Cervical paragangliomas-tumor control and long-term functional results after surgery.

Objective: To report long-term functional results of the surgical treatment of cervical paragangliomas. Patients and Methods: A retrospective review of 22 patients with 34 head and neck paragangliomas of which 27 were resected between 1981 and 2004. Of these, 16 were carotid body tumors and 11 were vagal paragangliomas. There were 13 women and 9 men with an average age of 48.6 years (range, 26 to 75 years; median, 49 years) and the mean follow-up period was 82 months (range, 3 to 184 months; median, 61 months). Results: There were 13 solitary tumors of which 5 were carotid body tumors and 8 vagal paragangliomas. Multiple head and neck paragangliomas were seen in 9 patients (41%). The incidence of associated multiple tumors was 64.3% for carotid body tumors and 38.5% for vagal paragangliomas. Complete tumor resection was achieved in all but 1 patient in whom a small intradural residual vagal paraganglioma had to be left. The internal carotid artery was preserved in all carotid body tumor resections. Lower cranial nerve deficits were sustained in 1 carotid body tumor resection only, but in all cases with multiple tumors. All patients with vagal paragangliomas had or developed a vagal nerve paralysis. In 4 cases minor complications developed postoperatively. No recurrent tumors were seen during the follow-up period. Conclusions: Even in large head and neck paragangliomas surgical treatment provides excellent tumor control with low postoperative morbidity. A wait-and-scan policy may be more appropriate for those patients with multiple tumors, advanced age, or high operative risk and for those whose tumors have recurred following radiotherapy.     

Management of vagal paraganglioma: is operative resection really the best option?

BACKGROUND: Vagal paragangliomas cannot be resected without sacrifice of the vagal nerve. The risk of bilateral vocal cord palsy has been reason to postpone treatment of this benign and slow growing neoplasm in hereditary cases. Postponement could be considered for solitary cases as well. METHODS: An institute-based review of 48 patients with vagal paragangliomas over the past 30 years was performed. RESULTS: Forty-eight patients with 58 vagal paragangliomas were studied. All but 4 patients had multiple paragangliomas and should be considered hereditary cases. The 10 patients that underwent an operation lost the vagal nerve; 60% of them had additional cranial nerve palsy postoperatively. In the group of patients who were followed for an average period of 8.5 years, 3 patients (8%) developed cranial nerve palsy. CONCLUSIONS: Aggressive treatment of vagal paragangliomas leads to unnecessary early loss of vagal nerve function. A period of clinical and radiologic follow-up preceding an operation may lead to prolonged preservation of voice and swallowing functions in these patients, without grave consequences for other lower cranial nerves.     

Outcomes after surgical resection of head and neck paragangliomas: a review of 61 patients

We reviewed the postoperative functional outcome following surgical resection of paragangliomas in patients with and without preoperative cranial nerve dysfunction. Patients who underwent surgical resections of head and neck paragangliomas were reviewed with functional outcomes defined as feeding tube and/or tracheostomy dependence, need for vocal cord medialization, and incidence of cerebral vascular accidents as primary end points. Secondary end points included pre- and postoperative function of lower cranial nerves and the impact of this dysfunction on long-term functional status. Sixty-one patients were identified: 27 with carotid paraganglioma (CP), 21 with jugular paraganglioma (JP), 8 with tympanic paragangliomas, 4 with vagal paragangliomas (VPs), and 1 with aortopulmonary paraganglioma. Following resection, 8 patients were feeding tube dependent, 14 patients required vocal cord medialization, 2 patients suffered strokes, but no patients required tracheostomy tubes. Twenty percent of patients (4/20) with JP and postoperative cranial neuropathies were feeding tube dependent, and 80% of patients (4/5) with CP and postoperative cranial nerve dysfunction were feeding tube dependent. Cranial nerve deficits were more common in patients with JP relative to those with CP. However, when cranial nerve dysfunction was present, our patients with CP had a higher incidence of temporary feeding tube dependence. Overall, 98% of patients were able to resume oral nutrition.     

