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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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Irfan S, Kadam AD, Ravichandran U. An Atypical Presentation of Acoustic Neuroma With Facial Paresthesia: A Case Report. Cureus 2024; 16:e56745. [PMID: 38650777 PMCID: PMC11033451 DOI: 10.7759/cureus.56745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 04/25/2024] Open
Abstract
Acoustic neuromas are benign neoplasms of the brain composed of Schwann cells, arising most commonly from the nerve sheath of the vestibular division of the VIII cranial nerve. They usually manifest as unilateral hearing loss, tinnitus, and unsteadiness. Some patients may present atypically with symptoms like orofacial pain, hemifacial numbness, sudden onset hearing loss, or trigeminal neuralgia. Here we report an interesting case of acoustic neuroma in which the patient presented with unilateral facial numbness and tooth pain. Persistent atypical symptoms should always raise clinical suspicion of this pathology, necessitating the need for higher radiological investigations (CT or MRI) to aid in the early diagnosis and treatment.
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Affiliation(s)
- Shahul Irfan
- Internal Medicine, Government Medical College and Hospital Cuddalore, Chidambaram, IND
| | - Amogh D Kadam
- Internal Medicine, Government Medical College and Hospital Cuddalore, Chidambaram, IND
| | - Umarani Ravichandran
- Internal Medicine, Government Medical College and Hospital Cuddalore, Chidambaram, IND
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Turek G, Dzierzęcki S, Obierzyński P, Rogala A, Ząbek Z, Milewski R, Kiprian D, Zielińska-Turek J, Ząbek M. Outcomes and Prognostic Factors in the Treatment of Intracanalicular Vestibular Schwannomas Using Gamma Knife Stereotactic Radiation. Ann Otol Rhinol Laryngol 2023; 132:1564-1572. [PMID: 37096361 DOI: 10.1177/00034894231169341] [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] [Indexed: 04/26/2023]
Abstract
BACKGROUND No gold standard has been developed for the therapy of intracanalicular vestibular schwannomas (IVS). Options for treatment include a conservative approach, microsurgery, or radiosurgery. Although the efficacy of these treatment has been well-documented, little is known about the determinants of outcome in IVSs following radiosurgery. Therefore, we examined the results in relation to age, gender, tumor volume, distance to fundus, microcyst existence, and radiosensitivity in this group. In addition, we investigated possible predictors of facial nerve function and hearing preservation. METHODS Ninety-four patients with unilateral IVS were included in the evaluation (52 women and 42 males). The patients were separated into younger and older age groups based on their median age (55 years). The median IVS volume was 138 mm3, microcysts were identified in 16 tumors, and 63 tumors were adjacent to the fundus. The data were analyzed using Statistica software package ver. 13.3. RESULTS At final follow-up, a statistically significant decrease in tumor volume and no statistically significant decline in hearing were noted, but no differences between age groups were found. The sex had no effect on overall tumor growth control, facial nerve preservation, or hearing preservation. Localization of IVS close to the fundus and the presence of tumor microcysts had no effect on the control of tumor growth, preservation of hearing, and sparing of facial nerve following radiosurgery. Cochlear dose had no influence on hearing preservation. Higher tumor volume was associated with its pseudoprogression during early follow-up and a greater risk of hearing loss. CONCLUSIONS Age, sex, tumor volume, proximity to the fundus, and the existence of a microcyst were not predictive of radiosensitivity nor preservation of facial nerve function and hearing, based on the findings. There was no effect of cochlear dose on hearing. Initial greater tumor volume was associated with an increased probability of tumor pseudoprogression.
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Affiliation(s)
- Grzegorz Turek
- Department of Neurosurgery, Brodnowski Masovian Hospital, Warsaw, Poland
| | | | - Paweł Obierzyński
- Department of Neurosurgery, Brodnowski Masovian Hospital, Warsaw, Poland
| | - Adrian Rogala
- Department of Neurosurgery, Brodnowski Masovian Hospital, Warsaw, Poland
| | - Zuzanna Ząbek
- Medical Division, Medical University of Warsaw, Warsaw, Poland
| | - Robert Milewski
- Department of Statistics and Medical Informatics, Medical University of Bialystok, Białystok Poland
| | - Dorota Kiprian
- Head and Neck Cancer Department, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Justyna Zielińska-Turek
- Department of Neurology, Central Clinical Hospital of the Ministry of Internal Affairs and Administration, Warsaw, Poland
| | - Mirosław Ząbek
- Department of Neurosurgery, Brodnowski Masovian Hospital, Warsaw, Poland
- Warsaw Gamma Knife Center, Warsaw, Poland
- Department of Neurosurgery, Centre of Postgraduate Medical Education, Warsaw, Poland
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Ren Y, Merna CM, Tawfik KO, Schwartz MS, Friedman RA. Auditory Brain Stem Response Predictors of Hearing Outcomes after Middle Fossa Resection of Vestibular Schwannomas. Skull Base Surg 2022; 83:496-504. [DOI: 10.1055/s-0040-1722718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives To analyze the relationship between preoperative and intraoperative auditory brain stem response (ABR) characteristics and hearing outcomes in patients with vestibular schwannomas (VS) undergoing hearing preservation (HP) surgery via a middle cranial fossa (MCF) approach.
Design Prospective study.
Setting Academic tertiary skull base referral center.
Methods Pre- and postoperative pure-tone average (PTA) and word recognition score (WRS) were examined. Intraoperative ABR wave III latency, wave V latency, and amplitude were recorded. HP was defined as postoperative WRS ≥50%.
Participants Adult patients with VS and WRS ≥50% who underwent MCF tumor resection between November 2017 and September 2019.
Main Outcome Measures Postoperative hearing outcomes.
Results Sixty patients were included. Mean tumor size was 9.2 mm (range, 3–17). HP rates were 56.7% for the cohort and 69.7% for tumors <10 mm. A complete loss of wave V was associated with an 82.9% increase in postoperative PTA (p < 0.001) and 97.2% decrease in WRS (p < 0.001), whereas a diminished wave V was correlated with 62.7% increase in PTA (p < 0.001) and 55.7% decrease in WRS (p = 0.006). A diminished or absent wave V, but not increased wave III/V latency or decreased wave V amplitude, was correlated with a decline in postoperative hearing class (r = 0.735, p < 0.001). Receiver-operating characteristic analysis demonstrated that a stable wave V has the highest accuracy in predicting HP (sensitivity of 82.6%, specificity of 84.8%).
Conclusion Of the examined preoperative and intraoperative ABR characteristics, a stable wave V intraoperatively was the strongest predictor of HP after MCF resection of VS.
Level of Evidence Level III.
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Affiliation(s)
- Yin Ren
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, United States
| | - Catherine M. Merna
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, California, United States
| | - Kareem O. Tawfik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, United States
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Marc S. Schwartz
- Division of Neurosurgery, Department of Surgery, University of California, San Diego, San Diego, California, United States
| | - Rick A. Friedman
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California, San Diego, San Diego, California, United States
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Reddy P, Yan F, Liu YF, McRackan TR, Rizk HG. Hearing Preservation in Patients Who Undergo Labyrinthectomy and Translabyrinthine Procedures: A Case Report and Systematic Review. JAMA Otolaryngol Head Neck Surg 2021; 146:741-747. [PMID: 32584395 DOI: 10.1001/jamaoto.2020.1292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Preservation of endolymphatic fluids, maintenance of a fluid-filled vestibule, and preservation of the cochlear nerve and its vasculature are believed to be necessary to retaining hearing after an inner-ear operation. However, some studies have reported no hearing loss despite the violation of the vestibule, questioning the importance of maintaining a fluid-filled vestibule in preserving hearing. Objective To report on the preservation of hearing after a complete labyrinthectomy for Meniere disease and after disruption of the vestibule. Evidence Review This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A search of PubMed, Scopus, Ovid, and Cochrane Library databases was conducted to identify English-language articles on hearing preservation after labyrinthectomy, published from 1947 through December 11, 2019. The search strategy used a combination of boolean operators and included the following Medical Subject Heading terms and keywords: hearing preservation, labyrinth surgery, labyrinthectomy, vestibule violation, vestibule disruption, translabyrinthine approach, schwannoma removal, and semicircular canal ablation. Studies that included disruption of the vestibule and hearing preservation were included. Findings This systematic review identified 10 studies with 10 patients who underwent surgical removal of cholesteatoma or vestibular schwannoma and displayed postoperative hearing preservation. This study also reported on 1 patient with Meniere disease who retained hearing after undergoing a complete labyrinthectomy. Among these 11 patients, the mean (range) age was 45.1 (27-55) years, and 8 patients (73%) were women. Multiple theories exist that explain the mechanism behind hearing preservation, such as sealing of the ductus reuniens or closure of the remaining vestibule. Conclusions and Relevance This systematic review describes a set of patients who did not experience hearing loss after a labyrinthectomy or surgical violation of the vestibule, which seems to contradict prevailing principles for retaining hearing after inner-ear surgical procedures. This finding suggests that hearing preservation is possible after labyrinthine destruction despite the absence of a fluid-filled vestibule and that other mechanisms, such as occlusion of the ductus reuniens with granulation tissue or bone dust, may be sufficient to achieve that outcome.
