Surgical approaches to the parapharyngeal space. A comparison of external and endoscopic approaches. Systematic review
Abstract Introduction and objective: The parapharyngeal space is a deep craniocervical space where primary tumors are exceptional, constituting only 0.5% of all head and neck neoformations. Benign lesions represent 70-80%, with pleomorphic adenoma being the most frequent tumor in this location. The treatment of choice at present continues to be complete surgical resection of the lesion. Although classically the most commonly used surgical approach has been the external approach, nowadays, with the appearance of endoscopic techniques, new methods of approach useful for the resection of parapharyngeal tumors have been described. Methods: We present a systematic review of external, endonasal and transoral surgical approaches to the parapharyngeal space, with a total of 1725 patients and 92 (sides) of cadavers where the type of approach used/studied in each surgery was analyzed, comparing both the advantages and disadvantages offered by each of them. Results: The systematic review has a total of 40 articles, 1654 patients and 92 (sides) of cadavers where the type of approach used/studied in each surgery was analyzed. Discussion: External approaches have classically been the most used type of surgical approach. They present important advantages such as being the only type of approach with which the surgical field is completely exposed. The drawbacks include a great impact on the functionality of the tissues, a wide variety of postoperative complications and a longer surgical time and hospital admission time. Endoscopic approaches have had great development in recent years and present advantages such as being less damaging surgeries in terms of tissue functionality, avoiding facial scars or more comfortable and less painful post-operative treatments for the patient. But they also have drawbacks such as a lack of space or surgical scope of the technique and a limited application, which depends on both the size and type of tumor that the patient has. Conclusions: Although traditionally the most commonly used surgical approach has been the external approach, in recent decades and especially strikingly and relevantly in recent years, endoscopic surgery has been a revulsive when performing surgeries in this location. Both endonasal and transoral endoscopic approaches, with or without the use of robotic technology, have made it possible to operate on parapharyngeal lesions with less functional repercussions, a more comfortable and less painful postoperative period, and less prolonged hospitalization than with traditional techniques.
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Sun X, Yan B, Truong H, Borghei-Razavi H, Snyderman C, Fernandez-Miranda J. A Comparative Analysis of Endoscopic-Assisted Transoral and Transnasal Approaches to Parapharyngeal Space: A Cadaveric Study. J Neurol Surg B Skull Base. 2017;79(03):229–40.
Guo D, Sun C, Yin X, Qu H, Dai B, Hu L, Zhou C, Du X. A Retrospective Analysis on the Effects and Complications of Endoscope-Assisted Transoral Approach and Lateral Cervical Approach in the Resection of Parapharyngeal Space Tumors. Comput Intel Neurosci. 2022;7536330. https://doi.org/10.1155/2022/7536330
Pradeep Pradhan P, Preetam C, Kumar-Parida P, Samal S, Kumar-Samal D. Surgical Management of Parapharyngeal Space Tumours in a Single Tertiary Care Center. Indian J Otolaryngol Head Neck Surg. 2018;70(4):531–537.
Basaran B, Polat B, Unsaler S, Ulusan M, Aslan I, Hafiz G. Parapharyngeal space tumours: the eficiency of a transcervical approach without mandibulotomy through review of 44 cases. Acta Otorhinolaryngol. Ital. 2014;34:310-316.
Li L, London NR Jr, Gao Y, Carrau RL, Chen X. Endoscopic transoral approach for resection of retrostyloid parapharyngeal space tumors: Retrospective analysis of 16 patients. Head Neck. 2020;42(12):3531-3537.
Duek I, Sviri G, Billan S, Gil Z. Minimally Invasive Surgery for Resection of Parapharyngeal Space Tumors. J Neurol Surg B Skull Base. 2017;79(03):250–256.
Eguiluz-Melendez A, Torres-Bayona S, Vega MB, Hernández-Hernández V, Wang EW, Snyderman CH, et al. Keyhole Endoscopic-Assisted Transcervical Approach to the Upper and Middle Retrostyloid Parapharyngeal Space: An Anatomic Feasibility Study. J Neurol Surg B Skull Base. 2021;83(2):126–134.
