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Fujita Y, Uozumi Y, Fujimoto Y, Nagashima H, Kohta M, Tanaka K, Kimura H, Fujita A, Kohmura E, Sasayama T. A morphological features-based nomogram for predicting facial nerve function in the immediate postoperative period after vestibular schwannoma surgery. J Neurooncol 2025; 173:305-315. [PMID: 40080247 DOI: 10.1007/s11060-025-04984-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2025] [Accepted: 02/21/2025] [Indexed: 03/15/2025]
Abstract
PURPOSE Tumor morphology critically influences facial nerve (FN) outcomes following vestibular schwannoma (VS) surgery. This study aimed to develop a nomogram based on preoperative features for preoperative prediction of FN outcomes after VS surgery. METHODS A retrospective analysis included patients with sporadic VS who underwent surgical resection via the retrosigmoid approach. Tumor size was assessed using the Koos grade, the intrameatal components using the fundal fluid cap (FFC) sign, and the cerebellopontine angle cisternal components using our modified morphological subclassification. Logistic regression analysis was performed to construct a nomogram for predicting immediate postoperative FN function. RESULTS A total of 265 patients with VS met the inclusion criteria. Of these patients, 62 (23.4%) had poor FN function (House-Brackmann grade ≥ III) immediately after surgery. Univariate logistic regression analysis identified the Koos grade (p = 0.001), FFC sign (p = 0.023), and morphological subtype (p < 0.001) as significant predictors of poor FN function immediately after surgery. In multivariate logistic regression analysis, the FFC sign (OR 2.07, p = 0.042) and morphological subtype (OR 8.21, p < 0.001) remained statistically significant independent predictors of poor FN function. A nomogram constructed based on these indicators demonstrated good discrimination in the training cohort (area under the curve [AUC] 0.80), internal validation cohort (AUC 0.79), and external validation cohort (AUC 0.97). CONCLUSIONS A simple and reliable nomogram incorporating the Koos grade, FFC sign, and morphological subtype accurately predicts the risk of FN injury during surgery aimed at total resection of VS. This clinically straightforward tool can assist in patient counseling and development of more individualized surgical strategies to improve FN outcomes in patients with VS.
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Affiliation(s)
- Yuichi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yosuke Fujimoto
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hiroaki Nagashima
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kazuhiro Tanaka
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
- Department of Neurosurgery, Kinki Central Hospital, Itami, Hyogo, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Pitukkitronnagorn N, Chakkabat C, Jittapiromsak N. Apparent diffusion coefficient and magnetic resonance imaging characteristics in predicting response to radiosurgery in patients with vestibular schwannomas. Neuroradiol J 2025:19714009251313509. [PMID: 39764625 PMCID: PMC11705299 DOI: 10.1177/19714009251313509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2024] [Revised: 12/07/2024] [Accepted: 12/12/2024] [Indexed: 01/11/2025] Open
Abstract
OBJECTIVE Predicting treatment response in patients with vestibular schwannomas (VSs) remains challenging. This study aimed to evaluate the use of pre-treatment normalized apparent diffusion coefficient (nADC) values and magnetic resonance (MR) imaging characteristics in predicting treatment outcomes in patients with VSs undergoing radiosurgery. METHODS The MR images of 44 patients with VSs who underwent radiosurgery at our institution were retrospectively reviewed, and the patients were categorized into tumor control (n = 28) and progression (n = 16) groups based on treatment response after treatment initiation, with a median follow-up duration of 29.5 (13-115) months. Pre-treatment nADC values for the whole tumor and solid portion of the tumor were assessed for predictive significance. MRI characteristics were analyzed, including hemorrhage status, tumor morphology, and post-treatment loss of central enhancement. Interobserver reliability was also evaluated. RESULTS Early post-treatment enlargement was associated with tumor progression (p = .024). The mean pre-treatment nADC values for the solid part of the tumor were significantly higher in the tumor control group than in tumor progression group (1.32 vs 1.05, p = .005). The receiver operating characteristic curve analysis revealed a mean nADC of 1.18 as an optimal cutoff, with sensitivity and specificity of 76.2% and 86.7%, respectively, in predicting treatment response. CONCLUSION The mean nADC values for the solid part of the tumor demonstrated predictive value for treatment response, with implications for treatment planning. Notably, early post-treatment enlargement was correlated with tumor progression. Incorporating these findings into clinical practice may refine treatment strategies for patients with VSs undergoing radiosurgery.
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Affiliation(s)
- Nattapon Pitukkitronnagorn
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Chakkapong Chakkabat
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Nutchawan Jittapiromsak
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Feng S, Han S, Sun X, Li Y, Zhang Y, Li F, Wu Y, Xiao Y, Bai Y, Liang G. Endoscopic retrosigmoid trans-petrosal fissure approach for vestibular schwannomas: case series. Neurosurg Rev 2024; 47:548. [PMID: 39235642 DOI: 10.1007/s10143-024-02768-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/07/2024] [Accepted: 08/25/2024] [Indexed: 09/06/2024]
Abstract
The management of vestibular schwannoma (VS) remains one of the most formidable challenges in neurosurgery owing to the eloquent nature of surrounding anatomy. Although endoscopy-assisted microsurgery has recently gained momentum in cerebellopontine angle region surgery, the feasibility of pure endoscopic technique has been rarely reported. Here we present the operative technique and preliminary outcomes of fully endoscopic retrosigmoid trans-petrosal fissure approach (ER-TPFA) for VS surgery. Clinical data of 36 consecutive cases of VS treated with the ER-TPFA from March 2021 to March 2023 were analyzed. The patients were placed in a modified lateral park-bench position, with the Dandy incision and suboccipital craniotomy performed. With the endoscopic holder, endoscopic procedures were performed using standard two-hand microsurgical techniques by one surgeon. Arachnoidal dissection of the petrosal fissure was performed for identifying the brainstem end of facial nerve and separating the tumor from the cerebellum, without brain retraction seen in traditional microsurgical technique. The tumors had an averaged size of 3.0 cm in diameter. According to the Hannover classification, nearly all the tumors were grade III-IV (97.3%). Using ER-TPFA, 33 patients (91.7%) achieved gross total resection. Anatomic preservation of the facial nerve was achieved in 35 cases, with 33 patients (91.7%) retaining a House-Brackmann score of 1-2 postoperatively. Four out of ten patients still had serviceable hearing 6 months after operation. Postoperatively, there was no post-craniotomy hematoma, cerebellar edema, and new-onset cerebellar ataxia. With a better visualization of the cerebellopontine angle region, ER-TPFA may help preserve facial nerve function and maintain high gross total resection rate while minimizing complications. We believe this retractorless technique can be a safe and effective alternative for the management of VS with satisfactory clinical results.
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Affiliation(s)
- Sizhe Feng
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Song Han
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Xiaoyu Sun
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yuanyuan Li
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yin Zhang
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Fei Li
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yue Wu
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yuanyang Xiao
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yang Bai
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China.
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China.
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King AM, Cooper JN, Oganezova K, Mittal J, McKenna K, Godur DA, Zalta M, Danesh AA, Mittal R, Eshraghi AA. Vestibular Schwannoma and Tinnitus: A Systematic Review of Microsurgery Compared to Gamma Knife Radiosurgery. J Clin Med 2024; 13:3065. [PMID: 38892775 PMCID: PMC11173275 DOI: 10.3390/jcm13113065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/16/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Vestibular schwannoma (VS) is a benign tumor of the eighth cranial nerve formed from neoplastic Schwann cells. Although VS can cause a variety of symptoms, tinnitus is one of the most distressing symptoms for patients and can greatly impact quality of life. The objective of this systematic review is to comprehensively examine and compare the outcomes related to tinnitus in patients undergoing treatment for VS. Specifically, it evaluates patient experiences with tinnitus following the removal of VS using the various surgical approaches of traditional surgical resection and gamma knife radiosurgery (GKS). By delving into various aspects such as the severity of tinnitus post-treatment, the duration of symptom relief, patient quality of life, new onset of tinnitus after VS treatment, and any potential complications or side effects, this review aims to provide a detailed analysis of VS treatment on tinnitus outcomes. Methods: Following PRISMA guidelines, articles were included from PubMed, Science Direct, Scopus, and EMBASE. Quality assessment and risk of bias analysis were performed using a ROBINS-I tool. Results: Although VS-associated tinnitus is variable in its intensity and persistence post-resection, there was a trend towards a decreased tinnitus burden in patients. Irrespective of the surgical approach or the treatment with GKS, there were cases of persistent or worsened tinnitus within the studied cohorts. Conclusion: The findings of this systematic review highlight the complex relationship between VS resection and tinnitus outcomes. These findings underscore the need for individualized patient counseling and tailored treatment approaches in managing VS-associated tinnitus. The findings of this systematic review may help in guiding clinicians towards making more informed and personalized healthcare decisions. Further studies must be completed to fill gaps in the current literature.
