British Journal of Oral and Maxillofacial Surgery (2003) 41, 142–146

© 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0266-4356(03)00077-9, available online at www.sciencedirect.com

Double mandibular osteotomy with coronoidectomy for tumours in the

parapharyngeal space

N. Lazaridis, ∗ K. Antoniades †
∗ Professorof Oral and Maxillofacial Surgery; †Associate Professor of Oral and Maxillofacial Surgery, Department of
Oral and Maxillofacial Surgery, G. Papanicolaou General Hospital, Aristotle University of Thessaloniki,
10, Mitr. Gennadiou Street, 546 31 Thessaloniki, Greece

SUMMARY. Removal of deep-lobe parotid tumours from the parapharyngeal space is often difficult because
of limited surgical access and the critical vascular and neurologic structures nearby. Mandibulotomy, when
necessary, is useful for improving wider visibility and control of the vascular bundle and facial nerve, but may
cause damage to the inferior dental and lingual nerves. The double mandibular osteotomy with coronoidectomy
gives excellent access and avoids damage to these nerves.
© 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights
reserved.
Keywords: Osteotomy; Parapharyngeal space; Parotid tumour

INTRODUCTION We now present a modification of this technique to

include coronoidectomy, and report its use in two cases of
Tumours in the parapharyngeal space are uncommon,1 deep-lobe parotid tumours (Fig. 3).
and are diagnosed lately because of the anatomy of the
region. The rigid bony walls of the mandible direct tumour
growth medially to the parapharyngeal space.2 OPERATION
This silent anatomical space allows the tumour to grow
large and on routine clinical examination the finding of We start with a standard preauricular parotidectomy in-
bulging of the soft palate suggests the diagnosis. Such cision carried anteriorly into the submandibular region
tumours can be reached by superficial parotidectomy and that reaches the mandibular symphysis. Reflection of the
removed by deep lobectomy after preservation of the facial skin flaps exposes the parotid gland, the sternomastoid
nerve. Ehrlich3 proposed a transoral approach through a muscle, the greater auricular nerve and the cartilage of
curved incision through the palatopharyngeal arch, which the external ear canal. The lateral parotid lobe is dis-
is deepened until the capsule of the tumour is reached. placed forwardy and the main trunk of the facial nerve
However, the transparotid and intraoral approaches have is exposed as in a standard parotidectomy. The external
limited use. carotid artery is exposed deep within the inferior portion
The styloid process, the stylomandibular ligament of the parotid. Transsection of this vessel exposes the
and the mandible impede access to parapharyngeal fan-shaped stylomandibular ligament. This ligament and
deep-lobe parotid tumours. Division of the mandible was the digastric and stylohyoid muscles are transsected.
first proposed by Ariel et al.4 They suggested either re- The submandibular flap is dissected down toward the
section of the posterior aspect of the ascending ramus hyoid bone and upwards to the mandibular symphysis,
or actually dividing the ramus with a Gigli saw. Oth- following the plane beneath the platysma muscle. It is im-
ers have suggested alternative mandibular osteotomies portant to preserve the marginal mandibular branch of the
(Fig. 1). facial nerve. Next, the periosteum is split along the infe-
Most of these proposed techniques, however, involve rior border of the mandible and subperiosteal dissection
resection of the inferior alveolar nerve within the bone. allows a mandibular osteotomy to be made anterior to the
Seward described a mandibular osteotomy distal to the mental foramen, preferably at the interproximal space of
mental foramen without splitting the lip (sometimes com- the canine and the first premolar. The inferior dental nerve
bined with osteotomy of the condylar neck), to spare the is undisturbed. The masseter muscle is reflected superi-
inferior alveolar nerve (Fig. 2).5,6 orly to give access to the sigmoid notch.
142
 Double mandibular osteotomy with coronoidectomy 143

Fig. 1 Diagram showing the most important manoeuvres and osteotomies that have been proposed to improve surgical access to the parapharyngeal
space. (a and b) Mandibular dislocation without osteotomy; (c) osteotomy of the ramus above the lingula; (d) osteotomy of the posterior margin of
the ramus; (e and f) osteotomy at the angle of the mandible; (g and h) step-like mandibulotomy at the body; (i) oblique osteotomy of the body;
(j) inverted ‘L’ osteotomy; (k) osteotomy anterior to the mental foramen and osteotomy of the ramus above the lingula; (l) symphesial and
parasymphesial mandibulotomy.