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Affiliation(s)
- Priyanka Reddy
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Flora Yan
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Yuan F Liu
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Theodore R McRackan
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
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Bozhkov Y, Shawarba J, Feulner J, Winter F, Rampp S, Hoppe U, Doerfler A, Iro H, Buchfelder M, Roessler K. Prediction of Hearing Preservation in Vestibular Schwannoma Surgery According to Tumor Size and Anatomic Extension. Otolaryngol Head Neck Surg 2021; 166:530-536. [PMID: 34030502 DOI: 10.1177/01945998211012674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Vestibular schwannoma (VS) surgery is feasible for various tumor sizes that are inappropriate for wait and scan or radiosurgery. The predictive value of 2 grading systems was investigated for postoperative hearing preservation (HP) in a large series. STUDY DESIGN Retrospective analysis. SETTING Neurosurgical patient database of the University of Erlangen was queried between 2014 and 2017. METHODS Retrospective single-center analysis on 138 VSs operated on via a retrosigmoidal approach. The mean tumor size was 20.4 mm (SD, 7.6 mm) with fundal infiltration in 67.4%. The overall resection rate was 93.5%. Tumors were classified preoperatively by the 3-tier Erlangen grading system depending on size or the anatomically based 4-tier Koos grading system. RESULTS Preoperative hearing preservation was found in 70.3% of patients and was significantly correlated to tumor size (P = .001). For Erlangen grading, a mean postoperative serviceable hearing preservation rate of 32% was achieved: 83.3% for tumors <12 mm, 30.3% for tumors between 12 and 25 mm, and 5.3% for tumors >25 mm. In contrast, according to Koos grading, postoperative serviceable hearing preservation was 100% for grade 1 tumors (meatal), 35.6% for grade 2 (cisternal), 23.1% for grade 3 (brainstem contact), and 21.7% for grade 4 (brainstem compression). Of the total cohort, 86% had normal or nearly normal postoperative facial function (House-Brackmann grades 1 and 2). CONCLUSION Surgery on small VSs can achieve excellent hearing preservation. Different grading has a significant influence on and correlates with postoperative hearing preservation. Tumor size seems more important than anatomic relationship.
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Affiliation(s)
- Yavor Bozhkov
- Neurosurgical Clinic, University Hospital Erlangen, Erlangen, Germany
| | - Julia Shawarba
- Neurosurgical Clinic, University Hospital Erlangen, Erlangen, Germany
| | - Julian Feulner
- Neurosurgical Clinic, University Hospital Erlangen, Erlangen, Germany
| | - Fabian Winter
- Neurosurgical Clinic, Medical University Vienna, Vienna, Austria
| | - Stefan Rampp
- Neurosurgical Clinic, University Hospital Erlangen, Erlangen, Germany
| | - Ullrich Hoppe
- ENT Clinic, University Hospital Erlangen, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiolgy, University Hospital Erlangen, Erlangen, Germany
| | - Heinrich Iro
- ENT Clinic, University Hospital Erlangen, Erlangen, Germany
| | | | - Karl Roessler
- Neurosurgical Clinic, University Hospital Erlangen, Erlangen, Germany.,Neurosurgical Clinic, Medical University Vienna, Vienna, Austria
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Neves Cavada M, Fook-Ho Lee M, Jufas NE, Harvey RJ, Patel NP. Intracanalicular Vestibular Schwannoma: A Systematic Review and Meta-analysis of Therapeutics Outcomes. Otol Neurotol 2021; 42:351-362. [PMID: 33555742 DOI: 10.1097/mao.0000000000002979] [Citation(s) in RCA: 2] [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 perform a systematic review and meta-analysis summarizing the current evidence on the management of intracanalicular vestibular schwannoma. DATA SOURCES Embase (1947-), Medline (1946-), Cochrane library (1947-), Scopus (2010-), and CINAHL (1961-) were searched from 1969 to October 5, 2019 (50 years). STUDY SELECTION A search strategy was performed to identify patients with vestibular schwannoma confined to the internal auditory canal without extension to the cerebellopontine angle. Studies with patients aged less than 18, Neurofibromatosis type 2, revision cases, and non-English language were excluded. DATA EXTRACTION A standardized collection sheet was used for the extracted data and a quality assessment was performed using the Newcastle-Ottawa Scale with the comparability criterion omitted. DATA SYNTHESIS Seventy-one studies were included with 24 on observation, 14 on radiotherapy, and 34 on surgery. The primary outcome was serviceable hearing preservation. Secondary outcomes were preservation of facial nerve function, growth, involution, and dizziness. Sub-analysis on the type of surgery and type of radiotherapy were performed. Excel 2016 with MIX 2.0 Pro add-on package was used to analyze the data and create forest plots. Data were presented in proportion with a 95% confidence interval. CONCLUSIONS Serviceable hearing was observed in 31% of patients after observation, 56% after radiotherapy, and 51% after surgical treatment with mean follow-up time of 4.04 years, 4.92 years, and 2.23 years, respectively. Facial nerve function was found to be best preserved in both observation and radiotherapy groups. Vestibular schwannoma growth occurred in 33% of patients under observation. Involution occurred in 2% of patients under observation and in 38% after radiotherapy.
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Affiliation(s)
- Marina Neves Cavada
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Sydney Adventist Hospital
| | | | - Nicholas Emmanuel Jufas
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Kolling Deafness Research Centre, University of Sydney & Macquarie University
- Department of Otolaryngology, Head and Neck Surgery, Royal North Shore Hospital
- Discipline of Surgery, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Richard John Harvey
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales
| | - Nirmal P Patel
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Kolling Deafness Research Centre, University of Sydney & Macquarie University
- Department of Otolaryngology, Head and Neck Surgery, Royal North Shore Hospital
- Discipline of Surgery, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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8
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Mehta GU, Lekovic GP. The history of neurosurgery at the House Clinic in Los Angeles. J Neurosurg 2020. [DOI: 10.3171/2019.5.jns19602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although most widely known as the birthplace of neuro-otology, the House Clinic in Los Angeles has been the site of several major contributions to the field of neurosurgery. From the beginning of the formation of the Otologic Medical Group in 1958 (later renamed the House Ear Clinic), these contributions have been largely due to the innovative and collaborative work of neurosurgeon William E. Hitselberger, MD, and neuro-otologist William F. House, MD, DDS. Together they were responsible for the development and widespread adoption of the team approach to skull-base surgery. Specific neurosurgical advances accomplished at the House Clinic have included the first application of the operative microscope to neurosurgery, the application of middle fossa and translabyrinthine approaches for vestibular schwannoma, and the development of combined petrosal, retrolabyrinthine, and other alternative petrosal approaches and of hearing preservation surgery for vestibular schwannoma. The auditory brainstem implant, invented at the House Clinic in 1979, was the first ever successful application of central nervous system neuromodulation for restoration of function. Technological innovations at the House Clinic have also advanced neurosurgery. These include the first video transmission of microsurgery, the first suction irrigator, the first debulking instrument for tumors, and the House-Urban retractor for middle fossa surgery.
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Dzierzęcki S, Turek G, Czapski B, Dyttus‐Cebulok K, Tomasiuk R, Kaczor S, Ząbek M. Gamma knife surgery in the treatment of intracanalicular vestibular schwannomas. Acta Neurol Scand 2020; 141:415-422. [PMID: 31922606 DOI: 10.1111/ane.13220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 12/24/2019] [Accepted: 01/05/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE According to the literature, gamma knife surgery (GKS) is a promising method for intracanalicular vestibular schwannoma (IVS) management, providing excellent tumor growth control rates (91%-100%) and good hearing preservation rates (41%-76%), but this evidence originates primarily from a small series of patients. The aim of this study was to present the outcomes of GKS in the largest group of patients with IVS studied to date, with particular emphasis on the long-term outcomes of treatment. METHODS The study included 136 consecutive patients with unilateral IVS, who underwent GKS in 2011-2015. Mean age of the patients was 54 ± 12.6 years. All patients were operated on with a 192-source cobalt-60 gamma knife unit. All patients had complete follow-up documentation and the mean duration of the follow-up was 52 ± 13.8 months (6-83 months). Neurological status (facial and trigeminal nerve), hearing and instability/dizziness presence were determined prior to GKS, immediately after the procedure, and during the follow-up visits. RESULTS Tumor growth control was obtained in 124/136 (~91.2%) patients. Hearing improvement was observed in 32/136 (23.5%) patients, and there was a distinct cluster of 9 patients (6.6%) regaining serviceable hearing after GKS, whereas in 36 patients (26.5%) was stable. Four patients developed facial nerve dysfunction, including 3 periodic hemifacial spasm and 1 partial paresis, which resolved spontaneously within 12 months of GKS. None of the operated patients showed new, debilitating neurological deficits, including trigeminal sensory disturbances or hydrocephalus. CONCLUSIONS GKS is a highly effective treatment for IVS, associated with low morbidity and good tumor growth control.
