Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Intratemporal Tumors of the Facial Nerve Treatment & Management

  • Author: Jacek Szudek, MD, PhD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 11, 2016
 

Medical Therapy

In patients without facial dysfunction, a conservative strategy consisting of clinical and radiological observation should be considered as a treatment option. When facial nerve paralysis has developed to a House-Brackmann grade of more than III, an immediate operation is recommended to obtain a good postoperative facial functional recovery. On the other side of this debate, some experts report early schwannoma resection with facial nerve preservation. Little data have been published on the use of radiotherapy to treat facial nerve tumors.

Surgical resection of facial nerve neuromas is also indicated when a large cerebellopontine angle tumor compresses the brainstem or results in hydrocephalus. Note that brainstem compression and hydrocephalus are far more common among cases of vestibular schwannoma rather than facial nerve tumors. Other operative indications include tumor invading the inner ear or suspicion of malignancy or neurofibromatosis 1.[4]

Next

Surgical Therapy

Surgery is the preferred therapeutic modality for advanced schwannomas and hemangiomas of the facial nerve. The surgical approach depends on the anatomic location of the tumor, the extent of the tumor, and the hearing status in both ears. Timing of surgical intervention presents a thornier dilemma.[5]

Hemangiomas, with their proclivity to arise from the geniculate ganglion, are often confined to the middle cranial fossa and can therefore be removed via a subtemporal craniotomy. If the tumor extends laterally down the labyrinthine segment or along the tympanic segment of the facial nerve, a combined approach that incorporates a postauricular mastoidectomy may be necessary. A transmastoid approach is usually preferred. Since hemangiomas are extraneural, they can, if small, be removed while sparing the facial nerve.

Surgical removal of facial nerve schwannomas is approached similarly. These tumors are more likely to extend into the cerebellopontine angle and therefore may also reach a larger size before they become symptomatic. However, often the diagnosis of facial nerve schwannoma can only be made intraoperatively during removal of what had been regarded as a vestibular schwannoma.

In a retrospective study, Lahlou et al reported that of 19 patients who underwent surgery for intratemporal facial nerve schwannomas, postoperative facial nerve function was stable or improved in 57.9% of them and became worse in 42.1% them. Most of the patients had House-Brackmann grade III facial nerve function postoperatively, with none having grade V or VI. In addition, 52.6% of patients maintained stable postoperative hearing, with 10.5% of them experiencing an improvement.[6]

In a study of 17 cases of intratemporal facial nerve schwannoma, Lu et al found that stripping surgery removed the tumor completely in all patients, while leaving the nerve intact in 12 cases (70.6%). Six of these 12 patients (50%) experienced acceptable nerve recovery.[7]

In patients with residual or recurrent intracanalicular neuromas, the translabyrinthine approach is the preferred surgical route, allowing complete tumor removal; it may also be used for exposure of the intratemporal portion of the facial nerve for a hemihypoglossal-facial nerve anastomosis when a postoperative facial palsy exists. The facial nerve is exposed in its mastoid and tympanic parts, mobilized, and transected. Then, the long nerve stump is transposed into the neck and used for an end-to-side anastomosis with the hypoglossal nerve, although end-to-end anastomosis of distal facial nerve to its proximal counterpart is preferred with the removal of an intracanalicular residual schwannoma. Neurotization of the facial muscles through a nerve graft may be used when no distal trunk of the facial nerve is available for the anastomosis.

The translabyrinthine or transpetrosal route is useful for patients without useful hearing and a facial nerve neuroma in the internal auditory canal. In patients with useful hearing, a hearing-sparing approach (eg, middle fossa approach) is used. However, the middle fossa approach involves retraction of the temporal lobe.

Clinicians should beware that, although radiation doses delivered to middle and external ear structures are unlikely to contribute to post–gamma knife surgery complications, unexpectedly high doses may be delivered to sensitive areas of the intratemporal facial nerve. Rare cases of intratemporal facial nerve tumors are reported in the stereotactic radiosurgery literature. Therefore, data available are insufficient to determine whether this treatment modality is safe.

