Primary facial canal paraganglioma

Natural history of facial paraganglioma with 2 decades of follow-up: A case report and literature review

OBJECTIVE

To report 20 years of natural history data for a facial paraganglioma and provide a comprehensive review of the existing literature.

PATIENT

81-year-old female with a remote history of cardiac arrest while under anesthesia who elected to observe her facial paraganglioma for 20 years.

INTERVENTIONS

Observation, clinical documentation, radiographic surveillance.

MAIN OUTCOME MEASURES

Tumor progression, patient symptomatology, and review of management options.

RESULTS

The initial presentation of the facial paraganglioma was facial spasm. Over the course of observation, symptoms progressed to include complete facial nerve paralysis, pulsatile tinnitus, and otalgia on the affected side. Radiologic surveillance demonstrated incremental growth and erosion of surrounding structures, including the posterior external auditory canal, stylomastoid foramen, and lateral semicircular canal with near-dehiscence. Twenty-four cases of facial paraganglioma were identified in the extended literature search and are summarized herein.

CONCLUSIONS

This unique case contributes to the scarce literature surrounding facial paragangliomas by reporting the extended natural history of this disease.

Rare Diseases of the Salivary Glands and of Facial Nerve

Salivary gland diseases are rare. In the European Union (EU) a disease is considered to be rare if not more than 5 of 10,000 people are affected by it. According to estimates in Germany are about 4 million people with a rare disease. In the EU are about 30 million people with rare diseases [1]. In the present work most of the described diseases of salivary glands and of the facial nerve fall in this category. They form a very heterogeneous group whose treatment takes place mainly in specialized centers. Still, it is essential for the otolaryngologist to identify and to diagnose these diseases in order to initiate the right therapeutic steps. The work is a compilation of innate andacquired rare salivary gland disorders and of rare facial nerve disorders. The etiologies of inflammatory diseases, autoimmune disorders and tumors are taken into account. For the individual topics, the current literature, if available, was evaluated and turned into summarized facts. In this context the development of new processes, diagnostics, imaging and therapy are considered. Genetic backgrounds of salivary gland tumors and the trends in the treatment of tumorous lesions of the facial nerve are picked up. Furthermore, also rare diseases of the salivary glands in childhood are described. Some of them can occur in adults as well, but differ in frequency and symptoms. Due to the rarity of these diseases, it is recommended to tread these in centers with special expertise for it. Finally, the difficulties of initiation of studies and the problems of establishing disease registries concerning salivary gland disorders are discussed. This is very relevant because these pathologies are comparatively seldom.

Primary Paraganglioma of the Facial Canal: An Evidence-Based Approach

Objectives

To perform an evidence-based review evaluating presenting symptoms, imaging, and management for primary paragangliomas of the facial canal (PPFCs).

Data Sources

PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science.

Review Methods

Studies were assessed for quality of evidence and bias with the Cochrane bias tool, GRADE, and MINORS criteria. Demographic data, imaging modalities, management strategies, and status at last follow-up were obtained.

Results

Sixteen studies met inclusion criteria. In total, 21 patients with PPFCs were identified, 19 of which were histologically confirmed. Most common presenting symptoms included unilateral facial nerve dysfunction (n = 14, 73.7%) and pulsatile tinnitus (n = 8, 42.1%). Mean time from reported onset of facial dysfunction was 17.8 months. Computed tomography findings included an expanded descending facial nerve canal (n = 13, 76.5%). All cases with magnetic resonance imaging reported enhancement with contrast. Of the 18 patients who had surgery, 16 (88.9%) underwent full tumor resection while 1 (5.6%) had partial tumor debulking with adjuvant radiotherapy. Overall improvement in facial weakness was documented in 5 of 9 patients (55.6%) with initial facial nerve dysfunction and >6-month follow-up. No evidence of tumor recurrence was reported.

Conclusions

PPFCs are extraordinarily rare vascular neoplasms of the temporal bone. Early imaging with both computed tomography and magnetic resonance imaging is essential for narrowing the differential diagnosis, assessing the extent of tumor invasion, and accurate surgical planning. Surgical tumor resection with subsequent facial nerve reconstruction is recommended for patients with facial nerve dysfunction, while tumor biopsy or debulking may be indicated when normal facial movement in present.

