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Aberrant carotid artery presenting as a nonpulsatile parapharyngeal mass
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Seven patients were treated for parapharyngeal space masses. Six had benign tumors (neurilemoma in 3, pleomorphic adenoma in 1, extracranial meningioma in 1, and abscess in 1) and one had a malignant tumor (metastatic thyroid carcinoma). Meningioma and thyroid carcinoma are very rare in the parapharyngeal space. Surgical resection was performed in all seven patients. Four of them were operated on through a cervical-transpharyngeal approach with osteotomy. The meningioma involved X and XII cranial nerves and was adherent to C1 and C2 vertebrae; it was thought to have originated from one of the two cranial nerves involved or from the C2 nerve. The thyroid carcinoma in the parapharyngeal space was a retopharyngeal lymph node metastasis from a papillary thyroid carcinoma which had been treated eight years earlier. Preoperative radiologic evaluations, which included CT, MRI and angiography, were very useful in the selection of the surgical approach. © 1995, The Society of Practical Otolaryngology. All rights reserved.
To determine the number of tonsillectomies and adenoidectomies (T-As) from 1968 to 1972 and their associated morbidity and mortality rates, a questionnaire was sent to all the hospitals listed in the Directory of the American Hospital Association (6,759). The data were analyzed and statistical projections were made. An analysis was also made of the summary report of the "Study on Surgical Services for the United States," with regard to the incidence of T-A was also made. The results are presented in the following report.
Magnetic resonance imaging has replaced contrast-enhanced CT as the primary imaging modality for parapharyngeal space masses. It has several advantages over CT. MRI's superior contrast resolution enables the imager to better define normal anatomic structures and establish more precise tumor margins. Magnetic resonance's direct multiplanar imaging capability allows the diagnostician to offer his clinical colleagues a more accurate assessment of the total extent (in three dimensions) of disease and a better map of the spatial relationship of tumors to crucial vessels. This important information aids the clinician in making better informed decisions concerning the appropriate treatment plan (surgery versus radiation, surgical approach, radiation ports).
Magnetic resonance's major inadequacy, compared with CT, is suboptimal detection of calcifications and subtle bony changes. Because of this, there are clinical situations when both MRI and CT are required, either to make a more definitive diagnosis or to include (exclude) certain pathology in (from) the differential diagnosis. Although there is considerable overlap in the signal intensity of various lesions, it probably is beyond realistic expectations to seek complete tissue specificity from any imaging tool. Hopefully, MRI spectroscopy will enable us, as imagers, in combination with our basic science colleagues, to take that giant step forward.
• Three cases of an aberrant internal carotid artery presenting at or near the midline in the posterior part of the pharynx occurred. In all three cases, the anomalous finding was not correlated with the presenting symptoms of the patient. In two of the three cases intraoral pulsations were detected during initial examination. In the third case, pulsations were appreciated on reexamination after roentgenographic evaluation. Intraoral photographs, computed tomographic scan, magnetic resonance imaging, and arteriography of these findings are shown. A review of the literature and the embryology of the lateral pharyngeal carotid artery are presented along with the rare finding of the near midline carotid artery and the clinical implications of this anomaly.
(Arch Otolaryngol Head Neck Surg 1989;115:519-522)
Surgical and CT examinations of 104 patients, each of whom presented with a parapharyngeal space mass, has resulted in the development of an updated CT protocol designed to provide a preoperative diagnosis. When dynamic scanning is used, diagnostic angiography or digital venous imaging (DVI) can be avoided in almost all of these cases. A specific preoperative diagnosis can be made in 88% of the patients and a limited differential diagnosis, which includes the final diagnosis, can be made in virtually all cases. The protocol and the problems encountered in differential diagnosis are presented. Evidence to suggest that minor salivary gland benign mixed tumors may arise in salivary rest tissue, rather than pharyngeal mucosal glands, is also presented.
There is a 1% incidence of congenital internal carotid tortuosity, which places this vessel into apposition with the superior pharyngeal constrictor instead of its usual location 2 to 3 cm lateral to it. Two angiographically documented cases are reported and the embryologic cause of this anomaly is discussed. Palpation of the pharyngeal wall prior to tonsillectomy or adenoidectomy is recommended.