Previous
Next

Preoperative Details

Follow-up and appropriate timing of intervention are the key issues in managing patients with intratemporal facial nerve tumors. If a 3-mm hemangioma is discovered at the geniculate ganglion, it may be amenable to being stripped off of the nerve such that the nerve is left intact, but often, the tumors are larger. Hemangiomas insinuate between the nerve fibers, making nerve-sparing dissection difficult. Schwannomas often are tightly integrated into the nerve such that no safe surgical plane is identifiable. Thus, removal of these tumors endangers nerve integrity and function.

Because of the high likelihood that the facial nerve will be resected along with the tumor, a primary anastomosis (for smaller tumors) or a cable graft (using great auricular nerve, sural nerve, most commonly) may be required. Because the best expected functional result with these nerve repair techniques rarely exceeds a House-Brackmann grade III paresis, intervention is timed such that facial nerve function has degenerated to worse than House-Brackmann IV or so. However, intervention should not be delayed past the point where motor endplates have atrophied.

Obviously, patients need close follow-up on an outpatient basis in the surgeon's clinical practice. Patients should understand the nature of their disease and the rationale behind the timing of intervention to be better able to incorporate those considerations into the decision-making process.

Finally, the decision on how to treat these patients should be individualized and based on initial facial function, growth rate, surgical experience, and informed patient consent.

Previous
Next

Complications

Complications of surgery for facial nerve tumors are related to the surgical approach. For craniotomies, these complications include but are not limited to cerebrospinal fistula, seizures, hydrocephalus, meningitis, and possible loss of any and all neurologic functions. Complications of mastoid or translabyrinthine approaches include hearing loss, tinnitus, vertigo, infection, and hematoma. Discuss facial paralysis with the patient, so that expectations for functional recovery are realistic. Most patients who had worse than moderate facial palsy can expect no better.

Previous
 
Contributor Information and Disclosures
Author

Jacek Szudek, MD, PhD Resident Physician, Department of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton

Jacek Szudek, MD, PhD is a member of the following medical societies: College of Physicians and Surgeons of Alberta, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association

Disclosure: Nothing to disclose.

Coauthor(s)

Nader Sadeghi, MD, FRCSC Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Thyroid Association, American Academy of Otolaryngology-Head and Neck Surgery, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

K Paul Boyev, MD Director of Hearing and Balance Center, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of South Florida

K Paul Boyev, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association

Disclosure: Nothing to disclose.

Arjun S Joshi, MD Assistant Professor of Surgery, Division of Otolaryngology–Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Arjun S Joshi, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Thyroid Association

Disclosure: Nothing to disclose.

Alan A Z Alexander, MD, MS George Washington University School of Medicine

Alan A Z Alexander, MD, MS is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gerard J Gianoli, MD Clinical Associate Professor, Departments of Otolaryngology-Head and Neck Surgery and Pediatrics, Tulane University School of Medicine; President, The Ear and Balance Institute; Board of Directors, Ponchartrain Surgery Center

Gerard J Gianoli, MD is a member of the following medical societies: American Otological Society, Society of University Otolaryngologists-Head and Neck Surgeons, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Vesticon<br/>Received none from Vesticon, Inc. for board membership.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Received royalty from American biloogical group for other.

References
  1. Gross BC, Carlson ML, Moore EJ, Driscoll CL, Olsen KD. The intraparotid facial nerve schwannoma: a diagnostic and management conundrum. Am J Otolaryngol. 2011 Dec 19. [Medline].

  2. Warren HG, Prevatt AA, Daly KA, Antonelli PJ. Cellular telephone use and risk of intratemporal facial nerve tumor. Laryngoscope. 2003 Apr. 113(4):663-7. [Medline].

