Meningioma in the paeotid region

Abstract

Meningiomas occurring ectopically in the neck are exceptional. We report two patients who presented as parotid and parapharyngeal masses and analyze them along with 27 previously reported cases. Typical patients present with parotid or parapharyngeal masses and cranial nerve palsies. Meningioma is not considered in differential diagnosis. The tumor is an extension of an unsuspected intracranial mass, occasionally with associated multiple meningiomas or other neurogenic tumors. Ectopic meningiomas should be considered in patients with parotid and parapharyngeal masses, particularly those with cranial nerve deficits; jugular foramen syndrome is most characteristic. Associated occult intracranial and temporal bone tumors and the cranial form of neurofibromatosis should be suspected. Treatment of cervical meningiomas is excision. The most important aspect of intracranial-extracranial lesions is recognition and treatment of the intracranial portion.

Meningioma Presenting as a Parapharyngeal Tumor

“…In addition, the generally long duration of symptoms in meningiomas involving cranial nerves appears to speak against biologic aggressiveness, reaching a maximum of 11 years in Nichols' review, with the most common symptom, hoarseness, lasting a maximum of 6 years. 16 That duration was exceeded by one year in our case.…”

“…This situation has been reported in some series to be among the less common clinical presentations following extracranial extension of meningiomas into the orbit, skull and scalp as well as the paranasal sinuses and nose. 16,20 From the cytopathologist's viewpoint, however, the pattern of presentation exemplified in this case, though most unusual, is most significant, not only because the parotid gland and parapharyngeal space are among the more accessible regions by the aspirating needle, thereby making them more commonly the source of cytopathologic material than the other regions outlined above, but also because of the uniquely disparate types of differential diagnosis evoked in this particular situation. It is difficult to think of another clinicopathologic scenario in which salivary acinic cell carcinoma, metastatic papillary thyroid carcinoma and paraganglioma are all evoked as differential diagnoses of a meningioma.…”

“…6,8,11,16,20 Since these foramina normally admit the respective cranial and spinal nerves and since their perineuria are direct extensions of the arachnoid membrane, it is not surprising that a meningioma extending along one of these pathways would also become intimately associated with the cotransiting peripheral nerve or nerves. 6 In this case the meningioma had emerged through the jugular foramen, thereby following the course of the 9th-11th cranial nerves into the carotid sheath to involve the parapharyngeal space, copositioning itself with the deep lobe of the ipsilateral parotid gland so as to clinically mimic a primary salivary gland tumor.…”

“…16 Paragangliomas at this location have not only been known to mimic meningiomas on small biopsies 13 but have also been reported to cause parotid swelling and to be mistaken for acinic cell tumors on cytology 18 and even on histology, 5 thereby closely interlinking these three entities as mutual differential diagnoses in a shared complex of clinicopathologic features.…”

“…This is a drastic procedure, usually reserved for attempted curative eradication of unequivocally malignant tumors. Although a paper by Larson et al alludes to the potential biologic significance of perineural infiltration, 14 too few cases associated with peripheral nerves, 6,8,11,16,20 let alone those showing perineural infiltration, have been studied in comparison to meningiomas without this feature for any firm conclusions to be drawn. In addition, the generally long duration of symptoms in meningiomas involving cranial nerves appears to speak against biologic aggressiveness, reaching a maximum of 11 years in Nichols' review, with the most common symptom, hoarseness, lasting a maximum of 6 years.…”