Several approaches are described to the parapharyngeal space to permit resection of tumours in this region, with the most commonly employed approach being the transcervical route. The transoral approach remains somewhat controversial as it is felt that this approach can have a higher complication and recurrence rate. Nevertheless, this approach does seem intuitively appropriate for small tumours that are clearly visible transorally and located in the medial aspect of this region on imaging with benign radiological characteristics. The enhanced visibility and greater range of instrumentation manipulation possible with the use of surgical robots has also led to greater consideration of this approach for selected parapharyngeal tumours. This paper describes the experience of a tertiary centre in Italy with both the transcervical and transoral approach to parapharyngeal space tumours over a 22-year period with a mean follow-up duration of 93 months. A total of 34 patients were included. In 20 cases (59%), the tumours were treated with a transcervical approach whilst 11 (32%) were approached transorally. Three tumours were treated via a combination of approaches. Twenty-two tumours (65%) were benign, 12 (35%) malignant. Eight of the patients in the transcervical approach cohort experienced a facial nerve palsy. This was temporary in five, but permanent in three cases. Two of the patients with a permanent facial weakness had malignant tumours. No facial nerve weakness was recorded among patients treated via a transoral approach, but one patient experienced a wound dehiscence. Tumour recurrence occurred in 10 cases – eight with malignant tumours and two benign. Given the overall small numbers of patients and broad nature of pathologies treated, the authors were unable to make direct comparisons between patient outcomes based on the approach to the tumour. Nevertheless, it would seem reasonable to conclude that in a selected minority of patients with parapharyngeal tumours, the transoral approach may provide a safe and effective alternative to the transcervical approach.