1

Introduction

Facial nerve hemangiomas (FNHs) were firstly described by Politzer in 1901, which accounted for 0.7% among intratemporal tumors . FNHs may involve any segment along facial nerve in temporal bones, but internal auditory canal (IAC) and geniculate ganglion (GG) were the predilection sites . It was believed that the lesions arose from vascular plexuses around the facial nerve or Scarpa’s ganglion, which was a ganglion of the auditory nerve, and compressed the facial nerve or auditory nerve from outside . FNHs at IAC and GG were actually vascular malformations other than real tumors , but the traditional nomenclature had referred to the lesions as “hemangiomas” for over one century. Thus, we still called the lesions as hemangiomas in the paper.

Symptoms of FNHs at IAC and GG were distinctive. Majority of FNHs at IAC initially presented with sensorineural hearing loss of retrocochlear type followed by facial nerve dysfunction and vertigo, while those at GG commonly showed facial nerve deficit symptoms even when of extremely small size .

The aim of our study was to introduce our surgical experience about a large series of 15 cases who had FNH, emphasizing the importance of nerve integrity preservation in favorable outcomes of facial nerve.

2

Materials and methods

We retrospectively analyzed the clinical data of 15 patients which had FNH, who were surgically treated in a referral center. The diagnosis of FNH was made histologically. 10 patients were female and 5 male, with the mean age of 39.2 ± 2.9 years (range, 20 to 62 years).

We removed the lesions completely in all cases, and attempted to preserve nerve integrity if possible. With the aid of intraoperative facial nerve monitoring, facial nerve was recognized. The hemangiomas were separated from the nerve tissue, and the lesions were removed around the nerve fascicles. However, it was found that there were no clear margins between hemangiomas and the nerve fascicles in 5 cases, and the nerve integrity was sacrificed, followed by nerve grafting with either greater auricular nerve or sural nerve as the graft materials.

Surgical approach was mainly determined by the hemangiomas’ location and preoperative hearing level. For the patients with serviceable hearing, transmastoid approach was used to remove hemangiomas at GG, labyrinthine segment, tympanic segment or mastoid segment, middle cranial fossa approach was introduced when the lesions were located at IAC, and middle cranial fossa combined with transmastoid approach was adopted for hemangiomas involving IAC, GG and tympanic segment. Translabyrinthine approach was used for the lesions at IAC with dead ears. The critical procedure of the transmastoid approach to remove hemangiomas at GG or labyrinthine segment was to remove incus temporarily and then reposition exactly .

They were followed up for 4.7 ± 1.8 years (range, 2 to 8 years). Facial nerve function was evaluated by House–Brackmann grading system , and hearing was measured by clinical audiometer.

2

Materials and methods

We retrospectively analyzed the clinical data of 15 patients which had FNH, who were surgically treated in a referral center. The diagnosis of FNH was made histologically. 10 patients were female and 5 male, with the mean age of 39.2 ± 2.9 years (range, 20 to 62 years).

We removed the lesions completely in all cases, and attempted to preserve nerve integrity if possible. With the aid of intraoperative facial nerve monitoring, facial nerve was recognized. The hemangiomas were separated from the nerve tissue, and the lesions were removed around the nerve fascicles. However, it was found that there were no clear margins between hemangiomas and the nerve fascicles in 5 cases, and the nerve integrity was sacrificed, followed by nerve grafting with either greater auricular nerve or sural nerve as the graft materials.

Surgical approach was mainly determined by the hemangiomas’ location and preoperative hearing level. For the patients with serviceable hearing, transmastoid approach was used to remove hemangiomas at GG, labyrinthine segment, tympanic segment or mastoid segment, middle cranial fossa approach was introduced when the lesions were located at IAC, and middle cranial fossa combined with transmastoid approach was adopted for hemangiomas involving IAC, GG and tympanic segment. Translabyrinthine approach was used for the lesions at IAC with dead ears. The critical procedure of the transmastoid approach to remove hemangiomas at GG or labyrinthine segment was to remove incus temporarily and then reposition exactly .

They were followed up for 4.7 ± 1.8 years (range, 2 to 8 years). Facial nerve function was evaluated by House–Brackmann grading system , and hearing was measured by clinical audiometer.

3

Results

Summary of the cases is listed in Table 1 . 8 of 15 cases (53.3%) involved GG region, and 7 cases (46.7%) affected IAC. Mastoid segment alone, tympanic segment along with GG and IAC or labyrinthine segment together with GG was also affected in one case (6.7%), respectively.

Table 1

Summary of 15 cases who had facial nerve hemangiomas.

Case No.	Symptoms	Location	Duration a (months)	Preop. Grade	Postop. Grade	Nerve graft	Surgical approach	Initial hearing (dB)	Final hearing (dB)	Follow-up (years)
1	SNHL	IAC		I	I	None	MCF	55	55	3
2	SNHL	IAC		I	I	None	TL	Dead ear	Dead ear	5
3	FP	GG	6	III	II	None	TM	10	10	7
4	FP	GG, LS	10	IV	II	None	TM	5	5	4
5	SNHL	IAC		I	I	None	MCF	45	45	8
6	FP, MHL	IAC, GG, TS	40	VI	IV	GAN	MCF, TM	50	50	2
7	FP	MS	5	V	II	None	TM	15	15	5
8	FP	GG	36	IV	IV	GAN	TM	5	15	6
9	SNHL, V	IAC		I	I	None	TL	Dead ear	Dead ear	5
10	T	IAC		I	I	None	MCF	20	20	4
11	FP	GG	18	VI	IV	SN	TM	15	15	2
12	FP	GG	14	V	III	GAN	TM	5	15	7
13.	FP, SNHL	GG	24	VI	III	GAN	TM	Dead ear	Dead ear	6
14.	FP	IAC	18	III	II	None	MCF	5	5	4
15	FP	GG	5	IV	II	None	TM	15	20	3

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