Transoral Resection of Giant Parapharyngeal Space Tumors via a Combined Surgical Approach

Document Type: Original


Department of Otorhinolaryngology - Head and Neck Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, 1 Stilponos Kyriakidi St, 54636 Thessaloniki, Greece.


Parapharyngeal space (PPS) tumors account for 0.5% of the head and neck neoplasms. Based on the evidence, 80% of these tumors are of a benign nature. Surgical excision is the treatment of choice for this condition. The present study was conducted to propose transoral resection as an efficient way to excise the benign well-defined tumors of the PPS.
Materials and Methods:
This retrospective case series study was conducted on seven patients undergoing the transoral excision of the sizeable masses of the PPS via a combined approach. Computed tomography and magnetic resonance scans revealed giant masses in the PPS in all cases. These neoplasms were preoperatively diagnosed as well-delineated, non-vascular, and benign.
All patients underwent transoral tumor excision preceded by an auxiliary transcervical approach, which served as an assurance for the dissection and preservation of the cranial nerves and neurovascular bundle without any tumor spillage. Average hospital stay was limited to a maximum of 3 days, and all patients had an uneventful postoperative course. The follow-up examination did not indicate any recurrence.
Based on the findings, transoral resection can be concluded as an efficient way to excise benign, well-defined tumors of the PPS. This procedure appears to be safe when a secondary transcervical approach is applied. Given the unnecessity of performing mandibulotomy in this procedure, it is expected to have lower morbidity and fewer complications.


Main Subjects

1. Stell PM, Mansfield AO, Stoney PJ. Surgical approaches to tumors of the parapharyngeal space. Am J Otolaryngol. 1985;6(2):92-7.

2. Pensak ML, Gluckman JL, Sumrick KA. Parapharyngeal space tumors: an algorithm for evaluation and management. Laryngoscope 1994; 104: 1170–3.

3. Starek I, Mihal V, Novak Z. Paediatric tumours of the parapharyngeal space. Int J Pediatr Otorhinolaryngol 2004;68:601–6.

4. Mendelsohn AH, Bhuta S, Calcaterra TC, Shih HB, Abemayor E, St John MA. Parapharyngeal space pleomorphic adenoma: a 30-year review. Laryngoscope 2009;119:2170–4.

5. Lawson VG, LeLiever WC, Makerewich LA, Rabuzzi DD, Bell RD. Unusual parapharyngeal lesions. J Otolaryngol 1979;8:241–9.

6. Olsen KD. Tumors and surgery of the parapharyngeal space.Laryngoscope 1994;104:1–27.

7. Abemayor E, Lufkin R. Enhancing access to the parapharyngeal space. Laryngoscope 2002; 112: 757–9.

8. Bass RM. Approaches to the diagnosis and treatment of tumors of the parapharyngeal space. Head Neck Surg 1982;4:281–9.

9. Myers EN, Johnson JT, Curtin HG. Tumors of parapharyngeal space. 4th ed. In: Myers EN, Suen JY, Myers JN, Hanna EY, eds: Cancer of the Head and Neck, vol. 22. Philadelphia: WB Saunders 2003, pp 511–3.

10. Carrau RL, Myers EN, Johnson JT. Management of tumors arising in the parapharyngeal space. Laryngoscope 1990; 100: 583–9.

11. Allison RS, Van der Waal I, Snow GB. Parapharyngeal tumors: a review of 23 cases. Clin Otolaryngol 1989;14:199–203.

12. Fisch U. Inftratemporal fossa approach to tumors of the temporal bone and base of the skull. J Laryngol Otol 1978;92:949-67.

13. Papadogeorgakis N, Petsinis V, Goutzanis L, Kostakis G, Alexandridis C Parapharyngeal space tumors: surgical approaches in a series of 13 cases. Int. J. Oral Maxillofac. Surg. 2010;39:243–50.

14. Morfit HM. Retromandibular parotid surgery. Arch Surg 1955;70:906.

15. Cohen SM, Burkey BB, Netterville JL. Surgical management of parapharyngeal space masses. Head Neck 2005;27:669-75.

16. Luna-Ortiz K, Navarrete-Aleman JE, Granados-Garcia M, Herrera-Gómez A. Primary parapharyngeal space tumors in a Mexican cancer center.Otolaryngol Head Neck Surg 2005;132:

17. Shahab R, Heliwell T, Jones AS. How we do it: a series of 114 primary pharyngeal space neoplasms. Clin Otolaryngol 2005;30:364–7.

