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A case report of facial nerve hemangioma
Auris Nasus Larynx 34 (2007) 519–522 www.elsevier.com/locate/anl
A case report of facial nerve hemangioma Takenori Miyashita a,*, Hiroshi Hoshikawa a, Masahiro Kagawa b, Nozomu Mori a a
Department of Otolaryngology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan Department of Neurosurgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
b
Received 24 November 2006; accepted 17 February 2007 Available online 4 June 2007
Abstract Facial nerve hemangioma is a rare benign tumor that originates from the venous plexus surrounding the facial nerve. A case of facial nerve hemangioma in the geniculate ganglion was reported. A 47-year-old man was referred with a left progressive facial palsy over 1 year. There were no complaints of associated hearing loss, tinnitus, headache, dizziness or otalgia. He had a left-side grade VI (House and Brackmann) facial palsy. Audiometry revealed normal hearing thresholds in conversation area bilaterally. CT imaging demonstrated a tumor at the left first genu of the facial nerve with expansion to the cochlea wall and middle skull base. MRI imaging demonstrated a centrally enhancing lesion measuring 5 mm 10 mm in the geniculate ganglion. The tumor was totally removed by the middle cranial fossa approach. At the time of surgery the facial nerve was destroyed by the tumor in the geniculate ganglion. Histopathological examination diagnosed a hemangioma. # 2007 Published by Elsevier Ireland Ltd. Keywords: Facial nerve; Hemangioma; Geniculate ganglion; Facial palsy
1. Introduction Facial nerve hemangioma is a rare tumor that was first described by Politzer in 1901. Facial nerve hemangioma is reported to account for 0.7% of intratemporal tumors [1]. Internal auditory canal and geniculate ganglion are favorite sites of facial nerve hemangioma [2]. Since then, 46 cases of facial nerve hemangioma involving the geniculate ganglion have been reported [2–8]. The hemangioma develops extraneurally and causes symptoms by compression [9]. Characteristically, severe neurologic deficits can occur even when the tumor is of an extremely small size. Because the tumor is extraneural, it is possible to remove the tumor and preserve the facial nerve in some instances. However, it is not possible to preserve the facial nerve in cases with direct nerve infiltration. Early diagnosis and treatment favorably affect the ultimate facial nerve function in these patients with slowly progressive facial palsy or recurrent episodic facial paralysis [10]. * Corresponding author. Tel.: +81 878 91 2214; fax: +81 878 91 2215. E-mail address: [email protected] (T. Miyashita). 0385-8146/$ – see front matter # 2007 Published by Elsevier Ireland Ltd. doi:10.1016/j.anl.2007.02.007
High-resolution computed tomography (CT) and magnetic resonance imaging (MRI) can detect a small size of facial nerve tumor and are useful for early diagnosis [2]. We report a case of facial nerve hemangioma involving the geniculate ganglion.
2. Case report A 47-year-old man had experienced episodes of sudden left facial palsy and been treated for Bell’s palsy with steroid at another clinic 14 months before the first visit to our hospital. After the steroid treatment, the patient had facial move rehabilitation, although his facial palsy progressed. CT scan imaging at the clinic failed to reveal the lesion. The patient visited our hospital to have the expert examination and treatment for left progressive facial palsy. On initial examination he had a House-Brackmann (HB) grade VI weakness. The patient did not report hearing loss or any other vestibular or cochlear symptoms. Pure-tone audiometry revealed normal hearing thresholds bilaterally in conversation area with a moderate sensorineural hearing loss
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T. Miyashita et al. / Auris Nasus Larynx 34 (2007) 519–522
Fig. 1. Preoperative pure-tone audiogram. Pure-tone audiometry revealed moderate sensorineural hearing loss of high frequency area on the left ear.
on the left ear (Fig. 1). Microscopic examination of the tympanic membranes showed normal findings. Electroneuronography (ENoG) revealed 16.6% weakness on the left during maximal stimulation testing. Stapedial reflex was absent on the left (ipsi- and contra-stimulation) and was present on the right (ipsi- and contra-stimulation). High-resolution CT revealed a soft tissue mass of the left temporal bone involving the geniculate ganglion, and the partial bone defect of the middle fossa and cochlea (Fig. 2). Gadolinium-enhanced MRI demonstrated a centrally enhancing lesion of 5 mm 10 mm in size involving the left geniculate ganglion, with extension to the tympanic segment of the facial nerve (Fig. 3). This appearance was consistent with a facial nerve schwannoma. The tumor was totally removed by the middle cranial fossa approach. At the time of surgery, a dark red mass centered on the geniculate portion of the facial nerve was identified (Fig. 4). The nerve could not be separated from the tumor. Consequently, the tumor had to be removed together with the facial nerve. After removal of the tumor, the cochlear fistula was observed. The cochlear fistula was immediately packed with fascia and adhered with the fibrin glue. Following the tumor removal, the continuity of the facial nerve had been restored using a greater auricular nerve graft.
