The Intermaxillary-Mandibular Approach to the Post-Styloid Parapharyngeal Space: An Anatomic Study

Lesions of the parapharyngeal space (PPS) represent a challenging surgical pathology for resection, especially when critical structures like the parapharyngeal internal carotid artery (ppICA) are difficult to visualize and access. Current approaches provide inadequate visualization and incomplete access with significant morbidity. We investigate a novel approach, the intermaxillary-mandibular (IMM) approach, and compare this approach to traditional surgical approaches for visualization and access to the PPS and ppICA.

A single-institution anatomical study with endoscopic IMM approach and transcervical/transparotid (TCTP) approach dissections was performed in two cadaver heads. The qualitative advantages and disadvantages of both the IMM and traditional TCTP approaches are described and compared.

Using the IMM approach, the ppICA can be completely mobilized as it enters the skull base in the upper PPS (UPPS). Compared to traditional TCTPA approaches, the IMM approach provides greater visualization of the ppICA entering the skull base with less risk of facial nerve injury, and provides more direct access to the ppICA entering the skull base compared to the TCTPA with a surgical corridor length (SCL) of 50.2 versus 63.5 mm, p = 0.001.

Achieving surgical access to the PPS for ppICA lesions is difficult due to the proximity of critical structures and the bony confines of the mandible, maxilla, and skull base. Lesions near or involving the ppICA require wide access to the ppICA including complete mobilization for optimal and safe surgical intervention. Our novel IMM approach allows access to the entire UPPS and mobilization of the ppICA.

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