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  • Title: [Clinical diagnosis and surgical management of 110 cases of facial nerve schwannomas].
    Author: Sai N, Han WJ, Wang MM, Qin X, Zhang T, Shen WD, Liu J, Dai P, Yang SM, Han DY.
    Journal: Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi; 2019 Feb 07; 54(2):101-109. PubMed ID: 30776861.
    Abstract:
    Objective: To elucidate the clinical behavior, causes of misdiagnosis, surgical management, and outcomes of facial nerve schwannomas (FNS). Methods: A retrospective review in Chinese People's Liberation Army General Hospital from January 1, 2002 to December 31, 2015 was carried out and evaluated 110 patients with FNS, including 50 males and 60 females, aged 16-67 years old. The appropriate surgical strategy was selected based on each patient's clinical manifestations, facial nerve function, and imaging characteristics. After surgery, patients received follow-up visits to assess their facial nerve functions, with the effect of treatment compared to the reality before surgery. The Kruskal-Wallis H test was used to distinguish between the pre- and post-operation facial nerve functions in patients who had different facial nerve functions before the operations. Results: 110 cases of FNS mainly presented with facial paralysis, hearing loss, tinnitus, otalgia, dizziness, and facial spasm. 20 of the cases were misdiagnosed as Bell's Palsy, 6 were mistaken for chronic otitis media/cholesteatoma with radical mastoidectomy, 3 were mistaken for Meniere's disease, 1 was misdiagnosed as petrous bone cholesteatoma, and 4 were mistaken for acoustic neuroma. 81.8 % (90/110) of the patients had multiple segments of the facial nerve, including the vertical segment of the facial nerve, accounting for 65.5% (72/110), followed by the labyrinthine/geniculate segment, for 61.8% (68/110), and the horizontal segment, for 55.5% (61/110). The appropriate surgical approaches were chosed based on the sizes and scopes of the tumors evaluated by imaging: transmastoid approach in 73 cases, translabyrinthe approach in 14 cases, middle cranial fossa approach in 13 cases, retrosigmoid approach in 3 cases, transmastoid-middle cranial fossa approach in 3 cases, and transmastoid-neck approach in 4 cases, with all the patients undergoing a total/subtotal resection of the tumor. Eighty-seven patients had their facial nerves reconstructed. Among them, 6 received facial nerve end-to-end anastomosis, 55 received great auricular nerve graft, and 26 were subjected to facial nerve-hypoglossal nerve anastomosis. Because of long histories, facial muscle atrophies, or other reasons, the remaining patients were not received facial nerve reconstruction. The House-Brackmann(H-B) grading scale was used to evaluate the facial nerve function pre- and post-operation. Patients with better facial nerve functions and shorter history of facial paralysis before operation would get relatively better facial nerve function. The before and after operation comparisons revealed that the recovery of the facial nerve functions in patients with H-B Ⅰ-Ⅲ was better than the improvement in patients with H-B Ⅳ-Ⅴ. The difference was statistically significant (Kruskal-Wallis H test, H=8.508, P<0.05). Conclusions: The diagnosis of patients with unknown facial paralysis, hearing loss, and tinnitus should take into account the possibility of FNS. CT and other imaging examinations of the temporal bone can avoid misdiagnosis and determine the tumor size and extent of lesions, as well as provide the basis for the choice of the surgical approach. After tumors have been completely resected, facial nerve reconstruction can be performed simultaneously, according to the defect of the nerve. 目的： 分析总结面神经鞘瘤的临床特点、误诊原因、手术策略、面神经修复方法及效果。 方法： 回顾性分析解放军总医院耳鼻咽喉头颈外科2002年1月至2015年12月期间外科手术治疗的110例面神经鞘瘤患者的临床资料，其中男50例，女60例，年龄16~67岁。根据患者临床表现、面神经功能、影像特征，选择合适的手术策略。术后进行面神经功能随访，与术前比较，分析治疗效果。使用Kruskal-Wallis H检验对术前不同面神经功能患者的术后面神经功能恢复情况进行比较分析。 结果： 110例面神经鞘瘤患者的主要临床表现依次为面神经麻痹、听力下降、耳鸣、耳痛、眩晕、面肌痉挛等。其中20例曾被误诊为贝尔面神经麻痹，6例曾被误诊为中耳炎/中耳胆脂瘤并行乳突根治术，3例误诊为梅尼埃病，1例误诊为岩部胆脂瘤，4例误诊为听神经瘤。手术探查见81.8%（90/110）的患者肿瘤累及面神经多个节段，其中最多见的受累部位是面神经垂直段65.5%（72/110），其次是迷路段/膝状神经节61.8%（68/110）和水平段55.5%（61/110）。根据颞骨CT等影像学检查明确肿瘤大小和累及的范围，选择合适的手术入路，其中经乳突入路73例，经迷路入路14例，经中颅窝入路13例，经乙状窦后入路3例，经乳突、颅中窝联合入路3例，经乳突、颈部联合入路4例。除2例仅行面神经减压术外，其余患者均行肿瘤切除术。对87例有条件行面神经修复的患者同时行面神经修复术，其中面神经改道吻合6例，耳大神经移植55例，面神经-舌下神经吻合26例；其余患者因完全性面神经麻痹时间长、面部肌肉萎缩等原因未行面神经修复手术。术前面神经功能按House-Brackmann（H-B）法分级：Ⅰ级20例，Ⅱ级7例，Ⅲ级12例，Ⅳ级11例，Ⅴ级39例，Ⅵ级21例。术后随访资料完整的78例患者，面神经功能H-B分级：Ⅰ级2例，Ⅱ级1例，Ⅲ级21例，Ⅳ级20例，Ⅴ级22例，Ⅵ级12例（均未行面神经修复术）。术前H-B Ⅰ~Ⅲ级者术后面神经功能恢复情况要好于术前Ⅳ~Ⅴ级者，差异有统计学意义（H=8.508，P<0.05）。 结论： 对原因不明的面神经麻痹、听力下降、耳鸣患者应考虑到面神经鞘瘤的可能，颞骨CT等影像学检查可避免误诊并确定肿瘤大小、累及范围，为手术入路的选择提供依据。完全切除肿瘤后可根据面神经缺损情况选择改道吻合、耳大神经移植、面神经-舌下神经吻合术修复面神经功能，术前面神经功能较好、面神经麻痹时间较短的患者，切除肿瘤后修复面神经可获得更好的面神经功能。.
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