Chen Z, Chen Y-L, Yu Q, Zhou S-H, Bao Y-Y, Ruan L-X. Excision of tumors in the parapharyngeal space using an endoscopically assisted transoral approach: a case series and literature review. Int. J. Med. Res. 2019;47(3):1103–1113.
Pilolli F, Giordano I, Galli A, Bussi M. Parapharyngeal space tumours: video-assisted minimally invasive transcervical approach. Acta Otorhinolaryngol. Ital. 2016;36:259-264.
Luna-Ortiz K, Villa-Zepeda O, Carrillo JF, Molina-Frias E, Gómez-Pedraza A. Parapharyngeal Space Tumor: Submandibular Approach Without Mandibulotomy.J. Maxillofac Oral Surg. 2018;17(4):616–624.
Fang Y, Wu H, Tan AD, Cheng L. Transcervical endoscopic approach for parapharyngeal space: a cadaver study and clinical practice. Acta Otolaryngol. 2020;140(2):163-169.
Li L, London NR Jr, Prevedello DM, Carrau RL. Endonasal endoscopic transpterygoid approach to the upper parapharyngeal space. Head Neck. 2020;42(9):2734-2740.
Roger V, Patron V, Moreau S, Kanagalingam J, Babin E, Hitier M. Extended endonasal approach versus maxillary swing approach to the parapharyngeal space. Head Neck. 2018;40(6):1120-1130.
Liu Q, Wang H, Zhao W, Song X, Sun X, Yu H, Wang D, Fernandez-Miranda JC, Snyderman CH. Endoscopic transnasal transmaxillary approach to the upper parapharyngeal space and the skull base. Eur Arch Otorhinolaryngol. 2020;277(3):801-807.
Luzzi S, Giotta Lucifero A, Del Maestro M, Marfia G, Navone SE, Baldoncini M, Nuñez M, Campero A, Elbabaa SK, Galzio R. Anterolateral Approach for Retrostyloid Superior Parapharyngeal Space Schwannomas Involving the Jugular Foramen Area: A 20-Year Experience.World Neurosurg. 2019;132:40-52.
Matsuki T, Okamoto I, Tada Y, Masubuchi T, Fushimi C, Kamata S, Miyamoto S, Yamashita T, Miura K. Resection of Parapharyngeal Space Tumors Located in the Prestyloid Compartment: Efficacy of the Cervical Approach. Ann Surg Oncol. 2021;28(6):3066-3072.
Shin BJ, Lee DH, Lee JK, Lim SC. Surgical Treatment of Parapharyngeal Space Salivary Gland Tumor J Craniofac Surg. 2022;33(7):676-679.
Tao L, Shi XL, Li XM, Wu HT, Chen XL, Li C, Shen Y, Wei CS, Wang DH, Zhou L. Retrospective analysis of 188 cases of parapharyngeal space tumors. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2018;32(2):129-133.
Chu F, Tagliabue M, Giugliano G, Calabrese L, Preda L, Ansarin M. From transmandibular to transoral robotic approach for parapharyngeal space tumors. Am J Otolaryngol. 2017;38(4):375-379.
Cassoni A, Terenzi V, Della Monaca M, Bartoli D, Battisti A, Rajabtork Zadeh O, Valentini V. Parapharyngeal space benign tumours: our experience. J Craniomaxillofac Surg. 2014;42(2):101-105.
Boyce BJ, Curry JM, Luginbuhl A, Cognetti DM. Transoral robotic approach to parapharyngeal space tumors: Case series and technical limitations. Laryngoscope. 2016;126(8):1776-1782.
Ferrari M, Schreiber A, Mattavelli D, Lombardi D, Rampinelli V, Doglietto F, Rodella LF, Nicolai P. Surgical anatomy of the parapharyngeal space: Multiperspective, quantification-based study. Head Neck. 2019;41(3):642-656.
