Chung SM et al.: A Clinical Review of 9 Cases of Jugular Foramen Paragnaglioma 31 Table 2. Treatment outcome of 9 cases Cases Approach : extent of removal Additional treatment Complication Follow-up (months) 1 2 3 4 5 6 7 8 9 ITFA type A : TR ITFA type A : PR ITFA type A : TR ITFA type A : TR ITFA type A : PR ITFA type A : TR ITFA type A : TR ITFA type A : PR ITFA type A : TR None GKS None None Revision Op. GKS Arytenoid adduction None Arytenoid adduction GKS Arytenoid adduction None ITFA: infratemporal fossa approach; TR: total resection; PR: partial rection; GKS: gamma knife surgery; SNHL: sensorineural hearing loss; CN: cranial nerve. Fig. 3. Angiography showing ascending pharyngeal artery as tumor feeding vessel. 11th and 12th nerve palsy were newly developed post-operative- ly. Three patients received arytenoid adduction, 2 cases due to unilateral vocal cord palsy, and one case due to decreased vocal cord mobility. In other case, left vocal cord palsy developed, but the patient did not undergo arytenoid adduction since symptom due to vocal cord palsy was not prominent. DISCUSSION Our collected data showed some differences from the previous reports on jugular foramen paraganglioma. In previous reports, jugular foramen paraganglioma is known to occur predominant- ly in the age of 50 to 60, and female to male ratio is reported to be 5:1 (1, 2). However, the female to male ratio was 5:4, and tumors were detected at the mean age of 40.8 yr in our data, even though the age of detection was distributed widely, not being fo- Transient facial palsy Vocal cord palsy (L) SNHL (Deaf) None Transient facial palsy SNHL (Deaf) Transient facial palsy Transient facial palsy 11th, 12th CN Palsy None None 264 144 84 35 108 104 36 33 29 cused to certain age group. Our data showed no significant pref- erence to certain sex, age and site, in terms of incidence. Most common initial presenting symptom at the time of first visit to the outpatient was hoarseness, whereas the most common presenting symptom is known to be pulsatile tinnitus, followed by hearing loss in the previous reports (2, 7). Lower cranial nerve dysfunction is relatively common with glomus jugulare tumors and includes dysphagia, hoarseness, aspiration, tongue paralysis, shoulder drop, and voice weakness (3, 5, 7). Our result was con- sistent with that, and 7 out of 9 patients showed at least one low cranial nerve palsy, emphasizing the importance of neurologic evaluation of low cranial palsy at the time of first visit. Emphasis should also be given on the fact that patients without pulsatile tinnitus should not be excluded from the suspicion of jugular fora- men paraganglioma. Facial nerve paralysis is known to occur less commonly, but it signals advanced disease and is related with poor facial nerve prognosis outcome (3, 5, 7). Our data was consistent with the reports. Facial palsy was present in 2 cases in our data and both cases were advanced jugular foramen paragangliomas. Facial nerve function was not restored from the initial facial nerve palsy after the operation in both cases. On imaging evaluation with MRI, 7 patients were Type C tumors and remaining 2 cases were Type D tumors. It correlates with the fact that jugular foramen paragangliomas are slow growing and lack symptoms which results in the late diagnosis of the tumor (1, 3, 6). Successful embolization and surgical removal of tumor without massive bleeding were achieved in all cases. Ascending pharyngeal artery was the most common feeding vessel, as report- ed previously (11). Since the tumor is hypervascular in nature, angiography is crucial to identify main feeding vessels and em- bolize them prior to surgery which decreases the chance of mas- sive bleeding intraoperatively (11). Complete surgical resection is the ideal management of most jugular foramen paragangliomas (2, 5, 7-9). In our cases, all of the cases were approached with Type A infratemporal fossa ap-