Endoscopic-assisted transoral-transpharyngeal approach to parapharyngeal space and infratemporal fossa: focus on feasibility and lessons learned

Abstract

The parapharyngeal space (PPS) is a challenging anatomical region, rich in vascular and nervous vital structures. Surgery is considered the treatment of choice for the majority of PPS lesions. Herein, we present a retrospective evaluation on ten patients with various types of lesions of the parapharyngeal and infratemporal fossa (ITF) regions operated on via an endoscopic-assisted transoral-transpharyngeal approach (EATTA), focusing on feasibility and safety. A retrospective evaluation of patients treated by means of EATTA to PPS and/or ITF lesions was carried out. The clinical records of patients who were operated on with EATTA for PPS and/or ITF lesions between March 2009 and October 2015 at two referral centres were reviewed and the intra-operative and post-operative complications were analysed. Ten patients who underwent EATTA on the PPS and ITF were included in this series. The procedure was performed in six patients for tumour removal, in three patients for diagnostic purposes and in one patient for pain control. No major complications occurred. No conversion to external approach was required. We observed only two minor complications which were promptly solved. No dysphagia or other problems during the food intake were observed in our series. One day after surgery all patients, except one, referred a value of VAS minor than 4. To date, no evidence of disease recurrence has been assessed in all six oncological cases. Although preliminary, our experience seems to demonstrate the feasibility and safety of EATTA when properly planned and performed.

Contemporary management of primary parapharyngeal space tumors

“…Minimally invasive approaches have been advocated to minimize surgical morbidity while claiming complete PPS tumor resection. In general, the use of endoscopic approaches has not been standardized and should be used only in selected cases and performed by highly skilled surgeons . Wang et al have reported that although PPS tumors may be completely removed by both external and transoral endoscopic approaches, the latter has the advantages of reduced blood loss and postoperative pain level and preservation of facial cosmetic.…”

“…In general, the use of endoscopic approaches has not been standardized and should be used only in selected cases and performed by highly skilled surgeons. [62][63][64][65] Wang et al 66 have reported that although PPS tumors may be completely removed by both external and transoral endoscopic approaches, the latter has the advantages of reduced blood loss and postoperative pain level and preservation of facial cosmetic. Similar results have been reported by Fan et al 67 Endoscope-assisted transoral resection provides a wider view, reducing the risks of neurovascular injury or capsule rupture and allowing resection of large tumors 64,65 ; those tumors surrounded major vascular structures or with large lateral extension are not suitable.…”

Surgical anatomy of the parapharyngeal space: Multiperspective, quantification‐based study

“…6,[38][39][40][41][42] On the other hand, involvement of the entire parotid gland, lateral skull base, or neck lymph nodes should lead to adoption of a lateral approach. In particular, when the lesion involves the sinonasal tract, nasopharynx, median/paramedian skull base, pterygopalatine fossa, masticatory space, nasopharynx, oropharynx, and/or oral cavity, a transnasal, TO, or combined transnasal-TO approach should always be considered.…”

“…In particular, when the lesion involves the sinonasal tract, nasopharynx, median/paramedian skull base, pterygopalatine fossa, masticatory space, nasopharynx, oropharynx, and/or oral cavity, a transnasal, TO, or combined transnasal-TO approach should always be considered. 6,[38][39][40][41][42] On the other hand, involvement of the entire parotid gland, lateral skull base, or neck lymph nodes should lead to adoption of a lateral approach. 5,13,43 To provide a complete spectrum of the anatomic routes to the PPS, the present preclinical study intentionally also included invasive approaches requiring mandibulotomy or mandibulectomy (TOMan, TCMan, ITFA-D, ITFA-C), which are rarely adopted or are even considered obsolete.…”

Multiport Combined Endoscopic Approach to Nonembolized Juvenile Nasopharyngeal Angiofibroma with Parapharyngeal Extension: An Emerging Concept

“…They concluded that it is an excellent surgical window which provides great exposure for resection of parapharyngeal space lesions [24]. Turri-Zanoni et al illustrated three cases of malignancy involving the prestyloid parapharyngeal compartments successfully operated using EEA-ETOS approach.…”