Advances in the Management of Skull Base and Carotid Paragangliomas

The current management of head and neck paragangliomas has been highly impacted by advances in technology over the past 25 years. Enhanced MR imaging, preoperative angiography and embolization, intraoperative cranial nerve monitoring, stereotactic radiation, genetic testing, and improved surgical access and techniques have altered the treatment of these relatively rare tumors.

This is a 20-year consecutive series of 157 patients with 197 tumors managed by our group between the years 1995 and 2015. A high incidence of patients with multiple tumors was noted and the influence of altitude on the number of patients seen in our case series was very evident. The effect of preoperative angiography and embolization on blood loss and the need for transfusion will be presented. Intraoperative cranial nerve monitoring, use of the operating microscope for mobilizing cranial nerves, and resorting to subtotal tumor resection to preserve cranial nerves to improve outcomes will be highlighted. Patient outcomes data with regard to preoperative and postoperative cranial nerve function will be reviewed. Additional outcomes and complications with regard to the need for carotid artery replacement, cerebrovascular accidents, swallowing and voice dysfunction, and length of hospitalization will be examined and presented.

Treatment options with regard to surgery, radiation therapy, or serial imaging and follow-up will be outlined while presenting our evolving approach to the management of these patients. Controversial aspects such as primary radiation therapy versus surgical treatment, timing and decision making regarding surgical treatment, and the management of patients with multiple tumors will be discussed. Surgical techniques for improving access to the parapharyngeal space and infratemporal fossa and the management of cranial nerves to minimize morbidity will be emphasized.