SELECTED TOPICS
ANEWEXTERNALAPPROACHTOTHE
PTERYGOMAXILLARY FOSSA AND
PARAPHARYNGEALSPACE
E. L. Attia, MD, FRCS(C),
K.C. Bentley, DDS, MDCM, FICD, FACD,
T. Head, DDS, FRCS(C), and
D. Mulder, MD, MSc, FRCS(C)
~
Abstract: A new direct approach to the area of the
pterygomaxillary fossa and the parapharyngeal
space is described. This procedure was developed
because previously described methods either of-
fered limited access to the area or resulted in
significant functional defects. The approach de-
scribed here results in a wide-field exposure of
both the pterygomaxillary and parapharyngeal
spaces with no sacrifice of either mandibular func-
tion or the sensory supply of the face or oral cavity.
The parapharyngeal space is entered through a
transcervical incision. This, combined with double
osteotomies of the mandible, allows the ascending
ramus with its intact neurovascular bundle to be
reflected laterally and superiorly, along with the at-
tached masseter muscle and the overlying skin.
The result is an excellent exposure of the ptery-
gomaxillary fossa and the base of skull. Following
removal of the tumor, the ramus of the mandible is
replaced and fixed with interosseous wiring and
the application of arch bars, thus restoring normal
dental occlusion. The technique described here
was worked out on cadaveric dissection before be-
ing applied to a clinical case.
HEAD & NECK SURGERY 6:884-891 1984
CASE REPORT
The initial evaluation at Montreal General Hos-
pital of a 16-year-old boy revealed a history of
recurrent epistaxes, a sensation of fullness in the
face and throat, and difficulty breathing through
the nose. These symptoms had first been noted 4
years earlier, and at that time a nasal lesion,
884 A New External Approach
which had proved to be an angiofibroma, had been
removed through a transpalatal approach. Be-
cause of the recurrence of symptoms ll months
later, the patient had been transferred to a larger
center where angiography with embolization fol-
lowed by surgery through a transantral approach
had been carried out. Follow-up 1 year later, 16
months before he was seen at our institution,
had revealed a recurrence of the tumor. A third
attempt at surgical removal had been made
through a second transantral approach.
At our institution, examination revealed
swelling of the left side of the face and neck,
marked downward displacement of the palate
(Fig. 11, and a mass obstructing the posterior
choana and nasopharynx on the left side. A com-
puted tomographic (CT)scan showed an extensive
mass measuring 7 cm x 8 cm that occupied the
pterygomaxillary fossa and the lateral parapha-
ryngeal space (Fig. 2). This tumor extended
superiorly to the middle cranial fossa, inferiorly
to the level of the angle of the mandible, ante-
From the Department of Otolaryngology (Dr Attia), the Department o i
Oral Surgery and Dentistry (Drs. Bentley and Head), and the Department
of Surgery (Dr. Mulder), McGill University, Montreal, Quebec, Canada.
Address reprint requests to Dr. Attia at Montreal General Hospital, 1650
Cedar Avenue, Montreal, Quebec H3G 1A4.
Accepted for publication March 3, 1983.
0148-6403/0604/0884 $04.0010
1984 John Wiley & Sons, Inc.
HEAD & NECK SURGERY MariApr 1984

FIGURE 1. Displacement of the palate and uvula by the mass.
riorly into the maxillary sinus and the nasal
fossa, and medially across the midline of the
nasopharynx.
Angiography showed extensive vasculariza-
tion of the tumor, mainly from the left external
carotid artery system, but with one vessel from
the left internal carotid artery system feeding the
intracranial portion of the tumor (Fig. 3).
It was apparent from the size, location, and
vascularity of the tumor that the conventional ap-
proach to the pterygomaxillary fossa would be in-
adequate for complete resection. A multidiscipli-
nary team discussed the problem and decided on
the external approach described in this article.
The technique had been perfected by trial on
cadavers prior to its clinical use.
Under controlled hypotensive anesthesia, the
procedure was successfully used to resect the
tumor after preparation by preoperative emboli-
zation, operative ligation, and transection of the
external carotid artery on the left side. The post-
operative course was uneventful. The patient re-
covered with no sensory or motor deficits, and his
mandibular function was normal. He has re-
mained free of recurrence for the 12 months of
follow-up that have elapsed.
In designing this new approach the objectives
were:
1) to gain adequate exposure and direct access to
the pterygomaxillary fossa and the parapha-
ryngeal space in order to enucleate the tumor,
A New External A p p r o a c h
FIGURE 2. A computed tomographic scan, basal view, shows
extensive tumor in the pterygopalatine and parapharyngeal
spaces.
2) to gain adequate exposure and direct access to
the carotid artery system,
3) to preserve mandibular function, dental occlu-
sion, and the vitality of the teeth,
4) to avoid injury to the facial nerve,
5 ) to preserve sensation over the distribution of
the fifth cranial nerve, and
6) to achieve acceptable cosmetic results.
Surgical Procedure. Incision (Fig. 4). A curvilinear
incision was developed from the mastoid process
to the midline of the neck, at the level of the hyoid
bone, about 2 inches below the angle of the man-
dible. From there it was extended anteriorly in
the midline to the level of the mandible, curved
laterally around the contour of the chin and back
to the midline of the lower lip, and then extended
upwards t o transect the lip in the midline.
Exposure of the carotid artery (Fig. 5 ) . The
carotid sheath was identified and split open by
dissecting between the sternocleidomastoid mus-
cle and the superior portion of the strap muscles
of the larynx. The carotid artery was exposed at
its bifurcation, and the internal carotid artery
was traced superiorly to the base of the skull.
This was accomplished by dissecting the parotid
fascia away from the mastoid tip, as well as the
upper portion of the fascia enveloping the ster-
nomastoid muscle, which was reflected ante-
riorly. The posterior belly of the digastric was
identified and dissected to its insertion into the
HEAD i3 NECK SURGERY M a r / A p r 1984 885
 FIGURE 3. This angiogram shows extensive vascularization of the angiofibroma.

