This paper offers a very good overview of a large topic that encompasses a multitude of tumors, each with its own set of controversial issues in terms of diagnosis and management. The authors discuss the various diagnostic and therapeutic options available for these tumors in a general sense, rather than concentrating on the specifics of each pathology. Although this approach certainly provides a satisfactory overview, it does not delineate the many diagnostic and therapeutic dilemmas that may confront the practicing head and neck surgeon. However, given the space limitations for such a paper, a more detailed discussion probably was infeasible.
The authors offer a good summary of diagnostic testing. However, they do not clearly state whether computed tomography (CT) or magnetic resonance imaging (MRI) should be the screening modality of choice, or, as is my belief, whether both should be ordered, as they tend to supply complimentary information.
Although angiography has always been the standard diagnostic procedure to evaluate vascular tumors, with the increasing use of magnetic resonance angiography (MRA), angiography can be avoided in many situations. I believe that most paragangliomas, other than carotid body tumors, require embolization. Therefore, I usually perform angiography on the day before surgery in conjunction with embolization.
Caveats Regarding Surgery
Although the article addresses all surgical therapeutic options, albeit briefly, in my opinion intraoral resection should be condemned more strongly, particularly for the occasional surgeon. Inadequate excision and tumor seeding, not to mention uncontrollable hemorrhage from major vessel laceration and nerve damage, are all potential consequences of such an approach.
The authors also mention techniques that increase exposure to both the parapharyngeal space and skull base. However, it should be stressed that it is rare for mandibulotomy to be needed, except in extremely large or very vascular tumors, or in cases where control of the distal internal carotid artery is essential. In my experience, mandible dislocation does not offer any meaningful improvement in exposure.
Finally, it should be emphasized that resection of many of these benign tumors can result in cranial nerve palsies, which can have disastrous consequences, particularly in the elderly patient. Therefore, if vagal palsy is a possibility, patients should be well prepared regarding the potential consequences, including the effects on speech and swallowing. Failure to do so can lead to a very unhappy patient and a difficult rehabilitation. Therefore, the pros and cons of resection should be clearly discussed with the patient and family before a surgical procedure is performed. In many patients, particularly those who are elderly, watchful waiting is not an unreasonable alternative as long as one is sure that the lesion is benign.