Facial schwannomas are rare lesions, and reported series are generally small. Due to the complex management issues involved, these tumours are best managed in a tertiary referral setting. Observation is preferred until facial function deteriorates to a House-Brackmann grade III level, at which time surgery is considered. When facial function deteriorates to House-Brackmann grade IV, surgical intervention is indicated. We advocate surgical management based on the treatment algorithm described.

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This is a report of a patient with an air-bone gap, thought 10 years ago to be a conductive hearing loss due to otosclerosis and treated with a stapedectomy. It now transpires that the patient actually had a conductive hearing gain due to superior semicircular canal dehiscence. In retrospect for as long as he could remember the patient had experienced cochlear hypersensitivity to bone-conducted sounds so that he could hear his own heart beat and joints move, as well as a tuning fork placed at his ankle. He also had vestibular hypersensitivity to air-conducted sounds with sound-induced eye movements (Tullio phenomenon), pressure-induced nystagmus and low-threshold, high-amplitude vestibular-evoked myogenic potentials. Furthermore some of his acoustic reflexes were preserved even after stapedectomy and two revisions. This case shows that if acoustic reflexes are preserved in a patient with an air-bone gap then the patient needs to be checked for sound- and pressure-induced nystagmus and needs to have vestibular-evoked myogenic potential testing. If there is sound- or pressure-induced nystagmus and if the vestibular-evoked myogenic potentials are also preserved, the problem is most likely in the floor of the middle fossa and not in the middle ear, and the patient needs a high-resolution spiral computed tomography (CT) of the temporal bones to show this.

Facial nerve schwannomas are slow-growing tumors that may involve any part of the facial nerve. When they present with moderate to total facial palsy, complete resection is clearly indicated. However, in cases with mild or no facial dysfunction, the best course of treatment is less obvious. A series of 22 patients with facial nerve schwannoma is presented, of whom 12 underwent definitive excision and 10 were managed more conservatively. The best postoperative facial function in the group who had tumor removal was a House-Brackmann grade III, while 8 of the conservatively treated group had normal facial function up to 10 years after presentation. As well, no significant tumor growth was noted on serial radiologic imaging of those being observed. Delaying surgical resection of facial nerve schwannomas may allow patients to retain normal facial function indefinitely.