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Objective: Surgery is the standard treatment for most tumors in the prestyloid parapharyngeal space (PPS) but it can be a challenging procedure because of the anatomical complexity of the area. Prestyloid surgery can be performed with various lateral approaches or with a medial approach using transoral robotic surgery (TORS)-either alone or in combination with a transcervical incision. We have retrospectively compared our center's results with lateral and medial approaches.Methods: Between 2015 and 2020, 28 patients with prestyloid PPS tumors underwent surgery at our center: 14 with lateral approaches, including transcervical, transcervical-parotid, and transcervical-mandibular, and 14 with medial approaches (12 with TORS and two with TORS plus a transcervical incision). We compared surgical time, postsurgical complications, length of hospital stay, need for feeding tube, and relapse-free survival in the two patient groups.Results: Pleomorphic adenoma was the most frequent tumor and 60.7% of the tumors were benign. Tumor volume and maximum length were similar in the two groups of patients. Intraoperative image guidance and ultrasound were used in 33% of TORS. TORS was associated with less surgical time, fewer complications, and shorter hospital stays. Recurrence rates were similar in the two groups. Conclusion:The medial approach by TORS offers superior results in prestyloid tumors than the open lateral approach and can be refined by intraoperative guidance.

Introduction Surgery is the standard treatment for most tumors in the prestyloid parapharyngeal space (PPS) but it can be a challenging procedure because of the anatomical complexity of the area. Prestyloid surgery can be performed with various lateral approaches or with a medial approach using transoral robotic surgery (TORS) – either alone or in combination with a transcervical incision. Here we report our experience in the surgical management of prestyloid PPS tumors. Materials and Methods We have retrospectively compared results with lateral or medial approaches to surgical resection of prestyloid tumors. Between 2015 and 2020, 28 patients with prestyloid PPS tumors underwent surgery at our center: 14 with lateral approaches, including transcervical, transcervical-parotid, and transcervical-mandibular, 12 with TORS, and two with TORS plus a transcervical incision. Surgical time, post-surgical complications, length of hospital stay, need for feeding tube, and relapse-free survival in the two patient groups. Results Pleomorphic adenoma was the most frequent tumor and 60.7% of the tumors were benign. Tumor volume and maximum length were similar in patients undergoing surgery with a lateral approach and in those undergoing TORS. Intraoperative image guidance and ultrasound were used in 33% of TORS. TORS was associated with less surgical time, fewer complications, and shorter hospital stays. Survival rates were similar in the two groups. Conclusion The medial approach by TORS offers better surgical results in prestyloid tumors than the open lateral approach and can be refined by intraoperative guidance.