AMER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY X X (2 0 1 4) XXX – XXX
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Facial nerve hemangiomas at geniculate ganglion: preservation of nerve integrity is correlated with duration of facial palsy☆,☆☆ Kai Wang, MD a , Haiyan Chou, MM a,⁎, Yefeng Li, MD b a b
Department of Plastic Surgery, Henan Provincial People’s Hospital, Zhengzhou, Henan Province, P.R.C Department of Otolaryngology, Peking University Health Science Center, Beijing, P.R.C
ARTI CLE I NFO
A BS TRACT
Article history:
Objective: To study preservation of nerve integrity in 16 cases with facial nerve
Received 31 October 2014
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 (> 12 months) and shorter duration group (≤ 12 months) 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. © 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Facial nerve hemangiomas were uncommon and reported to be 0.7% among the tumors in temporal bones [1]. Internal auditory canal (IAC) and geniculate ganglion (GG) were most commonly affected [2]. Whereas symptoms of IAC and GG hemangiomas were quite distinctive. Most of patients with IAC hemangiomas
initially complained of sensorineural hearing loss other than facial nerve deficit symptoms, while almost all patients with GG hemangiomas presented with facial palsy even when the tumors were of extremely small size [3,4]. GG hemangiomas were believed to arise from geniculate capillary plexus and compressed facial nerve outside [5]. During clinical practice, it was difficult to remove the lesions
☆ Copyright transfer: In consideration of the American Journal of Otolaryngology's reviewing and editing my submission, "Facial nerve hemangiomas at geniculate ganglion: preservation of nerve integrity is correlated with duration of facial palsy", the authors undersigned transfers, assigns and otherwise conveys all copyright ownership to Elsevier Inc. in the event that such work is published in the American Journal of Otolaryngology. Signed by Haiyan Chou. ☆☆ Conflict of interests: We declare that there was no conflict of interests. ⁎ Corresponding author at: Department of Plastic Surgery, Henan Provincial People’s Hospital, Zhengzhou 450000, Henan Province, P.R.C. E-mail address: [email protected] (H. Chou).
http://dx.doi.org/10.1016/j.amjoto.2014.12.002 0196-0709/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
2
AMER ICA N JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D N E CK M EDI CI N E AN D S U RGE RY X X (2 0 1 4) XXX – XXX
totally without sacrificing facial nerve in most cases, since hemangiomas were found to be intimately adhered to facial nerve [6]. Nevertheless, nerve integrity was significant for better outcomes of facial nerve, since the patients who lost nerve integrity and underwent nerve grafting recovered to not better than grade III (House–Brackmann grading system [7]) [8]. In the current paper, we report a series of 16 cases with GG hemangiomas, and mainly aim to study the correlation between preservation of nerve integrity and duration of facial palsy.
All of the 7 cases with nerve intact recovered to grade III or better, among which 3 cases (42.9%) recovered to normal or nearnormal level, while the 9 cases who underwent nerve grafting recovered to grade III at the best, among which 6 cases (66.7%) recovered to grade IV or V. CT scan revealed no recurrence of hemangiomas during follow-up. After surgery, hearing maintained normal in 14 cases, improved in one case and remained absent in another one.
4. 2.
Materials and methods
The study included a consecutive series of 16 patients with GG hemangiomas, all of which were surgically removed in a referral center between 1998 and 2011 by the same surgeon. All patients had pathological confirmation. The lesions not involving GG of facial nerve were not included in the study. There were 12 female and 4 male, and the mean age was 43.4 ± 12.0ys (range, 19–60ys). Hemangiomas were totally removed in all cases, and nerve integrity was preserved if possible. Intraoperative facial nerve monitoring was used to help identify facial nerve and the lesions. For the patients with longer duration of complete facial palsy, there was no response for electrical stimulation of facial nerve, and the facial nerve was sacrificed. Facial nerve was also destructed for those patients whose facial nerve was infiltrated by the lesions or intimately adhered to hemangiomas. Nerve grafting was performed on those whose facial nerve had to be sacrificed. Surgical approach was mainly determined by tumor location and preoperative hearing. Middle cranial fossa approach was used to remove hemangiomas at GG or GG and labyrinthine segment with serviceable hearing, and middle cranial fossa combined with transmastoid approach was used to remove hemangiomas at GG and tympanic segment with serviceable hearing. Extralabyrinthine approach [9] was utilized for the lesions at GG without serviceable hearing. The patients were divided into two groups according to duration of facial palsy, longer duration group (>12 months) and shorter duration group (≤12 months). Preservation of nerve integrity among the two groups was recorded and compared. They were followed up for 4.25 ± 1.7ys (range, 2–7ys). Tumor recurrence was judged by high-resolution CT scan of temporal bone. Preoperative and postoperative hearing was measured by clinical audiometer. Fisher’s exact test was introduced for statistical analysis, and SPSS 17.0 software was involved.