Fig. 2. High-resolution CT. CT images showing a tumor at the left first genu of the facial nerve (arrow). The tumor expansively destroyed the cochlear wall and middle skull base (arrowhead).
Fig. 3. Gadolinium-enhanced MRI. MRI images showing a centrally enhancing lesion in the geniculate ganglion (arrow), measuring 5 mm 10 mm in diameter.
T. Miyashita et al. / Auris Nasus Larynx 34 (2007) 519–522
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Fig. 4. Treatment (operation). The tumor (white arrow heads) was totally removed by the middle cranial fossa approach. The tumor was removed with the facial nerve destroyed by it in the geniculate ganglion. After the removal the cochlear fistula was observed. The cochlear fistula was packed with a piece of fascia and adhered with the fibrin glue. Following tumor removal, continuity of the facial nerve had been restored using a greater auricular nerve graft (brack arrow heads).
Fig. 5. Histopathological evaluation (hematoxylin and eosin stain). Large vascular spaces are lined with a single layer of endothelium and surrounded by thick walls filled with uniform fibrous tissues (a and b). The hemangioma demonstrated facial nerve infiltration (c). Immunohistochemical analysis showed negative staining with S-100 protein (not shown). Pathologic diagnosis was cavernous hemangioma.
Histopathologic evaluation showed that the lesion was a cavernous hemangioma of the facial nerve (Fig. 5). As expected, the immediate postoperative left facial function of the patient was a House-Brackmann grade VI. Postoperative hearing loss (total deafness) of the left ear and vertigo (with paralytic nystagmus) were observed. The vertigo was in remission 2 weeks postoperatively. At 24 months after the surgery, the facial function had improved to a HouseBrackmann grade V. There has been no sign of recurrent tumor by MRI imaging.
3. Discussion Facial nerve hemangioma is a rare tumor, and the treatment is a complete surgical resection by the middle cranial fossa approach, the transmastoid approach or combined (the middle cranial fossa and transmastoid approach) approach [1,11]. Resection of the nerve and repairing using graft are often necessary because the hemangioma is often associated with an intense perineural reaction or direct facial nerve infiltration [10,12]. Especially, the hemangioma of the geniculate ganglion often demonstrated facial nerve infiltration. Six previous reports and this case with facial nerve infiltration were all involving the
perigeniculate region [7,12–14]. Facial nerve recovery after resection of the facial nerve with repairing using graft was better when the preoperative facial nerve deficit prolonged less than 1 year [5]. Another report recommended that nerve grafting should be undertaken within 2 years after the onset of complete palsy [6]. Therefore, early diagnosis and early resection are important. Gadolinium-enhanced MRI and high-resolution CT of the temporal bone are useful for an early diagnosis of facial nerve hemangioma [2]. Facial nerve hemangioma often display uniform enhancement with gadolinium on MRI, and occasionally can produce a honeycomb appearance (with irregular and indistinct bony margins and bony spicules with the tumor) on CT [15]. In this case nothing of this character was observed on MRI and CT. MRI and high-resolution CT could detect a small-sized facial nerve tumor, which failed to be found by plane routine CT. Since the hemangioma had direct infiltration into the facial nerve in this case, the resection of the nerve with repairing using graft was necessary. Some article reported that the hearing was preserved at preoperative levels when the cochlea was intact [3,5]. In cases with cochlear erosion by hemangioma, sensory neural hearing loss (SNHL) occurred immediately or progressively, and the hearing preservation is practically impossible [3,5]. The case of initially preserved hearing with
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T. Miyashita et al. / Auris Nasus Larynx 34 (2007) 519–522
the cochlear bony wall erosion by hemangioma was reported to show a subsequent decline of the hearing [3]. In this case, the cochlear bony wall was eroded by the hemangioma and severe SNHL was occurred after surgery although immediately the cochlear fistula was covered by the fascia.