Combined endovascular and surgical treatment of head and neck paragangliomas--a team approach

BACKGROUND: Paragangliomas are highly vascular tumors of neural crest origin that involve the walls of blood vessels or specific nerves within the head and neck. They may be multicentric, and they are rarely malignant. Surgery is the preferred treatment, and these tumors frequently extend to the skull base. There has been controversy concerning the role of preoperative angiography and embolization of these tumors and the benefits that these procedures offer in the evaluation and management of paragangliomas. METHODS: Forty-seven patients with 53 paragangliomas were treated from the period of 1990-2000. Initial evaluation usually included CT and/or MRI. All patients underwent bilateral carotid angiography, embolization of the tumor nidus, and cerebral angiography to define the patency of the circle of Willis. Carotid occlusion studies were performed with the patient under neuroleptic anesthesia when indicated. The tumors were excised within 48 hours of embolization. RESULTS: Carotid body tumors represented the most common paraganglioma, accounting for 28 tumors (53%). All patients underwent angiography and embolization with six patients (13%), demonstrating complications (three of these patients had embolized tumor involving the affected nerves). Cerebral angiography was performed in 28 patients, and 5 of these patients underwent and tolerated carotid occlusion studies. The range of mean blood loss according to tumor type was 450 to 517 mL. Postoperative cranial nerve dysfunction depended on the tumor type resected. Carotid body tumor surgery frequently required sympathetic chain resection (21%), with jugular and vagal paraganglioma removal frequently resulting in lower cranial nerve resection. These patients required various modes of postoperative rehabilitation, especially vocal cord medialization and swallowing therapy. CONCLUSIONS: The combined endovascular and surgical treatment of paragangliomas is acceptably safe and effective for treating these highly vascular neoplasms. Adequate resection may often require sacrifice of one or more cranial nerves, and appropriate rehabilitation is important in the treatment regimen.     

Management of cervical paragangliomas: review of a 15-year experience

Background and aims Cervical paragangliomas are highly vascular neoplasms and should be considered in the evaluation of all lateral neck masses. The aim of this study is to review an institutional experience in the management of these tumors.Materials and methods Thirteen patients with 14 paragangliomas were treated in our institution during a period of 15 years. There were eight women (61.5%) and five men (38.5%) with a mean age of 41.3±15 years. A painless lateral neck mass was the main finding in 69.2% of patients. There was no evidence of a functional tumor. Carotid angiography was performed in all patients to define the vascular anatomy of the lesion. The 78.6% of paragangliomas underwent selective embolization of the major feeding arteries. Surgical resection followed within the next 48 h.Results The majority of the lesions were paragangliomas of the carotid bifurcation (85.7%), while one patient was diagnosed with a jugular and one with a vagal paraganglioma. In one patient, bilateral paragangliomas in the carotid bifurcation were detected. There was no evidence of malignancy in any case. Preoperative embolization has proven successful in reducing tumor vascularity. Vascular reconstruction was necessary in one patient. The main postoperative complication was transient cranial nerve deficit in seven (53.8%) patients, and a permanent Horner’s syndrome was documented in one patient. No stroke occurred. The jugular paraganglioma was treated with irradiation due to skull base extension with significant symptomatic relief.Conclusion Combined therapeutic approach with preoperative selective embolization followed by surgical resection by an experienced team offers a safe and effective method for complete excision of the tumors with a reduced morbidity rate.     

Vagal paraganglioma.

OBJECTIVES: To report the outcomes of surgical treatment of vagal paragangliomas and to define a management protocol. DESIGN: A retrospective case series. PATIENTS AND METHODS: Sixteen consecutive patients with vagal paragangliomas managed by surgical resection using a cervicoparotid approach and pericapsular dissection using microsurgical techniques between 1990 and 2003. RESULTS: All patients either had or developed a vagal palsy. Additional cranial nerve deficits were sustained in 8 patients. No patients died as a result of surgery or from their disease. CONCLUSIONS: The technique used and described in this article allowed adequate exposure of the retrostyloid parapharyngeal space for the safe removal of all vagal tumors in this series. Careful consideration must be given to the likely natural progression of these tumors before committing to surgical resection. This is particularly important in patients with multifocal disease.     