3.
Discussions
GG hemangiomas usually produced facial nerve deficit symptoms at an early stage. Other symptoms may include sensorineural hearing loss, vertigo, conductive hearing loss, which were caused by cochlea erosion or middle ear invasion. Unlike schwannomas [10], GG hemangiomas tended to be restricted at GG region and rarely grew along fallopian canal. In the case series, 14 of 16 cases (87.5%) had hemangiomas restricted at GG region other than growing along labyrinthine segment, IAC, tympanic segment or even mastoid segment. The differential diagnosis of GG hemangiomas mainly included schwannomas of facial nerve and meningiomas. GG hemangiomas were characterized by the appearance of "honeycomb bone" and bone spicules with irregular borders on CT, which were caused by intralesional calcification [11] [Fig. 1], while schwannomas appeared as local enlargement of fallopian canal with well-defined margins. Unfortunately, intralesional calcification was only present in 39%–50% of the patients [6,12][Table 1]. Another valuable point was that GG hemangiomas produced facial nerve deficit symptoms at a smaller size [1,5]. Meningiomas at GG region were quite rare. Hemangiomas were difficult to be identified from meningiomas on CT, but the two tumors were different on T2 images of MRI. Hemangiomas were isointense on T1 images and hyperintense on T2 images, while meningiomas remained isointense on both T1 and T2 images [13].
Results
All of the patients presented with facial palsy of variable degree. One case developed conductive hearing loss due to tumor invasion into middle ear, and the other one had dead ear, since cochlea was invaded by the lesions. After surgery, facial nerve integrity was preserved in 7 of 16 cases (43.8%). Duration of facial palsy ranged from 3 months to 70 months, 25.4 ± 1.9 months on average. Among longer duration group, facial nerve integrity was preserved in 2 of 10 cases (20%). In contrast, facial nerve integrity was preserved in 5 of 6 cases (83.3%) among shorter duration group. The difference was significant (p < 0.05).
Fig. 1 – Hemangioma at geniculate ganglion. Intralesional calcification is visible.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
AMER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY X X (2 0 1 4) XXX – XXX
3
Table 1 – Summary of 16 cases with GG hemangiomas. Case no.
Symptoms
Location
Duration (months) ⁎
Initial grade
Final. grade
Initial hearing
Final hearing
Nerve graft
Surgical approach
Followup (ys)
1 2 3 4 5 6 7 8 9 10 11 12 13. 14 15 16
FP FP FP FP FP FP, CHL FP FP FP FP,SNHL FP FP FP FP FP FP
GG GG GG GG,LS GG GG,TS GG GG GG GG GG GG GG GG GG GG
18 70 5 33 10 5 28 30 42 28 8 3 50 40 30 7
VI VI V V V IV VI IV VI VI IV III VI IV V III
III V III V III III V III III IV II I IV III III II
Normal Normal Normal Normal Normal 40 dB Normal Normal Normal Dead ear Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal 25 dB Normal Normal Normal Dead ear Normal Normal Normal Normal Normal Normal
None GAN None GAN SN None SN GAN GAN GAN None None SN None GAN None
MCF MCF MCF MCF MCF MCF, TM MCF MCF MCF EL MCF MCF MCF MCF MCF MCF
4 2 5 7 3 4 3 2 6 4 5 7 6 5 3 2
FP, facial palsy; SNH, sensorineural hearing loss; CHL, conductive hearing loss; LS, labyrinthine segment; GG, geniculate ganglion; TS, tympanic segment; MCF–middle cranial fossa approach; TM, transmastoid approach; EL, extralabyrinthine approach. Case 1 and 9 showed less than 95% degeneration of facial nerve on electroneurography, while case 2. 7, 10 and 13 showed more than 95% degeneration of facial nerve. ⁎ Duration, duration of facial palsy.