References [1] Mangham CA, Carberry JN, Brackmann DE. Management of intratemporal vascular tumors. Laryngoscope 1981;91:867–76. [2] Friedman O, Neff BA, Willcox TO, Kenyon LC, Sataloff RT. Temporal bone hemangiomas involving the facial nerve. Otol Neurotol 2002;23:760–6. [3] Isaacson B, Telian SA, McKeever PE, Arts HA. Hemangiomas of the geniculate ganglion. Otol Neurotol 2005;26:796–802. [4] Ray A, Lammie GA, Shone G, Hourihan MD, Vafidis J. Venous angioma of the facial nerve: a case report. Surg Neurol 2004;61:198– 200. [5] Falcioni M, Russo A, Taibah A, Sanna M. Facial nerve tumors. Otol Neurotol 2003;24:942–7.
[6] Salib RJ, Tziambazis E, McDermott AL, Chavda SV, Irving RM. The crucial role of imaging in detection of facial nerve haemangiomas. J Laryngol Otol 2001;115:510–3. [7] Escada P, Capucho C, Silva JM, Ruah CB, Vital JP, Penha RS. Cavernous haemangioma of the facial nerve. J Laryngol Otol 1997;111:858–61. [8] Pulec JL. Facial nerve tumors. Ann Otol Rhinol Laryngol 1969;78:962–82. [9] Ylikoski J, Brackmann DE, Savolainen S. Pressure neuropathy of the facial nerve: a case report with light and electron microscopic findings. J Laryngol Otol 1984;98:909–14. [10] Shelton C, Brackmann DE, Lo WW, Carberry JN. Intratemporal facial nerve hemangiomas. Otolaryngol Head Neck Surg 1991;104:116–21. [11] Pulec JL. Facial nerve angioma. Ear Nose Throat J 1996;75:225–38. [12] Eby TL, Fisch U, Makek MS. Facial nerve management in temporal bone hemangiomas. Am J Otol 1992;13:223–32. [13] Curtin HD, Jensen JE, Barnes Jr L, May M. ‘‘Ossifying’’ hemangiomas of the temporal bone: evaluation with CT. Radiology 1987;164: 831–5. [14] Mazzoni A, Pareschi R, Calabrese V. Intratemporal vascular tumours. J Laryngol Otol 1988;102:353–6. [15] Hoffman M, Shelton C, Harnsberger HR. Imaging quiz case 2. Facial nerve hemangioma. Arch Otolaryngol Head Neck Surg 1997;123(763): 765–6.
A case report of facial nerve hemangioma Takenori Miyashita a,*, Hiroshi Hoshikawa a, Masahiro Kagawa b, Nozomu Mori a a
Department of Otolaryngology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan Department of Neurosurgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
b
Received 24 November 2006; accepted 17 February 2007 Available online 4 June 2007
Abstract Facial nerve hemangioma is a rare benign tumor that originates from the venous plexus surrounding the facial nerve. A case of facial nerve hemangioma in the geniculate ganglion was reported. A 47-year-old man was referred with a left progressive facial palsy over 1 year. There were no complaints of associated hearing loss, tinnitus, headache, dizziness or otalgia. He had a left-side grade VI (House and Brackmann) facial palsy. Audiometry revealed normal hearing thresholds in conversation area bilaterally. CT imaging demonstrated a tumor at the left first genu of the facial nerve with expansion to the cochlea wall and middle skull base. MRI imaging demonstrated a centrally enhancing lesion measuring 5 mm 10 mm in the geniculate ganglion. The tumor was totally removed by the middle cranial fossa approach. At the time of surgery the facial nerve was destroyed by the tumor in the geniculate ganglion. Histopathological examination diagnosed a hemangioma. # 2007 Published by Elsevier Ireland Ltd. Keywords: Facial nerve; Hemangioma; Geniculate ganglion; Facial palsy
1. Introduction Facial nerve hemangioma is a rare tumor that was first described by Politzer in 1901. Facial nerve hemangioma is reported to account for 0.7% of intratemporal tumors [1]. Internal auditory canal and geniculate ganglion are favorite sites of facial nerve hemangioma [2]. Since then, 46 cases of facial nerve hemangioma involving the geniculate ganglion have been reported [2–8]. The hemangioma develops extraneurally and causes symptoms by compression [9]. Characteristically, severe neurologic deficits can occur even when the tumor is of an extremely small size. Because the tumor is extraneural, it is possible to remove the tumor and preserve the facial nerve in some instances. However, it is not possible to preserve the facial nerve in cases with direct nerve infiltration. Early diagnosis and treatment favorably affect the ultimate facial nerve function in these patients with slowly progressive facial palsy or recurrent episodic facial paralysis [10]. * Corresponding author. Tel.: +81 878 91 2214; fax: +81 878 91 2215. E-mail address: [email protected] (T. Miyashita). 0385-8146/$ – see front matter # 2007 Published by Elsevier Ireland Ltd. doi:10.1016/j.anl.2007.02.007
High-resolution computed tomography (CT) and magnetic resonance imaging (MRI) can detect a small size of facial nerve tumor and are useful for early diagnosis [2]. We report a case of facial nerve hemangioma involving the geniculate ganglion.
