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Bilateral vagal paragangliomas

Case contributed by Dr Andrea Posteraro


A 45-year-old man presented with a 1-year history of right neck swelling. He reported increasing episodes of flushing, dizziness, migraine-type headaches, voice changes, and pain, which interrupted her daily activities. On examination, he was normotensive and had a right neck mass at level II; the superior border extended deep to the mandible. Complete head and neck examination, including flexible laryngoscopy and cranial nerve examination, was unremarkable.

Patient Data

Age: 45 years
Gender: Male

A 3-Tesla MRI scan showed two symmetrical masses, both in right and left carotid spaces with following features:

  • T1: hypo-intesity of masses on basal scan.
  • T1+C: a rapid wash-in and wash-out (as opposed to the more slow and steady enhancement of a schwannoma).
  • T2: bilateral masses with high signal with multiple flow voids, which may give a salt and pepper appearance; salt being blood products from haemorrhage (uncommon) and pepper being flow voids due to high vascularity (common).

 Right vocal cord paralysis was also reported.

Case Discussion

Vagal paragangliomas are uncommon tumours of the parapharyngeal space that present with distinct clinical and pathological characteristics that differentiate them from similar head and neck tumours. Epidemiology, tumour biology and radiologic appearances are well known but some controversies exist in diagnosis and treatment modalities. Pre-operative diagnosis of the tumour and prevention of postoperative neurological deficits are issues that are still unresolved. Adjunctive procedures to facilitate the rehabilitation of the patients do not seem to reduce post-operative neurological troubles and are not a standardized cure.

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Case information

rID: 58595
Case created: 24th Feb 2018
Last edited: 28th Feb 2018
System: Head & Neck
Inclusion in quiz mode: Included
Institution: University of Parma

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