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30 year old male with progressive facial paralysis.

Facial nerve schwannoma

Facial nerve hemangioma

Osseous metastasis

Perineural tumor spread

Paraganglioma.

Benign, non-encapsulated tumor arising from perineural vasculature

Most commonly located at geniculate fossa

IAC location less common

Present with slowly evolving facial paresis

CN 7 injury usually result of invasion, not compression

If detected early while still extraneural, may be separated from facial nerve at surgery.

Imaging

Poorly marginated soft tissue mass

May appear erosive

Ossific “honeycomb” matrix on CT

Avid enhancement on MR.

May normally enhance at geniculate ganglion, horizontal and descending portions

Perineural arteriovenous complex

Often assymetric

Enhancement in the IAC, labyrinthine segment, and parotid segment is abnormal.

Imaging of patient’s with acute facial nerve palsy should be limited to “atypical Bell’s palsy”

Persist >4 weeks

Paralysis is progressive

Other cranial nerves are involved

Pain is a prominent feature

Hemifacial spasm

Ultimately, ~5% of patients with Bell’s palsy are found to have a facial nerve lesion.