ORIGINAL ARTICLE Endoscope-assisted transoral approach to parapharyngeal space tumors Mete Iseri, Prof., Murat Ozturk, Assistant Prof., * Ahmet Kara, Selcuk Ucar, Omer Aydin, Prof., Gurkan Keskin, Prof. Otorhinolaryngology Department, Kocaeli University Medical Faculty, Kocaeli, Turkey. Accepted 20 December 2013 Published online 20 March 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23592 ABSTRACT: Background. Parapharyngeal space (PPS) tumors are rare tumors for which the surgical management differs widely. The purpose of this study was to discuss the advantages and disadvantages of the endoscope-assisted transoral approach over the traditional approaches. Methods. This prospective study included 4 patients who were diag- nosed with PPS tumors and treated with the endoscope-assisted trans- oral approach. Results. The endoscope-assisted transoral approach described here safely allowed for the resection of benign neoplasms with high surgical view to the parapharyngeal neurovascular structures. The average tumor size was 42 mm. Three patients had isolated PPS tumors, and 1 patient had a tumor originating from the deep lobe of the parotid gland. The postoperative histo- pathological diagnosis of the patients was pleomorphic adenoma for 3 of the patients, and marginal zone and follicular hyperplasia for the other. Conclusion. This technique provided less operative trauma, a more com- fortable postoperative period, and, most importantly, increased operative exposure. V C 2014 Wiley Periodicals, Inc. Head Neck 37: 243–248, 2015 KEY WORDS: parapharyngeal space tumors, endoscopes, transoral approaches INTRODUCTION Tumors of the parapharyngeal space (PPS) are relatively infrequent in the head and neck and account for only 0.5% of all head and neck neoplasms. 1–3 The frequency of benign tumors is about 80%, and the other 20% is composed of malignant tumors. 4–6 This region is divided into 2 compartments, as prestyloid (anterolateral) and ret- rostyloid (posteromedial) spaces, by thick layers of fascia extending from the styloid process to the tensor-vascular- styloid fascia. 4 Neurogenic tumors, paragangliomas, aneurysms, and vascular tumors are found in the poststy- loid compartment, whereas minor salivary gland tumors are more common in the prestyloid compartment. Surgical management of the PPS tumors is very chal- lenging because of the deep localization of this space and the close associations with the vital structures in this region. Most of the author’s choice is an external approach for such neoplasms, especially the cervical- transparotid approach. 1 Although the external approaches provide wider surgical exposure, they have more postop- erative complications and longer hospitalization times. 5 Many authors believe that the transoral approach is con- traindicated with PPS lesions because of the decreased exposure and the risk of hemorrhage, damage to cranial nerves, and tumor spillage. 1,2 An endoscope-assisted transoral approach can preserve the external approaches’ morbidities, such as facial nerve paralysis, postoperative salivary fistula, complications of mandibular osteotomy, and cosmetic deformity. Furthermore, it will provide shorter hospitalization times. In this report, 4 patients who were operated on with an endoscope-assisted trans- oral approach for neoplasms of the PPS space were pro- spectively reviewed and the advantages of this technique over the traditional transoral and external approaches are discussed. MATERIALS AND METHODS This prospective study included patients diagnosed with PPS tumors and treated with the endoscope-assisted trans- oral approach between the years 2010 and 2012. The Committee for Ethics in Clinical Researches of Kocaeli University approved the study, and written informed con- sents were provided from all patients. MRI was per- formed on all of the patients preoperatively to determine the boundaries of the mass and relationships with the adjacent anatomic structures. A dose of 1 g cefazolin sodium was administered to the patients preoperatively for prophylaxis. All patients were nasotracheally intuba- ted. After intubation, a mouth gag was placed in the mouth and an incision was made extending from the soft palate through the lower pole of the tonsil with monopo- lar cautery. The mucosa, submucosa, and the superior constrictor muscle were passed and the parapharyngeal neoplasms were exposed. The anterior parts of the mass were dissected from the adjacent tissues by blunt dissec- tion under direct view. After the partial dissection of the mass, endoscopic surgery was completed with 0, 30, and 45-degree 4 mm endoscopes to see and dissect the other *Corresponding author: Murat Ozturk, Otorhinolaryngology Department, Kocaeli University Medical Faculty, Kocaeli Universitesi Tip Fakultesi, KBB Ana- bilim Dali, 41380 Umuttepe, Kocaeli, Turkey. E-mail: muratkbb@gmail.com This work was published as an oral presentation at the 34th annual meeting of the National Ear, Nose, and Throat Congress in Antalya, Turkey, October 10–14, 2012. HEAD & NECK—DOI 10.1002/HED FEBRUARY 2015 243