Review of the experience of a single institution with a rare tumor may give inadequate and biased information. In an effort to better understand issues related to diagnosis and subsequent management of paraganglioma of the vagus nerve, review of the experience at two university medical centers was undertaken. A review of the records of all patients with a diagnosis of vagal paraganglioma at the University of Pittsburgh and the Eastern Virginia Medical School was undertaken. Presenting signs and symptoms, treatment, and subsequent outcome were assessed. Data on 19 patients with vagal paraganglioma were available. The most common initial finding was a neck mass. Forty-seven percent (9/19) had vocal cord paralysis at presentation. Angiography was beneficial in helping to make the diagnosis and in identifying synchronous tumors. History of familial paraganglioma was present in 47% (9/19). Multiple paragangliomas were diagnosed in 53% (10/19) cases in our study. Of the patients with familial vagal paraganglioma, 89% (8/9) had multiple paraganglioma. All patients treated with surgery had postoperative vocal cord paralysis. Elective management of patients with bilateral vagal paraganglioma is a special dilemma. Radiation therapy of selected "operable" patients may be indicated because of the potential for bilateral vocal cord paralysis in these patients and its attendant sequela.