Park YM, De Virgilio A, Kim WS, Chung HP, Kim SH. Parapharyngeal space surgery via a transoral approach using a robotic surgical system: transoral robotic surgery. J Laparoendosc Adv Surg Tech A. 2013;23(3):231-236.
Dallan I, Fiacchini G, Turri-Zanoni M, Seccia V, Battaglia P, Casani AP, Cristofani-Mencacci L, Sellari-Franceschini S. Endoscopic-assisted transoral-transpharyngeal approach to parapharyngeal space and infratemporal fossa: focus on feasibility and lessons learned. Eur Arch Otorhinolaryngol. 2016;273(11):3965-3972.
Lao WP, Han PS, Lee NH, Gilde JE, Inman JC. Transoral Excision of Parapharyngeal Tumors. Ear Nose Throat J. 2021;100(10):454-458.
He L, Xie J, Gao X. Endoscope-assisted transoral resection of parapharyngeal space tumors: a retrospective study. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2020;34(9):824-827.
Shi X, Tao L, Li X, Wu H, Huang W, Chen X, Li C, Shen Y, Chen Q, Tang D, Wei C, Wang D, Zhou L. Surgical management of primary parapharyngeal space tumors: a 10-year review. Acta Otolaryngol. 2017;137(6):656-661.
Rzepakowska A, Osuch-Wójcikiewicz E, Krupa Z, Durmaj A, Niemczyk K. Surgical treatment results of parapharyngeal space tumors: a report of 22 cases. Otolaryngol Pol. 2018;72(4):9-16.
Sato H, Nonaka Y, Bawornvaraporn U, Fukushima T. Preauricular retromandibular trans tympanic plate and styloid process keyhole approach to parapharyngeal lesions: a laboratory study. Acta Neurochir. 2020;162(3):661-669.
Wang X, Gong S, Lu Y, Pan X, Luo X, Sun H. Endoscopy-assisted transoral resection of parapharyngeal space tumors: a retrospective analysis. Cell Biochem Biophys. 2015;71(2):1157-1163.
Gadre PK, Gadre KS, Halli RC, Kukarni A, Bhosale G. Mandibular subsigmoid access osteotomy in the management of parapharyngeal space tumors. J Craniofac Surg. 2013;24(2):579-582.
Battaglia P, Turri-Zanoni M, Dallan I, Gallo S, Sica E, Padoan G, Castelnuovo P. Endoscopic endonasal transpterygoid transmaxillary approach to the infratemporal and upper parapharyngeal tumors. Otolaryngol Head Neck Surg. 2014;150(4):696-702.
Liu Y, Yu HJ, Zhen HT. Transoral and endoscope-assisted transoral approaches to resecting benign tumours of the parapharyngeal space located in the medial portion of the carotid sheaths and extending toward the skull base: our experience. J Laryngol Otol. 2018;132(8):748-752.
Fan S, Lin SG, Zhang HQ, Li QX, Chen WX, Wang YY, Zhang DM, Lin ZY, Zhong JL, Chen WL, Li JS. A comparative study of the endoscopy-assisted transoral approach versus external approaches for the resection of large benign parapharyngeal space tumors. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;123(2):157-162.
Chu F, De Berardinis R, Tagliabue M, Zorzi S, Bandi F, Ansarin M. The Role of Transoral Robotic Surgery for Parapharyngeal Space: Experience of a Tertiary Center. J Craniofac Surg. 2020;31(1):117-120.
Chen H, Sun G, Tang E, Hu Q. Surgical Treatment of Primary Parapharyngeal Space Tumors: A Single-Institution Review of 28 Cases. J Oral Maxillofac Surg. 2019;77(7):1520.e1-1520.e16.
Zhu X, Shi X, Zhou L, Zhang M, Cheng L, Shi Y, Xu C, Wu C, Liu Q, Cao P, Tao L. Trends in the surgical management of parapharyngeal space tumors: A single-center retrospective analysis. Eur J Surg Oncol. 2022;22.
