Surgery for tumors of the parapharyngeal space(PPS) requires adequate exposure to identify andprotect vital structures. Thus transcervical andtranscervical-transparotid approaches to the PPSmay be enhanced by mandibulotomy for bettervisualisation. We have chosen this approach withsingle mandibulotomy just in front of foramen

mentale and without lip incision. We present a 39years old male who was undergone surgery for poli-centric recurrency of a pleomorphic adenoma of theparapharyngeal space.

Key words: parapharyngeal tumors, pleomorphicadenoma, transmandibular approach

INTRODUCTION

Parapharyngeal tumors are rare tumors, representingonly a 0.5% of head and neck neoplasms1. Most ofthem (55.6%) are of salivary gland origin, 27.8% are

neurogenic, and 16.6% are miscellaneous2. Removal ofparapharyngeal tumors has been always problem from

surgical point of view because of limited access and nu-merous neurovascular structures nearby3. There have beendescribed several surgical approaches to para-pharyngealspace and infratemporal fossa.4,5. Each one has advan-tages and disadvantages. In this case review we are pre-senting our experience with transmandibular approach toparapharyngeal space for removal of benign deep parotidlobe tumour.

CASE REPORT

We are presenting a case of 39 years old male with pro-gressive dysphagia over a few weeks period. Patient alsohad a history of pleomorphic adenoma excision in left su-perfitial lobe of parotid gland few years ago. Now in oro-pharynx there was bulging of left tonsil and left pharyn-geal side wall mucosa. On palpation small, non tender,mobile mass in left parotid region, infraauriculary was

presented. CT scan of the scull base and neck showedwell defined mass in the left parapharyngeal space extend-ing to the angle of the mandible and posterior to the ptery-goid plates, and another one, which was smaller and in-frauriculary located (Figure 1).

There were no lymphadenopathy noted. Parapharyngealtumor has been removed via transmandibular-transcervi-cal approach. Classic skin incision for parotidectomy wasperformed but extended anteriorly to opposite submentalregion (Figure 2). Left submandibular gland was re-moved for better access (Figure 3). Mandibular osteotomyanterior to mental foramen was done in a view of sparinginferior alveolar nerve, with elevation and lateral rotationof hemi mandible (Figure 4). This procedure enabled welltumour identification (Figure 5) and adequate excision(Figure 6).

Infraauricular parotid mass was identified and excisedsparing facial nerve by classical parotid approach. Osteo-tomy was plated with two titanium plates. Gingival cutsclosed together with mucosal and underlying tissue su-tures. Vacusac drain was positioned (Figure 7). His-topathology cofirmed pleomorphic adenoma sub-sequently. In postoperative period we observed gingivalinfection as a local wound complication, but appropriatemedical treatment has solved it.

DISCUSSION

The potential parapharygeal space contains the greatvessels of the neck, cranial nerves IX-XII, the sympatheticchain and lymph nodes. Surgical acces is difficult and theinfrequency of tumors in it make surgery of this part ofthe head and neck a challenge. The surgical tehnique hasbeen chosen according to localization, size and vascular-ity6. Our cervical-parotid approach adequate with para-midline mandibulotomy lead to adequate identification,preservation and control of vital neurovascular structures.This approach can make work of surgeons easier espe-cially when there is the need for mandibulotomy for better

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Transmandibular approach to polycentric recurrentpleomorphic adenoma of the parapharyngeal space

A. Grubor1, M. Jovanovi}1, M. Said2 , V. Vlastarakou2, J. Galea2, M. Gingell Littlejohn2

1Clinical Hospital Zemun, ENT and maxillofacial surgerydepartment, SCG2St’Lukes Hospital, ENT department, Gwardamangia, Malta

/PRIKAZ SLU^AJA 616.321-006-089

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visualization. In that cases it is not necesserarely to per-forme double mandibulotomy,7 therefore it spare su-rgeons time. But it also spare mandibular/mental nerve,and consequentialy neuropathies.