The definite treatment of hemangiomas was surgical removal. Hemangiomas at IAC could be totally removed without damaging facial nerve, while the lesions at GG could not be removed completely without sacrificing facial nerve in most cases [2,6,14,15], although hemangiomas at both IAC and GG were originated outside the nerve [5,16]. Larger hemangiomas at GG were intimately adhered to facial nerve in most cases [6], and the tumors even infiltrated directly into facial nerve [15]. In that case, it was almost impossible to separate the tumors from facial nerve without sacrificing facial nerve. In our study, facial nerve integrity was preserved in 43.8% of the cases, almost identical to 40% (6 of 15 cases who underwent total tumor removal) in Semaan MT et al.’s report [6]. About the rate of nerve integrity preservation, there was significant difference between longer duration group and shorter duration group (20% versus 83.3%, p < 0.05), as indicated that preservation of nerve integrity was correlated with duration of facial palsy. In other words, earlier management of GG hemangiomas was significant for preservation of nerve integrity. It was not difficult to understand, since GG hemangiomas which lasted for longer period may well be intimately adhered to facial nerve or even infiltrate directly into the nerve fascicles, rendering it difficult to separate the lesions from the nerve. All the cases with nerve integrity preserved recovered to grade III or better, among which 42.9% recovered completely or almost completely, while all the cases who lost nerve integrity and underwent nerve grafting recovered to not better than grade III, among which 66.7% recovered to grade IV or V. Interestingly, one case had moderate facial palsy (grade III) for three months before management, and recovered completely after surgery. During surgery, facial nerve was found to be mildly compressed by the lesions, and the
margin between the nerve fascicle and hemangiomas was clear. Given the facts above, it was indicated that early diagnosis and management of GG hemangiomas were necessary for better outcomes of facial nerve.
REFERENCES
[1] Mangham CA, Carberry JN, Brackmann DE. Management of intratemporal vascular tumors. Laryngoscope 1981;91: 867–76. [2] Piccirillo E, Agarwal M, Rohit, et al. Management of temporal bone hemangiomas. Ann Otol Rhinol Laryngol 2004;113: 431–7. [3] Saleh E, Naguib M, Russo A, et al. Vascular malformation of the internal auditory canal. J Laryngol Otol 1993;107: 1039–42. [4] Shelton C, Brackmann DE, Lo WW, et al. Intratemporal facial nerve hemangiomas. Otolaryngol Head Neck Surg 1991;104: 116–21. [5] Balkany T, Fradis M, Jafek BW, et al. Hemangioma of the facial nerve: role of the geniculate capillary plexus. Skull Base Surg 1991;1:59–63. [6] Semaan MT, Slattery WH, Brackmann DE. Geniculate ganglion hemangiomas: clinical results and long-term follow-up. Otol Neurotol 2010;31:665–70. [7] House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146–7. [8] Falcioni M, Taibah A, Russo A, et al. Facial nerve grafting. Otol Neurotol 2003;24:486–9. [9] Zini C, Sanna M, Jemmi M, et al. Transmastoid extralabyrinthine approach in traumatic facial palsy. Am J Otol 1985;6:216–21. [10] McMonagle B, Al-Sanosi A, Croxson G, et al. Facial schwannoma: results of a large case series and review. J Laryngol Otol 2008;122:1139–50.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
4
AMER ICA N JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D N E CK M EDI CI N E AN D S U RGE RY X X (2 0 1 4) XXX – XXX
[11] Lo WWM, Brackmann DE, Shelton C. Facial nerve hemangioma. Ann Otol Rhinol Laryngol 1989;98:160–1. [12] Escada P, Capucho C, Silva JM, et al. Cavernous haemangioma of the facial nerve. J Laryngol Otol 1997;111:858–61. [13] Omojola MF, al Hawashim NS, Zuwayed MA, et al. CT and MRI features of cavernous haemangioma of internal auditory canal. Br J Radiol 1997;70:1184–7.
