A new external approach to the pterygomaxillary fossa and parapharyngeal space.

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 offered limited access to the area or resulted in significant functional defects. The approach described here results in a wide-field exposure of both the pterygomaxillary and parapharyngeal spaces with no sacrifice of either mandibular function 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 attached masseter muscle and the overlying skin. The result is an excellent exposure of the pterygomaxillary 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 being applied to a clinical case.