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.     

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.     

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.     

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.     

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.     

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.     

Successful patient outcome following surgery of carotid body tumor and temporary hypoglossal nerve dysfunction

Carotid body tumors, also known as paragangliomas or chemodectomas, are rare tumors. They are mostly benign slow-growing tumors arising from neural crest cells, but can give rise to complications because of their location and close relation to carotid vessels and cranial nerves. A 40-year male patient diagnosed with a carotid body tumor is discussed along with a review of cranial nerve complications associated with the management of carotid body tumors. This case highlights the complete recovery after a temporary hypoglossal nerve deficit following surgery. Another important aspect is that syncopal attacks might occur in carotid body tumors and early surgery is required to prevent complications.     

Sympathetic paraganglioma as an unusual cause of Horner's syndrome

BACKGROUND: Paragangliomas are rare tumors arising from paraganglionic tissue of neural crest origin. They are present in any location where autonomic ganglia are found. The most common location in the head and neck is the carotid body, followed by the jugular bulb and vagus nerve. METHODS: A 30-year-old woman with a slowly growing left neck mass, aniscoria, and left eyelid ptosis was found to have a vascular tumor consistent with a paraganglioma arising near the left carotid bifurcation. After preoperative embolization, the patient underwent resection of the tumor. RESULTS: The tumor was found to be arising from the left sympathetic trunk and did not involve any other surrounding structures. Histopathologic analysis revealed the typical findings of a paraganglioma. CONCLUSIONS: Sympathetic paragangliomas are exceedingly rare tumors in the head and neck and should be considered in the differential diagnosis when clinical and radiographic evidence suggest a paraganglioma. The presentation is typically a slow-growing neck mass with the presence of an ipsilateral Horner's syndrome.     

Bilateral carotid body tumor resection in a female patient

IntroductionCarotid body tumors also called carotid paragangliomas are rare neuroendocrine neoplasms derived from neural crest cells, approximately 3% of all paragangliomas occur in the head and neck area (Xiao and She, 2015); although they represent 65% of the head and neck paragangliomas (Georgiadis et al., 2008).Presentation of caseWe present the therapeutic management of a 65-year-old woman with bilateral carotid body tumors. The patient presented to medical clinic for unrelated signs and symptoms of weight loss, dyspepsia, and epigastric pain. Physical examination showed bilateral non-tender neck masses for which imaging studies were ordered resulting in the diagnosis of bilateral carotid tumor. Surgical resection was staged with one week of distance between each tumor resection.DiscussionCarotid Body Tumors can arise from the paraganglia located within the adventitia of the medial aspect of the carotid bifurcation.Resection is the only curative treatment. Carotid body tumors resection represents a special challenge due to potential neurovascular complications.ConclusionsSurgical resection of carotid body tumors represents a special challenge to the surgeon because of the complex anatomical location of the tumor, including close relationship with the cranial nerves, involvement of the carotid vessels and large vascularization of the tumor. With the advance of diagnosis and improvement in surgical techniques as well as the understanding of biological behavior of tumors, surgical treatment has become a safer alternative for treating these tumors.     

A pediatric carotid body tumor

Carotid body tumors are rare childhood extra-adrenal paragangliomas. We present an 8-year old female with a neck mass mistaken as reactive lymphadenopathy. Computed tomography and magnetic resonance angiography, as well as preoperative embolization and balloon test occlusion, were utilized for planning and management. Surgical excision of the tumor was successful and pathological examination revealed a benign paraganglioma. Surgical treatment is curative for these benign lesions, however rare cases have presented years later with metastatic disease. Therefore, a child, like our patient, will require lifelong surveillance for the development of potential metastasis.     

Surgical management of carotid body tumors.

OBJECTIVE: The goal was to review our experience in the management of carotid body tumors at a tertiary referral center. METHODS: A retrospective review was performed of patients at University of California-Los Angeles Medical Center in whom carotid body tumor was diagnosed between 1973 and 1998. RESULTS: Twenty-nine patients with 36 carotid body tumors were identified. Thirty-five operations were performed. Seventeen patients underwent preoperative embolization. The blood loss for these patients was less than for those without embolization. Five patients had preoperative cranial nerve deficits. Neurologic deficits were noted in 41% of patients immediately after surgery. In 24% of patients, the deficits were permanent. CONCLUSION: Surgical resection is the treatment of choice for carotid body tumors. Embolization immediately before surgery decreases blood loss and facilitates tumor removal. In our series, the risk of new postsurgical cranial nerve deficits was small. Observation of these tumors is not recommended because progressive growth is associated with increased risk of neurologic deficits.     