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Affiliation(s)
- Sebastian Dzierzęcki
- Department of Neurosurgery Postgraduate Medical Centre Warsaw Poland
- Gamma Knife Centre Warsaw Poland
| | - Grzegorz Turek
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
| | - Bartosz Czapski
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
| | - Katarzyna Dyttus‐Cebulok
- Gamma Knife Centre Warsaw Poland
- Department of Radiation Oncology Maria Sklodowska‐Curie Institute of Oncology Warsaw Poland
| | - Ryszard Tomasiuk
- Department of Laboratory Diagnostics Brodno Masovian Hospital Warsaw Poland
| | - Szymon Kaczor
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
| | - Mirosław Ząbek
- Department of Neurosurgery Postgraduate Medical Centre Warsaw Poland
- Gamma Knife Centre Warsaw Poland
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
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10
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Surgical outcome in smaller symptomatic vestibular schwannomas. Is there a role for surgery? Acta Neurochir (Wien) 2018; 160:2263-2275. [PMID: 30229403 DOI: 10.1007/s00701-018-3674-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Currently, there is no consensus in the initial management of small vestibular schwannomas (VSs). They are routinely watched and/or referred for radiosurgical treatment, although surgical removal is also an option. We hereby evaluate clinical outcomes of patients who have undergone surgical removal of smaller symptomatic VSs. METHODS Patients with vestibular schwannomas (grade T1-T3b according to Hannover classification) were reviewed. Patients with symptomatic tumors who underwent surgery were evaluated. Their preoperative hearing status was based on the guideline of the committee on hearing and equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) foundation. Their postoperative facial nerve function, hearing status, vestibular symptoms, and degree of tumor resection were assessed. RESULTS Thirty patients were selected for surgery via a retrosigmoid approach based on their age, symptoms, and their own decision-making after discussion of management options. Most patients presented with hearing loss. Seventeen patients had useful hearing preoperatively. Among them, 10 patients (59%) preserved useful hearing (class A or B) postoperatively. MRI at 1-year follow-up confirmed complete resection in 26/29 patients. Also, 29 patients (97%) had HB grade I-II, and 1 patient had HB III at 1-year follow-up. Except for 1 patient with CSF leak, 1 patient with delayed facial nerve palsy, and 2 patients with asymptomatic sigmoid sinus occlusion, there were no other new morbidities. CONCLUSION Although both observation and radiosurgery are valid options in the management of smaller size vestibular schwannomas, surgical treatment seems to offer a high rate of facial nerve preservation, a reasonable rate of hearing sparing, and a high total resection rate. Clinicians should consider surgical treatment as a valid option in the initial management of symptomatic small vestibular schwannomas in younger patients.
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11
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Carrier DA, Arriaga MA. Cost-Effective Evaluation of Asymmetric Sensorineural Hearing Loss with Focused Magnetic Resonance Imaging. Otolaryngol Head Neck Surg 2018; 116:567-574. [DOI: 10.1016/s0194-5998(97)70229-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The poor sensitivity of audiometric brain stem response for small vestibular schwannomas (acoustic neuromas) creates a dilemma for the physician evaluating a patient with signs and symptoms of retrocochlear disease. Magnetic resonance imaging is recognized as the gold standard for the evaluation of these problems, but if a complete examination of the internal auditory canals and head is done on every patient, the cost is high. Although less expensive, screening with audiometric brain stem response risks missing up to 33% of small tumors. Therefore we developed a focused magnetic resonance imaging sequence for evaluation of patients with asymmetric sensorineural hearing loss and/or nonpulsatile tinnitus. The protocol includes a T1-weighted sagittal localizer, pregadolinium and post-gadolinium T1-weighted 3-mm contiguous axial slices through the internal auditory canal and the region of the cerebellopontine angle, and T2-weighted axial images through the entire brain. Total scanning time is about 12 minutes, and the estimated cost is $300 to $500. We retrospectively reviewed the imaging records of 485 screening examinations done during an 18-month period. Twenty-four patients had diagnoses definitely or probably producing the hearing loss for an overall positive rate of 5%. By eliminating the need for follow-up audiometric or electrophysiologic studies, we believe a focused magnetic resonance imaging-based diagnostic scheme is actually more cost-effective on a cost-per-patient basis.
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Affiliation(s)
- David A. Carrier
- Department of Neuroradiology, Wilford Hall Medical Center; Lackland AFB, Texas, and Pittsburgh, Pennsylvania
| | - Moises A. Arriaga
- Department of Otology/Neurotology Pittsburgh Ear Associates, Wilford Hall Medical Center Lackland AFB, Texas, and Pittsburgh, Pennsylvania
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Operative Mortality Rates of Acoustic Neuroma Surgery: A National Cancer Database Analysis. Otol Neurotol 2017; 38:751-753. [DOI: 10.1097/mao.0000000000001362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Acoustic Neuroma Mimicking Orofacial Pain: A Unique Case Report. Case Rep Otolaryngol 2017; 2016:1947616. [PMID: 28053796 PMCID: PMC5174163 DOI: 10.1155/2016/1947616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/19/2016] [Accepted: 11/14/2016] [Indexed: 11/17/2022] Open
Abstract
Acoustic neuroma (AN), also called vestibular schwannoma, is a tumor composed of Schwann cells that most frequently involve the vestibular division of the VII cranial nerve. The most common symptoms include orofacial pain, facial paralysis, trigeminal neuralgia, tinnitus, hearing loss, and imbalance that result from compression of cranial nerves V–IX. Symptoms of acoustic neuromas can mimic and present as temporomandibular disorder. Therefore, a thorough medical and dental history, radiographic evaluation, and properly conducted diagnostic testing are essential in differentiating odontogenic pain from pain that is nonodontogenic in nature. This article reports a rare case of a young pregnant female patient diagnosed with an acoustic neuroma located in the cerebellopontine angle that was originally treated for musculoskeletal temporomandibular joint disorder.
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Liu W, Ni M, Jia W, Zhou D, Zhang Q, Jiang Y, Jia G. How to Address Small- and Medium-Sized Acoustic Neuromas with Hearing: A Systematic Review and Decision Analysis. World Neurosurg 2015; 84:283-291.e1. [DOI: 10.1016/j.wneu.2015.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 03/09/2015] [Accepted: 03/09/2015] [Indexed: 11/25/2022]
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Mehrian-Shai R, Freedman S, Shams S, Doherty J, Slattery W, Hsu NYH, Reichardt JKV, Andalibi A, Toren A. Schwannomas exhibit distinct size-dependent gene-expression patterns. Future Oncol 2015; 11:1751-8. [PMID: 26075443 DOI: 10.2217/fon.15.72] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Neurofibromatosis type 2 (NF2)-associated vestibular schwannomas have variable size at presentation which presents a unique challenge in NF2 patient management. Therefore, we investigated the molecular signature characteristic of the differences in size for improved individualized precise therapy. MATERIALS & METHODS RNA expression analysis was performed on 15 small and 27 large NF2-associated vestibular schwannoma tumors using a microarray analyzing over 47,000 transcripts. RESULTS A signature of 11 genes was found to be correlated with NF2 tumor size. CONCLUSION We have identified the genetic hallmark that differentiates large NF2-associated tumors from smaller tumors. This is the first time that these genes have been shown to be the hallmark for NF2 tumor size.
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Affiliation(s)
- Ruty Mehrian-Shai
- Department of Pediatric Hemato-Oncology, The Cancer Research Center, Sheba Medical Center, 2 Sheba Road, Ramat Gan, 52621, Israel
| | - Shany Freedman
- Department of Pediatric Hemato-Oncology, The Cancer Research Center, Sheba Medical Center, 2 Sheba Road, Ramat Gan, 52621, Israel
| | - Soheil Shams
- BioDiscovery, 5155 W Rosecrans Ave # 310, Hawthorne, CA 90250, USA
| | - Joni Doherty
- Head & Neck Surgery, University of California, San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - William Slattery
- Department of Clinical Studies, House Ear Institute, 2100 W 3rd St #500, Los Angeles, CA 90057, USA
| | | | - Juergen K V Reichardt
- Division of Tropical Health & Medicine, James Cook University, Townsville, QLD, Australia
| | - Ali Andalibi
- Stony Brook University, Stony Brook, NY 11794, USA
| | - Amos Toren
- Department of Pediatric Hemato-Oncology, The Cancer Research Center, Sheba Medical Center, 2 Sheba Road, Ramat Gan, 52621, Israel
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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: 0.8] [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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Ansari SF, Terry C, Cohen-Gadol AA. Surgery for vestibular schwannomas: a systematic review of complications by approach. Neurosurg Focus 2012; 33:E14. [DOI: 10.3171/2012.6.focus12163] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Various studies report outcomes of vestibular schwannoma (VS) surgery, but few studies have compared outcomes across the various approaches. The authors conducted a systematic review of the available data on VS surgery, comparing the different approaches and their associated complications.
Methods
MEDLINE searches were conducted to collect studies that reported information on patients undergoing VS surgery. The authors set inclusion criteria for such studies, including the availability of follow-up data for at least 3 months, inclusion of preoperative and postoperative audiometric data, intraoperative monitoring, and reporting of results using established and standardized metrics. Data were collected on hearing loss, facial nerve dysfunction, persistent postoperative headache, CSF leak, operative mortality, residual tumor, tumor recurrence, cranial nerve (CN) dysfunction involving nerves other than CN VII or VIII, and other neurological complications. The authors reviewed data from 35 studies pertaining to 5064 patients who had undergone VS surgery.
Results
The analyses for hearing loss and facial nerve dysfunction were stratified into the following tumor categories: intracanalicular (IC), size (extrameatal diameter) < 1.5 cm, size 1.5–3.0 cm, and size > 3.0 cm. The middle cranial fossa approach was found to be superior to the retrosigmoid approach for hearing preservation in patients with tumors < 1.5 cm (hearing loss in 43.6% vs 64.3%, p < 0.001). All other size categories showed no significant difference between middle cranial fossa and retrosigmoid approaches with respect to hearing loss. The retrosigmoid approach was associated with significantly less facial nerve dysfunction in patients with IC tumors than the middle cranial fossa method was; however, neither differed significantly from the translabyrinthine corridor (4%, 16.7%, 0%, respectively, p < 0.001). The middle cranial fossa approach differed significantly from the translabyrinthine approach for patients with tumors < 1.5 cm, whereas neither differed from the retrosigmoid approach (3.3%, 11.5%, and 7.2%, respectively, p = 0.001). The retrosigmoid approach involved less facial nerve dysfunction than the middle cranial fossa or translabyrinthine approaches for tumors 1.5–3.0 cm (6.1%, 17.3%, and 15.8%, respectively; p < 0.001). The retrosigmoid approach was also superior to the translabyrinthine approach for tumors > 3.0 cm (30.2% vs 42.5%, respectively, p < 0.001). Postoperative headache was significantly more likely after the retrosigmoid approach than after the translabyrinthine approach, but neither differed significantly from the middle cranial fossa approach (17.3%, 0%, and 8%, respectively; p < 0.001). The incidence of CSF leak was significantly greater after the retrosigmoid approach than after either the middle cranial fossa or translabyrinthine approaches (10.3%, 5.3%, 7.1%; p = 0.001). The incidences of residual tumor, mortality, major non-CN complications, residual tumor, tumor recurrence, and dysfunction of other cranial nerves were not significantly different across the approaches.