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Affiliation(s)
- Ava M. King
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
| | - Jaimee N. Cooper
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Karina Oganezova
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
| | - Jeenu Mittal
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
| | - Keelin McKenna
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
| | - Dimitri A. Godur
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
| | - Max Zalta
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
| | - Ali A. Danesh
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
- Department of Communication Sciences and Disorders, Florida Atlantic University, Boca Raton, FL 33431, USA
- Department of Integrated Medical Sciences, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Rahul Mittal
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
| | - Adrien A. Eshraghi
- Department of Otolaryngology, Hearing Research and Cochlear Implant Laboratory, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.K.); (J.N.C.); (J.M.); (K.M.); (D.A.G.); (M.Z.); (A.A.D.); (R.M.)
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33143, USA
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Balossier A, Sahgal A, Kotecha R, Fariselli L, Gorgulho A, Levivier M, Ma L, Paddick I, Pollock BE, Sheehan JP, Suh JH, Yomo S, Zhang Z, Regis J. Management of sporadic intracanalicular vestibular schwannomas: A critical review and International Stereotactic Radiosurgery Society (ISRS) practice guidelines. Neuro Oncol 2024; 26:429-443. [PMID: 38134966 PMCID: PMC10912008 DOI: 10.1093/neuonc/noad253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The choice of an appropriate strategy for intracanalicular vestibular schwannoma (ICVS) is still debated. We conducted a systematic review and meta-analysis with the aim to compare treatment outcomes amongst management strategies (conservative surveillance (CS), microsurgical resection (MR), or stereotactic radiosurgery (SRS)) aiming to inform guideline recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS Using PRISMA guidelines, we reviewed manuscripts published between January 1990 and October 2021 referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical studies or case series reporting a cohort of ICVS managed with CS, MR, or SRS. Primary outcome measures included tumor control, the need for additional treatment, hearing outcomes, and posttreatment neurological deficits. These were pooled using meta-analytical techniques and compared using meta-regression with random effect. RESULTS Forty studies were included (2371 patients). The weighted pooled estimates for tumor control were 96% and 65% in SRS and CS series, respectively (P < .001). Need for further treatment was reported in 1%, 2%, and 25% for SRS, MR, and CS, respectively (P = .001). Hearing preservation was reported in 67%, 68%, and 55% for SRS, MR, and CS, respectively (P = .21). Persistent facial nerve deficit was reported in 0.1% and 10% for SRS and MR series, respectively (P = .01). CONCLUSIONS SRS is a noninvasive treatment with at least equivalent rates of tumor control and hearing preservation as compared to MR, with the caveat of better facial nerve preservation. As compared to CS, upfront SRS is an effective treatment in achieving tumor control with similar rates of hearing preservation.
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Affiliation(s)
- Anne Balossier
- AP-HM, Timone Hospital, Functional and Stereotactic Neurosurgery, Marseille, France
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Institut de Neurosciences des Systèmes (INS) UMR1106, Marseille, France
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
| | - Alessandra Gorgulho
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, and, D’Or Institute for Research and Education, São Paulo, Brazil
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Zhenwei Zhang
- Center of Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
| | - Jean Regis
- AP-HM, Timone Hospital, Functional and Stereotactic Neurosurgery, Marseille, France
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Institut de Neurosciences des Systèmes (INS) UMR1106, Marseille, France
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Alekseev IM, Ovchinnikov VA, Chupalenkov SM, Zuev AA. [Our approach to the treatment of vestibular schwannomas with arachnoid dissection of the facial nerve]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:38-49. [PMID: 39169580 DOI: 10.17116/neiro20248804138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Preserving the function of the facial nerve is extremely important in surgery for vestibular schwannomas. Two methods of arachnoid dissection are described for resection of vestibular schwannoma via retrosigmoid approach (from the brain stem and internal auditory canal). OBJECTIVE To evaluate the results of arachnoid dissection of the facial nerve from internal auditory canal when resecting the vestibular schwannoma. MATERIAL AND METHODS We analyzed 61 patients with vestibular schwannomas. Patients were divided into 2 groups depending on surgical technique. We estimated facial nerve function before and after surgery, preoperative dimension of vestibular schwannoma and extent of resection. The influence of various factors on extent of resection and postoperative facial nerve function was studied. RESULTS Vestibular schwannoma resection from the brain stem was performed in 30 patients, arachnoid dissection - in 31 patients. There was no significant between-group difference. Gross total resection was performed in 78.7% of cases. Both techniques demonstrated similar results regarding extent of resection. Arachnoid dissection showed the advantage regarding facial nerve function immediately after surgery (p=0.012) and 6 months later (p<0.001). Normal facial nerve function in 6 months after arachnoid dissection was observed in 80.7% of patients. Preoperative dimension of tumor influenced facial nerve function in addition to technique of resection (p=0.001). CONCLUSION We identified the factors influencing facial nerve function after resection of vestibular schwannoma. Surgical technique was the most significant factor. These data expand and popularize arachnoid dissection in surgery of vestibular schwannomas.
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Affiliation(s)
- I M Alekseev
- Pirogov National Medical Surgical Center, Moscow, Russia
| | | | | | - A A Zuev
- Pirogov National Medical Surgical Center, Moscow, Russia
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7
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Horsfall HL, Khan DZ, Collins J, Cooke S, Freeman SR, Gurusinghe N, Hampton S, Hardwidge C, Irving R, Kitchen N, King A, Khalil S, Koh CH, Leonard C, Marcus HJ, Muirhead W, Obholzer R, Pathmanaban O, Robertson IJA, Shapey J, Stoyanov D, Teo M, Tysome JR, Grover P, Saeed SR. Generating Operative Workflows for Vestibular Schwannoma Resection: A Two-Stage Delphi's Consensus in Collaboration with the British Skull Base Society. Part 2: The Translabyrinthine Approach. J Neurol Surg B Skull Base 2023; 84:433-443. [PMID: 37671296 PMCID: PMC10477015 DOI: 10.1055/s-0042-1755578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022] Open
Abstract
Objective An operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 2, we present a codified operative workflow for the translabyrinthine approach to vestibular schwannoma resection. Methods A mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached. Results Seventeen consultant skull base surgeons (nine neurosurgeons and eight ENT [ear, nose, and throat]) with median of 13.9 years of experience (interquartile range: 18.1 years) of independent practice participated. There was a 100% response rate across both the Delphi rounds. The translabyrinthine approach had the following five phases and 57 unique steps: Phase 1, approach and exposure; Phase 2, mastoidectomy; Phase 3, internal auditory canal and dural opening; Phase 4, tumor debulking and excision; and Phase 5, closure. Conclusion We present Part 2 of a national, multicenter, consensus-derived, codified operative workflow for the translabyrinthine approach to vestibular schwannomas. The five phases contain the operative, steps, instruments, technique errors, and event errors. The codified translabyrinthine approach presented in this manuscript can serve as foundational research for future work, such as the application of artificial intelligence to vestibular schwannoma resection and comparative surgical research.
