33 yo previously healthy male presents with 7 month h/o progressive facial weakness. Initial MRI at outside hospital read as ‘negative’. Repeat MRI and CT consistent with geniculate ganglion venous malformation. Facial nerve exam with tone but no volitional movement, +weak, but full eye closure, other cranial nerves intact. Hearing normal.
We know that all vascular malformations expand and hypertrophy overtime and that the facial nerve will certainly go out further. By then, we will have missed the window to salvage the facial musculature.- window re: facial nerve motor endplates.
Local otologists (29 of 30) all agree that he will ultimately require surgery, but all want to wait until the facial nerve is completely out (“until the eye doesn’t close”). Risks of hearing loss (20%), CSF leak, etc…..
I proposed nerve to masseter to buccal, selective neurectomy of cervical branch. I am trying to convince the neurotologist to remove the malformation (from my extensive experience with venous malformations, they all grow, and can usually can be teased off of the surrounding tissues, or they are intraosseous in the area of the genic. In this case, the canal is widened). IF the nerve in that section does need to be taken, we could do a small interposition graft. What is your experience and what evidence can I bring to the forum?
Thanks for your input.