Conclusions
The middle cranial fossa approach seems safest for hearing preservation in patients with smaller tumors. Based on the data, the retrosigmoid approach seems to be the most versatile corridor for facial nerve preservation for most tumor sizes, but it is associated with a higher risk of postoperative pain and CSF fistula. The translabyrinthine approach is associated with complete hearing loss but may be useful for patients with large tumors and poor preoperative hearing.
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Affiliation(s)
- Shaheryar F. Ansari
- 1Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery; and
| | - Colin Terry
- 2Methodist Research Institute, Indiana University Health, Indianapolis, Indiana
| | - Aaron A. Cohen-Gadol
- 1Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery; and
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Abstract
OBJECTIVE To compare hearing preservation after surgery for intracanalicular vestibular schwannomas with or without fundal extension. STUDY DESIGN Retrospective chart review. PATIENTS Patients with intracanalicular tumors (≤ 10-m maximal dimension) undergoing retrosigmoid craniotomy between 2001 and 2010. INTERVENTION Preoperative and postoperative audiograms, preoperative magnetic resonance imaging, and operative reports were reviewed. MAIN OUTCOME MEASURES Preoperative and postoperative hearing (American Academy of Otolaryngology-Head and Neck Surgery classification). RESULTS Complete data for 53 patients (27 female and 24 male subjects, sex was not recorded for 2 patients) meeting selection criteria was available. Fundal involvement was identified in 39 (73.6%) of the 53 patients. The remaining 14 patients did not have tumor with fundal extension (26.4%). Average tumor size for patients with fundal extension (+FE) was 6.9 ± 2.2 mm and without fundal extension (-FE) was 8.2 ± 1.9 mm (p = 0.05, Student's t test). Average preoperative speech discrimination score for the entire study was 90.5 ± 11.8 (n = 53). After retrosigmoid approach for tumor resection, 79% of patients (42/53) had preserved hearing defined as American Academy of Otolaryngology-Head and Neck Surgery class A, B, or C. Average postoperative speech discrimination score for these patients was 89.3 ± 12.1, and average postoperative pure-tone average was 35.9 ± 9.1%. Eighty-five percent (33/39) of +FE patients had preserved hearing (class A, B, or C). In contrast, 64% (9/14) of -FE patients had hearing preserved (class A, B, or C; Fisher's exact test, p = 0.034). CONCLUSION Hearing preservation rate after retrosigmoid craniotomy for intracanalicular vestibular schwannomas may be superior for tumors with fundal extension compared with tumors that do not extend to the fundus.
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McClelland S, Guo H, Okuyemi KS. Morbidity and mortality following acoustic neuroma excision in the United States: analysis of racial disparities during a decade in the radiosurgery era. Neuro Oncol 2011; 13:1252-9. [PMID: 21856684 PMCID: PMC3199160 DOI: 10.1093/neuonc/nor118] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 06/24/2011] [Indexed: 11/13/2022] Open
Abstract
Acoustic neuromas present a challenging problem, with the major treatment modalities involving operative excision, stereotactic radiosurgery, observation, and fractionated stereotactic radiotherapy. The morbidity/mortality following excision may differ by patient race. To address this concern, the morbidity of acoustic neuroma excision was assessed on a nationwide level. The Nationwide Inpatient Sample from 1994-2003 was used for analysis. Only patients admitted for acoustic neuroma excision were included (International Classification of Diseases, 9th edition, Clinical Modification = 225.1; primary procedure code = 04.01). Analysis was adjusted for several variables, including patient age, race, sex, primary payer for care, income in ZIP code of residence, surgeon caseload, and hospital caseload. Multivariate analyses revealed that postoperative mortality following acoustic neuroma excision was 0.5%, with adverse discharge disposition of 6.1%. The odds ratio for mortality in African Americans compared with Caucasians was 8.82 (95% confidence interval = 1.85-41.9, P = .006). Patients with high-caseload surgeons (more than 2 excisions/year), private insurance, and younger age had decreased mortality, better discharge disposition, and lower overall morbidity (P < .04). Neither hospital caseload nor median income were predictive factors. African Americans were 9 times more likely to die following surgery than Caucasians over a decade-long analysis. Given the relatively benign natural history of acoustic neuroma and the alarmingly increased mortality rate following surgical excision among older patients, African Americans, and patients receiving care from low-caseload surgeons, acoustic neuromas in these patient populations may be best managed by a more minimally invasive modality such as observation, fractionated stereotactic radiotherapy, or stereotactic radiosurgery.
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Affiliation(s)
- Shearwood McClelland
- Department of Neurological Surgery, Boston University School of Medicine, 88 East Newton Street, Robinson 4, Boston, MA 02118, USA.
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Grauvogel J, Scheiwe C, Kaminsky J. Use of piezosurgery for internal auditory canal drilling in acoustic neuroma surgery. Acta Neurochir (Wien) 2011; 153:1941-7; discussion 1947. [PMID: 21792697 DOI: 10.1007/s00701-011-1092-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 07/14/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Piezosurgery is based on microvibrations generated by the piezoelectrical effect and has a selective bone-cutting ability with preservation of soft tissue. This study examined the applicability of Piezosurgery compared to rotating drills (RD) for internal auditory canal (IAC) opening in acoustic neuroma (AN) surgery. MATERIALS AND METHODS Piezosurgery was used in eight patients for IAC drilling in AN surgery. After exposition of the IAC and tumor, the posterior wall of the IAC was drilled using Piezosurgery instead of RD. Piezosurgery was evaluated with respect to practicability, safety, preciseness of bone cutting, preservation of cranial nerves, influences on neurophysiological monitoring, and facial nerve and hearing outcome. RESULTS Piezosurgery was successfully used for selective bone cutting, while cranial nerves were structurally and functionally preserved, which could be measured by means of neuromonitoring. Piezosurgery guaranteed a safe and precise cut by removing bone layer by layer in a shaping way. Compared to RD, limited influence on neurophysiological monitoring attributable to Piezosurgery was noted, allowing for continuous neuromonitoring. No disadvantage due to microvibrations was noticed concerning hearing function. The angled tip showed better handling in right-sided than in left-sided tumors in the hands of a right-handed surgeon. The short, thick handpiece may be improved for more convenient handling. CONCLUSION Piezosurgery is a safe tool for selective bone cutting for opening of the IAC with preservation of facial nerve and hearing function in AN surgery. Piezosurgery has the potential to replace RD for this indication because of its safe and precise bone-cutting properties.
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Affiliation(s)
- Juergen Grauvogel
- Department of Neurosurgery, Albert Ludwig University of Freiburg, Breisacherstr. 64, 79106, Freiburg, Germany.
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Wuertenberger CJ, Rosahl SK. Vertigo and tinnitus caused by vascular compression of the vestibulocochlear nerve, not intracanalicular vestibular schwannoma: review and case presentation. Skull Base 2011; 19:417-24. [PMID: 20436843 DOI: 10.1055/s-0029-1220209] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Microvascular compression of the vestibulocochlear nerve is known to cause disabling tinnitus and vertigo. A review of the literature shows that the compression is usually located in the cerebellopontine angle, and that it is usually caused by an artery. The authors add the case of a 46-year-old man with venous compression of the vestibulocochlear nerve inside the internal auditory canal (IAC). The patient presented with a 2-year history of recurrent attacks of disabling vertigo and intermittent high-frequency tinnitus on the right side. Magnetic resonance images showed a small, contrast-enhancing lesion in the fundus of the right IAC, which was suspicious for vestibular schwannoma. During surgical exploration, a large venous loop was found extending into the IAC and compressing the vestibulocochlear nerve. The vessel was mobilized and rerouted out of the IAC. The presumed vestibular schwannoma at the cochlear fossa was left in situ. The patient's symptoms resolved immediately after surgery. Hearing was unchanged postoperatively. On follow-up, there has been no growth of the contrast-enhancing lesion in the IAC for 3 years so far.Disabling vertigo can also be caused by venous microvascular compression of the vestibulocochlear nerve inside the IAC and may be treated successfully by microvascular decompression. A sensitive, conservative approach to lesions in the fundus may be justified in the presence of an additional, more prominent pathology that causes compression of the vestibulocochlear nerve.