Clinical study of preoperative angiography and embolization of hypervascular neoplasms in the oral and maxillofacial region.

OBJECTIVE: The purpose of this study was to investigate the angiographic features of hypervascular head and neck neoplasms and to evaluate the effects of embolization on these lesions. METHODS: Angiograms and operation records of 25 patients with hypervascular neoplasms (23 neck paragangliomas, 1 hemangiopericytoma, and 1 hemangioendothelioma) were retrospectively analyzed, and the effects of 8 embolization procedures were estimated. RESULTS: Angiograms demonstrated that 23 neck paragangliomas (NPs) were manifested as richly vascularized lesions, and were divided into 3 types. Type I NPs (n = 2) were located cranial-laterally to the carotid bifurcation, and were removed with an intact carotid artery and injured vagus nerve. Type II (n = 17) lesions widened the bifurcations in 16 of 17 cases. During the operation, the continuity of the internal carotid arteries was preserved in 15 of 17 cases. Type III (n = 4) lesions enveloped the carotid bifurcations, and were removed together with the bifurcations in 3 of 4 cases. In 6 type II paraganglioma cases intra-arterial embolization was employed and the paragangliomas were removed with less blood loss (238 mL) than the nonembolized group (600 mL). Additionally, the infratemporal hemangiopericytoma and the parotid hemangioendothelioma were embolized and removed uneventfully. CONCLUSIONS: Angiographic studies are highly valuable for the diagnosis and preoperative analysis of hypervascular head and neck neoplasms. Also, embolization therapy may minimize intraoperative blood loss. Both methods should be employed in a team approach to lesion treatment.     

Paraganglioma of the neck. Analysis of 32 operated cases]

Between january 1965 and november 1990, 32 operations for neck paraganglioma were performed: 29 chemodectomas (carotid body tumors) and 3 paragangliomas of the vagus nerve. Seven subjects were affected with bilateral chemodectomas and one of them showed concurrent unilateral vagal paraganglioma. Two paragangliomas were malignant, with invasion of the latero-cervical lymphnodes revealed at operation. Four individuals came to observation from two different families, suggesting familiarity. Preoperative diagnosis was correctly made in 12 of 18 asymptomatic chemodectomas (66.6%), ten of whom observed during the last decade: angiography is the gold standard for diagnosis but CT scan, ultrasound and NMR imaging are going to earn the confidence of physicians for precise evaluation of latero-cervical masses. Surgery is to date the treatment of choice, and the results are dependent on the size of the tumor and the involvement of the neighbouring vascular, nervous and visceral structures. According to the majority of the literature, the 29 chemodectomas were classified in the three groups of Shamblin: I: 4 cases; II: 10; III: 15. Twenty out of the 24 transient or permanent postoperative complications took place in the third group: in five instances some procedures of internal carotid artery reconstruction were needed. Fourteen complications for chemodectomas and 2 for vagal paragangliomas affected the cranial nerves; three transient and one permanent ischemic central neurological deficits occurred in the group III chemodectomas. Not any operative mortality was registered in this series.     

Carotid body paraganglioma: review and surgical management

The term paraganglia best defines the spread in the body of clusters of cells with histological and cytochemical characteristics of neuroendocrine cells originating from the neural crest, with either sympathetic or parasympathetic function. Carotid body hyperplasia is associated with long-standing hypoxia as in native inhabitants in high altitude or in patients with chronic pneumonopathies, while carotid body paraganglioma is a rare parasympathetic tumor with significant morbidity. Tumor extension per se, associated cranial nerve involvement, and the estimated 3-10% malignant potential, particularly at a young age, make early diagnosis and treatment of carotid body paraganglioma mandatory. Biopsy should be avoided, because of the accompanying incidence of hemorrhage, while it is essential in all cases to investigate both sides of the neck to exclude bilateral tumors. The modalities of therapy include preoperative embolization, preoperative and postoperative radiation with ambiguous results of both, and complete surgical removal which constitutes the definite therapy. The current stroke rate is less than 5%. The histological appearance of a carotid body paraganglioma is not a reliable guide to its propensity for malignant behavior and recurrences are most likely to appear in patients who have multiple paragangliomas or a family history of carotid body paraganglioma.     

