Subcutaneous mandibulotomy: A new surgical access for large tumors of the parapharyngeal space

Objectives: Surgery for tumors of the parapharyngeal space (PPS) requires adequate exposure to identify and protect vital structures. Transcervical and transcervical-transparotid approaches to the PPS may be enhanced by mandibulotomy. However, midline mandibulotomy traditionally requires lip-splitting and extensive intraoral incisions, often necessitating tracheostomy and nasogastric feeding. We describe a new technique to gain exposure to the PPS while avoiding these consequences. Study Design: Case series. Methods: Five patients with PPS tumors underwent surgery using a new technique, the subcutaneous mandibulotomy approach (SMA). Each case was retrospectively assessed for tumor size, intraoperative access to the PPS, perioperative complications, and length of hospitalization. Results: In this series, the additional exposure achieved by SMA was adequate to safely remove large PPS tumors that could not be delivered through the transcervical-transparotid approach. All patients started oral diets on postoperative day 1 and were discharged within 3 days. There were no intraoperative complications, and postoperative complications were self-limited. The pathologic entities were a venous malformation, a paraganglioma, and three large, deep-lobe pleomorphic adenomas of the parotid. Conclusions: We introduce a new technique, the SMA, which affords excellent access to the PPS without the lip-split, chin-split, and floor of mouth incisions. The SMA avoids both nasogastric feeding and a tracheostomy and offers improved cosmesis compared with a traditional midline mandibulotomy. Our current stepwise approach to achieve exposure to the PPS includes use of the SMA as an intermediate step for extensive PPS lesions, which are inaccessible through the transcervical approach yet do not require full labiomandibulotomy for safe and complete removal.