Bone plates are fitted, and screw holes are drilled the lingula, where the neurovascular bundle is isolated and
before making the osteotomies to facilitate accurate ap- preserved.
proximation of the mandibular segments at the end of the Next an osteotomy is made at the base of the condylar
operation. The medial aspect of the mandible is freed to process to increase mandibular mobility and allow upward
144 British Journal of Oral and Maxillofacial Surgery

Fig. 2 (a and b) Osteotomy anterior to the mental foramen and condylar neck osteotomy.

rotation of the body and the ramus of the mandible. upwards and laterally to facilitate access to the deep part
The coronoidectomy improves the exposure of the tu- of the tumour. Nevertheless the size of the tumour and the
mour, increases the mobility of the mandibular segment, abundant haemorrhage during the operation did not allow
and prevents postoperative trismus (Fig. 3a and b). The its removal. The mandible was reduced with an AO recon-
periosteum is lifted off on the lingual side to allow up- struction plate. The postoperative course was uneventful
ward rotation of the mandible and the oral cavity is and the patient was discharged on a soft diet. She had a
not breached. The tumour can now be mobilised and course of radical radiotherapy.
excised. The histopathological examination showed a well-
After the tumour has been removed, the previously differentiated squamous cell carcinoma of the primary
fitted plates are reapplied to the mandible, in correct cheek tumour and two invaded lymph nodes of the 19
occlusion with maxillomandibular fixation. A few days lymph nodes in the specimen. Biopsy of the parotid tu-
of maxillomandibular fixation with elastics is usu- mour in the deep lobe showed a pleomorphic salivary
ally necessary, followed by the use of loose guiding adenoma and in some places a low grade adenocarcinoma.
elastics. The patient refused a further operation to remove the
Finally, the surgical incisions are closed in layers and residual parotid tumour and remained free of squamous
a suction drain is placed. Broad-spectrum antibiotics cell carcinoma for 4 years. The deep parotid tumour re-
are recommended for a few days, except when intrao- mained unchanged in size. Nevertheless, fibrosis in that
ral biopsy specimens are taken or transoral enucleations area created functional problems such as trismus and dif-
done. The latter is indicated for tumours arising within ficulties swallowing that finally forced the patient to seek
the oral mucosa. In such cases the intraoral mucosa is a second operation.
sutured and antibiotics are given for longer. In April 2000, she presented to our clinic where rad-
ical excision of the tumour was accomplished by the
technique that we have described. Histopathological ex-
CASE REPORTS amination confirmed that the mass was a pleomorphic
salivary adenoma. No splints or arch bars were applied
Case 1 and the patient was prescribed a soft diet. One year later
she is symptom-free with normal mouth opening.
A 63-year-old edentulous woman with a history of car-
cinoma on the right cheek and ipsilateral palpable lymph
nodes was referred to an oral and maxillofacial surgery
Case 2
clinic for evaluation in 1996. The computed tomogram
(CT) showed an independent tumour in the deep lobe of A 38-year-old woman presented to our clinic complaining
the left parotid salivary gland. The patient had a wide local of a lump in her throat and earache, which she had had for
excision of the primary lesion on the cheek and a unilateral several months. Examination showed a mass on the right
radical neck dissection. A superficial parotidectomy was pharyngeal wall without ulceration of the mucosa. A CT
done to remove the tumour of the deep lobe of the parotid showed a 7/4 cm mass within the deep lobe of the parotid
gland at the same operation. The body of the mandible gland, extending up to the base of the skull, down to the
was divided anterior to the ascending ramus according to lower border of the tonsillar bed, and crossing the midline
the method of Ariel et al.4 The ramus was then everted of the nasopharynx.
 Double mandibular osteotomy with coronoidectomy 145

course was uneventful and the patient was discharged on

a soft diet. Microscopic examination confirmed the cyto-
logical diagnosis. A transitory facial nerve palsy and sen-
sory impairment lasted about 2 months but had completely
recovered 1 month after that.