FIGURE 4. The incision splits the lip and curves around the
contour of the chin to the midline in the submental area. It
extends as a curvilinear transverse neck incision from mid-
line to mastoid.
\ i
FIGURE 5. The common carotid artery is exposed as is the
internal carotid as far as the base of the skull. The external
carotid artery is transected and ligated.

886 A New External Approach HEAD 8, NECK SURGERY MariApr 1984

mastoid. By retracting the posterior belly of the
digastric anteriorly and the sternomastoid poste-
riorly, the whole carotid course was well exposed.
The external carotid artery was transected at
the level of the bifurcation, ligated, and secured;
it was then reflected anteriorly and medially.
The submandibular triangle (Fig. 6 ) . The fas-
cia over the submandibular gland was incised,
exposing the facial artery and vein, which were
transected below the inferior border of the mandi-
ble and reflected superiorly. This protected the
mandibular branch of the facial nerve and ex-
posed the inferior border of the mandible.
Intruorul dissection (Fig. 7). A shallow vertical I
incision was made through the mucosa overlying \
the anterior border of the ascending ramus of the FIGURE 6. The ramus of the mandible is exposed. The man-
mandible. The incision began at the base of the dibular branch of the facial nerve is protected by reflection of
coronoid process and extended inferiorly. An inci- the transected facial vessels.
sion that extended down to bone was then car-
ried in an anteromedial direction through the
retromolar region to the midpoint of the posterior
aspect of the last mandibular molar tooth. The
incision was then extended through the gingival
sulcus on the lingual aspect of mandibular teeth
as far forward as the midline, and a full-thickness
mucoperiosteal flap was reflected from the lingual
aspect of these teeth and extended inferiorly to
the attachment of the mylohyoid muscle. The
reflection was extended posteriorly to detach the
pterygomandibular raphe and superior constric-
tor muscle from the mandible. The mucoperios-
teum was then reflected from the anterior border
of the ascending ramus up to the tip of the
coronoid process. The periosteum was reflected
from the medial aspect of the ascending ramus
inferiorly to the lingula, as well as to the poste-
rior border in preparation for the horizontal os-
teotomy.
The lip incision was extended through the mu- FIGURE 7. The mandibular osteotomies are arranged to
cosa and periosteum to the interval between the spare the inferior dental nerve and vessels. Detachment of
mandibular central incisor teeth. A gingival sul- the pterygoids and ligaments allows mobilization of the man-
cus incision was made on the labial aspect of the dibular segment.
left side as far posteriorly as the second bicuspid
tooth. A full-thickness mucoperiosteal flap was
then reflected from the anterior aspect of the proximity of the roots t o one another. The dissec-
mandible and carried laterally as far as the men- tion of the soft tissues still attached to the medial
tal foramen. aspect of the mandible was then completed by an
By means of burrs and fine osteotomes, an os- extraoral approach. The periosteum was incised
teotomy was performed in the interval between along the inferior border of the mandible from the
the lateral incisor and the cuspid teeth (it could region of the angle to the anterior osteotomy site.
have been between the cuspid and the first bicus- It was then reflected from the medial aspect of the
pid teeth), taking care not to injure the roots of body, thus medially displacing the submaxillary
these teeth. The site of the osteotomy was prede- salivary gland, the mylohyoid muscle, the poste-
termined by the availability of space and the rior portion of the anterior belly of the digastric

