Background: Geniculate ganglion hemangiomas (GGH) are rare vascular lesions underrepresented
in the neurosurgical literature. They extend extradural along the middle fossa, often
displacing the infratemporal segment of the facial nerve. The therapeutic approach
to GGHs remains controversial, as they are frequently misdiagnosed as facial nerve
schwannomas or middle fossa meningiomas. Surgery is a treatment strategy for symptomatic
GGHs at the earliest sign. Proposed techniques include fascicular-sparing resection
and facial nerve rerouting with grafting. However, no definitive evidence favors one
technique over another in preserving facial nerve integrity and function. Through
the description of a surgically managed symptomatic GGH, we herein report and discuss
literature data about surgical results from the two proposed techniques. Our primary
objective was to evaluate postoperative outcomes in terms of preserving facial nerve
integrity and function.
Methods: Patients strived were collected into two groups based on the surgical technique used
for tumor excision. Preoperative facial nerve dysfunction was assessed using the House-Brackmann
(HB) grading system, with grades I to II and V to VI representing mild and severe
deficits, respectively. The postoperative facial outcome was classified as improved,
unchanged, or worsened compared to preoperative status. Statistical analysis was performed
using ANOVA tests, including only patients with full or partially preserved facial
function (HB I-IV).
Results: Out of 116 cases of GGHs, 56 were treated with fascicular-sparing resection and 60
with nerve grafting. In the first group, HB grades were I to II in 23 patients (20%),
III in 11 (9%), IV in 6 (5%), and V-VI in 16 (14%). In the second group, 6 patients
(5%) presented with HB I-II, 8 (7%) with III, 14 (12%) with IV, and 32 (28%) with
V-VI ([Fig. 1]).
Postoperatively, facial nerve function improved in 23 (42%), remained unchanged in
30 (52%), and worsened in 3 (6%) patients treated with fascicular-sparing resection.
For those who underwent grafting, 21 patients (37%) showed improvement, 24 (42%) remained
unchanged, and 12 (21%) worsened; 3 patients were lost to follow-up ([Fig. 2]).
Among patients with improved or unchanged facial function, 53 (64%) were from the
fascicular-sparing group and only 30 (36%) from the grafting group, with a significant
difference (p = 0.0014). Furthermore, the assessment of patients with a postoperatively good facial
outcome (III HB) score revealed a significant efficacy of the fascicular-sparing technique
in achieving good facial outcomes (72 vs. 28%; p = 0.0022) again ([Fig. 3]).
Additionally, we present our experience managing a 38-year-old male with a symptomatic
GGH using a fascicular-sparing technique via a zygomatic middle fossa approach ([Fig. 4]).
Conclusion: The fascicular-sparing technique proved significantly more effective in preserving
or improving facial function, particularly in patients symptomatic with residual facial
function (I-III HB). Nerve grafting may be more appropriate for those with severe
dysfunction (HB V-VI). Broader, more comprehensive studies are necessary to substantiate
these results and pave the way for new therapeutic approaches.