DISCUSSION

The approach of choice to the parapharyngeal space to al-

low adequate removal of these tumours should meet two
criteria: wide intraoperative visibility for safe, radical dis-
section and minimal functional or cosmetic after-effects.
The intraoral approach was described by Ehrlich in
1950.3 It is indicated for small tumours as the surgical ex-
posure is often poor, preventing adequate vascular control
in the event of major haemorrhage. It also provides little
control of the adjacent neurovascular structures, and the
limited visibility can lead to rupture of the tumour and
spillage into the operative field.
Because the mandible lies lateral to the parapharyn-
geal space it prevents direct surgical access to this re-
gion, so a considerable number of surgical techniques have
been described to overcome this problem.7 There are two
surgical options: one involves anterior dislocation of the
mandible by division of the stylomandibular ligament and
forward traction of the mandible,8 and the second involves
mandibular osteotomies.
Mandibular dislocation sometimes entails resection of
the styloid process and the stylomandibular ligament.9
Ariel et al. described resection of the posterior margin
of the ramus of the mandible.4 Both approaches make the
isolation of the upper portion of large tumours difficult.
Osteotomy of the mandible provides excellent access
to the entire parapharyngeal space up to the base of the
skull, enabling complete removal of a tumour and vascular
control.
Various osteotomies through the angle,10 the ascend-
ing ramus11 or the horizontal ramus proximal to the
mental foramen give good access but result in section
of the inferior alveolar nerve. Several authors have re-
ported recovery of the function of the inferior alveolar
Fig. 3 (a) Diagram showing the design of the bone cuts for the double nerve when the mandible is reconstituted with bone
mandibular osteotomy and coronoidectomy; (b) upward rotation of the plates,10 but nerve recovery is unlikely to be reliable.
cut mandibular segment; (c) after the tumour has been removed the cut
mandibular segments are reapproximated and stabilised with adapted This view is supported by Robinson who continued to
bone plates. have altered sensation 2 years after the initial nerve
section.12
Osteotomies medial to the mental foramen avoid dam-
Aspiration biopsy cytology showed pleomorphic ade- age to the inferior alveolar nerve, but require a lip-splitting
noma. The patient was operated on by the technique that incision. The osteotomy may be in the midline or the
we have described. The tumour was easily mobilised and parasymphyseal area because the tumour lies at the apex
delivered without complications. The mandible was re- of a deep wound, even when the mandible is swung later-
constructed with previously designed Luhr miniplates. No ally. Seward described the possibility of approaching the
splints or arch bars were applied and the patient was given parapharyngeal space through a lateral neck dissection
a soft diet for 5 days postoperatively. The postoperative and a mandibular osteotomy distal to the mental foramen
146 British Journal of Oral and Maxillofacial Surgery

without splitting the lip to avoid scarring.5,6 This allows allows the surgeon to follow and protect both the lingual
the mandible to be lifted for access. and the hypoglossal nerves.
Another way to avoid damage to the inferior alveo-
lar nerve is to place the osteotomy horizontally in the
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elastic guidance of the occlusion.3 13. Attia EL, Bentley KC, Head T et al. A new external approach of
This double mandibular osteotomy with our modifica- the pterygomaxillary fossa and parapharyngeal space. Head Neck
tion of additional coronoidectomy proved useful in two Surg 1984; 6: 884–888.
cases in gaining wide exposure to the parapharyngeal
space and provided excellent visibility to secure local neu-
rovascular structures. The Authors
It helped to improve exposure and more importantly N. Lazaridis
improved postoperative rehabilitation. A superficial paro- Professor of Oral and Maxillofacial Surgery
tidectomy must be done first. This allows the main trunk K. Antoniades
Associate Professor of Oral and Maxillofacial Surgery
and the smaller branches of the seventh nerve to be Department of Oral and Maxillofacial Surgery
identified and avoided, as the dissection is retrograde G. Papanicolaou General Hospital
in the parapharyngeal space. Some authors7 think that Aristotle University of Thessaloniki, 10
Mitr. Gennadiou Street, 546 31 Thessaloniki, Greece
the submandibular gland should be removed rather than
mobilised, because that eliminates the possibility of post- Correspondence and requests for offprints to: N. Lazaridis, Professor
operative adenitis after the manipulation required for mo- of Oral and Maxillofacial Surgery, Department of Oral and
bilisation. In our first case, the submandibular gland had Maxillofacial Surgery, G. Papanicolaou General Hospital, Aristotle
University of Thessaloniki, 10, Mitr. Gennadiou Street, 546 31
been removed during the previous unilateral radical neck Thessaloniki, Greece. Tel: +30 310 244177; Fax: +30 932 413337;
dissection. In the second of our cases the submandibular E-mail: [email protected]
gland was not mobilised to remove the tumour. Neverthe-
less, we think that the removal of submandibular gland Accepted 9 April 2003