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Affiliation(s)
- Hugo Layard Horsfall
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Danyal Z. Khan
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Justin Collins
- Department of Urooncology, University College London Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Stephen Cooke
- Department of Neurosurgery, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Simon R. Freeman
- Department of Otolaryngology, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, United Kingdom
| | - Nihal Gurusinghe
- Department of Neurosurgery, Lancashire Teaching Hospital, Preston, United Kingdom
| | - Susie Hampton
- Department of Ear, Nose and Throat, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Carl Hardwidge
- Department of Neurosurgery, University Hospital Sussex, Brighton, United Kingdom
| | - Richard Irving
- Ear, Nose and Throat, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Neil Kitchen
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Andrew King
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Northern Care Alliance National Health Service Group, University of Manchester, Manchester, United Kingdom
| | - Sherif Khalil
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
| | - Chan H. Koh
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Colin Leonard
- Department of Ear, Nose and Throat, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Hani J. Marcus
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - William Muirhead
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Rupert Obholzer
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
| | - Omar Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, United Kingdom
| | - Iain J. A. Robertson
- Department of Neurosurgery, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Jonathan Shapey
- Department of Neurosurgery, Kings College Hospital, London, United Kingdom
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Mario Teo
- Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - James R. Tysome
- Department of Ear, Nose and Throat, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Patrick Grover
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Shakeel R. Saeed
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
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Roman A, Tufegdzic B, Pinto V, Lamperti M, Elhammady M, Roser F. After the Knife: A Detailed Roadmap for Vestibular Schwannoma Resection in the Semi-Sitting Position - How I do it. World Neurosurg 2023; 175:e1341-e1347. [PMID: 37169076 DOI: 10.1016/j.wneu.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Vestibular schwannoma surgery remains a neurosurgical challenge, with known risks, dependent on a number of factors, from patient selection to surgical experience of the team. The semi-sitting position has gained popularity as an alternative to the traditional supine position for vestibular schwannoma resection due to potential advantages such as improved surgical exposure due to clearer surgical field and anatomical orientation. However, there is a lack of standardized protocols for performing the procedure in the semi-sitting position, leading to variations in surgical techniques and outcomes. METHODS In this study, we aimed to establish a standardized approach for vestibular schwannoma resection using the semi-sitting position. Initiating after final position for semi-sitting, the authors have divided the surgical steps into five major parts for improved understanding and replication. Surgical techniques were analyzed through one hundred steps to identify commonalities, determining the optimal procedural steps for the semi-sitting position using surgical video for visual conceptualization. RESULTS The analysis described one hundred steps for vestibular schwannoma resection in the semi-sitting position, with visual demonstration of the various parts of the procedure through surgical videos. Specific recommendations for each step were outlined, including appropriate approach, monitoring strategies, and tumor and posterior fossa structures manipulation. Five major parts of the procedure were identified, leading to a reproducible standardization of the surgical procedure of vestibular schwannoma resection in the semi-sitting position. CONCLUSIONS This study provides a comprehensive standardized protocol for the semi-sitting procedure in vestibular schwannoma resection. By establishing a consistent approach, surgeons can minimize variations in surgical techniques and improve patient outcomes. The identified steps and recommendations can serve as a valuable resource for surgical teams involved in vestibular schwannoma resection and facilitate the dissemination and reproducibility of best practices.
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Affiliation(s)
- Alex Roman
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
| | - Boris Tufegdzic
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Vania Pinto
- Neurophysiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | - Florian Roser
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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Fujita Y, Uozumi Y, Sasayama T, Kohmura E. Presence of a fundal fluid cap on preoperative magnetic resonance imaging may predict long-term facial nerve function after resection of vestibular schwannoma via the retrosigmoid approach. J Neurosurg 2022; 138:972-980. [PMID: 36152320 DOI: 10.3171/2022.8.jns221516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Preservation of neurological function is a priority when performing a resection of a vestibular schwannoma (VS). Few studies have examined the radiographic value of a fundal fluid cap—i.e., cerebrospinal fluid in the lateral end of a VS within the internal auditory canal—for prediction of postoperative neurological function. The aim of this study was to clarify whether the presence of a fundal fluid cap on preoperative magnetic resonance images has a clinical impact on facial nerve function after resection of VSs.
METHODS
The presence of a fundal fluid cap and its prognostic impact on long-term postoperative facial nerve function were analyzed.
RESULTS
A fundal fluid cap was present in 102 of 143 patients who underwent resection of sporadic VSs via the retrosigmoid approach. Facial nerve function was acceptable (House-Brackmann grade I–II) immediately after surgery in 82 (80.4%) patients with a fundal fluid cap and in 26 (63.4%) of those without this sign. The preservation rate of facial nerve function increased in a time-dependent manner after surgery in patients with a fundal fluid cap but plateaued by 3 months postoperatively in those without a fundal fluid cap; the difference was statistically significant at 12 months (96.1% vs 82.9%, p = 0.013) and 24 months (97.1% vs 82.9%, p = 0.006) after surgery. The presence of a fundal fluid cap had a significantly positive effect on long-term facial nerve function at 24 months after surgery when tumor size and intraoperative neuromonitoring response were taken into account (OR 5.55, 95% CI 1.12–27.5, p = 0.034).
CONCLUSIONS
Neuromonitoring-guided microsurgery for total resection of VSs is more likely to be successful in terms of preservation of facial nerve function if a fundal fluid cap is present. This preoperative radiographic sign could be helpful when counseling patients and deciding the treatment strategy.
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Affiliation(s)
- Yuichi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo; and
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo; and
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo; and
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo; and
- Department of Neurosurgery, Kinki Central Hospital, Itami, Hyogo, Japan
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Fujita Y, Uozumi Y, Yamaguchi Y, Nakai T, Sasayama T, Kohmura E. Symptom-based opioid-free treatment for persistent postoperative headache after vestibular schwannoma resection via the retrosigmoid approach. World Neurosurg 2022; 162:e347-e357. [DOI: 10.1016/j.wneu.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/27/2022]
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Giovannini SJM, Caffaratti G, Centeno TR, Ruella M, Villamil F, Marengo R, Cervio A. Endoscopic resection through a retrosigmoid transmeatal approach of a large-sized vestibular schwannoma: operative video and technical nuances. NEUROSURGICAL FOCUS: VIDEO 2021; 5:V2. [PMID: 36285232 PMCID: PMC9551639 DOI: 10.3171/2021.7.focvid21106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/21/2021] [Indexed: 11/25/2022]
Abstract
Surgical management of vestibular schwannomas has improved over the last 30 years. Whereas in the past the primary goal was to preserve the patient’s life, today neurological function safeguarding is the main objective, with numerous strategies involving single resection, staged resections, postoperative radiosurgery, or single radiosurgery. The retrosigmoid approach remains the primary pathway for surgical access to the cerebellopontine angle (CPA). The use of an endoscope has great advantages. It contributes to the visualization and resection of residual tumor and also reduces the need for cerebellar retraction. The authors present a fully endoscopic resection of a large-sized vestibular schwannoma with facial nerve preservation. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21106
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Affiliation(s)
| | - Guido Caffaratti
- Department of Neurological Surgery, FLENI, Buenos Aires, Argentina
| | | | - Mauro Ruella
- Department of Neurological Surgery, FLENI, Buenos Aires, Argentina
| | - Facundo Villamil
- Department of Neurological Surgery, FLENI, Buenos Aires, Argentina
| | - Ricardo Marengo
- Department of Neurological Surgery, FLENI, Buenos Aires, Argentina
| | - Andrés Cervio
- Department of Neurological Surgery, FLENI, Buenos Aires, Argentina
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Evolution of microneurosurgical anatomy with special reference to the history of anatomy, surgical anatomy, and microsurgery: historical overview. Neurosurg Rev 2021; 45:253-261. [PMID: 34232407 DOI: 10.1007/s10143-021-01597-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
This article reviews the evolution of microneurosurgical anatomy (MNA) with special reference to the development of anatomy, surgical anatomy, and microsurgery. Anatomy can be said to have started in the ancient Greek era with the work of Hippocrates, Galen, and others as part of the pursuit of natural science. In the sixteenth century, Vesalius made a great contribution in reviving Galenian knowledge while adding new knowledge of human anatomy. Also in the sixteenth century, Ambroise Paré can be said to have started modern surgery. As surgery developed, more detailed anatomical knowledge became necessary for treating complicated diseases. Many noted surgeons at the time were also anatomists eager to spread anatomical knowledge in order to enhance surgical practice. Thus, surgery and anatomy developed together, with advances in each benefiting the other. The concept of surgical anatomy evolved in the eighteenth century and became especially popular in the nineteenth century. In the twentieth century, microsurgery was introduced in various surgical fields, starting with Carl O. Nylen in otology. It flourished and became popularized in the second half of the century, especially in the field of neurosurgery, following Jacobson and Suarez's success in microvascular anastomosis in animals and subsequent clinical application as developed by M.G. Yasargil and others. Knowledge of surgical anatomy as seen under the operating microscope became important for surgeons to perform microneurosurgical procedures accurately and safely, which led to the fuller development of MNA as conducted by many neurosurgeons, among whom A.L. Rhoton, Jr. might be mentioned as representative.