中枢神经系统副神经节瘤的诊断与治疗

目的 探讨中枢神经系统副神经节瘤的诊断和治疗特点。方法 1976－999年手术治疗17例副神经节瘤,其中厮静脉球瘤11例,椎管内转移性副神经节瘤2例,颈动脉体瘤、鞍区副神经经节瘤、颞骨副神经节瘤及顶叶转移性副神经节瘤各1例。术中采用系统动脉压降压3例,亚低温麻醉1例;术前行血管内栓塞治疗7例;术后联合普通放疗5例,联合γ－刀治疗2例。结果 肿瘤全切除11例,次全切除例,大部切除3例。术后10d死亡1例,远期随访6个月－6年,1例格拉斯哥预后评分（GOS）3分,其余均4－5分。结论 临床表现结合影像学特点有助于临床诊断。手术全切除肿瘤为治疗首选方案,术后复发率低;术前栓塞应作为常规辅助治疗,可有效控制术中出血;术后放射治疗可控制残留肿瘤的生长。     

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.     

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.     

A contemporary assessment of carotid body tumor surgery

Carotid body tumor resection remains a surgical challenge traditionally associated with a 15-30% incidence of cranial nerve injury. The authors reviewed their experience with carotid body tumor surgery to determine whether contemporary awareness of carotid body tumors is leading to earlier detection and operation, resulting in a lower incidence of postoperative cranial nerve injury. Twenty-seven carotid body tumors were resected in 25 patients between 1990 and 2000. No patient died and no patient had postoperative baroreflex failure syndrome. There was 1 stroke (4%) in a patient who required ligation of the internal carotid artery. There were 9 cranial nerve injuries (33%), most commonly to the vagus or hypoglossal nerves, which was not significantly different from the rate of cranial nerve injury (44%) in the 9 patients operated upon between 1984 and 1989 (p=0.37, Fisher's exact test). Multivariate analysis demonstrated that tumor size was the only significant factor predicting cranial nerve injury (p=0.045, logistic regression). Since carotid body tumors with large size or higher Shamblin grades had predictably high operative blood loss and rates of postoperative cranial nerve injury, a high index of suspicion and aggressive surgical management may lead to earlier detection and operation on smaller tumors, ultimately reducing the risk of nerve injury. Nevertheless, carotid body tumor surgery appears to be relatively free of mortality and major morbidity in contemporary practice.     

Primary intraosseous paraganglioma of the sacrum: a case report

BACKGROUND CONTEXT: Paragangliomas are neuroendocrine tumors that most frequently arise in the adrenal medulla, carotid body, and glomus jugulare. However, they have been reported in many other sites throughout the body. Within the central nervous system, the overwhelming majority of paragangliomas arise intradurally in the area of the cauda equina. We report a case of a woman who presented with back pain and radiculopathy and was found to have an intraosseous sacral mass on magnetic resonance imaging (MRI). Operative biopsy revealed that this lesion was a paraganglioma. Chest, abdomen, and pelvis computed tomography scans revealed no other tumors. This lesion was treated with limited resection, decompression, stabilization, and radiation therapy. PURPOSE: To report a rare case of an intrasacral paraganglioma that presented with back pain and radiculopathy and was treated with intralesional decompression, stabilization, and radiation. STUDY DESIGN: Observational case report. METHODS: A 69-year-old woman presented with back and leg pain. An MRI scan revealed a grade II spondylolisthesis at L5/S1 and a left-sided intraosseus mass at S1 with significant obstruction of the left S1 nerve root foramen. The patient underwent initially an open biopsy of this lesion that revealed a paraganglioma. Subsequently, she underwent transarterial embolization of this lesion, partial resection with decompression of the nerve root, and stabilization and arthrodesis from L4 to the ilium. RESULTS: Intraoperatively, a highly vascular lesion was encountered. The patient's back and leg pain improved significantly after surgery. She was referred for intensity-modulated radiation therapy. One year after surgery, she was neurologically intact without evidence of growth of the lesion. CONCLUSIONS: Only two cases of primary intraosseous sacral paragangliomas were reported in the past. We believe that paragangliomas should be included in the differential diagnosis of intraosseous sacral tumors. Optimal treatment of the lesions can be difficult because of their hypervascular nature and the high morbidity associated with complete surgical resection. Treatment should combine preoperative embolisation, surgical resection if possible, and radiation therapy.     

Preoperative embolization in the management of a mediastinal paraganglioma

Parangliomas are rare and highly vascular tumors of neuroendocrine cell origin which are treated by complete surgical resection. Preoperative embolization to reduce perioperative bleeding complications, although described in paragangliomas of the neck and carotid body, has never before been described in the case of a mediastinal paraganglioma. The following is a presentation of such a case of mediastinal paraganglioma, in which embolization was used successfully before surgical resection.     

