The infratemporal fossa approach type A is the best way to deal with recurrent tympano-jugular paragangliomas because facial nerve rerouting is fundamental to reaching the area of the internal carotid artery, where recurrence is likely to occur. Preservation of lower cranial nerve function is not feasible when there is tumor infiltration of the medial wall of the jugular bulb; any attempt at nerve dissection increases the risk of leaving some tumor remnants. Correct management of the internal carotid artery, including preoperative stent insertion or permanent preoperative balloon occlusion, is usually a fundamental step when dealing with these highly vascularized lesions. Because of the tumor tendency to infiltrate the bony structures, aggressive drilling of the temporal bone is also advised, especially at the level of the petrous apex. Patients affected by uncontrolled recurrences still die of this disease.