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A Journey Through 100 Years of Vestibular Schwannoma Surgery at Mayo Clinic: A Historical Illustrative Case Series. Otol Neurotol 2021; 41:e1379-e1392. [PMID: 33492816 DOI: 10.1097/mao.0000000000002888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: The present state of vestibular schwannoma (VS) management is the product of over a century of technical progress by revolutionary surgeons who transformed a once perilous operation. At the beginning of the 1900s, patients who did not succumb to their disease were treated exclusively with surgery, which itself was almost assuredly devastating. Through the pioneering work of surgeons such as Harvey Cushing, Walter Dandy, William House, and others, safer surgical approaches were established with concurrent advances in neuromonitoring, neuroanesthesia, radiology, and adoption of the operating microscope. Owing to refinements in radiosurgical treatment and a greater understanding of the natural history of disease, there has been a dramatic shift toward more conservative management in recent years. For more than 100 years, the Mayo Clinic in Rochester, MN, has maintained an active and uninterrupted VS practice with activities that are well documented and preserved through the Mayo Clinic historical archives. We herein report representative early cases to illustrate the fascinating evolution in VS surgery over the past century at a single-tertiary referral center. Original clinical, imaging, pathology, and operative reports are presented from each era of management. To accurately portray the medical context of each era, antiquated terminology is intentionally preserved as originally transcribed.
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Schackert G, Ralle S, Martin KD, Reiss G, Kowalski M, Sobottka SB, Hennig S, Podlesek D, Sandi-Gahun S, Juratli TA. Vestibular Schwannoma Surgery: Outcome and Complications in Lateral Decubitus Position versus Semi-sitting Position-A Personal Learning Curve in a Series of 544 Cases over 3 Decades. World Neurosurg 2020; 148:e182-e191. [PMID: 33383200 DOI: 10.1016/j.wneu.2020.12.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To retrospectively evaluate influence of intraoperative positioning (semisitting vs. lateral decubitus) and surgeon's learning curve with regard to functional outcome of patients with vestibular schwannoma. METHODS This study included 544 patients (median age 57 years) and spanned 3 decades: 1991-1999 (n = 103), 2000-2009 (n = 210), and 2010-2019 (n = 231). Surgery was performed in the lateral decubitus position in 318 patients and the semisitting position in 163 patients. Large T3 and T4 tumors were present in 77% of patients. RESULTS Complete tumor removal was achieved in 94.3% of patients. A significant reduction in surgery duration and blood loss was observed over 3 decades for T3 (from 325 to 261 minutes, P < 0.001) and T4 (from 440 to 330 minutes, P < 0.001), but not for T1 and T2, tumors. The semisitting position diminished surgical time in T3 and T4 tumors by 1 more hour (P < 0.001). Over 3 decades, facial nerve outcome improved significantly from 59.8% House-Brackmann grade 1-2 in the first decade to 81.7% in the last decade (P < 0.001). Furthermore, hearing was preserved in 45.3%: 23.3% of patients in the first decade and 50.5% in the last decade (P = 0.03). However, neither facial nerve outcome nor hearing preservation significantly differed in patients operated on in the lateral decubitus versus the semisitting position. The most common complication was cerebrospinal fluid leak (6.1%) followed by hemorrhage (3.5%) and pulmonary embolism (2.2%). CONCLUSIONS Follow-up over 3 decades illustrates a learning curve with significantly improved results. While the semisitting position accelerates the procedure and is associated with reduced blood loss, it does not significantly influence functional outcome.
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Affiliation(s)
- Gabriele Schackert
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Susann Ralle
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - K Daniel Martin
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gilfe Reiss
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Matthias Kowalski
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stephan B Sobottka
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Silke Hennig
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dino Podlesek
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sahr Sandi-Gahun
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Tareq A Juratli
- Department of Neurosurgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Elkatatny AAAM, Abdallah HAA, Ghoraba D, Amer TA, Hamdy T. Hypoglossal Facial Nerve Anastomosis for Post-Operative and Post-Traumatic Complete Facial Nerve Paralysis. Open Access Maced J Med Sci 2019; 7:3984-3996. [PMID: 32165940 PMCID: PMC7061404 DOI: 10.3889/oamjms.2019.490] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/07/2022] Open
Abstract
AIM: This study aims to evaluate the outcome of patients with complete facial paralysis following surgery to cerebellopontine angle tumours or following traumatic petrous bone fractures after reanimation by hypoglossal-facial anastomosis as regards clinical improvement of facial asymmetry and facial muscle contractility as well as complications associated with hypoglossal-facial reanimation procedure. METHODS: This thesis included a prospective study to be carried out on 15 patients with unilateral complete lower motor neuron facial paralysis (11 patients after cerebellopontine angle tumour resection and 4 patients after traumatic transverse petrous bone fracture) operated upon by end to end hypoglossal-facial nerve anastomosis in Cairo university hospitals in the period between June 2015 and January 2017. RESULTS: At one year follow up the improvement of facial nerve functions were as follows: Three cases (20%) had improved to House Hrackmann grade II, eleven cases (73.33%) had improved to grade III, and one patient (6.66%) had improved to House Brackmann grade IV. CONCLUSION: Despite the various techniques in facial reanimation following facial nerve paralysis, the end to end hypoglossal-facial nerve anastomosis remains the gold standard procedure with satisfying results in cases of the viable distal facial stump and non-atrophic muscles. Early hypoglossal-facial anastomotic repair after acute facial nerve injury is associated with better long-term facial function outcomes and should be considered in the management algorithm.
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Affiliation(s)
| | | | - Dina Ghoraba
- Department of Plastic Surgery, Kasr Alainy Medical school, Cairo University, Cairo, Egypt
| | - Tarek Ahmed Amer
- Department of Plastic Surgery, Kasr Alainy Medical school, Cairo University, Cairo, Egypt
| | - Tarek Hamdy
- Department of Neurosurgery, Kasr Alainy Medical School, Cairo University, Cairo, Egypt
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16
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Baro V, Landi A, Brigadoi S, Castellaro M, Moretto M, Anglani M, Ermani M, Causin F, Zanoletti E, Denaro L, Bertoldo A, d'Avella D. Preoperative Prediction of Facial Nerve in Patients with Vestibular Schwannomas: The Role of Diffusion Tensor Imaging—A Systematic Review. World Neurosurg 2019; 125:24-31. [DOI: 10.1016/j.wneu.2019.01.099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 11/26/2022]
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17
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Torres Maldonado S, Naples JG, Fathy R, Eliades SJ, Lee JYK, Brant JA, Ruckenstein MJ. Recent Trends in Vestibular Schwannoma Management: An 11-Year Analysis of the National Cancer Database. Otolaryngol Head Neck Surg 2019; 161:137-143. [DOI: 10.1177/0194599819835495] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
ObjectiveA better understanding of the natural history of vestibular schwannoma (VS) has resulted in a change in treatment paradigms. It has also been proposed that increased use of high-resolution magnetic resonance imaging has allowed for an increased identification of small tumors. The aim of this study was to evaluate recent trends in the presentation and primary management of VS in the United States.Study DesignRetrospective analysis of the National Cancer Database (NCDB).SettingNCDB database.Subjects and MethodsAll patients with a diagnosis of VS between 2004 and 2014 were included. Data were analyzed with univariable and multivariable logistic regression.ResultsIn total, 28,190 patients (mean age 55 years, 52.9% female) with VS were analyzed. Linear regression showed a small decrease in average tumor size over time (–0.06 mm/year, P = .03). Overall, 11,121 patients (40%) received surgery, 8512 (30%) radiation, and 7686 (27%) observation. Controlling for patient, tumor, and treatment center factors, the odds ratio (OR) for receiving surgery in 2014 was 0.60 (confidence interval [CI], 0.50-0.71) while the OR for receiving radiation was 0.75 (CI, 0.64-0.87) as compared to those diagnosed in 2004. The largest increases in observation rates occurred among tumors ≤2 cm ( P < .001).ConclusionThere was not a clinically significant change in the average tumor size at diagnosis. Although surgery remained the most common treatment modality in the United States, there was a strong shift in the management of VS away from primary surgery and radiation and toward a “wait-and-scan” approach.
