Surgical Management of Symptomatic Hemangioma of the Geniculate Ganglion: Fascicular-Sparing Resection or Grafting?

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.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
07 February 2025