Acta Oto-Laryngologica. 2014; 134: 974–976 ORIGINAL ARTICLE Facial nerve preservation in geniculate ganglion hemangiomas XIAOFENG MA1, DONG CHEN1, LI CAI1 & DAOWEN WANG2 1Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Liaoning Medical University, Jinzhou and 2Department of Otolaryngology Head and Neck Surgery, Peking University Health Science Center, Beijing, PR China Abstract 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. Keywords: Facial palsy, nerve graft, nerve deficit For personal use only. Introduction Material and methods Geniculate ganglion (GG) hemangiomas were first A consecutive case series of 12 patients who had GG described by Pulec in 1969 [1]. Since then, over hemangiomas underwent surgery at the authors’ insti- 40 cases of GG hemangiomas have been reported tute by the same surgeon between 1998 and 2011. [2]. Unlike hemangiomas at the internal auditory The diagnosis was pathologically confirmed. The case canal [3], the greater majority of patients with GG series consisted of eight females and four males, with hemangiomas presented with facial nerve deficit an average age of 41.2 ± 1.4 years (range 22–68 years). Acta Otolaryngol Downloaded from informahealthcare.com by Mrs Shirley Dempster on 09/02/14 symptoms, even when the tumors were extremely We performed total tumor removal, and attempted to small in size [4]. preserve nerve integrity. In detail, the facial nerve was GG hemangiomas were thought to arise from the identified from the tumors under intraoperative facial geniculate capillary plexus and compressed nerve nerve monitoring and electrical stimulation. We made outside [5]. Hence, it was possible to remove the an incision through the tumor near its junction with the tumors without damaging the facial nerve. However, facial nerve, and tried to identify the facial nerve fasci- it became impossible to preserve the facial nerve cles. The tumors were removed around the nerve when the tumors infiltrated the nerve directly [6]. fascicles. There were two cases in which the tumors Here, we report 12 cases with GG hemangiomas infiltrated into nerve fascicles, and the facial nerve was and discuss facial nerve preservation in GG sacrificed, followed by nerve grafting using greater hemangiomas. auricular nerve or sural nerve as the graft material. Correspondence: Dong Chen, Department of Otolaryngology Head and Neck Surgery, First Hospital of Liaoning Medical College, Jinzhou 121001, PR China. E-mail: [email protected] (Received 2 March 2014; accepted 13 April 2014) ISSN 0001-6489 print/ISSN 1651-2251 online Ó 2014 Informa Healthcare DOI: 10.3109/00016489.2014.919407 Facial nerve preservation in geniculate ganglion hemangiomas 975 The surgical approach was mainly determined by from any facial nerve deficit symptoms, and instead, tumor location. We used the middle cranial fossa presented with pulsatile tinnitus. Hemangiomas approach to resect hemangiomas at the GG or laby- affected the GG in only 10 of 12 cases (83.3%), rinthine segment, and used the middle cranial fossa with involvement of neither labyrinthine segment combined with the transmastoid approach to remove nor tympanic segment. tumors at the GG and tympanic segment. Hearing On CT images, the characteristic appearance of was saved in all patients, among which one recovered hemangiomas was irregular borders with intralesional from 50 dB to 20 dB. stippled calcification [10]. However, intralesional Tumor size referred to the maximum diameter of calcification was not present in every patient [8]. hemangiomas on MRI. The patients were divided On MRI images, hemangiomas were isointense on into two groups: larger size group (‡10 mm) and T1 images and hyperintense on T2 images [11]. smaller size group (<10 mm). They were followed Clinically, GG hemangiomas should be differenti- up for 5.2 ± 2.1 years (range 2–9 years). CT scan of ated from neuromas. GG neuromas were character- temporal bone was performed to assess tumor recur- ized by local enlargement of the GG region with rence, and facial nerve function was evaluated by the well-defined borders rather than irregular borders, House-Brackmann (H-B) grading system [7]. Hear- and there was no intralesional stippled calcification ing before and after surgery was measured by clinical [9]. Moreover, as discussed above, neuromas more audiometer. Fisher’s exact test was used for statistical commonly