The inflammatory pseudotumor presenting periodic acid-Schiff-positive inclusions with acute unilateral facial nerve palsy

Although most acute peripheral facial palsies can be attributed to Bell's palsy, other factors, such as infection, trauma, and neoplasm, can cause facial palsy as well. Among these, facial nerve tumors are rare but should be considered in the differential diagnosis of facial palsy. Palsies due to facial nerve tumors usually present with slow onset but occasionally present as acute episodes. In such cases, facial nerve decompression is the treatment of choice to allow the tumor room to grow without compressing the nerve or its blood supply. We describe a case of severe, acute facial palsy presenting with a spindle-shaped bone erosion on the mastoid portion of the facial canal. Although facial neuroma was suspected preoperatively, emergency decompression surgery revealed that an unusual inflammatory pseudotumor was responsible for the finding. Postoperative histological analysis revealed extensive destruction of the nerve fibers, with extensive infiltration of foamy macrophages containing characteristic, diastase-resistant, periodic acid-Schiff (PAS)-positive inclusions, which are hallmark of the uncommon bacterial infections. This was a case of facial palsy with an unusual etiology. The case shows the benefit of decompression surgery not only as treatment for the palsy but also as exploratory surgery in cases of facial nerve tumor.

Glomus faciale tumors: A report of 3 cases and literature review

Our objectives in reporting this case series are to familiarize readers with the rare occurrence of paragangliomas originating along the facial nerve and to provide a literature review. We describe 3 such cases that occurred at our tertiary care academic medical center. Two women and 1 man presented with a tumor adjacent to the vertical segment of the facial nerve. The first patient, a 48-year-old woman, presented with what appeared to be a parotid tumor at the stylomastoid foramen; she underwent a parotidectomy, transmastoid facial nerve decompression, and a shave biopsy of the tumor. The second patient, a 66-year-old man, underwent surgery via a postauricular infratemporal fossa approach, and a complete tumor resection was achieved. The third patient, a 56-year-old woman, presented with a middle ear mass; she underwent complete tumor removal through a transmastoid transcanal approach. All 3 patients exhibited normal facial nerve function both before and after surgery. Paragangliomas of the facial nerve are extremely rare, and their signs and symptoms are unlike those of any other temporal bone glomus tumors. Management options include surgical resection, radiologic surveillance, and radiotherapy. The facial nerve can be spared in selected cases.

Imaging of skull base lesions

Skull base imaging requires a thorough knowledge of the complex anatomy of this region, including the numerous fissures and foramina and the major neurovascular structures that traverse them. Computed tomography (CT) and magnetic resonance imaging (MRI) play complementary roles in imaging of the skull base. MR is the preferred modality for evaluation of the soft tissues, the cranial nerves, and the medullary spaces of bone, while CT is preferred for demonstrating thin cortical bone structure. The anatomic location and origin of a lesion as well as the specific CT and MR findings can often narrow the differential diagnosis to a short list of possibilities. However, the primary role of the imaging specialist in evaluating the skull base is usually to define the extent of the lesion and determine its relationship to vital neurovascular structures. Technologic advances in imaging and radiation therapy, as well as surgical technique, have allowed for more aggressive approaches and improved outcomes, further emphasizing the importance of precise preoperative mapping of skull base lesions via imaging. Tumors arising from and affecting the cranial nerves at the skull base are considered here.

Paraganglioma of the facial canal: a report of 2 cases and literature review

PURPOSE

1. Describe the presentation, imaging, and outcome of two cases of paraganglioma of the facial canal at our institution. 2. Summarize existing literature to better understand this lesion. 3. Clarify terminology.

METHODS

Retrospective chart review at single tertiary academic referral center. Literature review using the PubMed electronic database.

RESULTS

There are 12 cases of histologically-proven paraganglioma of the facial canal published in the English literature. We present two additional cases that were encountered at our institution. We also include three additional cases from a separate institution that have been accepted for publication in a different journal. We found that patients most commonly present with slowly progressive facial paralysis; though paralysis can be acute. The second most common symptom was pulsatile tinnitus, which was the only symptom in one patient. Radiographically, tumor location was in the descending segment in all but one case. The mass was often centered directly over the stylomastoid foramen, mimicking a parotid mass. We found circumferential widening of the proximal fallopian canal, and a "moth-eaten" bony destruction distally on CT imaging in several patients. In patients with poor facial nerve function (HB IV-VI), complete tumor removal with nerve sacrifice followed by great auricular or sural nerve grafting was performed with acceptable facial function results.

CONCLUSIONS

Paraganglioma of the facial canal remains a rare etiology of progressive facial paralysis. The lesions are found in the distal descending segment, or centered over the stylomastoid foramen 94% of the time. In patients with poor facial function, surgical removal with nerve sacrifice, followed by great auricular or sural nerve grafting, yields an acceptable functional result.

Atypical tumors of the facial nerve: case series and review of the literature

OBJECT

The authors present a series of 4 patients with rare facial nerve tumors. The relevant literature is reviewed and is discussed regarding diagnostic features, the role of operative management, and surgical approach.

METHODS

A retrospective chart review was conducted for patients with tumors of the facial nerve that were treated between 2008 and 2011. Patients undergoing observation with serial MRI and those who were treated with up-front radiosurgery and for whom tissue diagnosis was not available were excluded. In addition, patients with suspected vestibular schwannoma, facial nerve schwannoma, neurofibromatosis Type 2, and metastatic disease were also excluded. The charts of 4 patients (2 men and 2 women) with "atypical" tumors were reviewed and analyzed.

