BACKGROUND Primary parapharyngeal space neoplasms are rare. Tumor distribution characteristics and long-term outcome have been quite variable in the recent literature. We report the results of a retrospective review of 172 patients with primary parapharyngeal space neoplasms treated surgically from 1960 to 1990 at a large multispecialty clinic and teaching hospital. METHODS Initially, 195 patients seen at our institution were found to have parapharyngeal space neoplasms. Twenty-three patients previously treated elsewhere were excluded. The remaining 172 patients (96 female and 76 male) were from 11.7 months to 91.5 years of age. All patients were treated surgically; the transparotid-cervical approach was most widely used. RESULTS One hundred thirty-seven tumors (80%) were benign and 35 (20%) were malignant. High-resolution computed tomography or magnetic resonance imaging was essential in the diagnosis and presurgical planning. Fine-needle aspiration specimens were accurate in the diagnosis of 8 or 9 cases. Pleomorphic adenoma was the most common neoplasm (40%), followed by paraganglioma (20%), neurogenic tumor (14%), malignant salivary gland tumor (13%), miscellaneous malignant tumors (7%), and miscellaneous benign tumors (6%). Mandibulotomy was required for only 6% of all tumors; its use was reserved for malignant lesions and large skull base tumors when risk of tumor rupture was high. Recurrent or persistent disease was recorded in 27 patients with malignant tumors; of these, 24 (89%) are likely to die of disease. CONCLUSIONS The transparotid-cervical approach is the preferred procedure for most parapharyngeal tumors and can be combined with midline mandibulotomy for large vascular or selected malignant tumors. Recurrence after removal of pleomorphic adenomas is only 4%. Recurrent or persistent malignant disease is nearly always fatal. Perioperative mortality is zero, and morbidity is most often associated with cranial nerve neuropathy.