Vagal paragangliomas are uncommon, vascular tumors that can present in the head and neck region. They may involve the lower neck, parapharyngeal space, or extend intracranially and often involve the lower cranial nerves. An appropriate preoperative evaluation determines appropriate surgical candidates and allows counseling patients about postoperative cranial nerve deficits. This article discusses the surgical management of these complex tumors. © 2004 Elsevier Inc. All rights reserved.