RESULTS

A total of 12 patients with tumors of the facial nerve were identified during the study period. Patient characteristics, preoperative imaging, operative approach, tumor histology, and outcomes are described.

CONCLUSIONS

Atypical facial nerve tumors must be distinguished from the more common facial nerve schwannoma. How the authors of this study treat rare facial nerve tumors is based on their experience with the more common facial nerve schwannomas, characterized by a slow progression of symptoms and growth. Less is known about the rare lesions, and thus a conservative approach may be warranted. Open questions include the role of radiosurgery, facial nerve decompression, and indications for resection of tumor and cable grafting for these rare lesions.

A case of paraganglioma of the hypoglossal nerve

INTRODUCTION

Paragangliomas are rare tumours arising from the paraganglia of the autonomic nervous system.

CASE REPORT

We present a case of a paraganglioma arising from the hypoglossal nerve and producing an unusual clinical picture at presentation.

DISCUSSION

We supply radiological evidence of a paraganglioma originating from the hypoglossal nerve, and thus extend the evidence base for this rare site of origin. Our patient presented as an emergency with long tract neurological symptoms and progressive brainstem involvement. This presentation is not characteristic of paragangliomas in general, which usually have an indolent growth pattern and often demonstrate benign symptoms for a number of years prior to diagnosis. The location of a hypoglossal paraganglioma differs significantly from more common paragangliomas described in the neck and skull base, and this should inform the surgical approach undertaken.

Extracranial glomus faciale tumour

Objectives:

To describe a unique presentation of a predominantly extracranial glomus faciale tumour. To discuss the role of imaging in the differential diagnosis and evaluation of a hypervascular parotid mass. To review the previous literature concerning the glomus faciale tumour.

Case report:

A 54-year-old woman presented with a six-month history of facial weakness, pain and a parotid mass. Ultrasound revealed a hypervascular parotid mass and pre-operative core biopsy suggested a paraganglioma. Computed tomography defined its deep extent and demonstrated involvement of the petrous temporal bone along the descending portion of the facial nerve canal with a pattern of permeative lucency. A tumour was surgically removed which arose from the facial nerve from the second genu to the proximal divisions within the parotid gland and histology confirmed a paraganglioma.

Conclusions:

A facial nerve glomus faciale tumour should be considered in the differential diagnosis of a hypervascular parotid mass and may present in a predominantly extracranial location. Computed tomography will prove helpful in such a case in order to limit the differential diagnosis and to define the extent of skull base involvement.

Imaging the cranial nerves: part II: primary and secondary neoplastic conditions and neurovascular conflicts

There have been unprecedented improvements in cross-sectional imaging in the last decades. The emergence of volumetric CT, higher field MR scanners and higher resolution MR sequences is largely responsible for the increasing diagnostic yield of imaging in patients presenting with cranial nerve deficits. The introduction of parallel MR imaging in combination with small surface coils allows the depiction of submillimetric nerves and nerve branches, and volumetric CT and MR imaging is able to provide high quality multiplanar and curved reconstructions that can follow the often complex course of cranial nerves. Seeking the cause of a cranial nerve deficit is a common indication for imaging, and it is not uncommon that radiologists are the first specialists to see a patient with a cranial neuropathy. To increase the diagnostic yield of imaging, high-resolution studies with smaller fields of view are required. To keep imaging studies within a reasonable time frame, it is mandatory to tailor the study according to neuro-topographic testing. This review article focuses on the contribution of current imaging techniques in the depiction of primary and secondary neoplastic conditions affecting the cranial nerves as well as on neurovascular conflicts, an increasingly recognized cause of cranial neuralgias.

Multiple familial facial glomus: case report and review of the literature

Facial paraganglioma is an extremely rare tumor that originates from abnormal paraganglionic tissue situated in the intrapetrous facial canal. A review of the English-language literature shows that only 8 cases of facial nerve paraganglioma have been published. In each case the facial glomus presented itself sporadically, completely independent of any other form of paraganglioma. This study reports an intrapetrous facial glomus that occurred in a case of multiple paragangliomas with a hereditary pattern. To our knowledge, this is the first report of such a combination.

Glomus faciale, glomus jugulare, glomus tympanicum, glomus vagale, carotid body tumors, and simulating lesions. Role of MR imaging

In summary, MR imaging characteristics of a case of paraganglioma of the facial nerve are reported. The relationship of paragangliomas and the chromaffin system have been discussed. There are many reports of cases of synchronous paragangliomas and pheochromocytomas. These reports, along with simultaneous involvement in familial MEN syndromes, and the common embrylogic origin (neural crest) and similar histopathologic relationships between paragangliomas and pheochromocytoma, all support the fact that they are part of the chromaffin system.