Salzano G, Togo G, Maglitto F, Borriello G, Perri F, Audino G, Vaira LA, Maglione MG, Petrocelli M, Califano L, Ionna F. Trans-Oral Robotic Surgery: 14 Cases of Pleomorphic Adenoma of the Parapharyngeal Space. J Craniofac Surg. 2022;33(5):1587-1590.
Chen HL, Sun GW, Tang EY, Hu QG. Clinical analysis and surgical treatment evaluation of 23 cases with primary parapharyngeal space tumors. Zhonghua Kou Qiang Yi Xue Za Zhi. 2019;54(2):107-111.
Lim JY, Park YM, Kang MS, Kim DH, Choi EC, Kim SH, Koh YW. Comparison of Surgical Outcomes of Robotic and Conventional Approaches in Patients with Pre- and Poststyloid Parapharyngeal Space Tumors. Ann Surg Oncol. 2020;27(11):4535-4543.
Guo D, Sun C, Yin X, Qu H, Dai B, Hu L, Zhou C, Du X. A Retrospective Analysis on the Effects and Complications of Endoscope-Assisted Transoral Approach and Lateral Cervical Approach in the Resection of Parapharyngeal Space Tumors. Comput Intel Neurosci. 2022;7536330. https://doi.org/10.1155/2022/7536330
Pradeep Pradhan P, Preetam C, Kumar-Parida P, Samal S, Kumar-Samal D. Surgical Management of Parapharyngeal Space Tumours in a Single Tertiary Care Center. Indian J Otolaryngol Head Neck Surg. 2018;70(4):531–537.
Basaran B, Polat B, Unsaler S, Ulusan M, Aslan I, Hafiz G. Parapharyngeal space tumours: the eficiency of a transcervical approach without mandibulotomy through review of 44 cases. Acta Otorhinolaryngol. Ital. 2014;34:310-316.
Li L, London NR Jr, Gao Y, Carrau RL, Chen X. Endoscopic transoral approach for resection of retrostyloid parapharyngeal space tumors: Retrospective analysis of 16 patients. Head Neck. 2020;42(12):3531-3537.
Duek I, Sviri G, Billan S, Gil Z. Minimally Invasive Surgery for Resection of Parapharyngeal Space Tumors. J Neurol Surg B Skull Base. 2017;79(03):250–256.
Eguiluz-Melendez A, Torres-Bayona S, Vega MB, Hernández-Hernández V, Wang EW, Snyderman CH, et al. Keyhole Endoscopic-Assisted Transcervical Approach to the Upper and Middle Retrostyloid Parapharyngeal Space: An Anatomic Feasibility Study. J Neurol Surg B Skull Base. 2021;83(2):126–134.
Chen Z, Chen Y-L, Yu Q, Zhou S-H, Bao Y-Y, Ruan L-X. Excision of tumors in the parapharyngeal space using an endoscopically assisted transoral approach: a case series and literature review. Int. J. Med. Res. 2019;47(3):1103–1113.
Pilolli F, Giordano I, Galli A, Bussi M. Parapharyngeal space tumours: video-assisted minimally invasive transcervical approach. Acta Otorhinolaryngol. Ital. 2016;36:259-264.
Luna-Ortiz K, Villa-Zepeda O, Carrillo JF, Molina-Frias E, Gómez-Pedraza A. Parapharyngeal Space Tumor: Submandibular Approach Without Mandibulotomy.J. Maxillofac Oral Surg. 2018;17(4):616–624.
Fang Y, Wu H, Tan AD, Cheng L. Transcervical endoscopic approach for parapharyngeal space: a cadaver study and clinical practice. Acta Otolaryngol. 2020;140(2):163-169.
Li L, London NR Jr, Prevedello DM, Carrau RL. Endonasal endoscopic transpterygoid approach to the upper parapharyngeal space. Head Neck. 2020;42(9):2734-2740.