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Affiliation(s)
- Solymar Torres Maldonado
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James G. Naples
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramie Fathy
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven J. Eliades
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y. K. Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason A. Brant
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael J. Ruckenstein
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Schnurman Z, Golfinos JG, Roland JT, Kondziolka D. Knowledge silos: assessing knowledge sharing between specialties through the vestibular schwannoma literature. J Neurosurg 2018; 129:1278-1285. [PMID: 29192857 DOI: 10.3171/2017.6.jns171182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 06/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIt is common for a medical disorder to be managed or researched by individuals who work within different specialties. It is known that both neurosurgeons and neurotologists manage vestibular schwannoma (VS) patients. While overlap in specialty focus has the potential to stimulate multidisciplinary collaboration and innovative thinking, there is a risk of specialties forming closed-communication loops, called knowledge silos, which may inhibit knowledge diffusion. This study quantitatively assessed knowledge sharing between neurosurgery and otolaryngology on the subject of VS.METHODSA broad Web of Science search was used to download details for 4439 articles related to VS through 2016. The publishing journal's specialty and the authors' specialties (based on author department) were determined for available articles. All 114,647 of the article references were categorized by journal specialty. The prevalence of several VS topics was assessed using keyword searches of titles.RESULTSFor articles written by neurosurgeons, 44.0% of citations were from neurosurgery journal articles and 23.4% were from otolaryngology journals. The citations of otolaryngology authors included 11.6% neurosurgery journals and 56.5% otolaryngology journals. Both author specialty and journal specialty led to more citations of the same specialty, though author specialty had the largest effect. Comparing the specialties' literature, several VS topics had significantly different levels of coverage, including radiosurgery and hearing topics. Despite the availability of the Internet, there has been no change in the proportions of references for either specialty since 1997 (the year PubMed became publicly available).CONCLUSIONSPartial knowledge silos are observed between neurosurgery and otolaryngology on the topic of VS, based on the peer-reviewed literature. The increase in access provided by the Internet and searchable online databases has not decreased specialty reference bias. These findings offer lessons to improve cross-specialty collaboration, physician learning, and consensus building.
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Affiliation(s)
| | | | - J Thomas Roland
- 2Otolaryngology Head and Neck Surgery, NYU Langone Medical Center, New York, New York
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19
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Tripathi M, Satapathy A, Chauhan RB, Batish A, Gupta SK. Contralateral Hearing Loss After Resection of Vestibular Schwannoma in a Patient with Neurofibromatosis 2: Case Report and Literature Review. World Neurosurg 2018; 117:74-79. [PMID: 29902600 DOI: 10.1016/j.wneu.2018.05.245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 10/14/2022]
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20
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Kim SH, Lee SH, Choi SK, Lim YJ, Na SY, Yeo SG. Audiologic evaluation of vestibular schwannoma and other cerebellopontine angle tumors. Acta Otolaryngol 2015; 136:149-53. [PMID: 26479426 DOI: 10.3109/00016489.2015.1100326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Otologic accompanying symptoms, audiogram patterns, and hearing levels according to tumor size differed in patients with CPA tumors classified as VS and non-VS types. OBJECTIVES The diagnosis of CPA tumors is often delayed. Late-diagnosed tumors can grow until they compress and damage vital structures. This study evaluated the otologic symptoms and results of audiologic tests in patients with vestibular schwannomas (VS) and other types of CPA tumors. METHODS This study included 171 patients with otologic symptoms who were diagnosed with CPA tumors, including 116 with VS and 55 with other types of CPA tumors. Factors analyzed retrospectively included tumor type, size, and location and the results of audiometric examinations. RESULTS The most common chief complaint in patients diagnosed with CPA tumors was asymmetrical hearing loss, with most frequent accompanying symptoms being tinnitus in patients with VS and dizziness in those with other types of CPA tumor. The most frequent patterns of hearing loss were the descending type in patients with VS and the flat type in patients with non-VS tumors (p < 0.05). Pure tone thresholds tended to increase more in patients with VS than non-VS tumors according to tumor size, and pure tone averages were significantly higher in patients with VS than non-VS tumors of 11-25 mm in size (p < 0.05).
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Affiliation(s)
- Sang Hoon Kim
- a Department of Otorhinolaryngology-Head and Neck Surgery
| | - Sung Ho Lee
- b Department of Neurosurgery, School of Medicine , Kyung Hee University , Seoul , Korea
| | - Seok Keun Choi
- b Department of Neurosurgery, School of Medicine , Kyung Hee University , Seoul , Korea
| | - Young Jin Lim
- b Department of Neurosurgery, School of Medicine , Kyung Hee University , Seoul , Korea
| | - Se Young Na
- a Department of Otorhinolaryngology-Head and Neck Surgery
| | - Seung Geun Yeo
- a Department of Otorhinolaryngology-Head and Neck Surgery
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21
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Mendelsohn D, Westerberg BD, Dong C, Akagami R. Clinical and Radiographic Factors Predicting Hearing Preservation Rates in Large Vestibular Schwannomas. J Neurol Surg B Skull Base 2015; 77:193-8. [PMID: 27175312 DOI: 10.1055/s-0035-1564054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 07/22/2015] [Indexed: 01/06/2023] Open
Abstract
Objectives Postoperative hearing preservation rates for patients with large vestibular schwannomas range from 0 to 43%. The clinical and radiographic factors predicting hearing preservation in smaller vestibular schwannomas are well described; however, their importance in larger tumors is unclear. We investigated factors predicting hearing preservation in large vestibular schwannomas. Design Retrospective review. Setting Quaternary care academic center. Participants A total of 85 patients with unilateral vestibular schwannomas > 3 cm underwent retrosigmoid resections. Main Outcomes Measures Preoperative and postoperative serviceable hearing rates. Methods Clinical and radiographic data including preoperative and postoperative audiograms, preoperative symptoms, magnetic resonance imaging features, and postoperative facial weakness were analyzed. Results Hearing was preserved in 41% of patients (17 of 42) with preoperative serviceable hearing. Hypertension and diabetes increased the likelihood of preoperative hearing loss. Preoperative tinnitus predicted a lower likelihood of hearing preservation. No radiographic factors predicted hearing preservation; however, larger tumor size, smaller fourth ventricular width, and the presence of a cerebrospinal fluid cleft surrounding the tumor predicted postoperative facial weakness. Conclusion Systemic comorbidities may influence hearing loss preoperatively in patients with large vestibular schwannomas. The absence of tinnitus may reflect hearing reserve and propensity for hearing preservation. Preoperative radiographic features did not predict hearing preservation despite some associations with postoperative facial weakness.
