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

2. 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?

3. 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

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

5. Imaging Studies- pathologic features?

6. Imaging Studies- pathologic features?

7. 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

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

9. 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.

10. H&E Intraop slide
Frozen H&E

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

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

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

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

15. Special stains
What are findings and diagnosis?
Synaptophysin

16. Expert Diagnosis

17. Discussion