensor veli palatini muscle
– Ascending pharyngeal artery and venous plexus
– Most fat
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Contents – Carotid artery
– Internal jugular vein
– CN IX to XII
– Cervical sympathetic chain
– Glomus tissues
Poststyloid compartment
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• Suprahyoid
• Boundaries – Superior—skull base – Inferior—hyoid – Anterior—ptyergomandibular
raphe – Posterior—prevertebral fascia – Medial—buccopharyngeal fascia – Lateral—superficial layer of deep
fascia
Parapharyngeal space: keep in mind
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Parapharyngeal space: keep in mind
• 2 compartments: Prestyloid
• Muscular compartment • Medial—tonsillar fossa • Lateral—medial pterygoid • Contains fat, connective tissue,
nodes
Poststyloid
• Neurovascular compartment • Carotid sheath • Cranial nerves IX, X, XI, XII • Sympathetic chain
• Stylopharyngeal aponeurosis
– Prevents infectious spread from anterior to posterior
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Parapharyngeal space relationships
• Communicates with several deep neck spaces.
– Parotid
– Masticator
– Peritonsillar
– Submandibular
– Retropharyngeal
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Retropharyngeal Space
• Entire length of neck
• Boundaries:
– Anterior border - pharynx and esophagus (buccopharyngeal fascia)
– Posterior border - alar layer of deep fascia – Superior border - skull base – Inferior border – superior mediastinum
• Combines with buccopharyngeal fascia at level of T1-T2
– Lateral border – cloison sagittale – Midline raphe connects superior
constrictor to the deep layer of deep cervical fascia.
• Contains retropharyngeal nodes.
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Danger Space
• Extends from skull base to diaphragm
• Boundaries
– Anterior border - alar layer of
deep fascia – Posterior border - prevertebral
layer
• Contains loose areolar
tissue.
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Prevertebral Space
• Entire length of vertebral column
• Boundaries
– Anterior border - prevertebral fascia
– Posterior border - vertebral bodies and
deep neck muscles
– Lateral border – transverse processes
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Head & Neck Surgery Course
Dr Pierfrancesco PELLICCIA
Pr Benjamin LALLEMANT
Service ORL et CMF
CHU de Nîmes
CH de Arles
Parapharyngeal space: surgical options and
technique
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Surgical Options
• Transparotid approach
• Transcervical approach
• Cervical-parotid approach
• Cervical-transpharyngeal
(mandibular swing)
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Transparotid approach
• For deep lobe of parotid lesion
• Superficial parotidectomy with facial nerve preservation
• Retract facial nerve from the deep parotid lobe
• Dissect posterior and inferior around mandible
• Improve access by mandibulotomy
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Transparotid approach
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Transparotid approach (Total parotidectomy + SND of levels II-III for parotid cancer)
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Transcervical approach
• For poststyloid tumor
• Transverse incision at level of hyoid
• Submandibular gland removed or retracted
• Incision through the fascia deep to the submandibular space
• Increase exposure by releasing digastric, stylohyoid, styloglossus from hyoid, cut stylomandibular ligament, mandibulotomy
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Cervical-parotid approach
• Extend cervical incision up infront of ear
• Identify facial nerve
• Divide posterior belly digastric
• Divide styloglossus, stylohyoid close to styloid process
• Divide stylomandibular ligament
• Can combine with mandibulotomy
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Cervical-parotid approach
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Indications
• Can be used to remove majority of the parapharyngeal tumor
– All deep lobe parotid tumors and extraparotid salivary
tumors
– Low grade malignant tumors of deep lobe of parotid
– Many poststyloid tumors, including most neurogenic
tumors and small paragangliomas
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Cervical-transpharyngeal (mandibular swing)
• “Mandibular swing”
• Midline lip splitting or visor flap
• Mandibulotomy anteriorly, incise along floor of mouth to anterior tonsillar pillar
• Identify hypoglossal nerve and lingual nerve
• Divide styloglossus and stylopharyngeus muscle
• Need tracheotomy
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Cervical-transpharyngeal (mandibular swing)
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Indications
• All vascular tumors that extend into the superior portion of
the parapharyngeal space
• Malignant tumor invaded skull base or vertebral body