Double mandibular osteotomy with segmental mandibular swing approach to parapharyngeal space

Abstract

Surgical removal of benign tumors of the Parapharyngeal space (PPS) is the treatment of choice. PPS tumors may remain undetected for long periods of time and large tumors in the PPS can extend into the Retropharyngeal Space or into the Infra-Temporal Fossa. Anatomically, the mandible represents a significant obstacle to successful PPS surgery. Except for very small tumors, it is difficult to remove larger tumors from this region without some form of mandibular retraction. The standard mandibular “swing” approach involves splitting of the lower lip and a single parasymphysis osteotomy for retraction of the mandible laterally to expose the PPS. However, the morbidity associated with midline lip split and anesthesia of the hemi-labial region caused by the severing of the mental nerve is an unwanted complication of this approach. In this article, we describe an easier double mandibular osteotomy (Segmental Mandibular Swing Approach) which avoids the morbidity associated with lip splitting or intra-oral mucosal incision but allows excellent exposure of the superior and lateral aspect of PPS for easier removal of large tumors in this region.

Potential Surgical Exposure of the Parapharyngeal Internal Carotid Artery by Endonasal, Transoral, and Transcervical Approaches

“…29 Lateral mandibulotomy (parasymphysis or ramus osteotomy) is an alternative osteotomy technique, which rather requires manipulation of the lateral structures, that is, facial nerve and parotid gland to access the entire PPS. A double mandibular osteotomy without lip splitting technique was described in 2007 by Kolokythas et al 30 and in 2014 by Satpathy et al 31 Both studies reported minimal complications and adequate exposure of the PPS including the skull base and pterygomaxillary fossa, as well as visualization of the great vessels. Some prefer the traditional transoral approach to manage select lesions in the prestyloid space.…”

The Cutting Edge: A Review of Surgical Techniques in Oral Cancer Management-A Narrative Review

“…The upper cheek flap approach is optimal for the resection of larger tumors of the hard palate and the upper alveolus, particularly if located posteriorly. The mandibulotomy approach usually involves a lip-split, and has been preferred for advanced oral cancer because it can provide excellent exposure to the oral cavity and the oropharynx [17,18]. Compared to midline mandibulotomy, a paramedian mandibulotomy has merits for swallowing function since it preserves the geniohyoid and genioglossus muscles, and the anterior belly of the digastric muscle [19].…”

Evolution and current status of microsurgical tongue reconstruction, part II

“…Surgical access frequently requires manipulation of the mandible. Although mandibulotomy accompanied by lip splitting provides wide exposure of the oral cavity [ 45 , 46 ], this method was associated with many complication related to wound healing, fistulas, and bony union issues [ 47 , 48 ]. The introduction of alternative mandible-preserving techniques, including mandibular sparing, mandibular lingual release, and transcervical, transpharyngeal, and transhyoid approaches, all of which preserve mandibular integrity, has made it possible to avoid these complications [ 47 , 49 , 50 ].…”