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Affiliation(s)
- Daniel Mendelsohn
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian D Westerberg
- Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles Dong
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ryojo Akagami
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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Kunert P, Dziedzic T, Podgórska A, Czernicki T, Nowak A, Marchel A. Surgery for sporadic vestibular schwannoma. Part III: Facial and auditory nerve function. Neurol Neurochir Pol 2015; 49:373-80. [PMID: 26652871 DOI: 10.1016/j.pjnns.2015.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/31/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this analysis was to assess short-term and long-term outcomes with respect to the preservation of facial and auditory nerve function following surgery for sporadic vestibular schwannomas. MATERIAL AND METHODS The study included 220 consecutive patients operated on with the retrosigmoid (217) or translabyrinthine (3) approach. The mean extrameatal diameter of the tumor was 30mm. In 217 patients, gross total resection was performed and near-total in 3. Before surgery, the facial nerve (CNVII) weakness was found in 18% of patients and only 20% had serviceable hearing. Intraoperative neurophysiological CNVII monitoring was routinely used (the last 211 procedures). Intraoperative monitoring of the cochlear nerve function was used when the preservation of hearing was attempted (45 procedures). RESULTS The rate of CNVII continuity loss during surgery was 11%, however, this decreased to 6% in the second half of the series. Facial nerve function deteriorated, in 88% of the patients shortly after surgery. However, it improved in 87% in follow-up. Delayed CNVII palsy was found in 5% of the patients and had a good prognosis in 88%. Final satisfactory CNVII function (CNVII-SF, HB grades I-III) was achieved in 76% of the patients when excluding the anastomosis results, and 87% when including them. In recent years, the rate of CNVII-SF has risen to 94%. Non-serviceable hearing was preserved in 49% of the patients, on whom it was attempted. CONCLUSION Considering the size of the tumors and extent of the resections, the preservation of CNVII function is currently very high. A close surveillance of CNVII function evolution following surgery is mandatory, as 2/3 of the patients discharged with deep paresis will need different face reanimation procedures. The preservation of useful hearing is still problematic, especially in patients with large tumors.
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Affiliation(s)
- Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warszawa, Poland
| | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warszawa, Poland.
| | - Anna Podgórska
- Department of Neurosurgery, Medical University of Warsaw, Warszawa, Poland
| | - Tomasz Czernicki
- Department of Neurosurgery, Medical University of Warsaw, Warszawa, Poland
| | - Arkadiusz Nowak
- Department of Neurosurgery, Medical University of Warsaw, Warszawa, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warszawa, Poland
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Identification of cranial nerves near large vestibular schwannomas using superselective diffusion tensor tractography: experience with 23 cases. Acta Neurochir (Wien) 2015; 157:1239-49. [PMID: 25948078 DOI: 10.1007/s00701-015-2431-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The preservation of the facial nerve (FN) and acoustic function in large vestibular schwannoma (VS) surgery is challenging because of nerve course uncertainties and morphological deviations. Preoperative diffusion tensor tractography (DTT) has been proposed to predict the FN location. This study was conducted to evaluate the effectiveness of this technique for identifying the FN, cochlear nerve (CN) and trigeminal nerve (TN) in large VSs. METHODS The study included 23 consecutive patients with VS of Hannover classification T3b to T4b from November 2013 through May 2014. Diffusion tensor images and anatomical images were acquired. The DTT images of the cranial nerves were extracted before surgery for each patient to determine the relationships of these nerves with the tumor. The results were then validated during the tumorectomy. RESULTS In 21 (91.30%) patients, the location of the FN on the DTT images agreed with the intraoperative findings, including in 2 patients in whom the FN passed through the interface between the parenchyma and the cystic changes and in 3 patients with a membranoid FN. The CN or fibers of unclear function were observed on DTT images in four patients with functional hearing. One penetrating fiber of unknown function was effectively constructed. The TN was accurately detected on the DTT images for all patients. CONCLUSIONS DTT effectively revealed the location of the FN, including cases in which the FN was membranoid or passed through the interface between an area exhibiting cystic changes and the tumor nodule. Fibers aside from the FN and the TN were revealed by DTT in patients who retained functional hearing. Penetrating fibers were also found using DTT. This technique can be useful during VS resection.
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Leal AG, Silva EBD, Ramina R. Surgical exposure of the internal auditory canal through the retrosigmoid approach with semicircular canals anatomical preservation. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:425-30. [PMID: 26017209 DOI: 10.1590/0004-282x20150020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/29/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Evaluate the feasibility of an adequate exposure with anatomical preservation of labyrinth structures through retrosigmoid transmeatal approach (RSA) in surgeries for resection of acoustic neuromas/vestibular schwannomas (VS). METHOD Thirty patients underwent surgical resection and were preoperatively evaluated with fine slice high definition CT scans and 3D-MRI volumetric reconstructions. Extension of internal auditory canal (IAC) opening during surgery was measured using 3 mm right-angle calibrated hook and neuronavigation parameters. Postoperatively, the extension of IAC opening and integrity of the labyrinth were confirmed through preoperatively images procedures. RESULTS The preoperative length of IACs varied between 7.8 and 12.0 mm (mean 9.3 mm, SD 0.98, 95%CI 8.9 to 9.6, and median 9.0 mm). Postoperative images demonstrated adequate opening of the IAC and semicircular channels integrity. CONCLUSION A complete drilling of the posterior wall of IAC through the RSA is feasible and allows direct visualization of the IAC-fundus without damaging the semicircular canals.
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Current practices in vestibular schwannoma management: A survey of American and Canadian neurosurgeons. Clin Neurol Neurosurg 2014; 127:143-8. [DOI: 10.1016/j.clineuro.2014.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/29/2014] [Accepted: 10/04/2014] [Indexed: 11/18/2022]
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Acioly MA, Liebsch M, de Aguiar PHP, Tatagiba M. Facial Nerve Monitoring During Cerebellopontine Angle and Skull Base Tumor Surgery: A Systematic Review from Description to Current Success on Function Prediction. World Neurosurg 2013; 80:e271-300. [DOI: 10.1016/j.wneu.2011.09.026] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 09/06/2011] [Indexed: 11/17/2022]
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Surgical management of vestibular schwannoma: attempted preservation of hearing and facial function. The Journal of Laryngology & Otology 2013; 127:473-8. [PMID: 23552210 DOI: 10.1017/s0022215113000546] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Vestibular schwannomas are benign tumours which usually originate from the vestibular portion of the VIIIth cranial nerve. Treatment options include observation with serial imaging, stereotactic radiation and microsurgical removal. AIM The goal of surgery was complete eradication of tumour with preservation of hearing and facial nerve function. METHODS A retrospective review was undertaken of 24 cases of vestibular schwannoma jointly operated upon by a team of neurosurgeons and otologists at the Suez Canal University Hospital, with assessment of VIIth and VIIIth cranial nerve function, tumour size, and extent of growth. All surgery utilised a retromastoid, suboccipital approach. RESULTS Complete tumour removal was achieved in 19 patients. Anatomical preservation of the facial nerve was possible in 66.6 per cent of patients. Pre-operative, useful hearing was present in four patients, and preserved in 80 per cent. Cerebrospinal fluid leakage was diagnosed in two (8.3 per cent) patients, who responded to conservative therapy. CONCLUSION The retromastoid, suboccipital surgical approach to the skull base can be safely and successfully achieved using a microsurgical technique, with minimal or no damage to neurovascular structures, even for large tumours.
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Kunert P, Smolarek B, Marchel A. Facial nerve damage following surgery for cerebellopontine angle tumours. Prevention and comprehensive treatment. Neurol Neurochir Pol 2012; 45:480-8. [PMID: 22127944 DOI: 10.1016/s0028-3843(14)60317-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Facial nerve (CN VII) palsy or even its transient paresis causes physical disability but is also a psychosocial problem. Immediately after vestibular schwannoma removal, different degrees of CN VII paresis occur in 20-70% of patients. Facial nerve paresis is observed in 10-40% after surgery of cerebellopontine angle meningiomas. Postoperative facial nerve weakness significantly reduces or completely withdraws with time in the majority of cases. However, even if prognosis for CN VII regeneration is good, proper management is needed because of the potential for serious ophthalmic complications. In this paper, the authors raise the issue of perioperative prophylaxis and comprehensive treatment of postoperative paresis of CN VII. Prophylaxis and treatment of ophthalmic complications are discussed. Current trends in the treatment of intraoperative loss of facial nerve continuity, management of facial paresis with good prognosis and dealing with facial palsy with no spontaneous recovery are also described in the paper.
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Affiliation(s)
- Przemysław Kunert
- Katedra i Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, ul. Banacha 1 A, Warszawa.