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Lee SH, Willcox TO, Buchheit WA. Current results of the surgical management of acoustic neuroma. Skull Base 2011; 12:189-95. [PMID: 17167678 PMCID: PMC1656907 DOI: 10.1055/s-2002-35750-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A retrospective analysis of 162 consecutive cases in 160 patients who underwent microsurgical resection of vestibular schwannomas between October 1995 and June 2001 was undertaken to compare the results with those of other treatment modalities. Patient hospital records, operative video pictures, neuroimaging studies, audiograms, and follow-up data were reviewed. The mean follow-up period was 24 months.There were 34 small (<1.5 cm), 92 medium (1.5-3 cm), and 36 (>3 cm) large tumors. Six were recurrent tumors. Gross total resection was accomplished in all 34 small tumors and 92 medium tumors but only in 50% of the large tumors. Among the 126 small and medium tumors, the facial nerve was saved anatomically in 124 patients. On long-term follow up, facial function was preserved in 94.4% of all patients. Anatomically, the cochlear nerve was preserved in 55.9% of the small and 20.7% of the medium tumors. Function was preserved (Gardner-Robertson class 1 and 2) in 25% of the small and in 19.4% of the medium tumors. Cerebrospinal leakage was present in 10.5%, meningitis in 9.9%, wound infection in 3.7%, and hematoma or contusion in 2.5%. Only one patient died (mortality rate 0.6%). Our data reflect that surgical removal should be the standard management for acoustic tumors, particularly for large and medium tumors, and can be accomplished with acceptable complication rates.
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Sughrue ME, Yang I, Rutkowski MJ, Aranda D, Parsa AT. Preservation of facial nerve function after resection of vestibular schwannoma. Br J Neurosurg 2011; 24:666-71. [PMID: 21070151 DOI: 10.3109/02688697.2010.520761] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Most data regarding facial nerve function in patients undergoing microsurgical resection of vestibular schwannomas predominantly include series performed at a single institution. In an effort to minimise individual surgeon or institutional bias, we performed an analysis of the published literature on facial nerve outcomes following microsurgical resection of vestibular schwannomas. The objective of this study was to provide a comprehensive assessment of reported outcomes for facial nerve preservation after VS surgery. MATERIALS AND METHODS We identified a total of 296 studies involving over 25,000 patients that included outcome data for facial nerve function of vestibular schwannoma patients treated surgically. Data regarding surgical approach, tumour size, patient age, and use of intra-operative monitoring were extracted and correlated with facial nerve function after surgery. Patients with preoperative facial nerve dysfunction (House-Brackmann score 3 or higher) were excluded and 'facial nerve preservation' was defined as grade I or II House-Brackmann function at last follow-up visit. RESULTS A total of 79 articles reporting on 11,873 patients met our inclusion criteria contributing to our analysis. Patients treated with the middle cranial fossa approach had a trend towards higher overall facial nerve preservation rate (85%), compared to the translabyrinthine approach (81%, p = 0.07) , and did statistically better than the retrosigmoid approach (78%, p < 0.0001). Patients with an average tumour size <20 mm had significantly improved facial nerve preservation rates, compared to larger tumours (90% vs. 67%, p < 0.0001). Patients under 65 years of age had a lower facial nerve preservation rate (71% vs. 84%, p < 0.001). Finally, the use of intra-operative monitoring improved the facial nerve preservation rate (76% vs. 71%, p < 0.001). CONCLUSION Factors that appear to be associated with facial nerve preservation after microsurgical resection of a vestibular schwannoma include tumour size <20 mm, use of the middle fossa approach and use of neuromonitoring during surgery. These data provide a summary assessment of the published literature regarding facial nerve preservation after microsurgical resection of vestibular schwannoma.
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Affiliation(s)
- Michael E Sughrue
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave., San Francisco, CA 94143, USA
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Foroughi M, Pitkäniemi J, Nannapaneni R, Nath F. Excision of vestibular schwannomas – is there a learning curve and how best to demonstrate it? Br J Neurosurg 2010; 24:547-54. [DOI: 10.3109/02688697.2010.503815] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mapping clinical outcomes expectations to treatment decisions: an application to vestibular schwannoma management. Otol Neurotol 2010; 31:284-93. [PMID: 20101164 DOI: 10.1097/mao.0b013e3181cc06cb] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Complex medical decision making obligates tradeoff assessments among treatment outcomes expectations, but an accessible tool to perform the necessary analysis is conspicuously absent. We aimed to demonstrate methodology and feasibility of adapting conjoint analysis for mapping clinical outcomes expectations to treatment decisions in vestibular schwannoma (VS) management. STUDY DESIGN Prospective. SETTINGS Tertiary medical center and US-based otologists/neurotologists. SUBJECTS Treatment preference profiles among VS stakeholders-61 younger and 74 older prospective patients, 61 observation patients, and 60 surgeons-were assessed for the synthetic VS case scenario of a 10-mm tumor in association with useful hearing and normal facial function. MAIN OUTCOME MEASURE Treatment attribute utility. METHODS Conjoint analysis attribute levels were set in accordance to the results of a meta-analysis. Forty-five case series were disaggregated to formulate microsurgery facial nerve and hearing preservation outcomes expectations models. Attribute utilities were computed and mapped to the realistic treatment choices of translabyrinthine craniotomy, middle fossa craniotomy, and gamma knife radiosurgery. RESULTS Among the treatment attributes of likelihoods of causing deafness, temporary facial weakness for 2 months, and incurable cancer within 20 years, and recovery time, permanent deafness was less important to tumor surgeons, and temporary facial weakness was more important to tumor surgeons and observation patients (Wilcoxon rank-sum, p < 0.001). Inverse mapping of preference profiles to realistic treatment choices showed all study cohorts were inclined to choose gamma knife radiosurgery. CONCLUSION Mapping clinical outcomes expectations to treatment decisions for a synthetic clinical scenario revealed inhomogeneous drivers of choice selection among study cohorts. Medical decision engines that analyze personal preferences of outcomes expectations for VS and many other diseases may be developed to promote shared decision making among health care stakeholders and transparency in the informed consent process.
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Wanibuchi M, Fukushima T, McElveen JT, Friedman AH. Hearing preservation in surgery for large vestibular schwannomas. J Neurosurg 2009; 111:845-54. [PMID: 19344218 DOI: 10.3171/2008.12.jns08620] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hearing preservation remains a challenging problem in vestibular schwannoma (VS) surgery. The ability to preserve hearing in patients with large tumors is subject to particular difficulty. In this study, the authors focus on hearing preservation in patients harboring large VSs. METHODS A total of 344 consecutive patients underwent surgical removal of VSs over the past 9 years. Of these 344 cases, 195 VSs were > 20 mm in maximum cisternal diameter. Of the 195 cases, hearing preservation surgery was attempted for 54 patients who had a Class A, B, C, or D preoperative hearing level; that is, a pure tone average <or= 60 dB and speech discrimination score >or= 50% according to the Sanna/Fukushima classification. The tumors were classified as moderately large (21-30 mm based on the largest extrameatal diameter), large (31-40 mm), and giant (>or= 41 mm) according to the international criteria. The authors categorized patients with Class A, B, C, D, or E hearing (pure tone average <or= 80 dB and speech discrimination score >or= 40%) as having preserved hearing postoperatively. RESULTS Forty-one tumors (75.9%) were totally removed and 13 (24.1%) had near-total removal. Of the 54 patients, 29 maintained their hearing postoperatively; the overall hearing preservation rate was 53.7%. Analysis based on the preoperative hearing level showed that hearing was preserved in 14 (77.8%) of 18 cases for Class A; in 8 (47.1%) of 17 cases for Class B; in 4 (57.1%) of 7 cases for Class C; and in 3 (25.0%) of 12 cases for Class D. In addition, according to the analysis based on the tumor size, 20 (52.6%) of 38 patients with moderately large tumors retained their hearing, as did 5 (50.0%) of 10 patients with large tumors and 4 (66.7%) of 6 patients with giant tumors. Complications included 2 cases of bacterial meningitis that were cured by intravenous injection of antibiotics, 3 cases of subcutaneous CSF leakage that resolved without any surgical repair, and 1 case of temporary abducent nerve palsy. There were no deaths in this series. CONCLUSIONS The results indicate that successful hearing preservation surgery in large VSs is possible with meticulous technique and attention to adhesions between the tumor and the cochlear nerves.
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Hearing preservation and facial nerve function after microsurgery for intracanalicular vestibular schwannomas: comparison of middle fossa and retrosigmoid approaches. Acta Neurochir (Wien) 2009; 151:935-44; discussion 944-5. [PMID: 19415173 DOI: 10.1007/s00701-009-0344-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 01/19/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Therapeutic options for vestibular schwannomas (VS) include microsurgery, stereotactic radiosurgery and conservative management. Early treatment of intracanalicular vestibular schwannomas (IVS) may be advisable because their spontaneous course will show hearing loss in most cases. Advanced microsurgical techniques and continuous intraoperative monitoring of cranial nerves may allow hearing preservation (HP) without facial nerve damage. However, there are still controversies about the definition of hearing preservation, and the best surgical approach that should be used. METHODS In this study, we reviewed the main data from the recent literature on IVS surgery and compared hearing, facial function and complication rates after the retrosigmoid (RS) and middle fossa (MF) approaches, respectively. RESULTS The results showed that the average HP rate after IVS surgery ranged from 58% (RS) to 62% (MF). HP varied widely depending on the audiometric criteria that were used for definition of serviceable hearing. There was a trend to show that the MF approach offered a better quality of postoperative hearing (not statistically significant), whereas the RS approach offered a better facial nerve preservation and fewer complications (not statistically significant). CONCLUSIONS We believe that the timing of treatment in the course of the disease and selection between radiosurgical versus microsurgical procedure are key issues in the management of IVS. Preservation of hearing and good facial nerve function in surgery for VS is a reasonable goal for many patients with intracanalicular tumors and serviceable hearing. Once open surgery has been decided, selection of the approach mainly depends on individual anatomical considerations and experience of the surgeon.
