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The parapharyngeal space is a pyramidshaped space located between the base of the skull and the hyoid bone, lateral to the naso-oropharynx and medial to the jaw [1, 2]. It contains the deep lobe of the parotid gland, cranial nerves IX–XII, the internal jugular vein, and the carotid artery [1]. A variety of benign and malignant tumors arise in the parapharyngeal space, the most common being of salivary gland and neurogenic origin [1]. Because of its deep location and concerns about damaging adjacent structures, the parapharyngeal space is difficult to access for biopsy [1–3]. Percutaneous, transoral, or transnasal approaches have been used; however, sampling may be challenging even under imaging guidance [2–5]. Here we report for the first time a technique of transoral biopsy using a flexible gastrointestinal echoendoscope. A 41-year-old man with a remote history of mucoepidermoid carcinoma of the left parotid gland presented with a tumor of the right parapharyngeal space (▶Fig. 1). A multidisciplinary tumor board recommended biopsy; however, this was deemed difficult due to the tumor location. After discussion with a gastroenterologist experienced in endoscopic ultrasound (EUS), a decision was made for biopsy under EUS guidance. With the patient in the left lateral position and under intravenous sedation, a flexible echoendoscope (Olympus GFUCT180) was introduced in a standard manner into the oral cavity and torqued clockwise. After passing the palatopharyngeal fold, the EUS transducer was gently wedged against the right lateral wall of the pharynx (▶Fig. 2). In this position the tumor was easily identified on the EUS image. Three passes with a 22-gauge Acquire needle (Boston Scientific) were performed (▶Fig. 3, ▶Video 1). The specimen was processed for histological evaluation, which revealed pleomorphic adenoma (▶Fig. 4). The patient was discharged 48h later after an uneventful course. The tumor was resected 4 weeks later. Surgical pathology confirmed the diagnosis of pleomorphic adenoma of the deep lobe of the right parotid gland. Endoscopy_UCTN_Code_TTT_1AS_2AC E-Videos

Transoral endoscopic ultrasound-guided fine-needle biopsy of a tumor of the parapharyngeal space