2. Case report A 47-year-old man had experienced episodes of sudden left facial palsy and been treated for Bell’s palsy with steroid at another clinic 14 months before the first visit to our hospital. After the steroid treatment, the patient had facial move rehabilitation, although his facial palsy progressed. CT scan imaging at the clinic failed to reveal the lesion. The patient visited our hospital to have the expert examination and treatment for left progressive facial palsy. On initial examination he had a House-Brackmann (HB) grade VI weakness. The patient did not report hearing loss or any other vestibular or cochlear symptoms. Pure-tone audiometry revealed normal hearing thresholds bilaterally in conversation area with a moderate sensorineural hearing loss
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T. Miyashita et al. / Auris Nasus Larynx 34 (2007) 519–522
Fig. 1. Preoperative pure-tone audiogram. Pure-tone audiometry revealed moderate sensorineural hearing loss of high frequency area on the left ear.
on the left ear (Fig. 1). Microscopic examination of the tympanic membranes showed normal findings. Electroneuronography (ENoG) revealed 16.6% weakness on the left during maximal stimulation testing. Stapedial reflex was absent on the left (ipsi- and contra-stimulation) and was present on the right (ipsi- and contra-stimulation). High-resolution CT revealed a soft tissue mass of the left temporal bone involving the geniculate ganglion, and the partial bone defect of the middle fossa and cochlea (Fig. 2). Gadolinium-enhanced MRI demonstrated a centrally enhancing lesion of 5 mm 10 mm in size involving the left geniculate ganglion, with extension to the tympanic segment of the facial nerve (Fig. 3). This appearance was consistent with a facial nerve schwannoma. The tumor was totally removed by the middle cranial fossa approach. At the time of surgery, a dark red mass centered on the geniculate portion of the facial nerve was identified (Fig. 4). The nerve could not be separated from the tumor. Consequently, the tumor had to be removed together with the facial nerve. After removal of the tumor, the cochlear fistula was observed. The cochlear fistula was immediately packed with fascia and adhered with the fibrin glue. Following the tumor removal, the continuity of the facial nerve had been restored using a greater auricular nerve graft.
Fig. 2. High-resolution CT. CT images showing a tumor at the left first genu of the facial nerve (arrow). The tumor expansively destroyed the cochlear wall and middle skull base (arrowhead).
Fig. 3. Gadolinium-enhanced MRI. MRI images showing a centrally enhancing lesion in the geniculate ganglion (arrow), measuring 5 mm 10 mm in diameter.
T. Miyashita et al. / Auris Nasus Larynx 34 (2007) 519–522
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Fig. 4. Treatment (operation). The tumor (white arrow heads) was totally removed by the middle cranial fossa approach. The tumor was removed with the facial nerve destroyed by it in the geniculate ganglion. After the removal the cochlear fistula was observed. The cochlear fistula was packed with a piece of fascia and adhered with the fibrin glue. Following tumor removal, continuity of the facial nerve had been restored using a greater auricular nerve graft (brack arrow heads).
Fig. 5. Histopathological evaluation (hematoxylin and eosin stain). Large vascular spaces are lined with a single layer of endothelium and surrounded by thick walls filled with uniform fibrous tissues (a and b). The hemangioma demonstrated facial nerve infiltration (c). Immunohistochemical analysis showed negative staining with S-100 protein (not shown). Pathologic diagnosis was cavernous hemangioma.
Histopathologic evaluation showed that the lesion was a cavernous hemangioma of the facial nerve (Fig. 5). As expected, the immediate postoperative left facial function of the patient was a House-Brackmann grade VI. Postoperative hearing loss (total deafness) of the left ear and vertigo (with paralytic nystagmus) were observed. The vertigo was in remission 2 weeks postoperatively. At 24 months after the surgery, the facial function had improved to a HouseBrackmann grade V. There has been no sign of recurrent tumor by MRI imaging.