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Vandervelde C, Connor S. Diagnostic yield of MRI for audiovestibular dysfunction using contemporary referral criteria: correlation with presenting symptoms and impact on clinical management. Clin Radiol 2009; 64:156-63. [DOI: 10.1016/j.crad.2008.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 07/21/2008] [Accepted: 08/01/2008] [Indexed: 10/21/2022]
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Iwai Y, Yamanaka K, Kubo T, Aiba T. Gamma knife radiosurgery for intracanalicular acoustic neuromas. J Clin Neurosci 2008; 15:993-7. [PMID: 18617402 DOI: 10.1016/j.jocn.2007.09.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 09/17/2007] [Accepted: 09/20/2007] [Indexed: 11/27/2022]
Abstract
In the present study we reviewed our long-term experience with radiosurgery for intracanalicular acoustic neuromas. The study involved 25 patients with unilateral intracanalicular acoustic neuromas. The treatment volume was 0.07 to 0.8 cm(3) (median: 0.27 cm(3)). The marginal radiation dose used for treatment was 12 Gy for all patients. The follow-up period ranged from 36 to 132 months (mean: 89 months). The actuarial rate of tumour growth control at 5 and 10 years after radiosurgery was 96%. Hearing preservation was achieved in 16 patients (64%) and improvement (>20 dB relative to presurgical values) was noted in one patient (4%). No patients experienced post-radiosurgery facial palsy or other cranial nerve deficits. Based on our study and long-term follow-up, radiosurgery can produce high rates of tumour growth control and hearing preservation for intracanalicular acoustic neuromas, and is an alternative to surgical resection given its low level of invasiveness. When determining treatment for intracanalicular acoustic neuromas, the condition's benign natural course and the likelihood of hearing preservation must be taken into account.
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Affiliation(s)
- Yoshiyasu Iwai
- Department of Neurosurgery, Osaka City General Hospital, 2-13-22, Miyakojima-Hondori, Miyakojima, Osaka 534-0021, Japan.
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Asthagiri AR, Helm GA, Sheehan JP. Current concepts in management of meningiomas and schwannomas. Neurol Clin 2008; 25:1209-30, xi. [PMID: 17964032 DOI: 10.1016/j.ncl.2007.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Meningiomas and schwannomas are the two most common extra-axial intracranial tumors in adults. Since their initial discovery, these often-benign lesions have shared a parallel metamorphosis in their management. The goal of this article is to provide a review of the current literature surrounding the mainstays of therapy for these lesions.
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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: 1.0] [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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The treatment of a large acoustic tumor with fractionated stereotactic radiotherapy. J Robot Surg 2007; 1:227-30. [PMID: 25484968 PMCID: PMC4247447 DOI: 10.1007/s11701-007-0036-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2007] [Accepted: 07/27/2007] [Indexed: 11/23/2022]
Abstract
The treatment of acoustic neuromas (AN) usually involves surgical excision or stereotactic radiosurgery. However, for large AN (mean diameter > 3 cm), stereotactic radiosurgery is rarely used, leaving patients with limited noninvasive treatment options. Recently, the use of fractionated stereotactic radiotherapy (FSRT) has been effective in treating small to medium-sized AN. We present a patient with a large AN treated with FSRT. The patient was a 43-year-old man presenting with imbalance, tinnitus, vertigo, and right-sided hearing decline associated with vomiting and hydrocephalus. Magnetic resonance (MR) imaging revealed a large, 3.8-cm, right cerebellopontine-angle tumor compressing the fourth ventricle. Following right frontal ventriculoperitoneal shunt placement, the patient underwent FSRT for treatment of the tumor. Using the Radionics X-Knife 4.0 3D treatment planning system, a total of 54 Gy was delivered in 1.8-Gy daily fractions with the prescription isodose line of 90%. Treatments were delivered using a dedicated Varian 6/100 linear accelerator, and head immobilization was achieved with the Gill-Thomas-Cosman relocatable stereotactic frame. The patient was subsequently evaluated with serial contrast-enhanced MR imaging. Following FSRT, local control (defined as the absence of tumor progression) was achieved, and treatment was well tolerated. There was no hearing-related, trigeminal, or facial-nerve morbidity following FSRT at 63-month follow-up. Treating a patient with a large AN with FSRT resulted in local tumor control, with no trigeminal nerve, facial nerve, or hearing-related morbidity. These results support FSRT as a potential noninvasive treatment modality for AN some would consider too large for single-fraction stereotactic radiosurgery (SRS).
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McClelland S, Gerbi BJ, Higgins PD, Orner JB, Hall WA. Safety and efficacy of fractionated stereotactic radiotherapy for acoustic neuromas. J Neurooncol 2007; 86:191-4. [PMID: 17622486 DOI: 10.1007/s11060-007-9456-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2007] [Accepted: 06/25/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The treatment of acoustic neuromas (AN) has historically involved surgical excision or stereotactic radiosurgery, with a relatively limited number of reports available describing the use of fractionated stereotactic radiotherapy (FSRT). To enhance the existing knowledge regarding the safety and efficacy of this treatment modality, we describe our initial experience with FSRT for AN. METHODS From 1999-2005, 20 patients (12F, 8M) with AN underwent FSRT. All patients were treated using the Radionics X-Knife 4.0 3D planning system, receiving 54 Gy in 1.8 Gy daily fractions with a prescription isodose line of 90%. Treatments were delivered stereotactically using a dedicated Varian 6/100 linear accelerator, with immobilization achieved via the Gill-Thomas-Cosman relocatable frame. Median tumor size (maximum diameter) was 2.1 cm (range, 1.1-3.4 cm). Median patient age was 49.5 years, with median follow-up of 22 months (range, 1-66 months). All patients were evaluated with pre- and post-gadolinium-enhanced magnetic resonance imaging. RESULTS Following FSRT, local tumor control was achieved in every patient, with the treatment well-tolerated by all patients. No patient experienced acute complications or facial nerve weakness. Two patients experienced permanent trigeminal nerve morbidity manifesting as facial numbness. All nine patients with preserved hearing before treatment had hearing preservation at last follow-up, although four of these patients experienced hearing decline following FSRT. CONCLUSION In our series of 20 patients with AN, all had local tumor control following FSRT, with minimal morbidity. These results support the growing body of literature demonstrating the safety and efficacy of FSRT in achieving local control for AN, further validating the viability of FSRT as a treatment modality for this patient population.
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Affiliation(s)
- Shearwood McClelland
- Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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Piccirillo E, Jain Y, Augurio A, Sanna M. Preoperative predictive factors for hearing preservation in vestibular schwannoma surgery. Ann Otol Rhinol Laryngol 2006; 115:41-6. [PMID: 16466099 DOI: 10.1177/000348940611500107] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We performed a retrospective chart review to evaluate the various predictive factors for postoperative hearing preservation in the surgical management of vestibular schwannoma. METHODS Of 792 patients operated on for vestibular schwannoma between April 1987 and July 2002, 107 were candidates for hearing preservation surgery. These patients were divided into group 1 (hearing preserved) and group 2 (hearing not preserved), and both of these groups were evaluated for age, sex, pure tone average, sound discrimination score, tumor size, and auditory brain stem response parameters. A corrected chi2 test and a corrected t-test were used for statistical analysis. Multiple regression analysis was further done to evaluate independent predictive factors, either alone or in combination. The results were evaluated by use of the modified Sanna classification and the guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). RESULTS Preoperative pure tone average and tumor size were the 2 predictive factors in our study. A Pearson correlation test showed that there was no multicollinearity between the factors. On multiple regression analysis by backward elimination of nonsignificant factors, we found that tumor size is an independent predictive factor for postoperative hearing. According to the modified Sanna classification, postoperative hearing was preserved in 11.2% of patients (equivalent to class A of AAO-HNS guidelines). CONCLUSIONS In our series, preoperative pure tone average and tumor size were found to be predictors of postoperative hearing levels.
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Bozorg Grayeli A, Kalamarides M, Ferrary E, Bouccara D, El Gharem H, Rey A, Sterkers O. Conservative management versus surgery for small vestibular schwannomas. Acta Otolaryngol 2005; 125:1063-8. [PMID: 16298787 DOI: 10.1080/00016480510038013] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A high rate of deterioration in hearing function and the loss of patient compliance during conservative management should be taken into account when considering hearing preservation strategies for patients with vestibular schwannoma (VS). To compare conservative management with surgery for solitary small VS. Among 693 patients followed up for VS between 1991 and 2002, 114 (16%) intracanalicular VSs (stage 1) and 302 (44%) VSs measuring <15 mm in the cerebellopontine angle (stage 2) were included in this study. Initially, surgery was performed in 305 (73%) cases (50 stage 1, 255 stage 2) and 111 (27%) were managed conservatively (64 stage 1, 54 stage 2) by means of annual MRI scans and audiometry. Conservative management was chosen in patients aged >60 years and in those who refused surgery. In this subgroup, the mean follow-up period was 33 months (range 6-111 months). In the conservative management group, 47% of VSs showed significant growth, 47% were stable and 6% showed regression. Seventeen patients (15%) were operated on secondarily for tumour growth and 1 (1%) was irradiated for tumour growth and because surgery was contraindicated. Deterioration of hearing function by > or =1 class was observed in 56% of cases, 34% of patients were initially in hearing class D and only 10% showed stable hearing function. Of the conservative management group, 17% were lost during follow-up. After surgery, grade 1 or 2 facial function was obtained in 86% of cases. Following hearing preservation attempts (n=137), 54% of patients were in hearing classes A-C.
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Affiliation(s)
- Alexis Bozorg Grayeli
- Department of Otolaryngology--Head and Neck Surgery, Hôpital Beaujon, Clichy, France.
