ment in some cases, and may be the treatment modality of choice in recurrent/residual disease. The aim of treatment is to prevent further growth rather than to eradicate the disease.

The intricate temporal bone anatomy, the extent of tumor invasion and tumor vascularity combine to make these tumors difficult to manage by any mode of therapy. The critical question to be asked is whether the disease is likely to cause the patient serious problems in the natural course of his/her remaining years. At one end of the spectrum, a large tumor in a young, fit patient almost certainly warrants surgical treatment, whereas a small tumor in an elderly patient probably needs nothing more than careful review. Unfortunately, there is a "gray area" between these two ends of the spectrum although, currently, many would consider surgery as the first-line treatment. The judicious use of surgery is imperative, since an iatrogenic deficit involving the last four cranial nerves may pose life-threatening complications to an older patient with poor respiratory reserve.

Contraindications to surgical treatment include:

• Carotid involvement in the presence of poor collateral circulation.

• Contralateral vagus lesion - surgery that compromises the only functional vagus is a relative contraindication.

• Unresectable tumor - a neurosurgically unresectable intracranial extension is a relative contraindication.

• Anomalous venous drainage - where all intracranial venous return occurs via a single sigmoid sinus on the involved side. In this situation, it may be better to await complete occlusion of the jugular bulb (which allows progressive opening of collateral venous channels) before operating.

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