  3. Doshi J, Hughes R, Freeman SR, et al. Clinical and Radiological Guidance in Managing Facial Nerve Schwannomas. Otol Neurotol. 2014 Oct 1. [Medline].

  4. Edizer DT, Hajizade Y, Karaman E, Cansiz H. Intraparotid facial nerve neurofibroma in neurofibromatosis type 1. J Craniofac Surg. 2011 May. 22(3):1118-9. [Medline].

  5. Kim J, Moon IS, Lee JD, Shim DB, Lee WS. Useful surgical techniques for facial nerve preservation in tumorous intra-temporal lesions. Auris Nasus Larynx. 2010 Feb. 37(1):33-41. [Medline].

  6. Lahlou G, Nguyen Y, Russo FY, Ferrary E, Sterkers O, Bernardeschi D. Intratemporal facial nerve schwannoma: clinical presentation and management. Eur Arch Otorhinolaryngol. 2015 Dec 16. [Medline].

  7. Lu R, Li S, Zhang L, Li Y, Sun Q. Stripping surgery in intratemporal facial nerve schwannomas with poor facial nerve function. Am J Otolaryngol. 2015 May-Jun. 36 (3):338-41. [Medline].

  8. Chung JW, Ahn JH, Kim JH, Nam SY, Kim CJ, Lee KS. Facial nerve schwannomas: different manifestations and outcomes. Surg Neurol. 2004 Sep. 62(3):245-52; discussion 452. [Medline].

  9. Donzelli R, Maiuri F, Peca C, Cavallo LM, Motta G, de Divitiis E. Microsurgical repair of the facial nerve. Zentralbl Neurochir. 2005 May. 66(2):63-9. [Medline].

  10. Frosch MP, Anthony DC, De Girolami U. The Central Nervous System. Kumar V, ed. Robbins and Cotran Pathologic Basis of Disease. 7th ed. Philadelphia, Pa: WB Saunders; 2004. 1401-20.

  11. Isaacson B, Telian SA, McKeever PE, Arts HA. Hemangiomas of the geniculate ganglion. Otol Neurotol. 2005 Jul. 26(4):796-802. [Medline].

  12. Kirazli T, Oner K, Bilgen C, Ovül I, Midilli R. Facial nerve neuroma: clinical, diagnostic, and surgical features. Skull Base. 2004 May. 14(2):115-20. [Medline].

  13. Marzo SJ, Zender CA, Leonetti JP. Facial nerve schwannoma. Curr Opin Otolaryngol Head Neck Surg. 2009 Jun 24. [Medline].

  14. McMonagle B, Al-Sanosi A, Croxson G, Fagan P. Facial schwannoma: results of a large case series and review. J Laryngol Otol. 2008 Nov. 122(11):1139-50. [Medline].

  15. Minovi A, Vosschulte R, Hofmann E, Draf W, Bockmuhl U. Facial nerve neuroma: surgical concept and functional results. Skull Base. 2004 Nov. 14(4):195-200; discussion 200-1. [Medline].

  16. Perez R, Chen JM, Nedzelski JM. Intratemporal facial nerve schwannoma: a management dilemma. Otol Neurotol. 2005 Jan. 26(1):121-6. [Medline].

  17. Perez R, Chen JM, Nedzelski JM. Intratemporal facial nerve schwannoma: a management dilemma. Otol Neurotol. 2005 Jan. 26(1):121-6. [Medline].

  18. Schoen FJ. Blood Vessels. Kumar V, ed. Robbins and Cotran Pathologic Basis of Disease. 7th ed. Philadelphia, Pa: WB Saunders; 2004. 545-51.

  19. Shirazi MA, Leonetti JP, Marzo SJ, Anderson DE. Surgical management of facial neuromas: lessons learned. Otol Neurotol. 2007 Oct. 28(7):958-63. [Medline].

 
Previous
Next
 
A small acoustic neuroma within the internal auditory canal is easily observed on postgadolinium MRI.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.