Incision biopsy of the submandibular discrete lobule confirmed the diagnosis pleomorphic adenoma. Computed tomographic (CT) scan could not be done, as the patient could not afford the cost, while magnetic resonance imaging (MRI) facilities are not available at our centre.

The patient was subsequently admitted for surgical excision of the submandibular and parapharyngeal tumor. The submandibular lesion was approached through a left submandibular incision. The mass was found to be completely distinct from the parapharyngeal tumor, which was enucleated by blunt dissection. Recovery and immediate post-operative period were uneventful.

CT scan and magnetic resonance imaging (MRI) are important diagnostic tools in tumors of PPS. CT scan helps in determining the effect of disease on the surrounding structures, local spread, calcification in the tumor or hyperostosis and also to some extent in determining the type of tumor [11,13]. Magnetic resonance imaging (MRI) has been shown to be superior to computed tomography in the investigation of parapharyngeal space tumors [13-15]. The magnetic resonance imaging has the great advantage of direct, three-plane imaging which helps to show the position and extent of the tumor prior to surgery or radiotherapy as well as better soft-tissue demonstration of skull base involvement [13]. The vessels are clearly demonstrated due to the absence of signal from flowing blood, so that displacements can be appreciated without using contrast medium. Since internal carotid artery is more consistently identified on MR images than it is on CT scans, in most instances the likely histology of a tumor in the parapharyngeal region can be inferred from vessel displacement [13,14]. A final advantage of MRI over CT scan is the multisection capability of MRI, which reduces the patient scanning time and at the same time allows wide coverage of the area of tumor involvement [13]. The possibility of leaving behind clinically undetectable tumor is very high due to our inability to obtain CT scan and MRI prior to surgery and hence the chances of recurrence are high.

Fine-needle aspiration cytology (FNAC) is the modality of choice for obtaining biopsy sample for PA [7], which was not carried out in this case. If performed, the incision biopsy could have been avoided. The biopsy incision scar on the skin was however, included in the subsequent surgical excision specimen. However, it is to be emphasized that the incision biopsy is no more advocated for salivary gland tumors due to the risk of tumor seeding and subsequent multinodular recurrence [7,16], as was seen in the present case.

The treatment of pleomorphic adenoma is essentially surgical excision [7-9,11]. The excision of submandibular pleomorphic adenoma is usually straight forward with little or no complications due to direct surgical access. The parapharyngeal space is however, a complex anatomic region located between the mandibular ramus and the lateral pharynx and extending as an inverted pyramid from the skull base superiorly to the hyoid bone inferiorly [10]. Within this potential space are cranial nerves IX, X, XI, and XII, the sympathetic chain, the carotid artery, the jugular vein and lymph nodes. Due to the PPS's anatomic complexity, location and surrounding vital structures, resection of tumors from this space can prove challenging to the head and neck surgeon. The approach of choice to the parapharyngeal space to allow adequate removal of the tumor should meet two criteria: wide intra-operative visibility for safe radical dissection and minimal functional or cosmetic after-effects [17]. The presence of rigid bony vertical ramus of the mandible which forms the lateral wall of the parapharyngeal space prevents direct surgical access to this region [17]. So a considerable number of surgical techniques have been described to overcome this problem: one involves anterior dislocation of the mandible by division of stylomandibular ligament and forward traction of the mandible [18], and the second involves mandibular osteotomies [19-21]. Types of mandibulotomy that have been described are: median, parasymphyseal, horizontal, inverted "L" and double mandibular osteotomy with coronoidectomy; with or without lip split [17,19,20].

In this patient, a cervical submandibular approach [10] was used to gain access to both the lesions. Although the visibility and access to the parapharyngeal space was poor with this approach, the tumor was easily mobilized by blunt dissection. However, this is not a recommended technique and the sharp dissection should be carried out as far as possible to prevent injury to the great vessels and cervical nerves and also to facilitate en bloc removal of tumor without possibility of seeding. If need arise the digastrics, stylohyoid, and styloglossus muscle and stylohyoid ligament can be removed for access [10].

Although, the submandibular approach was found sufficient for the excision of both the submandibular and parapharyngeal tumor in the current case, this surgical approach is considered a shortcoming, as some authors have expressed concern about limited exposure, need for finger dissection, and poor vascular control at the skull base with this approach [10]. Injury to nerves and vessels as well as bleeding from the base of the skull has also been reported to be more common with blunt dissection than with sharp dissection. It is our opinion that the approach should be individualized based on the size and extent of tumor, and the knowledge, skill and experience of the operative surgeon.

Attempts have been made to classify pleomorphic adenoma as either epithelial/myoepithelial or myxo-chondroid predominant, based on the predominance of either epithelial/myoepithelial or mesenchyma-like tissue [16]. Pleomorphic adenoma of the submandibular and PPS space in the present case, were epithelial/myoepithelial and myxoid predominant respectively.