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Ciric I, Zhao JC, Rosenblatt S, Wiet R, O'Shaughnessy B. Suboccipital Retrosigmoid Approach for Removal of Vestibular Schwannomas: Facial Nerve Function and Hearing Preservation. Neurosurgery 2005; 56:560-70; discussion 560-70. [PMID: 15730582 DOI: 10.1227/01.neu.0000154059.34990.b8] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2004] [Accepted: 12/10/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
IN THIS REPORT, we discuss the pertinent bony, arachnoid, and neurovascular anatomy of vestibular schwannomas that has an impact on the surgical technique for removal of these tumors, with the goal of facial nerve and hearing preservation. The surgical technique is described in detail starting with anesthesia, positioning, and neurophysiological monitoring and continuing with the exposure, technical nuances of tumor removal, hemostasis, and closure. Positive prognostic factors for hearing preservation are also highlighted.
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Affiliation(s)
- Ivan Ciric
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, and Evanston Northwestern Healthcare, Evanston, Illinois, USA
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Mohr G, Sade B, Dufour JJ, Rappaport JM. Preservation of hearing in patients undergoing microsurgery for vestibular schwannoma: degree of meatal filling. J Neurosurg 2005; 102:1-5. [PMID: 15658088 DOI: 10.3171/jns.2005.102.1.0001] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Preservation of hearing has become a standard goal in selected patients undergoing surgery for a vestibular schwannoma (VS). This study was aimed at analyzing the role played by filling of the internal auditory canal (IAC) as well as those played by preoperative hearing quality, and tumor size in the postoperative preservation of serviceable hearing (SH).
Methods. Three hundred eighty-six patients with VS were treated. Hearing preservation was attempted in 128 cases (33.2%) by using intraoperative monitoring and following a retrosigmoid approach. The maximal extrameatal size of the tumor, its extension within the IAC, and pre- and postoperative hearing quality, according to the Gardner—Robertson classification, were evaluated. Preservation of SH was achieved in 24.2% of the 128 patients. With respect to tumor size, SH was preserved in 39% of 77 patients harboring a tumor 15 mm wide or smaller and in 2% of 51 patients with lesions 16 mm wide or larger (p < 0.001). With regard to filling of the IAC, among 63 patients harboring a tumor 15 mm or smaller, in whom magnetic resonance images were available, SH was preserved in 52.8% of 36 patients with partial filling and in 25.9% of 27 patients with complete filling (p = 0.032). Concerning preoperative hearing quality, in the patients with tumors 15 mm or smaller, SH was preserved in 46.5% of 43 patients with Gardner—Robertson Class I hearing and 29.4% of 34 patients with Class II hearing (p = 0.126). Both tumor size and the extent of IAC filling proved statistically significant in a multivariable analysis (p < 0.001 and p = 0.026, respectively).
Conclusions. Incomplete filling of the IAC and a tumor size of 15 mm or smaller are independent favorable factors in SH preservation. Excellent preoperative hearing appears to have a positive impact but does not have statistical significance. Intraoperative monitoring is useful in guiding the dissection; however, the surgeon's knowledge of topographical landmarks and meticulous surgical technique remain the essential factors of success.
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Affiliation(s)
- Gérard Mohr
- Department of Otolaryngology, Sir Mortimer B Davis-Jewish General Hospital, McGill University, Québec, Canada.
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Abstract
OBJECTIVES Cerebellopontine angle tumors are uncommon lesions that can potentially be cured by microsurgical removal. The primary objective of the surgical treatment differs between vestibular schwannoma and meningioma. This feature may be influenced by the site of tumor origin and displacement of neurovascular structures as well as by their different tumor biology. METHODS A review of the current literature was conducted. RESULTS AND CONCLUSIONS Relevant cranial nerves and vascular involvement as well as anatomical location with respect to the cerebellopontine angle are discussed for vestibular schwannoma and meningioma. The main factors influencing the surgical outcome are outlined with special reference to facial and cochlear nerve function and cerebrospinal fluid leakage. The retrosigmoid approach offers a comparable success rate for hearing conservation and probably a superior outcome in terms of facial nerve function when compared with the middle fossa approach. The intrameatal limitations of the retrosigmoid approach can be excluded by the intraoperative assistance of an endoscope. The advantages of endoscope-assisted surgery may include improved visualization of relevant structures, more complete tumor removal, and a lowered risk of cerebrospinal fluid leakage.
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Affiliation(s)
- B Schaller
- Klinik für Schädel-, Kiefer- und Gesichtschirurgie, Universitätsspital, Inselspital, Bern.
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Moriyama T, Fukushima T, Asaoka K, Roche PH, Barrs DM, McElveen JT. Hearing preservation in acoustic neuroma surgery: importance of adhesion between the cochlear nerve and the tumor. J Neurosurg 2002; 97:337-40. [PMID: 12186461 DOI: 10.3171/jns.2002.97.2.0337] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT To evaluate the possible prognostic factors for hearing preservation, the authors retrospectively reviewed the results of 30 consecutive acoustic neuroma operations in which hearing preservation was attempted, in a total series of 63 acoustic neuromas. METHODS Intracanalicular tumors or those that extended less than 3 mm outside the porus acusticus (10 cases) were resected via the middle fossa approach. The retrosigmoid approach was used for tumors exceeding the limits for the middle fossa approach (20 cases). Overall, hearing was preserved (pure tone average < or = 50 dB and speech discrimination score > or = 50%) in 21 patients (70%). There were 11 patients with severe adhesion between the cochlear nerve and tumor capsule, and 19 without. Hearing was preserved postoperatively in only two (18.2%) of 11 patients with severe adhesion, whereas all 19 without severe adhesion had hearing preservation. CONCLUSIONS The presence or absence of severe adhesion in the interface between the cochlear nerve and the tumor might be the most significant prognostic factor for hearing preservation postsurgery.
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Affiliation(s)
- Takuzou Moriyama
- Carolina Neuroscience Institute and Carolina Ear Research Institute, Raleigh, North Carolina 27609, USA.
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Lapsiwala SB, Pyle GM, Kaemmerle AW, Sasse FJ, Badie B. Correlation between auditory function and internal auditory canal pressure in patients with vestibular schwannomas. J Neurosurg 2002; 96:872-6. [PMID: 12005394 DOI: 10.3171/jns.2002.96.5.0872] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hearing loss is the most common presenting symptom in patients who harbor a vestibular schwannoma (VS). Although mechanical injury to the cochlear nerve and vascular compromise of the auditory apparatus have been proposed, the exact mechanism of this hearing loss remains unclear. To test whether pressure on the cochlear nerve from tumor growth in the internal auditory canal (IAC) is responsible for this clinical finding, the authors prospectively evaluated intracanalicular pressure (ICaP) in patients with VS and correlated this with preoperative brainstem response. METHODS In 40 consecutive patients undergoing a retrosigmoid-transmeatal approach for tumor excision, ICaP was measured by inserting a pressure microsensor into the IAC before any tumor manipulation. Pressure recordings were correlated with tumor size and preoperative auditory evoked potential (AEP) recordings. The ICaP, which varied widely among patients (range 0-45 mm Hg), was significantly elevated in most patients (median 16 mm Hg). Although these pressure measurements directly correlated to the extension of tumor into the IAC (p = 0.001), they did not correlate to total tumor size (p = 0.2). In 20 patients in whom baseline AEP recordings were available, the ICaP directly correlated to wave V latency (p = 0.0001), suggesting that pressure from tumor growth in the IAC may be responsible for hearing loss in these patients. CONCLUSIONS Tumor growth into the IAC results in elevation of ICaP and may play a role in hearing loss in patients with VS. The relevance of these findings to the surgical treatment of these tumors is discussed.
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MESH Headings
- Adult
- Aged
- Cohort Studies
- Ear, Inner/pathology
- Ear, Inner/physiopathology
- Evoked Potentials, Auditory, Brain Stem
- Female
- Hearing Loss, Central/diagnosis
- Hearing Loss, Central/etiology
- Hearing Loss, Central/physiopathology
- Humans
- Male
- Manometry/methods
- Middle Aged
- Neural Conduction
- Neuroma, Acoustic/complications
- Neuroma, Acoustic/physiopathology
- Neuroma, Acoustic/surgery
- Pressure
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Affiliation(s)
- Samir B Lapsiwala
- Department of Neurological Surgery, University of Wisconsin School of Medicine, Madison 53792, USA
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Badie B, Pyle GM, Nguyen PH, Hadar EJ. Elevation of internal auditory canal pressure by vestibular schwannomas. Otol Neurotol 2001; 22:696-700. [PMID: 11568682 DOI: 10.1097/00129492-200109000-00024] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The exact mechanism of hearing loss, the most common presenting symptom in patients with vestibular schwannomas, remains unclear. To test whether increased pressure in the internal auditory canal from tumor growth is responsible for this clinical finding, the intracanalicular pressure in patients harboring these tumors was measured. STUDY DESIGN Prospective study. SETTING Tertiary referral hospital. PATIENTS Fifteen consecutive patients undergoing a retrosigmoid approach for resection of vestibular schwannomas were included in the study. INTERVENTION The intracanalicular pressure in every patient was measured by introducing a pressure microsensor into the internal auditory canal. The pressure readings, which were performed before tumor resection, were then correlated with tumor size and respective preoperative hearing status. RESULTS Placement of the pressure monitor into the internal auditory canal revealed a biphasic waveform in every patient. Whereas the mean intracanalicular pressure was 20 mm Hg, there was significant variability among patients (range, 1-45 mm Hg). The intracanalicular pressure directly correlated with the amount of tumor in the internal auditory canal (r > 0.63, p < 0.012) but not with the total tumor size (r </= 0.40, p > 0.075). Furthermore, eight patients with class A preoperative hearing (American Academy of Otolaryngology-Head and Neck Surgery classification) had lower intracanalicular pressures than did five patients with class B hearing (16 +/- 5 vs. 28 +/- 4). Although this observation suggested an inverse correlation between the intracanalicular pressure and hearing function, the difference between the two groups was not statistically significant (p = 0.14). CONCLUSION Pressure on the cochlear nerve as a result of tumor growth in the internal auditory canal may be responsible for hearing loss in patients with vestibular schwannomas. Modification of surgical techniques to address the elevated intracanalicular pressure may be beneficial in improving hearing preservation in these patients.