This tehnique, which may seem more radical and com-plex is, however, a more logical and conservative ap-proach and owing to the excellent surgical field it is ableto keep the delicate surrounding structures intact and re-duce the risk of bleeding and potential neurological com-plications. Temporomandibular (TM) joint function afteroperation is essential for good rehabilitation of chewingand articulation. Many surgeons will make question re-garding TM joint function after un-natural lateral mobili-zation of the hemi mandible8. Un-natural manipulationsmay cause intraarticular lesions if they are overextended.Therefore some authors do double mandibulotomy,9 toprevent lesion in the joint.

We should mention that lateral extension during inter-vention was not with too much force, exactly to preventjoint lesions. Six months postoperatively, there was notany visible malfunction of the joint. In addition, we thinkthat limitation of joint motion and pain cannot be directlyrelated to the tehnique; they mostly depend on the extentof tumor resection or postoperative radiotherapy.

Discussion can be made also regarding of polycentricgrowth of recurrent pleomorphic adenoma which was notso frequently described in literature10. Hypocellular pleo-morphic adenomas often have a thin capsule and consti-tute the most frequently encountered histological type inrecurrence11.

Recurrence of adenomas can be caused by inadequatemanipulation during prior surgery, when rupture of cap-sule can be made. Considering the fact that the larger re-current tumor was on unexpectable place in the deepestpart of the inner unoperated lobe, the possibility for tumorrest is minimal. In the superficial lobe possibilities for tu-mor rest are better, even with total extraction in a capsuleaccording to the histopathological findings, and this canbe subject of discussion. In our oppinion managament re-currence of benign parotid disease do not obligate us forsurgery based on total parotidectomy.

CONCLUSION

Herein we want to present that our approach is good forvisibility of the atypical recurrence of PPS tumor and yetnot to complicated for surgeon. It also didn’t cause anymalfunction of the temporomandibular joint 6 monthsconsequentially. Single mandibulotomy procedures isvery useful for improving wider visibility and control ofthe vascular bundle and facial nerve, but may cause dam-age of TM joint if the extension of hemimandible is over-extended.

REZIME

Hirurgija tumora parafaringealnog prostora (PPS) za-hteva adekvatan prikaz radi identifikacije i za{titite vital-nih struktura. Transcervikalni i transcervikalno-tran-sparotidan pristup parafaringealnom prostoru mo‘e bitiudru‘en sa mandibulotomijom radi bolje vizualizacije. Mismo odabrali ovu tehniku uz jednostruku mandibulo-

Figure 2 SKIN INCISION WAS MADE ON PREVIOUS SCAR AND EX-TENDED FORWARD TO OPPOSITE SUBMENTAL REGION

Figure 1 AXIAL CT SCAN OF PPS WITH TUMOR ON LEFT SIDE NAR-ROWING EPIPHARYNX

Figure 3 SUBMANDIBULAR SALIVARY GLAND VISUALIZATIONAND EXTRACTION

104 A. Grubor et al. ACI Vol. LII

tomiju neposredno ispred foramena mentale i bez rezausne. Prikazujemo slu~aj 39 godina starog mu{karcakome je hirur{ki odstranjen policentri~ni recidiv pleo-morfnog adenoma u parafaringealnom prostoru.

Klju~ne re~i: parafaringealni tumori, polimorfniadenom, transmandibularni pristup

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Figure 5INNER LOBE TUMOR VISUALIZATION AND EXTRACTION

Figure 6 EXTRACTED TUMOR OF THE INNER PAROTID GLANDLOBE

Figure 7 CUTS CLOSED AND VACUSAC DRAIN POSITIONED

Figure 4 MANDIBULAR OSTEOTOMY JUST IN FRONT OF THE FO-RAMEN MENTALE

Br. 3 Transmandibular approach to polycentric recurrent adenoma 105of the pharapharyngeal space

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