Intratemporal hemangiomas involving the facial nerve: diagnosis and management

Surgical management of symptomatic hemangioma of the geniculate ganglion: fascicular-sparing resection or grafting?

Geniculate ganglion hemangioma (GGH) is rarely presented in the neurosurgical literature. It extends extradurally on the middle fossa floor and displaces the intratemporal part of the facial nerve. Surgical treatment is advisable at early symptoms. Proposed techniques include fascicular-sparing resection or nerve interruption with grafting. No definitive conclusions exist about the superiority of a certain technique in preserving facial nerve integrity and function. Through the description of a surgically managed symptomatic GGH, we herein discuss literature data about the surgical results of fascicular-sparing resection versus grafting. A PRISMA-based literature search was performed on the PubMed database. Only articles in English and published since 1990 were selected and furtherly filtered based on the best relevance. Statistical comparisons were performed with ANOVA. One hundred sixteen GGHs were collected, 56 were treated by fascicular-sparing resection, and 60 were treated by grafting. The facial function was improved, or unchanged, in 53 patients of the fascicular-sparing group and 30 patients of the grafting one. Sixty-five patients achieved a good (House-Brackmann (HB) grade III) postoperative facial outcome, of which 47 and 18 belonged to the fascicular-sparing and grafting group, respectively. Greater efficacy of the fascicular-sparing technique in the achievement of a better facial outcome was found (p = 0.0014; p = 0.0022). A surgical resection at the earliest symptoms is critical to preserve the facial nerve function in GGHs. Fascicular-sparing resection should be pursued in symptomatic cases with residual facial function (I-III HB). Conversely, grafting has a rationale for higher HB grades (V-VI). Broader studies are required to confirm these findings and turn them into new therapeutic perspectives.

Facial nerve paralysis associated with temporal bone masses

OBJECTIVE

To investigate the clinical and electrophysiological features of facial nerve paralysis (FNP) due to benign temporal bone masses (TBMs) and elucidate its differences as compared with Bell's palsy.

METHODS

FNP assessed by the House-Brackmann (HB) grading system and by electroneurography (ENoG) were compared retrospectively.

RESULTS

We reviewed 914 patient records and identified 31 patients with FNP due to benign TBMs. Moderate FNP (HB Grades II-IV) was dominant for facial nerve schwannoma (FNS) (n=15), whereas severe FNP (Grades V and VI) was dominant for cholesteatomas (n=8) and hemangiomas (n=3). The average ENoG value was 19.8% for FNS, 15.6% for cholesteatoma, and 0% for hemangioma. Analysis of the correlation between HB grade and ENoG value for FNP due to TBMs and Bell's palsy revealed that given the same ENoG value, the corresponding HB grade was better for FNS, followed by cholesteatoma, and worst in Bell's palsy.

CONCLUSIONS

Facial nerve damage caused by benign TBMs could depend on the underlying pathology. Facial movement and ENoG values did not correlate when comparing TBMs and Bell's palsy. When the HB grade is found to be unexpectedly better than the ENoG value, TBMs should be included in the differential diagnosis.

Management of Temporal Bone Hemangiomas

Temporal bone hemangiomas are rare tumors that require a high degree of clinical suspicion on the part of the otolaryngologist to be diagnosed early. The purpose of this report is to present 10 histologically confirmed cases of hemangiomas located within the temporal bone treated at the Gruppo Otologico of Piacenza-Rome, Italy. A short review of the literature is also presented. The symptomatology of these extraneural vascular tumors depends on their location. Tumors located within the internal auditory canal present mainly with hearing loss, while a facial nerve deficit is the predominant symptom in geniculate ganglion tumors. The treatment modality is also dependent on the location of the tumor, as well as the clinical features and tumor size. The final facial nerve outcome is directly affected by the duration of the facial nerve deficit, and so the treatment should not be delayed once the diagnosis is made.

