Chung SM et al.: A Clinical Review of 9 Cases of Jugular Foramen Paragnaglioma 29 residual tumors when gross total removal of extensive tumor could not be carried out (10). Control of jugular foramen paraganglioma ranged from 85 to 100% (10). Gamma knife surgery is recently introduced and can be used as a primary tool in cases without significant cervical extension or in patients with recurrent tumors in intracranial area (10). To identify the clinical characteristics and most effective sur- gical approach, the authors have made a retrospective analysis of the patterns of clinical presentation, surgical approaches and treatment outcomes in 9 patients with jugular foramen paragan- glioma who underwent surgical treatment. MATERIALS AND METHODS This study included 9 patients with jugular foramen paraganglioma confirmed by permanent pathologic reports. The patient group consisted of 4 men and 5 women who underwent surgery by a single surgeon between 1986 and 2005. Mean age at the time of diagnosis was 40.8 yr, ranging from 26 to 60 yr. Follow up peri- od was 29 month to 264 months, with mean follow up period of 93 months. Five cases occurred on the right side and remaining 4 cases on the left, and there was one case where bilateral lesion was detected. Review of clinical records was performed, analyzing initial clini- cal symptoms and signs, audiological examinations and neurolog- ical deficits, radiological features, surgical approaches, extent of resection, treatment outcomes and postoperative complications. The extent of jugular foramen paraganglioma was classified according to Fisch classification, based on radiological findings. The extent of removal was determined according to intraopera- tive findings and postoperative imaging study. RESULTS Initial aymptoms and signs Most common initial symptom at the time of first outpatient visit Table 1. Clinical presentation of 9 cases was hoarseness which was observed in 4 patients, followed by pulsatile tinnitus which was noted in 3 cases (Table 1). Sudden sensorineuronal hearing loss in 2 patients, facial palsy in 2 patients and neck mass in 1 patient were also reported. All patients except for 2 cases had at least one low cranial nerve palsy on evalua- tion. Most common neurologic deficit on presentation was 10th nerve palsy, followed by 9th nerve, 12th nerve, and 7th nerve in order. Results of MRI and angiography Magnetic resonance imaging (MRI) and angiography were per- formed in all cases. The extent of jugular foramen paragangliomas were classified according to Fisch classification with radiologic findings of MRI. Seven patients were classified as Type C (Fig. 1) and remainnig 2 patients were Type D (Fig. 2). Size of the tumor varied from as small as 1.5×1 cm to as large as 4.5×9 cm. On angiography, all tumors had at least one main feeding vessel. Ascending pharyngeal artery was the most common feeding vessel, and successful embolization of the feeding ves- sel was achieved in all cases (Fig. 3). Surgical result Nine patients underwent a total of 11 operations (Table 2). Type A infratemporal approach alone was used in all cases. Complete resection was achieved in 6 patients, and all of them is under reg- ular outpatient follow-up without any sign of recurrence. All type D tumors resulted in partial resection and 1 out of 7 Type C tumors was partially resected. The residual tumor in the 2 cases of Type D jugular foramen gangliomas was the portion of intracranial ex- tension. In one type D tumor case (case 5), 1 cm sized residual tumor was suspected in postoperative MRI after first operation in 1999. The patient received gamma knife radiosurgery (GKS) on the remnant tumor and was continuously observed with MRI at the outpatient. However, the patient had to undergo revision operation in cooperation with neurosurgery department in 2006 because the tumor mass grew as large as 4 cm. Tumor still remain- ed after the second operation and revision operation by neuro- surgery department was performed in 2007, still resulting in small Cases 1 2 3 4 5 6 7 8 9 Sex/ age F/32 M/35 M/26 M/48 M/45 F/50 F/60 F/29 F/42 Site Left Right Left Left Left Right Right Right Right Initial Sx. Pulsatile tinnitus (L), headache Facial palsy (R) Pulsatile tinnitus (L), otalgia (L) Hoarseness Hoarseness chronic cough S-SNHL (R) Hoarseness Hoarseness, facial palsy (L) SNHL (L), pulsatile tinnitus (L) Neurologic deficits None 7th CN Palsy None 10th CN Palsy 9th, 10th, 11th, 12th CN Palsy 9th, 10th, 12th CN Palsy 10th CN Palsy 7th, 9th, 10th, 12th CN Palsy 9th CN Palsy Imaging classification Type C (1.5×1 cm) Type C (3×3 cm) Type C (3×2 cm) Type C (2.2×2 cm) Type D (4.5×3.5 cm) Type C (2.2×2.5 cm) Type C (4.5×2.2 cm) Type D (4.5×9 cm) Type C (2.5×1.5 cm) Tumor feeding vessels APA APA, OA APA APA APA, OA APA, OA, PAA OA, APA PAA, OA APA CN: cranial nerve; APA: ascending pharyngeal artery; OA: occipital artery; PAA: posterior auricular artery; SNHL: sensorineural hearing loss.