[14] Bhatia S, Karmarkar S, Calabrese V, et al. Intratemporal hemangiomas involving the facial nerve: diagnosis and management. Skull Base Surg 1995;5:227–32. [15] Isaacson B, Telian SA, McKeever PE, et al. Hemangiomas of the geniculate ganglion. Otol Neurotol 2005;26:796–802. [16] Fisch U. Possibilities of microsurgery of the petrous bone and the base of the skull. Ther Umsch 1987;44:102–8.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Facial nerve hemangiomas at geniculate ganglion: preservation of nerve integrity is correlated with duration of facial palsy☆,☆☆ Kai Wang, MD a , Haiyan Chou, MM a,⁎, Yefeng Li, MD b a b
Department of Plastic Surgery, Henan Provincial People’s Hospital, Zhengzhou, Henan Province, P.R.C Department of Otolaryngology, Peking University Health Science Center, Beijing, P.R.C
ARTI CLE I NFO
A BS TRACT
Article history:
Objective: To study preservation of nerve integrity in 16 cases with facial nerve
Received 31 October 2014
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 (> 12 months) and shorter duration group (≤ 12 months) 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. © 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Facial nerve hemangiomas were uncommon and reported to be 0.7% among the tumors in temporal bones [1]. Internal auditory canal (IAC) and geniculate ganglion (GG) were most commonly affected [2]. Whereas symptoms of IAC and GG hemangiomas were quite distinctive. Most of patients with IAC hemangiomas
initially complained of sensorineural hearing loss other than facial nerve deficit symptoms, while almost all patients with GG hemangiomas presented with facial palsy even when the tumors were of extremely small size [3,4]. GG hemangiomas were believed to arise from geniculate capillary plexus and compressed facial nerve outside [5]. During clinical practice, it was difficult to remove the lesions
☆ Copyright transfer: In consideration of the American Journal of Otolaryngology's reviewing and editing my submission, "Facial nerve hemangiomas at geniculate ganglion: preservation of nerve integrity is correlated with duration of facial palsy", the authors undersigned transfers, assigns and otherwise conveys all copyright ownership to Elsevier Inc. in the event that such work is published in the American Journal of Otolaryngology. Signed by Haiyan Chou. ☆☆ Conflict of interests: We declare that there was no conflict of interests. ⁎ Corresponding author at: Department of Plastic Surgery, Henan Provincial People’s Hospital, Zhengzhou 450000, Henan Province, P.R.C. E-mail address: [email protected] (H. Chou).
http://dx.doi.org/10.1016/j.amjoto.2014.12.002 0196-0709/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
2
AMER ICA N JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D N E CK M EDI CI N E AN D S U RGE RY X X (2 0 1 4) XXX – XXX
totally without sacrificing facial nerve in most cases, since hemangiomas were found to be intimately adhered to facial nerve [6]. Nevertheless, nerve integrity was significant for better outcomes of facial nerve, since the patients who lost nerve integrity and underwent nerve grafting recovered to not better than grade III (House–Brackmann grading system [7]) [8]. In the current paper, we report a series of 16 cases with GG hemangiomas, and mainly aim to study the correlation between preservation of nerve integrity and duration of facial palsy.
All of the 7 cases with nerve intact recovered to grade III or better, among which 3 cases (42.9%) recovered to normal or nearnormal level, while the 9 cases who underwent nerve grafting recovered to grade III at the best, among which 6 cases (66.7%) recovered to grade IV or V. CT scan revealed no recurrence of hemangiomas during follow-up. After surgery, hearing maintained normal in 14 cases, improved in one case and remained absent in another one.
4. 2.
Materials and methods
The study included a consecutive series of 16 patients with GG hemangiomas, all of which were surgically removed in a referral center between 1998 and 2011 by the same surgeon. All patients had pathological confirmation. The lesions not involving GG of facial nerve were not included in the study. There were 12 female and 4 male, and the mean age was 43.4 ± 12.0ys (range, 19–60ys). Hemangiomas were totally removed in all cases, and nerve integrity was preserved if possible. Intraoperative facial nerve monitoring was used to help identify facial nerve and the lesions. For the patients with longer duration of complete facial palsy, there was no response for electrical stimulation of facial nerve, and the facial nerve was sacrificed. Facial nerve was also destructed for those patients whose facial nerve was infiltrated by the lesions or intimately adhered to hemangiomas. Nerve grafting was performed on those whose facial nerve had to be sacrificed. Surgical approach was mainly determined by tumor location and preoperative hearing. Middle cranial fossa approach was used to remove hemangiomas at GG or GG and labyrinthine segment with serviceable hearing, and middle cranial fossa combined with transmastoid approach was used to remove hemangiomas at GG and tympanic segment with serviceable hearing. Extralabyrinthine approach [9] was utilized for the lesions at GG without serviceable hearing. The patients were divided into two groups according to duration of facial palsy, longer duration group (>12 months) and shorter duration group (≤12 months). Preservation of nerve integrity among the two groups was recorded and compared. They were followed up for 4.25 ± 1.7ys (range, 2–7ys). Tumor recurrence was judged by high-resolution CT scan of temporal bone. Preoperative and postoperative hearing was measured by clinical audiometer. Fisher’s exact test was introduced for statistical analysis, and SPSS 17.0 software was involved.
