2026 Proffered Presentations
S015: FUNCTIONAL OUTCOMES OF SUBPERINEURAL ONION-PEELING DISSECTION FOR MICROSURGICAL RESECTION OF VAGAL PARAGANGLIOMAS
Caryn J Ha1; Shrey B Shah, BA1; Raj Malhotra, MD1; Rachel Kaye, MD, FACS1; James K Liu, MD, FAANS, FACS2; 1Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; 2Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
Introduction: Vagal paragangliomas are rare neuroendocrine tumors originating from the autonomic ganglia of the vagus nerve. Optimal treatment remains controversial, as surgical resection carries a significant risk of lower cranial nerve morbidity. Advancements in microsurgical techniques are critical to reducing complications and improving functional outcomes.
Objective: To evaluate the clinical features and functional outcomes in patients who underwent microsurgical resection of vagal paragangliomas using the subperineural onion-peeling technique.
Methods: A retrospective review was conducted of 18 patients who underwent the subperineural onion-peeling technique by a single surgeon between January 2012 and January 2025. Data collected included demographics, presenting symptoms, tumor characteristics, complications, and functional oral recovery, assessed by modified barium swallow and laryngoscopy. Time to functional oral intake was defined as the earliest date the patient tolerated a diet of multiple consistencies: thin liquids and pureed, chopped, or soft solids.
Results: Of the 18 patients, 66.7% (n=12) were female, and 33.3% (n=6) were male. The mean age at the time of resection was 42.1 years (SD + 13.8, range: 16-60). Genetic mutations were associated with 50.0% (n=9) tumors. The mean tumor size was 39.3 mm (SD + 17.3), with 50.0% (n=9) extending into the jugular foramen. Tumors were left-sided in 61.1% (n=11) of cases, right-sided in 27.8% (n=5), and bilateral in 11.1% (n=2). Six patients (33.3%) had functional tumors, in which two secreted norepinephrine, two secreted dopamine, and two secreted both dopamine and epinephrine. The most common presenting symptoms were dysphonia or hoarseness (77.8%, n=14), followed by dysphagia (61.1%, n=11). Gross total resection was obtained in 77.8% (n=14) and near total resection in 22.2%(n=4). The vagal nerve was anatomically preserved in 88.9% (n=16) of patients. Post-operative complications included hematoma (5.6%, n=1), transient facial palsy (5.6%, n=1), stroke (5.6%, n=1), and first bite syndrome (11.1%, n=2). Mean length of hospitalization was 10.7 days (SD + 6.8, range: 4-30 days). No patients required tracheostomy during admission, and 88.9% (n=16) were discharged without a feeding tube. Within the first eight postoperative days, 72.2% of patients achieved functional oral intake. By 1 month, 88.9% of patients had recovered, increasing to 94.4% by 2 months, and 100% by 14 months. Median length of follow-up was 5.2 months (range: 1-98.8 months). No recurrences were reported at last follow-up.
Conclusion: The subperineural onion-peeling technique is associated with high rates of near-to-gross total resection with vagal nerve preservation and excellent functional outcomes. All patients regained functional oral intake, and no recurrences were observed. These findings support its utility in reducing morbidity while maintaining effective tumor control.