Microsurgical Management Strategy in Multiple Paraganglioma Resection: Surgical Video

Introduction: Multiple head and neck paragangliomas are rare neuroendocrine tumors that present unique management challenges because of their multicentricity, close relationship with major neurovascular structures, and the need to preserve cranial nerve function. Careful staging and sequential surgical planning are essential to minimize neurological morbidity. We present the staged microsurgical management of synchronous bilateral carotid body tumors associated with a right jugular foramen paraganglioma. Case Report: A 46-year-old woman came with a firm, painless left-sided cervical mass and right-sided pulsatile tinnitus. Neurological examination demonstrated no cranial nerve deficits. Twenty-four-hour urinary vanillylmandelic acid (VMA) levels were within normal limits, excluding a functioning paraganglioma. Magnetic resonance imaging and computed tomography angiography demonstrated three synchronous paragangliomas: a right carotid body tumor (Shamblin type I), a right jugular foramen paraganglioma, and a left carotid body tumor (Shamblin type III) encasing the carotid bifurcation. Because the right jugular foramen lesion was responsible for the patient's pulsatile tinnitus and represented the most complex lesion, a staged surgical strategy was adopted. Seventy-two hours before surgery, the jugular foramen paraganglioma underwent selective endovascular embolization using calibrated microparticles, achieving significant devascularization. The first-stage procedure consisted of a modified Fisch type A infratemporal fossa approach, preserving the facial nerve in its anatomical position without anterior rerouting. Through the same cervical exposure, the right carotid body tumor was completely dissected from the carotid bifurcation and excised, followed by microsurgical resection of the jugular foramen paraganglioma. Careful microsurgical dissection allowed preservation of the lower cranial nerves, facial nerve, internal carotid artery, internal jugular vein, and surrounding neurovascular structures. Gross-total resection of both tumors was achieved. Results: The patient experienced complete resolution of pulsatile tinnitus and remained neurologically intact without new postoperative cranial nerve deficits. Six months later, the contralateral Shamblin type III carotid body tumor was resected through a standard transcervical approach. Because of its favorable vascular anatomy, preoperative embolization was not performed. Careful subadventitial microsurgical dissection allowed complete tumor removal while preserving the common, internal, and external carotid arteries, as well as the vagus and hypoglossal nerves. The postoperative course was uneventful, without vascular or neurological complications. Conclusion: Staged microsurgical treatment represents a safe and effective strategy for patients with multiple head and neck paragangliomas. Prioritizing the symptomatic and technically more complex lesion allows preservation of cranial nerve function while reducing overall surgical morbidity. A modified Fisch type A approach without facial nerve transposition provides excellent exposure for selected jugular foramen paragangliomas, and meticulous microsurgical technique permits safe resection of synchronous carotid body tumors with excellent functional outcomes.