Cranial and cervical nerve injuries after repeat carotid endarterectomy

BACKGROUND AND PURPOSE: The incidence of cranial and/or cervical nerve injuries after primary carotid endarterectomy (CEA) ranges from 3% to 48%; however, the clinical outcome of these injuries after repeat CEA has not been thoroughly analyzed in the English-language medical literature. This prospective study analyzes the incidence and outcome of cranial nerve injuries after repeat CEA. PATIENTS AND METHODS: This study includes 89 consecutive patients who had repeat CEAs. Preoperative and postoperative cranial nerve evaluations were performed, including clinical examinations (neurologic) and direct laryngoscopy. Patients with vagal or glossopharyngeal nerve injuries also underwent comprehensive speech evaluations, video stroboscopy, fluoroscopy, and methylene blue testing for aspiration. Patients with postoperative cranial nerve injuries were followed up for a long time to assess their recovery. RESULTS: Twenty-five cranial and/or cervical nerve injuries were identified in 19 patients (21%). They included 8 hypoglossal nerves (9%), 11 vagal nerves or branches (12%) (6 recurrent laryngeal nerves [7%], 3 superior laryngeal nerves [3%], and 2 complex vagal nerves [2%]), 3 marginal mandibular nerves (3%), 2 greater auricular nerves (2%), and 1 glossopharyngeal nerve (1%). Twenty-two (88%) of these injuries were transient with a complete healing time ranging from 2 weeks to 28 months (18 of 22 injuries healed within 12 months). The remaining three injuries (12%) were permanent (1 recurrent laryngeal nerve, 1 glossopharyngeal nerve, and 1 complex vagal nerve injury). The recurrent laryngeal nerve injury had a longer healing time than the other cranial nerve injuries. CONCLUSIONS: Repeat CEA is associated with a high incidence of cranial and/or cervical nerve injuries, most of which are transient. However, some of these have a long healing time, and a few can be permanent with significant disability.     

Complex tumors of the glomus jugulare: criteria,treatment, and outcome

OBJECT: Tumors of the glomus jugulare are benign, slow-growing paragangliomas. Their natural history, surgical treatment, and outcome have been well addressed in the recent literature; however, there remains a subgroup of complex tumors--multiple, giant, malignant, neuropeptide-secreting lesions, and those treated previously by an intervention with an adverse outcome--that is high risk, presents surgical challenges, and is associated with treatment controversy. In this article the authors report on a series of patients with complex glomus jugulare tumors and focus on treatment decisions, avoidance of complications, surgical refinements, and patient outcomes. METHODS: In this retrospective study, the patient population was composed of 11 male and 32 female patients (mean age 47 years) with complex tumors of the glomus jugulare who were treated by the senior author within the past 20 years. These include 38 patients with giant tumors, 11 with multiple paragangliomas (seven bilateral and four ipsilateral), two with tumors that hypersecreted catecholamine, and one with a malignant tumor. Six patients had associated lesions: one dural arteriovenous malformation, one carotid artery (CA) aneurysm, two adrenal tumors, and two other cranial tumors. All but one patient presented with neurological deficits. Cranial nerve deficits, particularly those associated with the lower cranial nerves, were the prominent feature. Twenty-eight patients underwent resection in an attempt at total removal, and gross-total resection was achieved in 24 patients. Particularly challenging were cases in which the patient had undergone prior embolization or CA occlusion, after which new feeding vessels from the internal CA and vertebrobasilar artery circulation developed. The surgical technique was tailored to each patient and each tumor. It was modified to preserve facial nerve function, particularly in patients with bilateral tumors. Intrabulbar dissection was performed to increase the likelihood that the lower cranial nerves would be preserved. Each tumor was isolated to improve its resectability and prevent blood loss. No operative mortality occurred. In one patient hemiplegia developed postoperatively due to CA thrombosis, but the patient recovered after an endovascular injection of urokinase. In four patients a cerebrospinal fluid leak was treated through spinal drainage, and in five patients infection developed in the external ear canal. Two of these infections progressed to osteomyelitis of the temporal bone. There were two recurrences, one in a patient with a malignant tumor who eventually died of the disease. CONCLUSIONS: Despite the challenges encountered in treating complex glomus jugulare tumors, resection is indicated and successful. Multiple tumors mandate a treatment plan that addresses the risk of bilateral cranial nerve deficits. The intrabulbar dissection technique can be used with any tumor, as long as the tumor itself has not penetrated the wall of the jugular bulb or infiltrated the cranial nerves. Tumors that hypersecrete catecholamine require perioperative management and malignant tumors carry a poor prognosis.     