3.
Discussions
GG hemangiomas usually produced facial nerve deficit symptoms at an early stage. Other symptoms may include sensorineural hearing loss, vertigo, conductive hearing loss, which were caused by cochlea erosion or middle ear invasion. Unlike schwannomas [10], GG hemangiomas tended to be restricted at GG region and rarely grew along fallopian canal. In the case series, 14 of 16 cases (87.5%) had hemangiomas restricted at GG region other than growing along labyrinthine segment, IAC, tympanic segment or even mastoid segment. The differential diagnosis of GG hemangiomas mainly included schwannomas of facial nerve and meningiomas. GG hemangiomas were characterized by the appearance of "honeycomb bone" and bone spicules with irregular borders on CT, which were caused by intralesional calcification [11] [Fig. 1], while schwannomas appeared as local enlargement of fallopian canal with well-defined margins. Unfortunately, intralesional calcification was only present in 39%–50% of the patients [6,12][Table 1]. Another valuable point was that GG hemangiomas produced facial nerve deficit symptoms at a smaller size [1,5]. Meningiomas at GG region were quite rare. Hemangiomas were difficult to be identified from meningiomas on CT, but the two tumors were different on T2 images of MRI. Hemangiomas were isointense on T1 images and hyperintense on T2 images, while meningiomas remained isointense on both T1 and T2 images [13].
Results
All of the patients presented with facial palsy of variable degree. One case developed conductive hearing loss due to tumor invasion into middle ear, and the other one had dead ear, since cochlea was invaded by the lesions. After surgery, facial nerve integrity was preserved in 7 of 16 cases (43.8%). Duration of facial palsy ranged from 3 months to 70 months, 25.4 ± 1.9 months on average. Among longer duration group, facial nerve integrity was preserved in 2 of 10 cases (20%). In contrast, facial nerve integrity was preserved in 5 of 6 cases (83.3%) among shorter duration group. The difference was significant (p < 0.05).
Fig. 1 – Hemangioma at geniculate ganglion. Intralesional calcification is visible.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
AMER IC AN JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D NE CK M E D ICI N E AN D S U RGE RY X X (2 0 1 4) XXX – XXX
3
Table 1 – Summary of 16 cases with GG hemangiomas. Case no.
Symptoms
Location
Duration (months) ⁎
Initial grade
Final. grade
Initial hearing
Final hearing
Nerve graft
Surgical approach
Followup (ys)
1 2 3 4 5 6 7 8 9 10 11 12 13. 14 15 16
FP FP FP FP FP FP, CHL FP FP FP FP,SNHL FP FP FP FP FP FP
GG GG GG GG,LS GG GG,TS GG GG GG GG GG GG GG GG GG GG
18 70 5 33 10 5 28 30 42 28 8 3 50 40 30 7
VI VI V V V IV VI IV VI VI IV III VI IV V III
III V III V III III V III III IV II I IV III III II
Normal Normal Normal Normal Normal 40 dB Normal Normal Normal Dead ear Normal Normal Normal Normal Normal Normal
Normal Normal Normal Normal Normal 25 dB Normal Normal Normal Dead ear Normal Normal Normal Normal Normal Normal
None GAN None GAN SN None SN GAN GAN GAN None None SN None GAN None
MCF MCF MCF MCF MCF MCF, TM MCF MCF MCF EL MCF MCF MCF MCF MCF MCF
4 2 5 7 3 4 3 2 6 4 5 7 6 5 3 2
FP, facial palsy; SNH, sensorineural hearing loss; CHL, conductive hearing loss; LS, labyrinthine segment; GG, geniculate ganglion; TS, tympanic segment; MCF–middle cranial fossa approach; TM, transmastoid approach; EL, extralabyrinthine approach. Case 1 and 9 showed less than 95% degeneration of facial nerve on electroneurography, while case 2. 7, 10 and 13 showed more than 95% degeneration of facial nerve. ⁎ Duration, duration of facial palsy.
