Abstract
Primary tumors of the parapharyngeal space are extremely rare, and lipomas are among the least common primary parapharyngeal space masses. Parapharyngeal lipomas typically present as a painless neck mass, and some may present with neurologic deficits or vascular compromise attributed to the lipomas’ mass effect on nearby neurovascular structures. We report long term follow-up of two large parapharyngeal lipomas. One lesion was managed expectantly, and the other was managed with a partial transcervical excision. We demonstrate that conservative management and long term patient follow-up may be reasonable if the patient is asymptomatic and liposarcoma is ruled out. Considering the uncertainty in the need for removal, the management strategy for the individual patient is best to be tailored to their clinical presentation.
1
Introduction
Primary tumors of the parapharyngeal space are extremely rare and comprise approximately 0.5% of all head and neck masses . Of this 0.5%, lipomas are among the least common primary parapharyngeal space masses . To date, only 10 prior cases reporting primary parapharyngeal space lipomas in adults have been published in contemporary English language literature ( Table 1 ).
| Author, year | Age, gender | Mass size and location | Management | Outcome |
|---|---|---|---|---|
| Elango, 1995 | 55, Female | 4.5 × 3.5 × 1 cm. Well defined fat density mass in the right parapharyngeal space. | Transcervical excision | No post-operative complications. Follow-up time not reported. |
| Scott et al., 1999 | 69, Male | 16 × 4.5 × 1.5 cm. Right parapharyngeal space extending from the skull base to the level of the true vocal folds, into the parotid gland. | Transcervical excision | No post-operative complications. Follow-up time not reported. |
| Smith et al., 2002 | 49, Male | No size reported. Poststyloid parapharyngeal space. Extension into foramen transversarium at the level of the 2nd cervical vertebra, encasing the vertebral artery. | Transcervical excision | No recurrence or functional deficits at 30 months. |
| Pellanda et al., 2003 | 53, Male | 9 × 4 × 5 cm. Extending into right parapharyngeal space. | ‘Surgical excision’ | No recurrence or functional deficits at 2 months. |
| Ulku et al., 2004 | 18, Male | No size reported. Right poststyloid parapharyngeal space extending superiorly to the base of skull | Transcervical excision | No recurrence or functional deficits at 12 months. |
| Singh et al., 2004 | 38, Female | 10 × 6 cm. Superiorly the mass extended into the right parotid region, medial to the mandible, inferiorly to the right thyroid lobe. Displaced the carotid sheath, and submandibular gland. | Modified Blair incision approach | Transient right marginal mandibular nerve paresis at 2 weeks. |
| McNeill et al., 2006 | 75, Male | 6 × 3 cm. Situated deep in the left parapharyngeal space, extending to the level of the hyoid. | Observation | No significant deficits at 18 months |
| Rogers et al., 2010 | 56, Male | 7.5 × 4.0 × 2.5 cm. Left parapharyngeal mass extending from the skull base to the thyroid cartilage. | Transcervical excision | Mild dysphagia, no recurrence at 6 months. |
| Arshad et al., 2013 | 68, Male | 6.6 × 4.2 × 1.9 cm left parapharyngeal mass. | Transoral robotic excision (TORS) | No significant deficits at 6 months |
| Pal et al., 2015 | 40, Female | 7 × 5 cm. Right parapharyngeal lesion superiorly from the skull base to the tip of epiglottis, extending into the carotid space. | Transcervical excision | Transient right marginal mandibular nerve paresis, no residual deficit at 9 months |
Parapharyngeal lipomas typically present as a painless neck mass . In many patients, this can be an incidental finding on a physical examination. Few patients present with neurologic deficits or vascular compromise attributed to the lipomas’ mass effect on nearby neurovascular structures. Work-up includes a full history and physical examination with close scrutiny of cranial nerve function. Computed tomography (CT) with contrast and/or magnetic resonance imaging (MRI) is essential to characterize the lesion and can enhance diagnostic accuracy .
As parapharyngeal lipomas are exceedingly rare, there is little consensus for their management. In a review of recent cases noted above, most authors have reported transcervical excision. Other lesions of the parapharyngeal space are often treated by surgical excision with approaches depending on the mass’ pathology, size and relationship to the great vessels .
We present two cases of large parapharyngeal space lipomas. We describe the presentation and imaging findings, and propose a conservative management rationale with a review of the relevant contemporary literature. IRB approval was obtained for the presentation of clinical data. Express permission was obtained from the patient in Case 1 to use the physical examination photograph.
2
Case 1
An 83 year-old male was seen in consultation for left parapharyngeal fullness. The patient initially presented to an otolaryngologist for nasal polyps and dysphonia, and left parapharyngeal fullness was incidentally noted. The patient was otherwise healthy, and denied xerostomia, throat or ear pain, dysphagia, odynophagia, neck masses or lesions, cough, hemoptysis or weight loss. His physical examination was remarkable for left parapharyngeal and neck fullness, with no clinical lymphadenopathy. No significant findings were noted on flexible nasopharyngoscopy. His cranial nerve examination was normal and there was no trismus.
To further characterize this lesion, computed tomography (CT) imaging and magnetic resonance imaging (MRI) were obtained ( Figs. 1–4 ). The CT demonstrated a lobulated, fat density appearing lesion with scattered thin septations involving the left prestyloid parapharyngeal and paravertebral space with bony scalloping of the left aspect of the C1 cervical vertebra. The fatty mass insinuated around the left internal carotid artery and abutted portions of the left vertebral artery. The MRI reaffirmed the lobulated fat signal mass centered in the left prestyloid parapharyngeal space extending from the level of the clivus down to the C2-3 cervical vertebrae levels with well-defined margins. To rule out liposarcoma, a CT-guided fine needle aspiration was performed. Pathologic analysis determined the sample to be benign connective tissue elements with mature adipose tissue fragments.
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