Geniculate ganglion ‘hemangiomas’—venous malformations: from a pathologic to a therapeutic paradigm shift

Background: Vascular lesions historically named ‘geniculate ganglion hemangiomas’ (GGH) require clinical and biological re-evaluation. Aims/objectives: To challenge the historical nomenclature of ‘geniculate ganglion hemangiomas’ and to explore the implications of their reclassification as venous malformations (VMs), focusing on function-preserving and minimally invasive strategies. Material and methods: Retrospective clinical, surgical, and histopathologic reviews of six patients treated for geniculate ganglion vascular lesions at a tertiary referral center. Surgical approaches included endoscopic ear surgery (EES) and middle cranial fossa (MCF) approaches. Specimens were re-evaluated according to ISSVA criteria. Results: All patients presented with facial nerve dysfunction and underwent complete surgical excision. Nerve grafting or reanimation procedures were required in four cases. Histopathologic and immunohistochemical findings in all cases were consistent with slow-flow VMs rather than true hemangiomas. Conclusions: These lesions should be reclassified as geniculate ganglion venous malformations (GGVMs) according to ISSVA criteria. Their non-neoplastic nature challenges mandatory radical excision. Minimally invasive EES offers a potential corridor for targeted, function-preserving strategies, though non-resective modalities remain unvalidated in this cohort and require future trial investigation. Significance: This shift potentially redefines preoperative counseling and surgical decision-making paradigm. EES offers a minimally invasive corridor, potentially allowing targeted therapies, thereby minimizing facial nerve morbidity.