Many jugular paragangliomas are indolent and can be observed for several years without risk of rapid growth. With this finding in mind, some authors [12, 13] have reviewed the role of limited surgery with the primary goal of symptom relief (Fig. 10.2). Cosetti et al. [12] treated three patients over the age of 70 with a limited resection that primarily addressed the middle ear component of tumors. All three patients had immediate relief of their pulsatile tinnitus after surgery, improved hearing, and no new cranial nerve deficits. One of these patients had radiologic progression 6 years after surgery, and this was treated with radiation therapy. Willen et al. [13] described similar subtotal resections in five patients over the age of 60 with Fisch class C3 tumors or greater; however, all patients in their series also underwent postoperative radiosurgery to the residual tumor. All patients had relief of their pulsatile tinnitus and stable or improved hearing. They reported no new lower cranial nerve deficits as a result of their treatment, and no tumors had grown after a mean of 19 months of follow-up. It should be noted that in the elderly population, subtotal resection has been described in symptomatic patients with a primary goal of symptom relief while avoiding cranial nerve injury. In asymptomatic patients with advanced age, conservative therapy can be considered.

Rarely, patients may present with symptomatic brain stem compression or hydrocephalus from advanced tumors. In these cases, primary radiation treatment is not advisable due to concerns for posttreatment swelling leading to progressive brain stem compression. While gross total resection is still preferred in young, relatively healthy patients, it can be extremely challenging and cause unnecessary morbidity in patients of advanced age or limited life expectancy. In this scenario, performing a subtotal resection with the primary goal of brain stem decompression is a viable strategy. Carlson et al. [14] described four cases of advanced (Fisch grade D₂) jugular paragangliomas who presented with significant brain stem compression. Subtotal resections were performed in three of these via a combined transtemporal and transcervical approach. All three patients eventually received postoperative radiation treatment to their residual tumor. Successful decompression, as well as, long-term tumor control was achieved in all three patients with 6–9 years of follow-up.

Wanna et al. [15] described subtotal resection in 12 patients with Glasscock-Jackson grade 3 or 4 tumors and intact lower cranial nerves (Fig. 10.3). In eight (66.7%) cases, no subsequent growth was observed after surgery with a mean follow-up of 3.7 years. The remaining four tumors grew at an average of 2 years after surgery. It was noted that the latter cases had significantly higher residual tumor following subtotal resection compared to those that showed no growth (59.2% vs. 11.9%). Moreover, no cases achieving greater than 80% of tumor resection when comparing pre- and postoperative imaging showed postoperative growth. There were no new permanent cranial nerve deficits following surgery in any of the cases, and no patient experienced carotid injury.