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  • Title: [Differential diagnosis and management of hemangioma at geniculate ganglion].
    Author: Huang AY, Chai YC, Xue L, Chen HS, Hu LX, Jia H, Zhang ZH, Wu H, Wang ZY.
    Journal: Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi; 2022 Jul 07; 57(7):819-826. PubMed ID: 35866274.
    Abstract:
    Objective: To investigate the clinical characteristics, differential diagnosis, treatments and prognosis of facial nerve hemangioma and schwannoma at genicular ganglion, so as to provide reference for clinical diagnosis and treatments of facial nerve tumor at genicular ganglion. Methods: Clinical data of 13 patients with facial nerve tumors at genicular ganglion confirmed by postoperative pathology in the Ninth People's Hospital affiliated to Shanghai Jiaotong University School of Medicine from March 2018 to April 2020 were retrospectively analyzed, including seven cases of hemangioma and six cases of schwannoma. There were eight males and five females. Their ages ranged from 20 to 65, with an average age of 40. The course of disease ranged from 3 to 118 months, with an average of 52 months. All the patients underwent preoperative HRCT of the temporal bone and facial nerve dynamic contrast-enhanced(DCE) MRI examinations. All the patients had detailed surgical procedures and at least one-year postoperative follow-up. Results: On HRCT of the temporal bone, (4/7) hemangioma at geniculate ganglion showed characteristic honeycomb appearance, while 6/6 schwannoma and 3/7 hemangiomas showed expansive bone changes. On DCE-MRI, geniculate ganglion hemangioma (7/7) showed characteristic "point-to-surface" enhancement, and schwannoma (6/6) showed characteristic "face-to-surface" enhancement. For five hemangioma-patients with HB-Ⅱ-Ⅳ before surgery, the facial nerve anatomy was completely preserved through transcanal endoscopic approach(TEA), and the facial nerve function improved one year after surgery (two cases of HB-I, two cases of HB-Ⅱ, and one case of HB-Ⅲ). For two patients, with preoperative facial nerve function HB-Ⅴ-Ⅵ, since their tumors was inseparable from the nerves, they were performed with facial nerve anastomosis during the surgery, and the facial nerve function was improved to HB-Ⅳ level one year after surgery. For six patients with meningioma whose facial nerve function was greater than or equal to HB-Ⅲ, based on the preoperative hearing level, the involved segments, and duration of facial paralysis, three of them were conducted surgeries through middle cranial fossa approach, one by translabyrinthine approach, and one via mastoid approach. Two patients among them with complete facial paralysis over three years preoperatively were not performed facial nerve anastomosis after total resections of the tumors, and there was no improvement in facial nerve function one year after surgery. Three patients underwent facial nerve anastomosis after total tumor resections, and their facial nerve function was HB-Ⅲ in one patient, HB-Ⅳ in two patients one year after surgery. One patient (preoperative HB-Ⅲ) had a normal hearing level preoperatively, and the tumor involved the labyrinth segment. To protect the hearing, partial tumor was resected through the middle cranial fossa approach, and facial nerve function improved to HB-Ⅱ one year after surgery. Conclusions: Temporal bone HRCT combined with DCE-MRI are useful for the differential diagnosis of hemangioma and schwannoma at geniculate ganglion and provide references for preoperative clinical decision makings. It is extremely necessary to select the appropriate surgical approach based on the patient's hearing and involved segments. For geniculate ganglion hemangioma, early surgery can improve the possibilities of anatomical integrity of facial nerve, thereby improving facial nerve function postoperatively.TEA is a kind of surgical method worth consideration, with the characteristics of minimally invasive, favorable postoperative features, and so on. For schwannoma, one-stage functional reconstruction of the facial nerve is recommended during the resection of the tumors because of the inevitable damage to the anatomical integrity of the facial nerve. 目的： 分别探讨面神经膝状神经节血管瘤和神经鞘瘤的临床特征、鉴别诊断及治疗和预后，为面神经膝状神经节肿瘤的临床诊治提供参考。 方法： 回顾性分析2018年3月至2020年4月上海交通大学医学院附属第九人民医院13例经术后病理证实的面神经膝状神经节肿瘤患者的临床资料，其中膝状神经节血管瘤7例，神经鞘瘤6例；男8例，女5例；年龄20~65岁，平均年龄40岁；病程3~118个月，平均52个月。所有患者术前均具有颞骨高分辨率CT（HRCT）及动态增强MRI检查，手术具有详细的方案，且术后至少随访1年。 结果： 颞骨HRCT显示，膝状神经节血管瘤具有特征性的蜂窝状骨质改变（4/7），6/6的神经鞘瘤和3/7的血管瘤表现为膨胀性骨质改变。在动态增强MRI上，膝状神经节血管瘤（7/7）表现为特征性的“点到面”强化方式，神经鞘瘤（6/6）表现为特征性的“面到面”强化方式。对于术前面神经功能HB分级Ⅱ~Ⅳ级的5例血管瘤患者，采用耳内镜下经耳道径路手术，面神经解剖完整保留，术后1年面神经功能较术前均有改善（HB分级Ⅰ级2例，Ⅱ级2例，Ⅲ级1例）。2例术前面神经功能HB分级Ⅴ~Ⅵ级的患者，面神经与肿瘤不可分，采用肿瘤切除后一期面神经功能重建，术后1年面神经功能均恢复至HB分级Ⅳ级。6例神经鞘瘤患者手术时面神经功能均大于或等于HB分级Ⅲ级，根据术前听力，肿瘤累及范围、面神经麻痹时程采用颅中窝径路手术3例、迷路径路手术1例、耳内镜下经耳道径路手术1例、乳突径路手术1例，其中2例患者因术前完全性面神经麻痹3年以上，肿瘤全切后未行面神经功能重建，术后1年面神经功能无改善，3例在肿瘤全切除后行一期面神经重建，术后1年的面神经功能HB分级Ⅲ级1例、Ⅳ级2例，1例（术前HB分级Ⅲ级）因肿瘤侵犯迷路段，且听力正常，为不影响听力，行肿瘤部分切除和面神经减压，术后1年面神经功能恢复至HB分级Ⅱ级。 结论： 颞骨HRCT联合动态增强MRI可帮助膝状神经节血管瘤和神经鞘瘤的鉴别诊断，为术前临床决策提供参考。根据患者的听力情况、肿瘤累及范围等选择合适的手术径路极其必要。对于膝状神经节血管瘤，早期手术可提高面神经解剖完整率，从而提高术后面神经功能，而耳内镜下经耳道径路具有微创、美观等特点，是值得考虑的方案之一。对于神经鞘瘤，在肿瘤完全切除的同时，因不可避免引起面神经解剖完整性的中断，建议一期行面神经功能重建。.
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