affected multiple segments of the facial analysis, and SPSS 16.0 software was utilized. nerve, while GG hemangiomas were always restricted at the GG region. Another point to notice was that Results GG hemangiomas produced facial nerve deficit symp- toms, even when they were quite small in size [4]. In all, 11 of 12 patients (91.7%) complained of facial Cholesteatoma should not be confused with ossi- nerve deficit symptoms, and only 1 patient presented fying hemangiomas, although dystrophic calcification with pulsatile tinnitus instead of facial weakness. may occur within the lesion. Congenital cholestea- One case suffered from conductive hearing loss, since toma exhibited a more defined and smooth erosion of the tumors invaded the middle ear cavity. Taste the bone on CT, and did not show up as enhanced disturbance was found in only one patient. with the administration of contrast medium [12]. The facial nerve remained intact in 10 of 12 cases Meningiomas could be not distinguished from For personal use only. (83.30%) after surgery, and the facial nerve was hemangiomas on CT, but the two tumors were sacrificed and grafted in 2 cases. Specifically, the facial different on T2 images of MRI. Meningiomas were nerve was intact in 100% of the patients in the smaller isointense on both T1 and T2 images, while GG size group, compared with one of three patients hemangiomas were isointense on T1 images and (33.3%) in the larger size group (p < 0.05). hyperintense on T2 images [11]. All patients with nerve intact recovered to grade III Since GG hemangiomas seemed to arise extraneu- or better according to the H-B system, among which rally, it was possible to remove the tumors without 7 of 10 patients (70%) recovered to grade I or grade damaging the facial nerve. Dai et al. [13] successfully II. In contrast, two cases who had nerve grafting removed GG hemangiomas in all of their nine cases recovered to grade III or grade IV. There was no without destruction of the nerve fascicle, and Casas- Acta Otolaryngol Downloaded from informahealthcare.com by Mrs Shirley Dempster on 09/02/14 evidence of tumor recurrence during the follow-up. Rodera et al. [14] reported two cases of GG heman- Eleven cases maintained normal hearing after surgery, giomas in which the tumors were dissected totally and the other one improved from 50 dB to 20 dB. with conservation of the anatomy and function of facial nerve. Discussion However, some authors claimed that they preserved facial nerve in the minority of cases [6,8,15], since GG hemangiomas mainly present with progressive larger GG hemangiomas were found to be intimately facial palsy even when they are extremely small in adhered to the facial nerve in most cases [8]. The size, and can also cause other symptoms such as tumors even directly infiltrated into the nerve sensorineural hearing loss, vertigo, and conductive [6,10,16–18]. In that case, facial nerve integrity could hearing loss [8]. Different from GG neuromas, which not be preserved. However, we assumed there was still usually involved labyrinthine segment, internal a chance to dissect the tumors without destruction of auditory canal segment or tympanic segment [9], nerve integrity when they were intimately adhered to GG hemangiomas tended to be restricted at the the facial nerve, although it was difficult, but it GG only. In all, 91.7% of the current cases com- became impossible when the tumors infiltrated into plained of facial palsy. Interestingly, one case was free the nerve fascicle. 976 X. Ma et al. In the current series, the anatomy of the facial nerve [4] Shelton C, Brackmann DE, Lo WW, Carberry JN. Intra- was preserved in 83.30% of the cases, except two cases temporal facial nerve hemangiomas. Otolaryngol Head Neck – fi Surg 1991;104:116 21. that were found to have tumor in ltration into the [5] Balkany T, Fradis M, Jafek BW, Rucker NC. Hemangioma of nerve without clear borders, supporting our assump- the facial nerve: role of the geniculate capillary plexus. Skull tion above. In detail, facial nerve integrity was Base Surg 1991;1:59–63. maintained in 100% of the patients in the smaller [6] Isaacson B, Telian SA, McKeever PE, Arts HA. size group in contrast to 33.3% in the larger size group Hemangiomas of the geniculate ganglion. Otol Neurotol < 2005;26:796–802. (p 0.05). This indicated that facial nerve integrity was [7] House JW, Brackmann DE.