The association of medially positioned internal carotid arteries and velocardiofacial (Shprintzen) syndrome was first made in 1987. This is also the most common syndrome associated with facial clefting. The potentially dangerous implications in children with this syndrome requiring pharyngoplasty for velopharyngeal incompetence and stigmatized hypernasal speech involve potential damage to these vessels. This three-part study was undertaken to analyze this anatomic variant. First, a group of 25 children with velocardiofacial syndrome, velopharyngeal incompetence, and obvious posterior pharyngeal pulsations seen on nasendoscopy was studied by CT angiography to determine the degree of this abnormal vascular pattern. This technique, together with three-dimensional reconstructions, made it possible to determine the precise location of these abnormally positioned vessels. Second, our routine superiorly based pharyngeal flap was measured by lateral cervical x-ray to show the distal tip of the flap. The variance was minimal and demonstrated the tip of most flaps to be at the disk between the C2 and C3 vertebrae. By correlating this information with the CT angiography, the risk of surgery can be determined on strict anatomic grounds, allowing customized flap design in some unilateral cases. In this series of children, routine superiorly based pharyngoplasty would be safe in 52 percent, while in 28 percent a pharyngeal flap would be safe if custom designed, and in the remaining 20 percent surgery should not be attempted because the risk of damage to the carotid arteries is too great. Third, in a double-blind study, velocardiofacial children with obvious pulsations seen on nasendoscopy were grouped with other children with palatal dysfunction. When only endoral examination was performed by plastic surgeons and plastic surgical residents, no vascular pulsations were ever seen. This indicates another important role of nasendoscopy in the preoperative assessment of children for palatopharyngoplasty.
We report fusiform aneurysms in both internal carotid arteries in a 74-year-old man who presented with a nonpulsatile retropharyngeal mass. Both helical CT and MR imaging disclosed the nature of the lesions. Arteriography, required for therapeutic decisions, confirmed the diagnosis. Because of the rarity of this condition and the potential for misdiagnosis, we describe the findings on complementary radiologic examinations.
Injuries to the internal carotid artery during simple pharyngeal surgical procedures can be catastrophic for the risk of massive bleeding. The aims of the study were 1) to report five cases of congenital and asymptomatic anomalies of the internal carotid artery with a review of the literature, 2) to assess the relationships between these anomalies and the possible risk in "routine" pharyngeal surgery, and 3) to determine the most accurate imaging techniques to evaluate these anomalies.
Retrospective study of five patients with congenital anomalies of the internal carotid artery bulging the pharyngeal wall. METHODS Clinical records, pathology reports, and original imaging features of these kind of vascular lesions (computed tomography scans, three-dimensional time-of-flight magnetic resonance angiogram, and Doppler ultrasonography) were reviewed for each patient; vascular lesions were related to possible risk factors for pharyngeal surgery; and a review of the literature was made.
All the patients were admitted for other diseases. The five anomalies, except one, were bulging the posterior pharyngeal wall and were asymptomatic. The peculiar literature referred 14 previous descriptions of similar anomalies.
Some of the anomalies of the internal carotid artery can determine a bulge of the posterior pharyngeal wall. Because of the submucous position of the carotid artery at this level, such anomalies can constitute a risk factor for serious hemorrhage in routine surgical procedures that have become outpatient procedures and are often performed by inexperienced surgeons. The three-dimensional time-of-flight magnetic resonance angiogram together with Doppler ultrasonography were shown to be the most accurate imaging techniques to evaluate these anomalies.
Iatrogenic injury to the internal carotid artery (ICA) is a rare complication of pharyngeal surgery that most commonly occurs in children with an anomalous course to the internal carotid artery. Most aberrant arteries are asymptomatic. They can remain undiscovered preoperatively or be found incidentally on radiographic studies completed for an unrelated reason. Evaluation of definitive internal carotid artery injuries is well documented in the trauma literature. We present a case of a suspected intraoperative injury to the internal carotid artery during routine pharyngeal surgery. Ultimately no injury was found, however, aberrant internal carotid arteries were coincidentally discovered.
Internal carotid aneurysm presenting as pharyngeal mass
- Yoshizki
Bilateral internal carotid aneurysms presenting as a nonpulsatile parapharyngeal masses
- Munoz A