Diagnosis and treatment of cavernous hemangioma of the internal auditory canal

OBJECTIVE

Cavernous hemangioma of the internal auditory canal (IAC) is an extremely rare type of tumor, and only 50 cases have been reported in the literature prior to this study. The aim in this study was to describe the symptomatology, radiological features, and surgical outcomes for patients with cavernous hemangioma of the IAC and to discuss the diagnostic criteria and treatment strategy for the disease.

METHODS

The study included 6 patients with cavernous hemangioma of the IAC. All patients presented with sensorineural hearing loss and tinnitus, and 2 also suffered from vertigo. Five patients reported a history of facial symptoms with hemispasm or palsy: 3 had progressive facial weakness, 1 had a hemispasm, and 1 had a history of recovery from sudden facial paresis. All patients underwent CT and MRI to rule out intracanalicular vestibular schwannomas and facial nerve neuromas. Five patients had their tumors surgically removed, while 1 patient, who did not have facial problems, was followed up with a wait-and-scan approach.

RESULTS

All patients had a presurgical diagnosis of cavernous hemangioma of the IAC, which was confirmed pathologically in the 5 patients who underwent surgical removal of the tumor. The translabyrinthine approach was used to remove the tumor in 4 patients, while the middle cranial fossa approach was used in the 1 patient who still had functional hearing. Tumors adhered to cranial nerves VII and/or VIII and were difficult to dissect from nerve sheaths during surgeries. Complete hearing loss occurred in all 5 patients. In 3 patients, the facial nerve could not be separated from the tumor, and primary end-to-end anastomosis was performed. Intact facial nerve preservation was achieved in 2 patients. Patients were followed up for at least 1 year after treatment, and MRI showed no evidence of tumor regrowth. All patients experienced some level of recovery in facial nerve function.

CONCLUSIONS

Cavernous hemangioma of the IAC can be diagnosed preoperatively through analysis of clinical features and neuroimaging. Early surgical intervention may preserve the functional integrity of the facial nerve and provide a better outcome after nerve reconstruction. However, preservation of functional hearing may not be achieved, even with the retrosigmoid or middle cranial fossa approaches. The translabyrinthine approach seems to be the most appropriate approach overall, as the facial nerve can be easily located and reconstructed.

Facial nerve hemangiomas at geniculate ganglion: preservation of nerve integrity is correlated with duration of facial palsy

OBJECTIVE

To study preservation of nerve integrity in 16 cases with facial nerve hemangiomas at geniculate ganglion (GG).

METHODS

16 cases with facial nerve hemangiomas at GG, who presented with facial palsy, were included in the study. Preservation of nerve integrity was attempted by the same surgeon during surgical removal, and those who failed to preserve nerve integrity underwent nerve grafting. The patients were divided into longer duration group (>12months) and shorter duration group (≤12months) according to duration of facial palsy, and preservation of nerve integrity in the couple of groups was compared.

RESULTS

Nerve integrity was preserved in 2 of 10 cases (20%) among longer duration group, while it was preserved in 5 of 6 cases (83.3%) among shorter duration group (p<0.05). All the cases with nerve integrity preserved recovered to grade III or better, among which 3 cases recovered to grade I or grade II, while only 3 of 9 cases (33.3%) with nerve grafting recovered to grade III at the best.

CONCLUSIONS

Preservation of nerve integrity was correlated with duration of facial palsy in cases with hemangiomas at GG. Patients with nerve integrity preserved showed better outcomes of facial nerve.

Facial nerve preservation in geniculate ganglion hemangiomas

CONCLUSIONS

Facial nerve preservation was related to tumor size, and the patients with facial nerve preservation obtained better recovery. Hence it is necessary to perform surgical removal as soon as possible.

OBJECTIVE

To study facial nerve preservation in patients with geniculate ganglion (GG) hemangiomas.

METHODS

Twelve patients who had GG hemangiomas were managed at a single institute. All patients underwent total tumor removal, and the surgeon attempted to preserve the facial nerve. Tumor size was measured by MRI, and the patients were divided into two groups according to tumor size: larger size group (≥10 mm) and smaller size group (<10 mm).