Jugular foramen paragangliomas: management, outcome and avoidance of complications in a series of 75 cases

Jugular foramen paragangliomas are rare skull base tumours posing multiple complex diagnostic and management problems. We did a study to evaluate surgical technique, outcome and complications in 75 cases of tumours treated by multidisciplinary approach (i.e. combined neurosurgery, neuroradiology, ear, nose and throat surgery and intensive care unit team). Retrospective study on 75 consecutive patients with jugular foramen paragangliomas treated surgically from 1989 to 2005. Preoperative balloon occlusion test was performed in all patients as well as embolization (100%). A combined limited infratemporal and juxtacondylar approach was used in all patients. Gross total resection was achieved in 59 patients (78.7%). The most common complication was represented by lower cranial nerve deficits in five patients (6.6%), which was only temporary in three. Postoperative facial nerve weakness occurred in five cases (6.6%) and resolved in three of them. The remaining two patients underwent facial nerve reconstruction by hypoglossal/facial nerve anastomosis. Four patients (5.3%) had a postoperative cerebrospinal fluid leak, which was successfully treated by lumbar drainage. Two patients (2.7%) died because of complications related to surgical injury of lower cranial nerves: one patient developed aspiration pneumonia and septicemia and the second one developed a large cervico-bulbar hematoma that led to severe respiratory distress and ultimately global cerebral hypoxia. Paragangliomas are rare and complex skull base lesions that may be managed with low morbidity and mortality if a multidisciplinary approach is considered. Facial and lower cranial nerve postoperative deficits can be limited.     

Carotid Body Tumors: The Role of Preoperative Embolization

Resection of carotid body tumors (neck paragangliomas) carries inherent risks of injury to the cranial nerves and other structures as well excessive blood loss. Preoperative embolization has been used to lessen the morbidity in tumors that are larger than 2 cm in diameter. Two female patients presented for treatment with large asymptomatic carotid body tumors-one 4 cm and one 5 cm in diameter. Both patients had preoperative angiography the day before surgery that revealed the feeding arterial vessels so that successful embolization could be accomplished with gel. Success was judged by diminution of the angiographic blush. Both patients had an uneventful surgical excision the following day with the carotid body tumors being able to be resected periadventitially without damage to either the external or internal carotid artery. The cranial nerves were preserved in both patients and blood loss was only 200 cc in both cases. We conclude that preoperative embolization is an important adjunct in treating patients with large carotid body tumors. The surgical exploration proceeds much smoother, the blood loss is minimal, and patients have minimal morbidity.     

Cranial nerve preservation in lesions of the jugular fossa.

The most significant objection to the proposal of lateral transtemporal cranial base surgery for the treatment of jugular foramen tumors is the perceived lasting morbidity attendant to aggregate cranial nerve loss. As techniques become more standardized and earlier diagnosis generates smaller tumors for treatment, outcome has become more predictable. Surgery has become the recognized management preference for these cranial base lesions. The purpose of this article is to assess the role of surgery in the treatment of jugular foramen lesions, as well as to review some of the technical highlights of conservation surgery, its clinical prerequisites, and reasonable expectations. We review 100 lateral skull base surgical cases of lesions involving the jugular foramen. The majority of these lesions--77 of 100--were paragangliomas. For these glomus tumors, cranial nerve preservation correlated well to tumor size and location. The diversity of the remaining 23 cases prevented any substantive conclusions.     

