2026 Proffered Presentations
S274: QUALITY OF LIFE OUTCOMES OF SUBPERINEURAL ONION-PEELING DISSECTION FOR MICROSURGICAL RESECTION OF VAGAL PARAGANGLIOMAS
Caryn J Ha, MSc1; 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 a rare subset of head and neck neuroendocrine tumors that arise along the vagus nerve near the skull base. Their proximity to critical neurovascular structures makes resection technically demanding and carries a substantial risk of postoperative lower cranial nerve morbidity, often leading to long-term impairment in swallowing, speech, and overall quality of life. Although stereotactic radiosurgery is increasingly favored for local tumor control, paragangliomas with SDH mutations progress aggressively, and surgery is the only curative option. There remains a need for surgical approaches that minimize functional morbidity and preserve quality of life.
Objective: To evaluate the quality of life 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 and tumor characteristics. Quality of life was measured using validated instruments: the University of Washington Quality of Life Questionnaire (UW-QoL version 4.1), the Voice Handicap Index-10 (VHI-10), and the Eating Assessment Tool-10 (EAT-10). To capture patient-reported satisfaction, an additional single-item question was included: “If you had to do this operation all over again, would you make the same choice?” VHI-10 scores were stratified by dysphonia severity: mild (11-17), moderate (18-28), and severe (>28). EAT-10 scores were stratified by dysphagia severity: mild (3-7), moderate (>7), and severe (>15). Questionnaires were administered to patients with a minimum follow-up of 6 months.
Results: Of the 18 patients, 72.2% (n=13) completed the questionnaires in which 61.5% (n=8) were female and 38.5% (n=5) were male. Genetic mutations associated with paragangliomas were identified in 46.2% (n=6) of respondents, all of which were SDH mutations. The vagal nerve was anatomically preserved in 92.3%(n=12) of these patients. On UW-QoL, the highest mean scores were observed for swallowing (93.1 + 13.2), saliva (93.1 + 13.2), and chewing (92.3 + 18.8). The lowest mean scores were for mood (65.4 + 29.8) and shoulder function (73.8 + 37.3). The mean VHI-10 was 14.2 + 7.7 (median 13, IQR:12-16, range 2-31). The majority of patients (76.9%, n=10) had normal or mild voice impairment, while 15.4% (n=2) had moderate, and 7.7% (n=1) had severe. The mean EAT-10 score was 4.4 + 4.2 (median 2, IQR:2-7, range 0-14). Most patients (76.9%, n=10) had normal or mild swallowing impairment, while 23.1% (n=3) had moderate, and 0.0% had severe. Patient satisfaction with surgery was high, with 92.3% (n=12) reporting they would make the same choice to undergo the operation again.
Conclusion: The subperineural onion-peeling technique demonstrates high rates of vagal nerve preservation, patient-reported satisfaction, and favorable quality of life outcomes. These results suggest a valuable approach for the surgical management of vagal paragangliomas associated with low treatment-related morbidity.