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.
Persky
Mark S
MS
Department of Otolaryngology-Head and Neck Surgery, Beth Israel Medical Center, 10 Union Square East, New York, New York 10003, USA. mpersky@bethisraelny.org
Setton
Avi
A
Niimi
Yasunari
Y
Hartman
Jonathan
J
Frank
Douglas
D
Berenstein
Alex
A
D000328:Adult; D000368:Aged; D000792:Angiography; D016063:Blood Loss, Surgical; D002345:Carotid Body Tumor / Q000000981:diagnostic imaging / Q000601:surgery*; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic; D005260:Female; D006258:Head and Neck Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010235:Paraganglioma / Q000000981:diagnostic imaging / Q000601:surgery*; D010348:Patient Care Team; D016896:Treatment Outcome