Vestibular schwannoma is the most common neoplasm in the cerebellopontine angle, and fast spin-echo T2-weighted magnetic resonance imaging is the most sensitive test for diagnosing it. This study evaluated the financial and time costs of unnecessary magnetic resonance imaging referrals before and after the application of a magnetic resonance imaging protocol.

A full audit cycle was used for the assessment. The first cycle in January 2012 was retrospective and evaluated the financial impact of current selection criteria for magnetic resonance imaging referral against standard guidelines. The second cycle in January 2014 was prospective after implementation of the protocol.

There were 46 and 112 patients who had magnetic resonance imaging during first and second cycle, respectively. Of the referrals for magnetic resonance imaging, 65 per cent versus 81 per cent of the referrals were appropriate in the first and second cycles, respectively. The relative risk was reduced from 0.5 to 0.2. The waiting times for magnetic resonance imaging scans improved.

Selection criteria for magnetic resonance imaging referral are important in reducing waiting times for scans, patient anxiety and conserving trust resources.

Identifying the nerve of origin in head and neck schwannomas is a diagnostic challenge. Surgical management leads to a risk of permanent deficit. Accurate identification of the nerve would improve operative planning and patient counselling.

Three patients with head and neck schwannomas underwent a diagnostic procedure hypothesised to identify the nerve of origin. The masses were infiltrated with 1 per cent lidocaine solution, and the patients were observed for neurological deficits.

All three patients experienced temporary loss of nerve function after lidocaine injection. Facial nerve palsy, voice changes with documented unilateral same-side vocal fold paralysis, and numbness in the distribution of the maxillary nerve (V2), respectively, led to a likely identification of the nerve of origin.

Injection of lidocaine into a schwannoma is a safe, in-office procedure that produces a temporary nerve deficit, which may enable accurate identification of the nerve of origin of a schwannoma. Identifying the nerve of origin enhances operative planning and patient counselling.

External approaches have been traditionally used for the complete excision of large retropharyngeal space lesions.

This paper describes a case of a large schwannoma of the retropharyngeal space excised transorally with the use of a robotic system. This lesion measured 2.7 × 1.2 cm in axial dimensions and over 5.8 cm in craniocaudal length. The lesion was delivered en bloc with an intact capsule. No peri- or post-operative complications were encountered. The procedure allowed quick resumption of an oral diet and a return to normal activity for the patient.

This is, to our knowledge, the first report of this technique used in the excision of a large retropharyngeal space mass.

Infratemporal fossa schwannomas are benign, encapsulated tumours of the trigeminal nerve limited to the infratemporal fossa. Because of the complications and significant morbidity associated with traditional surgical approaches to the infratemporal fossa, which include facial nerve dysfunction, hearing loss, dental malocclusion and cosmetic problems, less invasive alternatives have been sought.

This paper reports two cases of infratemporal fossa schwannomas treated in 2012 using mini-invasive approaches. The literature regarding different infratemporal fossa approaches was reviewed.

The first schwannoma was 30 mm in size and was removed completely by a preauricular subtemporal approach. The second one was 25 mm in size and was removed completely using a purely transnasal endoscopic approach. In both cases, there were no intra-operative or post-operative complications.

These two approaches allow non-invasive and wide exposure of the infratemporal fossa as compared to classical approaches. Surgical approach should be selected according to the tumour's anatomical location with respect to the maxillary sinus posterior wall. The preauricular subtemporal approach is recommended for tumours localised posterolaterally with respect to the maxillary sinus posterior wall. Medial and anterior tumours near the maxillary sinus posterior wall can be best removed using a transnasal endoscopic approach.

The head and neck region harbours crucial structures and hence the surgical technique used to remove schwannomas from this region should cause minimal damage to these structures, with complete removal of pathology.

This study entailed a retrospective analysis of 10 patients with head and neck schwannomas that were excised using a nerve-sparing subcapsular dissection technique. The primary aims were to assess the functional impact of the surgical technique on the structure of origin and to evaluate local control.