A New External Approach HEAD & NECK SURGERY MariApr 1984 887
FIGURE 8. (A) Upward reflection of the mandible gives excellent exposure of the pterygomaxillary and parapharyngeal spaces.
The pterygoid muscles are separated to remove the tumor. (B) lntraoperative view shows exposure of the pterygomaxillary and
parapharyngeal spaces. The pterygoid muscles are wrapped around the tumor.
where it attached to the mandible, and the con-
tents of the floor of the mouth. The horizontal
osteotomy of the ascending ramus was then per-
formed through an intraoral approach. From an
extraoral approach the remaining attached peri-
osteum, medial pterygoid muscle, and spheno-
mandibular ligament were detached from the me-
dial aspect of the ascending ramus. Care was
taken to preserve the neurovascular bundle en-
tering the mandibular foramen in order not to
create a sensory deficit over the distribution of
the inferior dental and mental nerves.
The osteotomized mandible was then reflected
superiorly to provide access to the lateral pha-
ryngeal region (Fig. 8). After removing the tumor
(Fig. 9),the mandible was returned to its original
position. Preformed Winter’s arch bars were at-
tached to the maxillary and mandibular teeth by
means of 26-gauge stainless steel wires. A 26-
gauge stainless steel wire was placed between the
proximal and distal fragments of the horizontal
osteotomy in the ramus at the anterior border
and, after closure of the intraoral incision with 4-
0 Dexon in interrupted fashion, the teeth were
placed into a preformed acrylic splint. Intermaxil-
lary fixation was achieved with 24-gauge
stainless steel wires between the arch bars. A
24-gauge stainless steel wire was then placed
interosseously at the inferior border of the ante-
rior osteotomy site (Fig. 10).
888 A New External Approach
The lip was closed in layers. The pterygomas-
seteric sling was closed, and the inferior margin
of the detached periosteum on the medial aspect
of the body of the mandible was repositioned and
sutured to the attached periosteum on the inferior
border of the mandible. The neck was then closed
in layers (Fig. 11).
F O I I O W . ~ ~ .The patient was examined 1year after
the operation, and the surgical scar showed good
healing with some keloid formation (Fig. 12). The
panorex view showed good bone healing (Fig. 13).
Intraoral examination showed good occlusion and
a normal palate.
DISCUSSION
Tumors of the pterygomaxillary fossa and upper
parapharyngeal space present serious problems
in terms of surgical ac~essibility.l-~
The transantral a p p r o a ~ hgives
~ , ~ limited ac-
cess to the pterygomaxillary fossa, whereas the
transpalatine approach7 exposes the nasopharynx
but gives very limited access to both the ptery-
gomaxillary and parapharyngeal spaces. A com-
bination of the transpalatine and transantral ap-
proaches has been advocated for more extensive
di~ease.~
For extensive disease, the multidisciplinary
approach has always been a d v o ~ a t e d .However,
~,~
HEAD & NECK SURGERY MariApr 1984
 i

FIGURE 9. Excised tumor.

FIGURE 11. (A) Closure in layers. (6)Final closure.

FIGURE 10. lnterosseous wiring and intermaxillary fixation.

A New External Approach HEAD 8, NECK SURGERY MariApr 1984 889

 accessibility has often been at the expense of loss
of function.
Our approach offers an excision that allows a
good cosmetic result and accessibility to the great
vessels of the neck for initial hemostatic control.
The osteotomies provide adequate exposure, pre-
serve the inferior dental nerve, and maintain the
blood supply of the osteotomized segment of
the mandible by leaving intact the attachment of
the periosteum and masseter muscle to the lat-
eral aspect of the mandible. This approach also
preserves dental occlusion and offers easy fixation
by interosseous wiring, the application of arch
bars, and intermaxillary wiring. The parotid and
digastric separation leads to good access to the
base of the skull and the preservation of facial
nerve functions.

Summary. A new surgical approach for exposing

FIGURE 12. Appearance of the scar 1 year after the opera-
tion.
the pterygomaxillary fossa and the parapharyn-
geal space is described. In the case reported, the
procedure resulted in excellent postoperative oc-
clusion, good facial nerve function, and no sen-
sory deficit. More important, the achievement of
excellent exposure of these relatively inaccessible
anatomical recesses facilitated control of hemo-
stasis, and led to a complete and safe excision of a
widely extended tumor.

FIGURE 13. Panorex view shows good bone healing 1 year after the operation.

890 A New External Approach HEAD & NECK SURGERY MariApr 1984
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A New External Approach
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HEAD & NECK SURGERY MariApr 1984 891