Modified attia approach for enormous pleomorphic adenoma of para-pharyngeal space with all-embracing chondroid calcification – A rare case report

Parapharyngeal space (PPS) is one of potential space of head and neck region and due to its hidden anatomical location, pathologies arising in this space are late to diagnose. This inverted pyramidal space was termed previously as pterygomaxillary space, lateral pharyngeal space and pharyngio-maxillary space. Parapharyngeal space is the current term that has come to stay because of indistinct image of its location. Anatomically parapharyngeal space divides into two spaces i.e. pre-styloid and post styloid. This space contains highly vital structure like carotid sheath, cranial nerves IX, X, XI, and XII, sympathetic trunk, superior cervical ganglion of trunk, maxillary artery, ascending pharyngeal artery and deep part of parotid gland. This space is also full of loose connective tissue and minor salivary glands and lymph nodes. Pathologies are more likely to happen from above mentioned vital structures namely neurogenic tumor (schwanoma, neurofibroma, glomus vagale tumors) and benign or malignant salivary gland tumors. PPS tumors are very rare and accounts for 0.5% tumors of head and neck region. Most of these tumors i.e. 72% are benign and 40-50% originates from the salivary glands [1]. Pleomorphic adenoma in PPS can develop de novo probably from displaced or aberrant salivary gland tissue within the lymph node, minor salivary gland or deep lobe of parotid gland that can extend through stylomandibular tunnel through PPS [2,3]. Due to close proximity to vital and vascular structures and not easy accessibility leads to high difficulty index for maxillofacial surgeons in management of PPS tumors.