Stylomandibular tenotomy in the transcervical removal of large benign parapharyngeal tumours

Abstract

We used a simple modification of the transcervical approach in a selected group of nine patients with large benign parapharyngeal space tumours, all of whom met the following inclusion criteria: The tumour was benign on fine needle aspiration, the encapsulated tumour was not attached to skull base or great vessels in the parapharyngeal space on imaging. Adequate exposure was achieved by just dividing the stylomandibular ligament and retracting the mandible anteriorly. It was possible to remove the tumours successfully and safely in all nine patients without the need for mandibulotomy or superficial parotidectomy. In seven cases, the tumour crossed the midline. There were no major perioperative neurological or vascular complications. On subsequent follow up, there were no clinical or radiological signs of residual or recurrent tumour.

Full text

British Journal of Oral and Maxillofacial Surgery (2002) 40, 313–316
© 2002 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0266-4356(02)00146-8, available online at http://www.idealibrary.com on
Stylomandibular tenotomy in the transcervical removal of large
benign parapharyngeal tumours
A. A. Orabi,∗M. A. Riad,†M. B. O’Regan ‡
∗Specialist Registrar, Otolaryngology – Head and Neck Surgery Department, North Manchester General Hospital,
Crumpsall, Manchester M8 5RB, UK; †Consultant Otolaryngologist, Otolaryngology – Head and Neck Surgery
Department, Ninewells Hospital, Dundee, Scotland, UK; ‡Consultant, Maxillofacial Surgery Department, Queen
Margaret Hospital, Dunfermline, Scotland, UK
SUMMARY. We used a simple modification of the transcervical approach in a selected group of nine patients
with large benign parapharyngeal space tumours, all of whom met the following inclusion criteria: The tumour
was benign on fine needle aspiration, the encapsulated tumour was not attached to skull base or great vessels
in the parapharyngeal space on imaging. Adequate exposure was achieved by just dividing the stylomandibular
ligament and retracting the mandible anteriorly. It was possible to remove the tumours successfully and safely
in all nine patients without the need for mandibulotomy or superficial parotidectomy. In seven cases, the tumour
crossed the midline. There were no major perioperative neurological or vascular complications. On subsequent
follow up, there were no clinical or radiological signs of residual or recurrent tumour.
© 2002 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights
reserved.
INTRODUCTION
Less than 1% of all head and neck tumours are in the para-
pharyngeal space.1They are usually benign and are likely
to arise from the salivary glands.1,2They are sometimes
huge and their removal may be difficult.3Several surgi-
cal approaches have been described1,4,5to achieve good
access while minimising the risk of neurovascular injury.
These approaches may require mandibulotomy or superfi-
cial parotidectomy, or both, with additional morbidity.3–5
PATIENTS AND METHOD
During the 4-year period from 1996–1999 inclusive, we
successfully treated nine patients with large benign para-
pharyngeal space tumours using the modified transcervi-
cal approach. Table 1 shows their clinical details, Fig. 1
the peroral view of one of the tumours and Fig. 2 the ra-
diological findings.
OPERATIVE TECHNIQUE
A standard transcervical incision was made 1.5in. be-
low the mandibular margin, and deepened through the
platysma and deep cervical fascia. The angle of the
mandible and the stylomandibular ligament were identi-
Fig. 1 Peroral view of a large benign parapharyngeal tumour
displacing the oropharyngeal wall.
fied.The stylomandibularligament was thendivided close
to the mandible. The mandible was retracted forwards us-
ing bicortical transmandibular stainless steel wire (Fig. 3)
to achieve wide exposure of the tumour, followed by
circumferential extracapsular dissection of the tumour
before delivery (Fig. 4). None of the capsules ruptured
and no contents spilled. Finally, the wound was closed in
layers over a suction drain. The stylomandibular ligament
was not repaired. There were no problems with the tem-
promandibular joint postoperatively and none required
313