颈动脉体瘤诊治的临床分析：附38例报告

目的：总结颈动脉体瘤（CBT）的临床特征与诊治经验。 方法：回顾性分析2008年10月—2019年4月在中南大学湘雅医院血管外科治疗的38例CBT患者资料,其中男14例,女24例;年龄23~76岁;单侧36例,双侧2例;40个瘤体中,Shamblin I型6个、II型12个、III型22个。 结果：所有患者均行颈部CTA或MRA明确诊断。38例患者中,3例单侧患者行保守治疗,其余35例患者共37个瘤体行手术切除治疗,其中1例手术患者术前行DSA检查并行双侧颈外动脉栓塞术。无术中死亡病例,手术平均时间（140±48）min,术中平均出血量（194±148）mL;Shamblin I型病变均行单纯CBT切除,Shamblin II、III型病变行单纯CBT切除或CBT切除+其他手术（颈部动脉离断、重建、结扎）。所有手术患者术后病理检查均证实为颈部良性副神经节瘤。术后发生短暂脑神经损伤8例,永久脑神经损伤2例,死亡1例。单纯CBT切除患者的神经损伤发生率明显低于CBT切除联合其他手术患者（P<0.05）。随访半月至10年,手术患者未出现肿瘤复发及其他并发症。3例保守治疗患者均带瘤生存。 结论：CTA或MRA为诊断CBT的首选方法,手术切除是CBT的首选治疗方法。手术方式的选择还需根据瘤体的大小形态以及分型决定。     

Preoperative embolization of carotid body tumors: When is it appropriate?

To determine when to use preoperative embolization, we retrospectively reviewed a consecutive series of concurrently treated patients who underwent carotid body tumor resection between 1984 and 1994. Eleven nonembolized tumors (N-EMB group) and 11 embolized tumors (EMB group) were resected. The two groups were similar with respect to demographics and presentation, with the exception that more patients in the EMB group complained of painful neck masses. There was no significant difference in the pretreatment size of the neck mass between the two groups (N-EMB = 4.3 ± 1.5 cm; N-EMB = 5.1 ± 2.1 cm). Zero to 6 days after embolization, surgical resection was performed. There was no difference in the distribution of tumors, which were grouped according to Shamblin's classification, between the N-EMB and EMB patients. Two patients in each group required resection of the internal carotid artery, whereas a total of seven cranial nerves were resected. There were no differences in blood loss, number of blood transfusions, operative time, or perioperative morbidity between the N-EMB and EMB groups. Ten patients had new cranial nerve deficits and four of these patients required treatment for tenth nerve paralysis. Overall the total hospital stay was similar in the two groups, but the EMB group had a significantly longer preoperative stay compared to the N-EMB group (1.5±0.8 vs. 0.8±0.4 days;p=0.02). These data show that preoperative embolization does not significantly improve outcome in patients undergoing resection of carotid body tumors measuring 4 to 5 cm. Therefore, in this era of cost-containment, preoperative embolization should not be used in the treatment of midsized carotid body tumors. Presented at the Fifth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Breckenridge, Colo., January 29, 1995.     

Trends in neurovascular complications of surgical management for carotid body and cervical paragangliomas: a fifty-year experience with 153 tumors

Almost 75% of carotid body and cervical paragangliomas are adherent to or surround adjacent arteries and cranial nerves. Their resection can result in neurovascular injury, stroke, and excessive blood loss. To assess trends in neurovascular complications, we reviewed 153 carotid body and cervical paragangliomas that were surgically managed between 1935 and 1985. Results of the past 10 years were compared with two previous time periods: period I (1935 to 1965), when carotid artery reconstruction was uncommon at our institution, and period II (1966 to 1975), when methods of intraoperative electroencephalographic monitoring and carotid patch angioplasty were being developed. During the past 10 years (period III), surgical approach to these tumors has included intraoperative monitoring of cerebral blood flow, selective use of shunts, vein patch or graft reconstructions after extensive tumor resections, and mobilization of the parotid gland to facilitate adequate exposure of high tumors. Although tumor resection was attempted in 80% of patients in period I, surgical resection was complete in 98% during periods II and III. Three trends were observed: (1) The perioperative stroke rate has decreased dramatically from 23% in period I to 2.7% in period III (p = 0.007); (2) the perioperative mortality rate has been reduced from 6% in period I to no deaths in the past 10 years, but (3) the rate of postoperative cranial nerve dysfunction remains unchanged over 50 years (period I, 46%; period III, 40%). The median tumor size among patients with postoperative complications was significantly larger than those without complications (median size: 17 vs. 7 cm3, p = 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)