Author(s)
Omid Moshtaghi, BS
Ronald Sahyouni, BA
Yarah M. Haidar, MD
Kasra N. Ziai, MD
Harrison W. Lin, MD
Hamid R. Djalilian, MD
Affiliation(s)
University of California
Abstract:
Educational Objective: At the conclusion of this presentation, the participants should be able to understand the possibility of cholesteatomas involving the facial nerve. Objectives: To understand the diagnostic challenge of middle ear cholesteatoma (MEC) invading the middle cranial fossa and causing facial paralysis. Study Design: Retrospective case series. Methods: Case records of two patients presenting with longstanding facial paralysis who were found to have missed MECs invading the facial nerve in the middle fossa were reviewed. Results: Patients A and B presented with facial paralysis (grade VI and V, respectively) for facial reanimation. Both patients had a history of cholesteatoma resection 20 and 15 years prior, respectively. They reported facial paralysis for 7 and 1 years, respectively. Both had had temporal bone imaging that was reported as negative by the reading radiologist. On CT imaging, patient A showed infiltration of the geniculate ganglion and cochlea. On MRI, patient B showed cholesteatoma expansion around the superior semicircular canal involving the geniculate ganglion. Both had resection by middle cranial fossa approach. Patient A experienced no improvement in facial function and hearing postoperatively. Patient B improved from grade V to III and experienced no hearing deficits. Conclusions: Cholesteatomas located on the floor of the middle fossa can be missed by traditional imaging techniques and require a high index of suspicion. The reading radiologists overlooked both lesions in these two cases. To confirm diagnosis, a non-echoplanar DWI is beneficial for assessing a possible presence of cholesteatoma on the floor of the middle fossa. In addition, these cases show that patients with a history of cholesteatoma resection must obtain radiological surveillance if no second look surgery is performed.