RESULTS

Generally, the facial nerve was successfully preserved in 10 of 12 cases (83.30%), and nerve grafting was required in 2 cases. Seven of 10 patients (70%) with nerve intact recovered to grade I or grade II, while the 2 cases with nerve grafting recovered to grade III or grade IV. Among the smaller size group, the facial nerves of all patients (100%) were intact. In contrast, only one of three patients (33.3%) in the larger size group maintained nerve integrity after surgery.

Surgical experience of nine cases with intratemporal facial hemangiomas and a brief literature review

CONCLUSIONS

It was practicable to remove hemangiomas at the labyrinth region and distal internal auditory canal with complete or serviceable hearing preservation by the transmastoid approach. The majority of cases where the nerve integrity was preserved achieved acceptable recovery of facial nerve function during the first few years according to our study. Long-term outcomes of nerve graft were acceptable, while short-term outcomes were unsatisfactory based on the literature.

OBJECTIVE

This study aimed to present our surgical experience of nine intratemporal facial nerve hemangiomas and provide a brief literature review.

METHODS

Clinical data for the cases were retrospectively analyzed. They were followed up for 5-59 months and related literature was reviewed.

RESULTS

All of the hemangiomas were removed by the transmastoid approach, and only three cases developed mild conductive hearing loss. Nerve integrity was preserved for all cases. In all, 66.7% of patients maintained or recovered to grade III or better, and one patient with grade VI recovered to grade V during the average follow-up period of 2 years. In the literature the majority of grafted patients recovered to an acceptable level 5 years later, although recovery was usually poor during the first year.

Manual stimulation of facial muscles improves functional recovery after hypoglossal–facial anastomosis and interpositional nerve grafting of the facial nerve in adult rats

The facial nerve in humans is often prone to injuries requiring surgical intervention. In the best case, nerve reconstruction is achieved by a facial-facial anastomosis (FFA), i.e. suture of the proximal and distal stumps of the severed facial nerve. Although a method of choice, FFA rarely leads to a satisfactory functional recovery. We have recently devised and validated, in an established experimental paradigm in rats, a novel strategy to improve the outcome of FFA by daily manual stimulation (MS) of facial muscles. This treatment results in full recovery of facial movements (whisking) and is achieved by reducing the proportion of functionally detrimental poly-innervated motor end-plates. Here we asked whether MS could also be beneficial after two other commonly used surgical methods of clinical facial nerve reconstruction namely hypoglossal-facial anastomosis (HFA) and interpositional nerve grafting (IPNG) which, however, seem to have a poorer outcome compared to FFA. Compared to FFA, daily MS for 2 months after HFA and IPGN did not completely restore function but, nevertheless, significantly improved the amplitude of whisker movements by 50% compared with untreated animals. Functional improvement was associated with a reduction in the proportion of polyinnervated end-plates. MS did not reduce the extent of axonal branching at the lesion site nor the subsequent misdirected axonal regrowth to inappropriate targets. Our data show that a simple approach leading to improved quality of muscle fiber reinnervation is functionally beneficial after different types of clinically relevant surgical interventions.

Cavernous angiomas within the internal auditory canal

OBJECT

The aim of this study was to describe the symptomatology, radiological features, and surgical treatment of patients with cavernous angiomas within the internal auditory canal (IAC).

METHODS

The authors reviewed the cases of seven patients with cavernous angiomas in the IAC that had been surgically treated in the 22-year period between 1983 and 2005. All the patients had presented with sensorineural hearing loss, and four suffered from tinnitus. Four patients also reported facial symptoms such as hemispasm or progressive palsy; one of these patients had presented with sudden facial paresis due to intrameatal tumor hemorrhage. According to computed tomography (CT) results, the lesions caused enlargement of the IAC. Interestingly, these same angiomas showed variable features on magnetic resonance (MR) imaging, making their differentiation from intrameatal vestibular schwannomas (VSs) sometimes impossible. In all patients the lesions were totally removed via the suboccipital retrosigmoid approach. They could be dissected away from the facial nerve in five cases, whereas in two cases, because of the location of the lesion, the seventh cranial nerve had to be sectioned and repaired with a sural nerve graft. Transient worsening of seventh cranial nerve symptoms occurred in two patients, with postoperative improvement in each of them. The cochlear nerve could not be functionally preserved because of its extreme adherence to the tumor, although its continuity was preserved in four patients. Complete deafness was the only postoperative complication.