The definite treatment of hemangiomas was surgical removal. Hemangiomas at IAC could be totally removed without damaging facial nerve, while the lesions at GG could not be removed completely without sacrificing facial nerve in most cases [2,6,14,15], although hemangiomas at both IAC and GG were originated outside the nerve [5,16]. Larger hemangiomas at GG were intimately adhered to facial nerve in most cases [6], and the tumors even infiltrated directly into facial nerve [15]. In that case, it was almost impossible to separate the tumors from facial nerve without sacrificing facial nerve. In our study, facial nerve integrity was preserved in 43.8% of the cases, almost identical to 40% (6 of 15 cases who underwent total tumor removal) in Semaan MT et al.’s report [6]. About the rate of nerve integrity preservation, there was significant difference between longer duration group and shorter duration group (20% versus 83.3%, p < 0.05), as indicated that preservation of nerve integrity was correlated with duration of facial palsy. In other words, earlier management of GG hemangiomas was significant for preservation of nerve integrity. It was not difficult to understand, since GG hemangiomas which lasted for longer period may well be intimately adhered to facial nerve or even infiltrate directly into the nerve fascicles, rendering it difficult to separate the lesions from the nerve. All the cases with nerve integrity preserved recovered to grade III or better, among which 42.9% recovered completely or almost completely, while all the cases who lost nerve integrity and underwent nerve grafting recovered to not better than grade III, among which 66.7% recovered to grade IV or V. Interestingly, one case had moderate facial palsy (grade III) for three months before management, and recovered completely after surgery. During surgery, facial nerve was found to be mildly compressed by the lesions, and the
margin between the nerve fascicle and hemangiomas was clear. Given the facts above, it was indicated that early diagnosis and management of GG hemangiomas were necessary for better outcomes of facial nerve.
REFERENCES
[1] Mangham CA, Carberry JN, Brackmann DE. Management of intratemporal vascular tumors. Laryngoscope 1981;91: 867–76. [2] Piccirillo E, Agarwal M, Rohit, et al. Management of temporal bone hemangiomas. Ann Otol Rhinol Laryngol 2004;113: 431–7. [3] Saleh E, Naguib M, Russo A, et al. Vascular malformation of the internal auditory canal. J Laryngol Otol 1993;107: 1039–42. [4] Shelton C, Brackmann DE, Lo WW, et al. Intratemporal facial nerve hemangiomas. Otolaryngol Head Neck Surg 1991;104: 116–21. [5] Balkany T, Fradis M, Jafek BW, et al. Hemangioma of the facial nerve: role of the geniculate capillary plexus. Skull Base Surg 1991;1:59–63. [6] Semaan MT, Slattery WH, Brackmann DE. Geniculate ganglion hemangiomas: clinical results and long-term follow-up. Otol Neurotol 2010;31:665–70. [7] House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146–7. [8] Falcioni M, Taibah A, Russo A, et al. Facial nerve grafting. Otol Neurotol 2003;24:486–9. [9] Zini C, Sanna M, Jemmi M, et al. Transmastoid extralabyrinthine approach in traumatic facial palsy. Am J Otol 1985;6:216–21. [10] McMonagle B, Al-Sanosi A, Croxson G, et al. Facial schwannoma: results of a large case series and review. J Laryngol Otol 2008;122:1139–50.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
4
AMER ICA N JOURNAL OF OT OLA RYNGOLOGY– H E A D A N D N E CK M EDI CI N E AN D S U RGE RY X X (2 0 1 4) XXX – XXX
[11] Lo WWM, Brackmann DE, Shelton C. Facial nerve hemangioma. Ann Otol Rhinol Laryngol 1989;98:160–1. [12] Escada P, Capucho C, Silva JM, et al. Cavernous haemangioma of the facial nerve. J Laryngol Otol 1997;111:858–61. [13] Omojola MF, al Hawashim NS, Zuwayed MA, et al. CT and MRI features of cavernous haemangioma of internal auditory canal. Br J Radiol 1997;70:1184–7.
[14] Bhatia S, Karmarkar S, Calabrese V, et al. Intratemporal hemangiomas involving the facial nerve: diagnosis and management. Skull Base Surg 1995;5:227–32. [15] Isaacson B, Telian SA, McKeever PE, et al. Hemangiomas of the geniculate ganglion. Otol Neurotol 2005;26:796–802. [16] Fisch U. Possibilities of microsurgery of the petrous bone and the base of the skull. Ther Umsch 1987;44:102–8.
Please cite this article as: Wang K, et al, , Am J Otolaryngol–Head and Neck Med and Surg (2014), http://dx.doi.org/10.1016/ j.amjoto.2014.12.002