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Quantitative parameters of facial motor evoked potential during vestibular schwannoma surgery predict postoperative facial nerve function. Acta Neurochir (Wien) 2011; 153:1169-79. [PMID: 21455744 DOI: 10.1007/s00701-011-0995-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Facial motor evoked potential (FMEP) amplitude ratio reduction at the end of the surgery has been identified as a good predictor for postoperative facial nerve outcome. We sought to investigate variations in FMEP amplitude and waveform morphology during vestibular schwannoma (VS) resection and to correlate these measures with postoperative facial function immediately after surgery and at the last follow-up. METHODS Intraoperative orbicularis oculi and oris muscles FMEP data from 35 patients undergoing surgery for VS resection were collected, then analysed by surgical stage: initial, dural opening, tumour dissection (TuDis), tumour resection (TuRes) and final. FINDINGS Immediately after surgery, postoperative facial function correlated significantly with the FMEP amplitude ratio during TuDis, TuRes and final stages in both the orbicularis oculi (p = 0.003, 0.055 and 0.028, respectively) and oris muscles (p = 0.002, 0.104 and 0.014, respectively). At the last follow-up, however, facial function correlated significantly with the FMEP amplitude ratio only during the TuDis (p = 0.005) and final (p = 0.102) stages for the orbicularis oris muscle. At both time points, postoperative facial paresis correlated significantly with FMEP waveform deterioration in orbicularis oculi during the final stage (immediate, p = 0.023; follow-up, p = 0.116) and in orbicularis oris during the TuDis, TuRes and final stages (immediate, p = 0.071, 0.000 and 0.001, respectively; follow-up, p = 0.015, 0.001 and 0.01, respectively). CONCLUSIONS FMEP amplitude ratio and waveform morphology during VS resection seem to represent independent quantitative parameters that can be used to predict postoperative facial function. Event-to-baseline FMEP monitoring is quite useful to dictate when intraoperative changes in surgical strategy are warranted to reduce the chances of facial nerve injury.
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Wind JJ, Leonetti JP, Raffin MJM, Pisansky MT, Herr B, Triemstra JD, Anderson DE. Hearing preservation in the resection of vestibular schwannomas: patterns of hearing preservation and patient-assessed hearing function. J Neurosurg 2011; 114:1232-40. [DOI: 10.3171/2010.11.jns091752] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
No extant literature documents the analysis of patient perceptions of hearing as a corollary to objective audiometric measures in patients with vestibular schwannoma (VS), or acoustic neuroma. Therefore, using objective audiometric data and patient perceptions of hearing function as outlined on a questionnaire, the authors evaluated the hearing of patients who underwent VS resection.
Methods
This investigation involved a retrospective review of 176 patients who had undergone VS resections in which hearing preservation was a goal. Both pre- and postoperative audiometry, expressed as a speech discrimination score (SDS) and pure tone threshold average (PTA), were performed, and the results were analyzed. Intraoperative auditory brainstem responses were also recorded. Eighty-seven of the patients (49.4%) completed a postoperative questionnaire designed to assess hearing function in a variety of social and auditory situations. Multiple linear regression analyses were completed to compare available audiometric results with questionnaire responses for each patient.
Results
One hundred forty-two patients (80.7%) had PTA and SDS audiometric data pertaining to the surgically treated ear; 94 of these patients (66.2%) had measurable postoperative hearing, as defined by a PTA < 120 dB or SD > 0%. Eighty-seven patients (49.4%) completed the retrospective questionnaire, and 74 of them had complete audiometric data and thus were included in a comparative analysis. Questionnaire data showed major postoperative subjective hearing decrements, even among patients with the same pre- and postoperative objective audiometric hearing status. Moreover, the subscore reflecting hearing while exposed to background noise, or the “cocktail party effect,” characterized the most significant patient-perceived hearing deficit following VS resection.
Conclusions
The authors' analysis of a patient-perceived hearing questionnaire showed that hearing during exposure to background noise, or the cocktail party effect, represents a significant postoperative hearing deficit and that patient perception of this deficit has a strong relation with audiometric data. Furthermore, questionnaire responses revealed a significant disparity between subjective hearing function and standard audiometrics such that even with similar levels of audiometric data, subjective measures of hearing, especially the cocktail party effect, decreased postoperatively. The authors posit that the incorporation of patient-perceived hearing function evaluation along with standard audiometry is an illustrative means of identifying subjective hearing deficits after VS resection and may ultimately aid in specific and subsequent treatment for these patients.
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Affiliation(s)
- Joshua J. Wind
- 1Department of Neurological Surgery, George Washington University, Washington, DC
| | | | - Michael J. M. Raffin
- 4Otolaryngology, Head and Neck Surgery, and
- 5Audiology, Loyola University Medical Center, Maywood, Illinois
| | | | - Brian Herr
- 4Otolaryngology, Head and Neck Surgery, and
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Silk PS, Lane JI, Driscoll CL. Surgical Approaches to Vestibular Schwannomas: What the Radiologist Needs to Know. Radiographics 2009; 29:1955-70. [DOI: 10.1148/rg.297095713] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Clinical, Radiographic, and Audiometric Predictors in Conservative Management of Vestibular Schwannoma. Otol Neurotol 2009; 30:507-14. [DOI: 10.1097/mao.0b013e31819d3465] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Akard W, Tubbs RS, Seymour ZA, Hitselberger WE, Cohen-Gadol AA. Evolution of techniques for the resection of vestibular schwannomas: from saving life to saving function. J Neurosurg 2009; 110:642-7. [DOI: 10.3171/2008.3.17473] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The current state of surgery for vestibular schwannomas (VSs) is the result of a century of step-by-step technical progress by groundbreaking surgeons who transformed the procedure from its hazardous infancy and high mortality rate to its current state of safety and low morbidity rate. Harvey Cushing advocated bilateral suboccipital decompression and developed the method of intracapsular tumor enucleation. Walter Dandy supported the unilateral suboccipital approach and developed the technique of gross-total tumor resection. Microsurgical techniques revolutionized VS surgery to its current status. In this article, the authors review the early history of surgery for VSs with an emphasis on contributions from pioneering surgeons. The authors examined the Cushing Brain Tumor Registry for clues regarding the bona fide intention of Cushing for the resection of these tumors.
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Affiliation(s)
- William Akard
- 1Clarian Neuroscience Institute, Indianapolis Neurosurgical Group, Inc., and Department of Neurosurgery, Indiana University, Indianapolis, Indiana
| | - R. Shane Tubbs
- 2Department of Cell Biology and Section of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama; and
| | - Zachary A. Seymour
- 1Clarian Neuroscience Institute, Indianapolis Neurosurgical Group, Inc., and Department of Neurosurgery, Indiana University, Indianapolis, Indiana
| | - William E. Hitselberger
- 3House Ear Institute and Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Aaron A. Cohen-Gadol
- 1Clarian Neuroscience Institute, Indianapolis Neurosurgical Group, Inc., and Department of Neurosurgery, Indiana University, Indianapolis, Indiana
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Lüdemann WO, Stieglitz LH, Gerganov V, Samii A, Samii M. Fat Implant is Superior to Muscle Implant in Vestibular Schwannoma Surgery for the Prevention of Cerebrospinal Fluid Fistulae. Oper Neurosurg (Hagerstown) 2008. [DOI: 10.1227/01.neu.0000310710.70769.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Meticulous sealing of opened air cells in the petrous bone is necessary for the prevention of cerebrospinal fluid (CSF) fistulae after vestibular schwannoma surgery. We performed a retrospective analysis to determine whether muscle or fat tissue is superior for this purpose.
Methods:
Between January 2001 and December 2006, 420 patients underwent retrosigmoidal microsurgical removal by a standardized procedure. The opened air cells at the inner auditory canal and the mastoid bone were sealed with muscle in 283 patients and with fat tissue in 137 patients. Analysis was performed regarding the incidence of postoperative CSF fistulae and correlation with the patient's sex and tumor grade.
Results:
The rate of postoperative CSF leak after application of fat tissue was lower (2.2%) than after use of muscle (5.7%). Women had less postoperative CSF leakage (3.4%) than men (5.6%). There was an inverse correlation with tumor grade. Patients with smaller tumors seemed to have a higher rate of CSF leakage than those with large tumors without hydrocephalus. Only large tumors with severe dislocation of the brainstem causing hydrocephalus showed a higher incidence of CSF leaks.
Conclusion:
Fat implantation is superior to muscle implantation for the prevention of CSF leakage after vestibular schwannoma surgery and should, therefore, be used for the sealing of opened air cells in cranial base surgery.