The spinal accessory nerve plexus, the trapezius muscle, and shoulder stabilization after radical neck cancer surgery.

A clinical and anatomic study of the spinal accessory, the eleventh cranial nerve, and trapezius muscle function of patients who had radical neck cancer surgery was conducted. This study was done not only to document the indispensibility of the trapezius muscle to shoulder-girdle stability, but also to clarify the role of the eleventh cranial nerve in the variable motor and sensory changes occurring after the loss of this muscle. Seventeen male patients, 49-69 years of age, (average of 60 years of age) undergoing a total of 23 radical neck dissections were examined for upper extremity function, particularly in regard to the trapezius muscle, and for subjective signs of pain. The eleventh nerve, usually regarded as the sole motor innervation to the trapezius, was cut in 17 instances because of tumor involvement. Dissection of four fresh and 30 preserved adult cadavers helped to reconcile the motor and sensory differences in patients who had undergone loss of the eleventh nerve. The dissections and clinical observations corroborate that the trapezius is a key part of a "muscle continuum" that stabilizes the shoulder. Variations in origins and insertions of the trapezius may influence its function in different individuals. As regards the spinal accessory nerve, it is concluded that varying motor and sensory connections form a plexus with the eleventh nerve, accounting, in part, for the variations in motor innervation and function of the trapezius, as well as for a variable spectrum of sensory changes when the eleventh nerve is cut. For this reason, it is suggested that the term "spinal accessory nerve plexus" be used to refer to the eleventh nerve when it is considered in the context of radical neck cancer surgery.     

颈动脉体瘤外科治疗并发症的分析

目的：总结46例颈动脉体瘤手术治疗结果以及并发症防治的经验。方法;对采用肿瘤剥除术,同时切除颈外动脉术,与颈动脉分叉－并切除后血管重建术以及颈总动脉结扎术等方法治疗的颈动脉体瘤手术效果和并发症进行回顾性分析。结果：手术切除率91．3％,偏瘫2例,舌下神经损伤4例,舌咽神经损伤2例,迷走神经损伤1例,副神经损伤1例,其中1例同时有舌咽,迷走,舌下神经损伤。长期随访复发2例,再次手术切除。所有病例无手术死亡。结论：术前选择性血管造影,田径赛眼声多普勒等检查以明确诊断,合理的Matas训练以及选择适当的术式,对于颈动脉体瘤外科治疗和减少并发症是必要的。     

Baroreflex failure syndrome after bilateral excision of carotid body tumors: an underestimated problem

Carotid body tumors (CBTs) are relatively rare paragangliomas that develop from neural crest cells at the bifurcation of the common carotid artery. They are generally slow growing and benign. Excision is currently considered the treatment of choice, although vascular and especially neural injuries are still relatively frequent in patients with large or bilaterally resected tumors. The baroreflex failure syndrome (BFS) has recently been identified as a severe, rarely recognized, and certainly underestimated complication after the bilateral excision of CBTs. The present report describes a case of a bilateral CBT followed by BFS and reviews the experiences reported in the literature. In light of the low incidence of malignancy of these tumors, their biologic behavior, their very high rate of cranial nerve palsy, and the occurrence of BFS in bilaterally resected paragangliomas, the current practice of bilaterally removing these tumors is questioned.     