3. Discussion Facial nerve hemangioma is a rare tumor, and the treatment is a complete surgical resection by the middle cranial fossa approach, the transmastoid approach or combined (the middle cranial fossa and transmastoid approach) approach [1,11]. Resection of the nerve and repairing using graft are often necessary because the hemangioma is often associated with an intense perineural reaction or direct facial nerve infiltration [10,12]. Especially, the hemangioma of the geniculate ganglion often demonstrated facial nerve infiltration. Six previous reports and this case with facial nerve infiltration were all involving the
perigeniculate region [7,12–14]. Facial nerve recovery after resection of the facial nerve with repairing using graft was better when the preoperative facial nerve deficit prolonged less than 1 year [5]. Another report recommended that nerve grafting should be undertaken within 2 years after the onset of complete palsy [6]. Therefore, early diagnosis and early resection are important. Gadolinium-enhanced MRI and high-resolution CT of the temporal bone are useful for an early diagnosis of facial nerve hemangioma [2]. Facial nerve hemangioma often display uniform enhancement with gadolinium on MRI, and occasionally can produce a honeycomb appearance (with irregular and indistinct bony margins and bony spicules with the tumor) on CT [15]. In this case nothing of this character was observed on MRI and CT. MRI and high-resolution CT could detect a small-sized facial nerve tumor, which failed to be found by plane routine CT. Since the hemangioma had direct infiltration into the facial nerve in this case, the resection of the nerve with repairing using graft was necessary. Some article reported that the hearing was preserved at preoperative levels when the cochlea was intact [3,5]. In cases with cochlear erosion by hemangioma, sensory neural hearing loss (SNHL) occurred immediately or progressively, and the hearing preservation is practically impossible [3,5]. The case of initially preserved hearing with
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T. Miyashita et al. / Auris Nasus Larynx 34 (2007) 519–522
the cochlear bony wall erosion by hemangioma was reported to show a subsequent decline of the hearing [3]. In this case, the cochlear bony wall was eroded by the hemangioma and severe SNHL was occurred after surgery although immediately the cochlear fistula was covered by the fascia.
References [1] Mangham CA, Carberry JN, Brackmann DE. Management of intratemporal vascular tumors. Laryngoscope 1981;91:867–76. [2] Friedman O, Neff BA, Willcox TO, Kenyon LC, Sataloff RT. Temporal bone hemangiomas involving the facial nerve. Otol Neurotol 2002;23:760–6. [3] Isaacson B, Telian SA, McKeever PE, Arts HA. Hemangiomas of the geniculate ganglion. Otol Neurotol 2005;26:796–802. [4] Ray A, Lammie GA, Shone G, Hourihan MD, Vafidis J. Venous angioma of the facial nerve: a case report. Surg Neurol 2004;61:198– 200. [5] Falcioni M, Russo A, Taibah A, Sanna M. Facial nerve tumors. Otol Neurotol 2003;24:942–7.
[6] Salib RJ, Tziambazis E, McDermott AL, Chavda SV, Irving RM. The crucial role of imaging in detection of facial nerve haemangiomas. J Laryngol Otol 2001;115:510–3. [7] Escada P, Capucho C, Silva JM, Ruah CB, Vital JP, Penha RS. Cavernous haemangioma of the facial nerve. J Laryngol Otol 1997;111:858–61. [8] Pulec JL. Facial nerve tumors. Ann Otol Rhinol Laryngol 1969;78:962–82. [9] Ylikoski J, Brackmann DE, Savolainen S. Pressure neuropathy of the facial nerve: a case report with light and electron microscopic findings. J Laryngol Otol 1984;98:909–14. [10] Shelton C, Brackmann DE, Lo WW, Carberry JN. Intratemporal facial nerve hemangiomas. Otolaryngol Head Neck Surg 1991;104:116–21. [11] Pulec JL. Facial nerve angioma. Ear Nose Throat J 1996;75:225–38. [12] Eby TL, Fisch U, Makek MS. Facial nerve management in temporal bone hemangiomas. Am J Otol 1992;13:223–32. [13] Curtin HD, Jensen JE, Barnes Jr L, May M. ‘‘Ossifying’’ hemangiomas of the temporal bone: evaluation with CT. Radiology 1987;164: 831–5. [14] Mazzoni A, Pareschi R, Calabrese V. Intratemporal vascular tumours. J Laryngol Otol 1988;102:353–6. [15] Hoffman M, Shelton C, Harnsberger HR. Imaging quiz case 2. Facial nerve hemangioma. Arch Otolaryngol Head Neck Surg 1997;123(763): 765–6.