A giant mixed tumor originating from the parapharyngeal space.

A 66-year-old man presented with difficulty in breathing and swallowing caused by swelling in his throat. He was aware of this swelling for the last three years but he had avoided referring to a hospital until he started to have serious apnea attacks. Physical examination revealed a large mass in the oropharynx bulging submucosally from the right lateral pharyngeal wall that nearly occluded the whole oropharynx. The other remarkable findings were absence of the gag reflex on the right soft palate, deviation of the tongue to the right side and right vocal cord paralysis, reflecting glossopharyngeal, vagus and hypoglossal nerve palsies. On magnetic resonance imaging (MRI), a mass in the right parapharyngeal space was observed with the dimensions of 83x51x84 cm (anteroposterior x transverse x craniocaudal) obliterating nearly the whole parapharyngeal space at the level of the oropharynx and hypopharynx. The tumor had pushed the carotid space posteriorly and the masticator space anterolaterally. It had a heterogeneous hypointense signal but peripheral hyperintense signal due to hemorrhage on T1 weighted (T1W1) and heterogeneous hyperintense signal on T2W2. This mass lesion had also enlarged the stylomandibular foramen and had a solid component enhancing contrast intensely with a central large necrotic component (Figure 1a-c). Following MRI of the mass a transoral fine needle aspiration (FNA) biopsy was performed, the result of which was non-diagnostic necrotic cells. The mass was surgically excised through a transcervical-transparotid approach.