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Affiliation(s)
- Wolf O. Lüdemann
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Lennart H. Stieglitz
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Venelin Gerganov
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Amir Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Madjid Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
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Cardoso AC, Fernandes YB, Ramina R, Borges G. Acoustic neuroma (vestibular schwannoma): surgical results on 240 patients operated on dorsal decubitus position. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:605-9. [PMID: 17876399 DOI: 10.1590/s0004-282x2007000400011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 04/18/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: To evaluate the result of the surgical treatment of vestibular schwannoma (VS) operated in dorsal decubitus (mastoid position). METHOD: 240 patients with a VS underwent a retrosigmoid craniotomy for tumor resection in dorsal decubitus (mastoid position). The function of 7th and 8th cranial nerves was monitored during surgery and the opened internal auditory canal (IAC) was reconstructed using a vascularized dura flap, muscle and fibrin glue. RESULTS: Complete tumor removal was achieved in 99% of the cases, with a mortality of 1.6%. The facial nerve function was preserved in 85% of cases and hearing in 40% of the patients (with preoperative hearing) with tumors of up 1.5 cm in diameter. The incidence of cerebrospinal fluid leak was 5.8% and meningitis 2.9%. Venous air embolism was registered in 3% of cases; it was not associated to mortality. CONCLUSION: Surgical removal of VS in dorsal position has several advantages; the morbidity and mortality are very low.
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Nguyen-Huynh AT, Jackler RK, Pfister M, Tseng J. The aborted early history of the translabyrinthine approach: a victim of suppression or technical prematurity? Otol Neurotol 2007; 28:269-79. [PMID: 17255895 DOI: 10.1097/mao.0b013e31802b3264] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To ascertain the reasons translabyrinthine (TL) approach to acoustic neuroma, initially attempted in 1911, became relegated to obscurity for nearly half a century. STUDY DESIGN A scholarly review of more than 40 publications in German and English from the late 19th to the mid-20th century. LITERATURE SUMMARY Surgeons who first contemplated approaching the cerebellopontine angle recognized that the shortest route from the surface was through the petrous bone. In the late 19th century, otologic surgeons devised numerous procedures to deal with infection in and around the semicircular canals. This familiarity led R. Panse of Dresden to propose (but not actually perform) a TL approach (1904). F.H. Quix of Utrecht performed the first pure TL approach (1911), but others before him had used petrosectomy to augment the suboccipital approach. Subsequent TL attempts by other surgeons met with variable results. Devastating criticism of the method was proffered by leading acoustic neuroma surgeons of the day such as H. Cushing (1921) and W. Dandy (1925). The most important criticisms were that the approach provided only a deep and narrow field of action, was surrounded by major vascular structures, and led to great difficulty with cerebrospinal fluid leakage. HISTORICAL PERSPECTIVE The literature on this subject is replete with erroneous citations. Panse is often miscited as having performed the first surgery. It has also become traditional to give Quix great credit, even though his procedure failed to remove much of the tumor. Poor outcome and intense criticism led surgeons to abandon the TL approach until W.F. House, armed with operating microscope and high-speed drill, successfully resurrected it in the 1960s. He concisely summarizes the pioneers' efforts: "They had the ideas and desire, but not the technical tools."
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Affiliation(s)
- Anh T Nguyen-Huynh
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA. nguyanh.ohsu.edu
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Samii M, Koerbel A, Safavi-Abbasi S, Di Rocco F, Samii A, Gharabaghi A. Using an end-to-side interposed sural nerve graft for facial nerve reinforcement after vestibular schwannoma resection. J Neurosurg 2006; 105:920-3. [PMID: 17405267 DOI: 10.3171/jns.2006.105.6.920] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ Increasing rates of facial and cochlear nerve preservation after vestibular schwannoma surgery have been achieved in the last 30 years. However, the management of a partially or completely damaged facial nerve remains an important issue. In such a case, several immediate or delayed repair techniques have been used.
On the basis of recent studies of successful end-to-side neurorrhaphy, the authors applied this technique in a patient with an anatomically preserved but partially injured facial nerve during vestibular schwannoma surgery. The authors interposed a sural nerve graft to reinforce the facial nerve whose partial anatomical continuity had been preserved. On follow-up examinations 18 months after surgery, satisfactory cosmetic results for facial nerve function were observed.
The end-to-side interposed nerve graft appears to be a reasonable alternative in cases of partial facial nerve injury, and might be a future therapeutic option for other cranial nerve injuries.
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Affiliation(s)
- Madjid Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany.
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Abstract
Object
The facial nerve in vestibular schwannomas (VSs) is located on the ventral tumor surface in more than 90% of cases; other courses are rare. A split facial nerve course with two distinct bundles has thus far been described exclusively for medial extrameatal tumors.
Methods
Between 1996 and 2005, 16 consecutive cases of 241 surgically treated VSs were observed to have distinct splitting of the facial nerve. The mean tumor size measured 27 mm. In one third of the cases, intrameatal tumor extension with obliteration of the fundus was documented. All patients underwent extensive intraoperative neurophysiological monitoring using multichannel electromyography recordings. Patients were reevaluated 12 months after surgery.
In all 16 patients, distinct splitting of the facial nerve was demonstrated. The major portion of the facial nerve followed a typical course on the ventral tumor surface. The smaller nerve portion in all cases ran parallel to the brainstem up to the level of the trigeminal root exit zone and crossed on the cranial tumor pole to the internal auditory canal. The two nerve portions rejoined at the level of the porus acusticus. The smaller portion carried fibers exclusively to the orbicularis oris muscle, whereas the major portion supplied all three branches of the facial nerve.
Conclusions
In VSs, an aberrant course with distinct splitting of the facial nerve adds considerably to the surgical challenge. Long-term facial nerve results are excellent with extensive neurophysiological monitoring, which allows the differentiation and identification of aberrant facial nerve fibers and avoids additional risks to facial nerve preservation.
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Affiliation(s)
- Christian Strauss
- Department of Neurosurgery, Martin-Luther- University of Halle-Wittenberg, Halle, Germany.
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Lin VYW, Houlden D, Bethune A, Nolan M, Pirouzmand F, Rowed D, Nedzelski JM, Chen JM. A Novel Method in Predicting Immediate Postoperative Facial Nerve Function Post Acoustic Neuroma Excision. Otol Neurotol 2006; 27:1017-22. [PMID: 17006353 DOI: 10.1097/01.mao.0000235308.87689.35] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED To determine whether the percentage calculated by dividing the amplitude of postexcision direct facial nerve stimulus responses (at pontomedullary junction) by the amplitude of distal ipsilateral transcutaneous (stylomastoid region) maximal stimulus responses and response amplitude progression by increasing stimulus intensities have predictive value for determining normal or near-normal (House-Brackmann Grade 1 or 2) immediate postoperative facial nerve function. STUDY DESIGN Intraoperative recordings of three muscle groups: 1) frontalis, 2) orbicularis oculi, and 3) orbicularis oris. Postexcision direct facial nerve stimulation at the pontomedullary junction and transcutaneous maximal facial nerve stimulation at the ipsilateral stylomastoid region and their associated response amplitudes were recorded. SETTING Tertiary referral center. PATIENTS AND METHODS Patients who underwent acoustic neuroma surgery from January 2004 to March 2006 with intraoperative facial nerve monitoring and an intact facial nerve after tumor excision were included. Recordings were available for 38 patients. RESULTS With a stimulus intensity of 0.3 mA at the root exit zone, there was an 81% positive predictive value in patients that exhibited a compound action potential of greater than 20% of maximum (sensitivity, 81%). This increased to 93% when the compound action potential was greater than 50% of maximum. When the amplitude increase was greater than 5 microV, there was a 77% positive predictive value (sensitivity, 87%). CONCLUSION The percentage of the response amplitude of direct facial nerve stimulation at the pontomedullary junction when compared with the maximum response amplitude of ipsilateral transcutaneous stimulation at the stylomastoid foramen is a good predictor of normal to near-normal immediate postoperative facial nerve function. Progression of amplitude response also seems to be a good predictor of normal to near-normal immediate postoperative facial nerve function.
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Affiliation(s)
- Vincent Y W Lin
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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