Neuropathology Case Study J. Seth McAfee, M.D.

Clinical History Patient is a 34 y/o male presenting with left sided facial paralysis of 18 months duration. It was preceded by several months of ipsilateral xerophthalmia. He was diagnosed with Bell’s Palsy, which failed to improve with standard treatment. Other pertinent information from the history?

Clues in the history Associated auditory/vestibular symptoms? None History of ipsilateral facial exanthem? None Otalgia or otorrhea? None Prior episodes of facial paralysis? None Head and neck tumor history? Carotid body tumor resected from contralateral side 12 years prior Trouble with phonation, breathing, swallowing? None

Differential Diagnosis? Stroke Multiple Sclerosis Ramsay Hunt Bells Palsy Acoustic Neuroma Glomus jugulare Cholesterol granuloma Facial nerve paraganglioma Chronic mastoiditis with cholesteatoma Parotid mass

Imaging Studies- pathologic features?

Imaging Studies- pathologic features?

Diagnostic Imaging Features MRI: Irregularly shaped left sided mass Isointense to brain on T1, enhancing post contrast Mass positioned at/adjacent to the left jugular fossa Flow voids CT: Irregular bony destruction “Moth eaten” appearance Separation from the jugular bulb Bony expansion of the fallopian canal

Differential Diagnosis? Glomus jugulare Jugular foramen schwannoma Jugular foramen meningioma Facial paraganglioma Cholesterol granuloma Chordoma Chondrosarcoma PICA/Vertebral a. aneurysm

Course of Treatment Following preoperative embolization, the patient was taken to the operating room for a transmastoid/transpetrous resection of the lesion. The mass was found to be centered over the vertical portion of the facial nerve, extending into the middle ear and lateral to the jugular fossa. Embolization material was found to be surrounding the facial nerve. The mass and facial nerve were resected, and the facial nerve was reconstructed with a cable graft, utilizing the greater auricular nerve. Malleus/incus were resected, facilitating total tumor resection, and an ossicular chain reconstruction was performed (prosthesis from stapes to tympanic membrane). Specimen were taken for histopathologic evaluation.

H&E Intraop slide Frozen H&E

Expert interpretation and differential diagnosis Based on clinical history, findings, imaging and gross findings or intraop preparations

H&E of permanent H&E Permanent of frozen H&E Permanent with embolization material

Differential Diagnosis and further studies? Based on clinical history, findings, imaging and gross findings or intraop preparations and permanent section H&E

Expert differential diagnosis and recommended work up Based on clinical history, findings, imaging and gross findings or intraop preparations and permanent section H&E

Special stains What are findings and diagnosis? Synaptophysin

Expert Diagnosis

Discussion