18. Hamza A, Fagan JJ, Weissman JL, Myers EN. Neurilemomas of the parapharyngeal space. Arch Otolaryngol Head Neck Surg 1997;123:622-6.

19. Malone JP, Agrawal A, Schuller DE. Safety and efficacy of transcervical resection of parapharyngeal space neoplasms. Ann Otol Rhinol Laryngol 2001; 110:1093-8.

20. Ducic Y, Oxford L, Pontius AT. Transoral approach to the superomedial parapharyngeal space. Otolaryngol Head Neck Surg 2006;134:466–70.

21. Bozza F, Vigili MG, Ruscito P, Marzetti A, Marzetti F. Surgical management of parapharyngeal space tumours: results of 10-year follow-up. Acta Otorhinolaryngol Ital. 2009;29(1):10-5.

22. Leonetti JP, Marzo SJ, Petruzzelli GJ, Herr B. Recurrent pleomorphic adenoma of the parotid gland. Otolaryngol Head Neck Surg 2005;133:

23. Spiro RH, Gerold FP, Strong EW. Mandibular “swing” approach for oral and oropharyngeal tumors. Head Neck Surg 1981;3:371-8, 1981

24. Vikatmaa P, Makitie AA, Railo M, Törnwall J, Albäck A, Lepäntalo M. Midline mandibulotomy and interposition grafting for lesions involving the internal carotid artery below the skull base. J Vasc Surg 2009;49:86–92.

25. Ehrlich H. Mixed tumors of the pterygomaxillary space; operative removal; oral approach. Oral Surg Oral Med Oral Pathol. 1950; 3(11):1366-71.26.

26. McElroth DC, Remine WH, Devine KD. Tumours of the parapharyngeal region. Surgery Gynecology and Obstetrics 1963;116:88-6.

27. Goodwin WJ Jr, Chandler JR. Transoral excision of lateral pharyngeal space tumors presenting intraorally. Laryngoscope 1988; 98: 266–9.

28. Huges III KV, Olsen KD, McCaffrey TV. Parapharyngeal space neoplasms. Head Neck 1995; 17(2):124–30.

29. Khafif A, Segev Y, Kaplan DM, Gil Z, Fliss DM. Surgical management of parapharyngeal space tumors—a 10 year review. Otolaryngol Head Neck Surg 2005;132:401–6.

30. O’Malley B, Quon H, Leonhardt F, Chalian AA, Weinstein GS. Transoral Robotic Surgery for Parapharyngeal Space Tumors. ORL 2010;72:

31. Betka J, Chovanec M, Klozar J, Taudy M, Plzák J, Kodetová D, et al.: Transoral and combined transoral–transcervical approach in the surgery of parapharyngeal tumors. Eur Arch Otorhinolaryngol 2010;267:765–72.

32. Alborno T, Hofmann T, Beham A, Stammberger H. Giant hamartoma of the retro- and parapharyngeal region. Case report and review of literature. Int J Pediatr Otorhinolaryngol. 2004; 68(4): 511-5.

33. Zitsch R, Patenaude B, Tidmore T. An extraoral parapharyngeal space approach via vertical ramus osteotomy. Am J Otorhinolaryngol Head Neck Med Surg 2007;28:330–3.

34. Sharma PK, Massey BL. Avoiding pitfalls in surgery of the neck, parapharyngeal space, and infratemporal fossa. Otolaryngol Clin North Am 2005; 38:795–808.

35. Flood T, Hislop W. A modified surgical approach for parapharyngeal space tumours: use of the inverted ‘L’ osteotomy. Brit J Oral Maxillofac Surg 1991;29:82-6.

36. Mafee MF, Venkatesan TK, Ameli N, Camras L, Friedman M. Tumors of parotid gland and parapharyngeal space - role of computed tomography and magnetic resonance imaging. Head Neck Surg 1996;7:348–57.