Roger V, Patron V, Moreau S, Kanagalingam J, Babin E, Hitier M. Extended endonasal approach versus maxillary swing approach to the parapharyngeal space. Head Neck. 2018;40(6):1120-1130.
Liu Q, Wang H, Zhao W, Song X, Sun X, Yu H, Wang D, Fernandez-Miranda JC, Snyderman CH. Endoscopic transnasal transmaxillary approach to the upper parapharyngeal space and the skull base. Eur Arch Otorhinolaryngol. 2020;277(3):801-807.
Luzzi S, Giotta Lucifero A, Del Maestro M, Marfia G, Navone SE, Baldoncini M, Nuñez M, Campero A, Elbabaa SK, Galzio R. Anterolateral Approach for Retrostyloid Superior Parapharyngeal Space Schwannomas Involving the Jugular Foramen Area: A 20-Year Experience.World Neurosurg. 2019;132:40-52.
Matsuki T, Okamoto I, Tada Y, Masubuchi T, Fushimi C, Kamata S, Miyamoto S, Yamashita T, Miura K. Resection of Parapharyngeal Space Tumors Located in the Prestyloid Compartment: Efficacy of the Cervical Approach. Ann Surg Oncol. 2021;28(6):3066-3072.
Shin BJ, Lee DH, Lee JK, Lim SC. Surgical Treatment of Parapharyngeal Space Salivary Gland Tumor J Craniofac Surg. 2022;33(7):676-679.
Tao L, Shi XL, Li XM, Wu HT, Chen XL, Li C, Shen Y, Wei CS, Wang DH, Zhou L. Retrospective analysis of 188 cases of parapharyngeal space tumors. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2018;32(2):129-133.
Chu F, Tagliabue M, Giugliano G, Calabrese L, Preda L, Ansarin M. From transmandibular to transoral robotic approach for parapharyngeal space tumors. Am J Otolaryngol. 2017;38(4):375-379.
Cassoni A, Terenzi V, Della Monaca M, Bartoli D, Battisti A, Rajabtork Zadeh O, Valentini V. Parapharyngeal space benign tumours: our experience. J Craniomaxillofac Surg. 2014;42(2):101-105.
Boyce BJ, Curry JM, Luginbuhl A, Cognetti DM. Transoral robotic approach to parapharyngeal space tumors: Case series and technical limitations. Laryngoscope. 2016;126(8):1776-1782.
Ferrari M, Schreiber A, Mattavelli D, Lombardi D, Rampinelli V, Doglietto F, Rodella LF, Nicolai P. Surgical anatomy of the parapharyngeal space: Multiperspective, quantification-based study. Head Neck. 2019;41(3):642-656.
Park YM, De Virgilio A, Kim WS, Chung HP, Kim SH. Parapharyngeal space surgery via a transoral approach using a robotic surgical system: transoral robotic surgery. J Laparoendosc Adv Surg Tech A. 2013;23(3):231-236.
Dallan I, Fiacchini G, Turri-Zanoni M, Seccia V, Battaglia P, Casani AP, Cristofani-Mencacci L, Sellari-Franceschini S. Endoscopic-assisted transoral-transpharyngeal approach to parapharyngeal space and infratemporal fossa: focus on feasibility and lessons learned. Eur Arch Otorhinolaryngol. 2016;273(11):3965-3972.
Lao WP, Han PS, Lee NH, Gilde JE, Inman JC. Transoral Excision of Parapharyngeal Tumors. Ear Nose Throat J. 2021;100(10):454-458.
He L, Xie J, Gao X. Endoscope-assisted transoral resection of parapharyngeal space tumors: a retrospective study. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2020;34(9):824-827.
Shi X, Tao L, Li X, Wu H, Huang W, Chen X, Li C, Shen Y, Chen Q, Tang D, Wei C, Wang D, Zhou L. Surgical management of primary parapharyngeal space tumors: a 10-year review. Acta Otolaryngol. 2017;137(6):656-661.