One patient with parapharyngeal schwannoma developed symptoms suggestive of ‘first bite syndrome’ in the late post-operative period. Another patient with facial nerve schwannoma had House–Brackmann grade II weakness in the immediate post-operative period, which subsequently resolved. None of the patients developed recurrence during a median follow-up period of two years.

The nerve-sparing subcapsular dissection technique provided effective local control of tumour pathology, with relative preservation of neural function post-operatively.

This review summarises the contemporary, multidisciplinary approach to managing parapharyngeal space neoplasms.

Parapharyngeal space neoplasms are uncommon head and neck tumours and are most often benign. Most tumours are of either salivary gland or neurogenic origin. Patients tend to be asymptomatic even when tumours reach large sizes. Patients may present with a mass in the pharynx or neck, although frequently the tumour is found incidentally on an imaging study. Due to the limitations of physical examination in this anatomical area, imaging studies are essential to the evaluation of parapharyngeal space neoplasms. Cytopathology may provide additional diagnostic information. Open biopsy is rarely necessary and can be hazardous. Treatment is primarily surgical, and various surgical approaches can be tailored for a given neoplasm. Recently, a trend toward observation of select patients with asymptomatic neurogenic tumours has been advocated.

The evaluation and management of parapharyngeal space tumours is best done by a multidisciplinary team. Treatment should be individualised, and the risks and benefits of surgical intervention need to be carefully weighed. Complications are best avoided by careful surgical planning.

We report a case of benign intranodal neurilemmoma, an extremely rare tumour arising from a nerve sheath within a lymph node.

A 67-year-old woman underwent surgery for a left-sided parotid mass. Histopathological analysis revealed a tumour arising from a lymph node within the superficial lobe of the parotid gland. The tumour demonstrated histological features of an intranodal neurilemmoma.

This case represents the first report of an intranodal neurilemmoma arising within a parotid lymph node, and supports the proposal that intranodal neurilemmoma be recognised as a distinct histological entity.

We report a rare presentation of ancient schwannoma of the oesophagus, management of which required tracheal resection.

A 40-year-old woman was referred to our hospital with a six-year history of progressively worsening stridor. She had undergone laser excision of a tracheal tumour thrice in the past. Fibre-optic bronchoscopy showed a tumour arising from the posterior wall of the trachea. Computed tomography scanning showed evidence of extension along the retrotracheal plane. The patient required tracheal resection and anastomosis due to significant involvement of the posterior tracheal wall. The mass was seen to be arising from the oesophagus, and was able to be enucleated from the oesophageal wall. Histopathology was typical of an ancient schwannoma.

This case emphasises the need to consider oesophageal schwannomas in the differential diagnosis of posterior tracheal tumours; it also highlights the need for careful pre-operative assessment in the management of these tumours in order to avoid complications.

We report an extremely rare case of malignant triton tumour.

Case report and review of the world literature concerning malignant triton tumour and heredity.

We present the case of a 47-year-old woman who underwent a lateral rhinotomy surgical resection of a malignant triton tumour of the right paranasal sinuses, a rare location for this tumour. Thereafter, she received adjuvant radiotherapy. The prognosis for this group of tumours is poor. Radical surgical excision of the tumour followed by radiation therapy must be the treatment of choice.

To our knowledge, this is a rare report in the world literature of malignant triton tumour. This case indicates that malignant triton tumour of the paranasal sinuses is a rare disease which otolaryngologists should be aware of, and one which should be included in the differential diagnosis of malignant lesions involving the sinonasal tract.

To highlight the difficulty in making a correct diagnosis of benign schwannoma in the paranasal region, to raise awareness of this rare condition, and to suggest the most appropriate treatment.

Retrieval of cases retrospectively from archives of the histopathology department of a major UK cancer centre with central review of all cases.

Five cases were identified since 1990 and clinical and pathological features are summarised. Median follow up of patients was 8.1 years. Radiological appearances of local bone invasion and histological features of tumour unencapsulation and hypercellularity could give the mistaken impression of malignant disease and lead to unnecessary over-treatment.

Central pathological review and clinical awareness is required. Although local recurrence can occur, the prognosis is excellent. The treatment of choice is local excision. Radiotherapy can be considered, but in most cases it would incur unnecessary morbidity.