A multidisciplinary approach to carotid paragangliomas

The surgical management of carotid paragangliomas can be problematic. A multidisciplinary approach was used to include vascular surgery, otolaryngology, and neuroradiology to treat these patients over 9 years. From January 1992 to July 2001, a multidisciplinary team evaluated patients with carotid paragangliomas. Analyzed patient data included age, gender, diagnostic evaluation, tumor size, preoperative tumor embolization, operative exposure, need for extracranial arterial sacrifice/reconstruction, postoperative morbidity including cranial nerve dysfunction, and long-term follow-up. Twenty-five carotid paragangliomas in 20 patients underwent multidisciplinary evaluation and management. Average age was 51 years (range, 28-83 years), and 52% were male. Diagnostic evaluation included computed tomography in 76%, magnetic resonance imaging/magnetic resonance angiography in 52%, catheter angiography in 60%, and duplex ultrasonography in 16%. An extended neck exposure was required in 11 cases (44%), mandibulotomy was used once (4%), and mandibular subluxation was never required. The external carotid artery (ECA) was sacrificed in 8 cases (32%). The carotid bifurcation was resected in 1 patient (4%) requiring interposition reconstruction of the internal carotid artery. Preoperative tumor embolization was performed for 13 tumors (52%). Operative blood loss for patients undergoing preoperative embolization (Group I) was comparable to the nonembolized group (group II): group I lost 365 +/-180 mL versus 360 +/- 101 mL for group II (P = .48). This occurred despite larger tumors (group I - 4.2 cm versus group II - 2.1 cm, P = .03) and a higher mean Shamblin class (group I - 2.5 versus group II - 1.45, P = .001) for group I. There were no perioperative mortalities. Transient cranial nerve dysfunction occurred in 13 CBTs (52%), 2 (8%) of which remained present after 4 months. Patients with carotid paragangliomas benefit from a multidisciplinary team approach. Neuroradiology has been used for selective preoperative embolization, which has decreased estimated blood loss during excision of larger complex tumors. A combined surgical team of otolaryngology and vascular surgery provides for exposure of the distal internal carotid artery as high as the skull base, limited permanent cranial nerve dysfunction, and selective early division and excision of the external carotid artery for complete tumor resection.     

Cranial and neck nerve injuries following carotid endarterectomy intervention. Review of the literature

The aim of the study was to establish the operative techniques and findings that can influence the reported incidence of cranial and cervical nerve injuries. Eight main studies comprising 1,616 carotid endarterectomies and published over the period from 1990 to October 2000 were reviewed. There were no statistically significant differences between neck incision (vertical or transverse) and number of injuries. In one study, multiple deficits were observed most frequently in patients treated by the eversion technique (P = 0.2). Additional prospective trials are needed in large numbers of patients to assess the incidence of cranial and cervical nerve injuries. Most injuries are transient and involve the vagus and hypoglossal nerves. A number of factors related to the operation, such as general anaesthesia, eversion technique and the surgeon's experience, may influence the incidence of such injuries. Repeat endarterectomy is associated with a high incidence of cranial and/or cervical nerve injuries. This is extremely important for establishing the real advantage of endovascular angioplasty or stenting of the carotid artery.     

Acoustic neuromas

Opinion statement Patients with acoustic neuromas have several treatment options that include observation, surgical resection, stereotactic radiosurgery, and fractionated radiotherapy. Resection is indicated for patients with larger tumors that have caused major neurologic deficits from brain compression. Surgeons perform stereotactic radiosurgery as the main alternative to acoustic tumor resection with the goals of preserved neurologic function and prevention of tumor growth. The long-term outcomes of radiosurgery, particularly with gamma knife technique, have proven its role in the primary or adjuvant management of this disease. Radiotherapy can be offered to selected patients with larger tumors in whom radiosurgery may not be feasible. Patients with neurofibromatosis type-2 pose specific challenges, particularly in regard to preservation of hearing and other cranial nerve function. The primary clinical issues include avoiding tumor-related or treatment-related mortality, prevention of further tumor-related neurologic disability, minimizing treatment risks such as spinal fluid leakage, infections, or cardiopulmonary complications, maintaining regional cranial nerve function (facial, trigeminal, cochlear, and glossopharyngeal/vagal), avoiding hydrocephalus, maintaining quality of life and employment, and reducing cost. All treatment choices should strive to meet all of these goals.