Commentary

Parapharyngeal tumors are relatively uncommon but can pose a challenge to diagnose and treat. The examination is essentially radiographic. Typically I rely on magnetic resonance imaging and angiography. If the mass is vascular (e.g., carotid body tumor), embolization is performed within 24 hours of resection. In multiple studies, embolization has significantly reduced intraoperative blood loss and the need for transfusion.

Multiple surgical approaches exist. The transcervical-transparotid approaches are usually sufficient. Certain adjuncts such as removing the submandibular gland or dividing the stylomandibular ligament enhance exposure. However, if exposure is still poor and access to control the vessels is compromised, the mandibular “swing” can be performed with a relatively low rate of morbidity. The transoral approach is only feasible for small tumors with the jugular vein or carotid vessels displaced laterally. This approach is seldom used.

Morbidity should be minimal. Excision of schwannomas and neurofibromas involving the cranial nerves may result in temporary or permanent paralysis. The most commonly injured nerve is the facial nerve, specifically, the marginal mandibular branch. It is usually injured by traction or when the skin flap is raised.