314 British Journal of Oral and Maxillofacial Surgery

Stylomandibular tenotomy in the removal of parapharyngeal tumours 315
Fig. 2 Axial magnetic resonance image (T1W with contrast) of one of
the tumours crossing the midline with evidence of encapsulation.
Fig. 3 Diagram of the modified transcervical stylomandibular
tenotomy.
Fig. 4 Intraoperative view showing delivery of a large encapsulated
benign parapharyngeal tumour. Symbols: ‘m’, mandible; ‘e’, ear.
intermaxillary fixation. Patients were followed up for
between 24 and 60 months with no signs of recurrence.
DISCUSSION
We haveidentified four factors that influence the choice of
surgicalapproach for removalof parapharyngeal tumours.
These included the size of the lesion, its histological type,
and its radiological relationship to the great vessels and to
the base of the skull. There is no consensus or standardi-
sation that relates these factors to the choice of approach.
Size has been the major factor in deciding the surgical
approach to benign parapharyngeal space tumours1,3–5
resulting in unnecessary adjunctive procedures with their
associated morbidity. Such procedures involve mandibu-
lotomy (of ramus, the angle or the body)6–9and superfi-
cial parotidectomy.10–12 However, size was not a major
determining factor when we chose to use the modified
transcervical approach with stylomandibular tenotomy in
our patients.
The three determining factors were the histological
type of the tumour, the presence of a capsule, and its radi-
ological relationship to the great vessels and base of the
skull. If the tumour is benign, encapsulated, and not at-
tachedto thegreat vesselsor the skull base, it is possible to
use the transcervical approach with stylomandibular teno-
tomy. This was successful in the last six patients and no
other procedures were required.
We did a superficial parotidectomy for the first three
patients, which we think in retrospect was unnecessary as
in many parotid tumours the capsules of the superficial
and deep lobes are in direct contact with branches of the
facial nerve. Unless the tumour is small, therefore, parotid
tumoursmay notbe entirely surrounded by salivarytissue.
In other words, superficial parotidectomy gives a false
impression of safety. Our experience also indicates that
whenthereis radiologicalevidenceofencapsulation of the
tumour, it is possible to remove it intact within its capsule
by blunt dissection.
Modified transcervical approach is a simple, short pro-
cedure. It is reliable even with large tumours with no extra
morbidity from mandibulotomy or superficial parotidec-
tomy. However, it can be done only in selected cases. If
there is appreciable bleeding from terminal branches of
the external carotid artery, the facial nerve should be ex-
posed before ligation of the vessels.
REFERENCES
1. Flood TR, Hislop WS. A modified surgical approach for
parapharyngeal space tumours: use of the inverted ‘L’ osteotomy.
Br J Oral Maxillofac Surg 1991; 29: 82–86.
2. Porter MJ, Suen WM, John DG, van Hasselt CA. Fibromatosis of
the parapharyngeal space. J Laryngol Otol 1994; 108: 1102–
1104.

316 British Journal of Oral and Maxillofacial Surgery
3. Uslu S, Inal E, Ataoglu O, Sezer C. Pleomorphic adenoma of an
unusual size in the deep lobe of the parotid gland. Int J Pediatr
Otolaryngol 1995; 33: 163–169.
4. Bozzetti A, Biglioli F, Gianni AB, Brusati R. Mandibulotomy for
access to benign deep lobe parotid tumours with parapharyngeal
extension: report of four cases. J Oral Maxillofac Surg 1998; 56:
272–276.
5. Shaheen OH. Tumours of the infratemporal fossa and
parapharyngeal space. In: Hibbert J, editor. Scott-Brown’s
Otolaryngology. 6th ed. Oxford: Butterworth-Heinemann, 1997:
5(22): 11–19.
6. Bass RM. Approaches to the diagnosis and treatment of the
parapharyngeal space. Head Neck Surg 1982; 4: 281–289.
7. Pogrel MA, Kaplan MJ. Surgical approach to the pterygomaxillary
region. J Oral Maxillofac Surg 1986; 44: 183–191.
8. Berdal P, Hall JG. Parapharyngeal growth of parotid tumours. Acta
Otolaryngol 1970; 263: 164–166.
9. Carr RJ, Bowerman JE. A review of tumours of the deep lobe of
the parotid salivary gland. Br J Oral Maxillofac Surg 1986; 24:
155–168.
10. Maran AGD, Mackenzie IJ, Murray JAM. The parapharyngeal
space. J Laryngol Otol 1984; 98: 371–380.
11. Attia EL, Bentley KC, Head T et al. A new external approach to
the pterygomaxillary fossa and paraphayrngeal space. Head Neck
Surg 1984; 6(4): 884–891.
12. Spiro RH, Gerold FP, Strong EW. Mandibular “swing” approach
for oral and oropharyngeal tumours. Head Neck Surg 1981; 3:
371–380.
The Authors
A. A. Orabi MSc, FRCS
Specialist Registrar, Otolaryngology – Head and Neck Surgery
Department, North Manchester General Hospital, Crumpsall,
Manchester M8 5RB, UK
M. A. Riad MD, FRCS
Consultant Otolaryngologist, Otolaryngology – Head and Neck
Surgery Department, Ninewells Hospital, Dundee, Scotland, UK
M. B. O’Regan FFD, MBBDS, FDS (Edin)
Consultant, Maxillofacial Surgery Department, Queen Margaret
Hospital, Dunfermline, Scotland, UK
Correspondence and requests for offprints to: A. A. Orabi,
Otolaryngology – Head and Neck Surgery Department, North
Manchester General Hospital, Crumpsall, Manchester M8 5RB, UK.
Fax: +44 (0) 161 720 2251; E-mail: aaorabi@hotmail.com
Accepted 25 March 2002