Facial nerve canal paragangliomas: a reconstruction-focused management approach and proposed decision-making framework

To evaluate outcomes of early integration of facial nerve management for facial nerve canal paragangliomas (FNC PGLs), prioritising facial nerve rehabilitation alongside tumour control.

A retrospective case series was conducted at the Sydney Head and Neck Cancer Institute and Sydney Facial Nerve Service, Chris O'Brien Lifehouse. Three patients with FNC PGLs underwent multidisciplinary assessment including imaging, biochemical evaluation, and SDHx genetic testing. Surgical planning integrated tumour treatment with facial nerve reconstruction. Dynamic procedures (cross-facial nerve grafts, masseteric and hypoglossal transfers, interpositional grafts) were combined with static techniques (tensor fascia lata slings, eyelid weights, brow lifts). Outcomes were assessed using House-Brackmann (HB) grading, Speech Handicap Index (SHI), Oral Competence Questionnaire (OCQ), speech intelligibility, and speech error analysis.

All patients demonstrated improved facial nerve function, from preoperative HB grades IV-VI to HB III postoperatively, with a mean time to movement of 7 months (SD 4). Mean speech intelligibility improved from 78.3% to 86.7%, with corresponding improvements in SHI and OCQ scores. Static procedures restored resting symmetry, eye closure, and midface tone, while dynamic reanimation enabled spontaneous or volitional movement. No major treatment-related complications occurred. Tumour control was maintained in all patients at 60-68 months follow-up.

Early integration of facial nerve management in FNC PGLs may attain durable tumour control while achieving meaningful improvement in facial nerve function. Early integration of facial nerve rehabilitation within a multidisciplinary framework improves oncologic and functional outcomes.

Level 4.