CONCLUSIONS

Cavernous angiomas of the IAC are very uncommon lesions that can imitate the symptoms of VSs. Although it is the most sensitive study available, MR imaging does not show sufficiently specific findings to differentiate the two lesion types. Thus, the preoperative diagnosis must be based on patient symptoms plus the CT and MR imaging features.

Facial Nerve Tumors

OBJECTIVE

To evaluate the surgical results in primary facial nerve (FN) tumors.

STUDY DESIGN

Retrospective case review.

SETTING

Private neuro-otological and skull-base tertiary referral center.

PATIENTS

Twenty eight consecutive patients affected by primary FN tumors that underwent surgery between December 1990 and February 2001.

INTERVENTIONS

The lesions were removed through a variety of surgical approaches, depending on tumor location and extension, as well as preoperative hearing. In one case, partial removal was performed.

MAIN OUTCOME MEASURES

Preoperative and postoperative FN function; preoperative and postoperative hearing level; and postoperative complications.

RESULTS

Based on histologic examination, tumors were distributed as follows: 18 schwannomas, six hemangiomas, two meningiomas, and two neurofibromas. Tumor location varied, with lesions distributed along the entire length of the nerve. Facial dysfunction was the most frequently recorded symptom, followed by hearing loss. Only five patients presented a preoperative grade 1 facial function. In the remaining patients of the group, the facial deficit lasted from 2 to 120 months, with a mean of 31.2 months. Anatomic integrity of the nerve was preserved in 4 cases; all others required a nerve interruption followed by reconstruction using a sural nerve graft. The complications recorded were: one cerebrospinal fluid leak, one postoperative retraction pocket, and one external auditory canal wall resorption requiring a surgical revision. Preoperative hearing remained unchanged in 8 out of the 15 patients in whom a hearing preservation procedure was attempted. In 25 cases, a follow-up of equal to or longer than 1 year was available, with the FN functions: two grade 1, eight grade 3, nine grade 4, three grade 5, and three grade 6. Patients with a preoperative deficit lasting more than 1 year demonstrated the worst recovery.

CONCLUSIONS

Primary FN tumors are rare lesions that include different histologic types. FN deficit represents the most common symptom, but it is not present in all cases. A conservative strategy is often adopted in presence of a normal preoperative facial function. When surgical management is selected, the decision on surgical approach to use depends on tumor size and location, as well as on preoperative hearing. FN integrity may be spared in rare occasions, but more frequently nerve reconstruction is required. Final facial function recovery is mainly dependent on the preoperative presence of FN deficit and its duration.

Facial nerve grafting

OBJECTIVE

To evaluate the results of facial nerve reconstruction by means of grafting and to determine the influence of different variables on final functional recovery.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary otologic and skull base referral center.

PATIENTS

Sixty nine patients underwent facial nerve grafting. Facial nerve tumors (24) or vestibular schwannomas (18) affected most of them. Preoperatively, 47 patients had a clinical facial nerve deficit lasting from 1 to 120 months, with a mean of 20.2 months.

MAIN OUTCOME MEASURES

Final facial nerve motor function.

RESULTS

Among the 56 patients with a follow-up time equal to or longer than 1 year, 26 recovered to a Grade III (46.4%), 14 to a Grade IV (25%), while 16 remained at Grade V or Grade VI according to the House-Brackmann scale. Patients with a preoperative facial nerve deficit for more than 1 year showed the lowest rate of recovery, with only 3 cases (19%) reaching Grade III.

CONCLUSIONS

Duration of the preoperative facial nerve deficit emerged as the most important factor influencing final results. According to the authors' data, the 1-year period after the occurrence of the preoperative clinical deficit seemed to be the cutoff point in achieving a high rate of good postoperative recovery. Among the other factors that might have influenced the final outcome, only the underlying cause of the lesion played a significant role.