Rzepakowska A, Osuch-Wójcikiewicz E, Krupa Z, Durmaj A, Niemczyk K. Surgical treatment results of parapharyngeal space tumors: a report of 22 cases. Otolaryngol Pol. 2018;72(4):9-16.
Sato H, Nonaka Y, Bawornvaraporn U, Fukushima T. Preauricular retromandibular trans tympanic plate and styloid process keyhole approach to parapharyngeal lesions: a laboratory study. Acta Neurochir. 2020;162(3):661-669.
Wang X, Gong S, Lu Y, Pan X, Luo X, Sun H. Endoscopy-assisted transoral resection of parapharyngeal space tumors: a retrospective analysis. Cell Biochem Biophys. 2015;71(2):1157-1163.
Gadre PK, Gadre KS, Halli RC, Kukarni A, Bhosale G. Mandibular subsigmoid access osteotomy in the management of parapharyngeal space tumors. J Craniofac Surg. 2013;24(2):579-582.
Battaglia P, Turri-Zanoni M, Dallan I, Gallo S, Sica E, Padoan G, Castelnuovo P. Endoscopic endonasal transpterygoid transmaxillary approach to the infratemporal and upper parapharyngeal tumors. Otolaryngol Head Neck Surg. 2014;150(4):696-702.
Liu Y, Yu HJ, Zhen HT. Transoral and endoscope-assisted transoral approaches to resecting benign tumours of the parapharyngeal space located in the medial portion of the carotid sheaths and extending toward the skull base: our experience. J Laryngol Otol. 2018;132(8):748-752.
Fan S, Lin SG, Zhang HQ, Li QX, Chen WX, Wang YY, Zhang DM, Lin ZY, Zhong JL, Chen WL, Li JS. A comparative study of the endoscopy-assisted transoral approach versus external approaches for the resection of large benign parapharyngeal space tumors. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;123(2):157-162.
Chu F, De Berardinis R, Tagliabue M, Zorzi S, Bandi F, Ansarin M. The Role of Transoral Robotic Surgery for Parapharyngeal Space: Experience of a Tertiary Center. J Craniofac Surg. 2020;31(1):117-120.
Chen H, Sun G, Tang E, Hu Q. Surgical Treatment of Primary Parapharyngeal Space Tumors: A Single-Institution Review of 28 Cases. J Oral Maxillofac Surg. 2019;77(7):1520.e1-1520.e16.
Zhu X, Shi X, Zhou L, Zhang M, Cheng L, Shi Y, Xu C, Wu C, Liu Q, Cao P, Tao L. Trends in the surgical management of parapharyngeal space tumors: A single-center retrospective analysis. Eur J Surg Oncol. 2022;22.
Salzano G, Togo G, Maglitto F, Borriello G, Perri F, Audino G, Vaira LA, Maglione MG, Petrocelli M, Califano L, Ionna F. Trans-Oral Robotic Surgery: 14 Cases of Pleomorphic Adenoma of the Parapharyngeal Space. J Craniofac Surg. 2022;33(5):1587-1590.
Chen HL, Sun GW, Tang EY, Hu QG. Clinical analysis and surgical treatment evaluation of 23 cases with primary parapharyngeal space tumors. Zhonghua Kou Qiang Yi Xue Za Zhi. 2019;54(2):107-111.
Lim JY, Park YM, Kang MS, Kim DH, Choi EC, Kim SH, Koh YW. Comparison of Surgical Outcomes of Robotic and Conventional Approaches in Patients with Pre- and Poststyloid Parapharyngeal Space Tumors. Ann Surg Oncol. 2020;27(11):4535-4543.
Losada-Campa, J., Torres-Morientes, L. M., Pastor-Vázquez, J. F., Tamayo-Gómez, E., Martín-Fernández, M., & Santos-Pérez, J. (2024). Surgical approaches to the parapharyngeal space. A comparison of external and endoscopic approaches. Systematic review. Revista ORL, 15(2), e31852. https://doi.org/10.14201/orl.31852
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