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Affiliation(s)
- B Badie
- Department of Neurologic Surgery, University of Wisconsin School of Medicine, Madison, Wisconsin 53792-3232, USA
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Kanzaki J, Inoue Y, Ogawa K. The learning curve in post-operative hearing results in vestibular schwannoma surgery. Auris Nasus Larynx 2001; 28:209-13. [PMID: 11489362 DOI: 10.1016/s0385-8146(01)00086-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE We chronologically investigated whether the hearing preservation (HP) rate improved or not in vestibular schwannoma (VS) surgery. SUBJECTS AND METHODS HP surgery has been attempted in 127 VS patients with pre-operative class A and B hearing from 1976 to 1999. The HP rate was chronologically compared with hearing level and tumor size. RESULTS The preservation rate of pre-operative class A hearing which was preserved post-operatively as class A has recently been increasing especially in patients with an intracanalicular (IC) tumor. This rate was improved to 67% from 1995, although this was 33% from 1989 to 1994. However, the preservation rate of pre-operative class B in patients with an IC tumor and that of pre-operative class A hearing which was preserved as class A in patients with a larger tumor extending into the posterior fossa, have not improved over the last 10 years. CONCLUSION These results indicate that the improvement of the HP rate is mainly due to the increased number of patients with an IC tumor with class A pre-operative hearing. In patients with a tumor of 4-20 mm in size, especially in those showing pre-operative class B hearing, there may be histologically some limitations such as gliosis in the cochlear nerve in the preservation rate of good quality (class A or B) of hearing.
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MESH Headings
- Adolescent
- Adult
- Audiometry, Evoked Response/methods
- Audiometry, Pure-Tone/methods
- Ear Neoplasms/complications
- Ear Neoplasms/surgery
- Ear, Inner/diagnostic imaging
- Ear, Inner/pathology
- Ear, Inner/surgery
- Evoked Potentials, Auditory, Brain Stem/physiology
- Female
- Hearing Disorders/diagnosis
- Hearing Disorders/etiology
- Humans
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Monitoring, Intraoperative
- Neoplasm Invasiveness
- Neoplasm Staging
- Neuroma, Acoustic/complications
- Neuroma, Acoustic/diagnosis
- Neuroma, Acoustic/surgery
- Otologic Surgical Procedures/methods
- Postoperative Care
- Preoperative Care
- Severity of Illness Index
- Time Factors
- Tomography, X-Ray Computed
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Affiliation(s)
- J Kanzaki
- Department of Otolaryngology, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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Dubrulle F, Ernst O, Vincent C, Vaneecloo FM, Lejeune JP, Lemaitre L. Cochlear fossa enhancement at MR evaluation of vestibular Schwannoma: correlation with success at hearing-preservation surgery. Radiology 2000; 215:458-62. [PMID: 10796925 DOI: 10.1148/radiology.215.2.r00ma20458] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To describe a sign in magnetic resonance (MR) imaging that could reflect the state of the cochlear nerve before hearing-preservation surgery in small vestibular schwannomas. MATERIALS AND METHODS Thirty-one patients with serviceable hearing underwent 1.5-T MR imaging before hearing-preservation surgery. The presence of cochlear fossa enhancement on T1-weighted spin-echo images obtained after the administration of contrast material was compared with the results of hearing-preservation surgery. RESULTS Cochlear fossa enhancement was present in 13 patients, and all of them had total hearing loss after surgery. There was no cochlear fossa enhancement in 18 patients; 15 maintained serviceable hearing after surgery, and three had postoperative hearing loss with no serviceable hearing (sensitivity, 81%; specificity, 100%). CONCLUSION Cochlear fossa enhancement on T1-weighted spin-echo images seems to be a reliable sign for analyzing the state of the cochlear nerve. The absence of cochlear fossa enhancement could become an additional criterion for selecting the surgical approach in vestibular schwannomas.
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Affiliation(s)
- F Dubrulle
- Department of Radiology, Hopital Huriez-Sud, Centre Hospitalier Universitaire de Lille, 1 Place de Verdun, 59037 Lille, France.
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Kumon Y, Sakaki S, Kohno K, Ohta S, Nakagawa K, Ohue S, Murakami S, Yanagihara N. Selection of surgical approaches for small acoustic neurinomas. SURGICAL NEUROLOGY 2000; 53:52-9; discussion 59-60. [PMID: 10697233 DOI: 10.1016/s0090-3019(99)00199-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the results of surgery for small acoustic neurinomas at our institute via the middle cranial fossa and retrosigmoid approaches, and to determine the indications for each approach. METHODS Fifty-three patients with unilateral tumors less than 2 cm in diameter were studied. Surgery was performed via the middle cranial fossa approach in 36 tumors and via the retrosigmoid approach in 17 tumors. RESULTS The hearing preservation rate was 68% (36/53) in all patients, 93% (14/15) in patients with intracanalicular tumors, 79% (15/19) in patients with tumors less than 1 cm in diameter, and 43% (7/19) in patients with tumors between 1 and 2 cm in diameter. The facial nerve function was excellent or good in 80% (42/53), 74% (11/15), 84% (16/19), and 78% (15/19), respectively. Among the 19 patients with tumors between 1 and 2 cm in diameter, the frequencies of hearing preservation and of excellent or good facial nerve function (47% and 87%, respectively) in the 15 patients approached via the retrosigmoid approach were higher than those (0% and 50%, respectively) in the four patients approached via the middle cranial fossa approach. CONCLUSIONS We conclude that tumors smaller than 2 cm should be removed because preservation of hearing as well as facial nerve function may be possible in almost all of these patients. Tumors larger than 1 cm should be surgically treated through the retrosigmoid approach.
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Affiliation(s)
- Y Kumon
- Department of Neurological Surgery, Ehime University School of Medicine, Onsen-gun, Japan
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Moffat DA, da Cruz MJ, Baguley DM, Beynon GJ, Hardy DG. Hearing preservation in solitary vestibular schwannoma surgery using the retrosigmoid approach. Otolaryngol Head Neck Surg 1999; 121:781-8. [PMID: 10580238 DOI: 10.1053/hn.1999.v121.a91263] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The results of 50 cases of vestibular schwannoma surgery with hearing preservation performed by the retrosigmoid approach at Addenbrooke's Hospital, Cambridge, during a 10-year period are presented. The hearing-preservation rate, using audiometric criteria set by others as "serviceable hearing" (Wade PJ, House W. Otolaryngol Head Neck Surg 1984;92:1184-93; Silverstein H, et al. Otolaryngol Head Neck Surg 1986;95:285-91; Cohen NL, et al. Am J Otol 1993;14:423-33) was 8% (4 of 50 cases). When the more stringent selection criteria of near-normal hearing and reporting criteria of socially useful hearing preservation (pure-tone average < 30 dB/speech discrimination score > 70%) is used, the hearing-preservation rate is 4.8% (1 of 21 cases). The only preoperative factor that may predict a favorable hearing-preservation outcome is normal auditory brain stem response morphology (Fisher's exact 2-tailed test, P < 0.001). The number of suitable candidates for hearing-preservation surgery are few. Reasonable indications for attempted vestibular schwannoma surgery with hearing preservation are discussed.
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Affiliation(s)
- D A Moffat
- Department of Otoneurosurgical and Skull Base Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
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Niranjan A, Lunsford LD, Flickinger JC, Maitz A, Kondziolka D. Dose reduction improves hearing preservation rates after intracanalicular acoustic tumor radiosurgery. Neurosurgery 1999; 45:753-62; discussion 762-5. [PMID: 10515468 DOI: 10.1097/00006123-199910000-00003] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To assess the potential for long-term serviceable hearing preservation in intracanalicular acoustic tumor patients who underwent stereotactic radiosurgery. METHODS Between August 1987 and December 1997, 29 patients with intracanalicular acoustic tumors underwent stereotactic radiosurgery at our center using the Leksell gamma knife (Elekta Instruments, Inc., Atlanta, GA). Fifteen assessable patients had serviceable preradiosurgery hearing (pure tone average, < or = 50 dB; speech discrimination score, > or = 50%). We retrospectively analyzed our hearing results and compared hearing preservation in patients who received a minimal tumor dose of 14 Gy or less versus those who received more than 14 Gy to the tumor margin. RESULTS No perioperative patient morbidity or mortality was observed. Serviceable hearing was preserved in 11 (73%) of 15 assessable patients (actuarial rate, 65%). Long-term follow-up demonstrated serviceable hearing preservation in 10 (100%) of 10 patients who received marginal tumor doses of 14 Gy or less but in only one of five patients who received more than 14 Gy. Preradiosurgery Gardner-Robertson class was preserved in 49%, and testable hearing was present in 68% of patients who had any testable hearing at presentation. Five patients demonstrated improvement in hearing (three had serviceable and two had nonserviceable hearing before radiosurgery). No patient developed a facial or trigeminal neuropathy. Seven of 13 patients with preoperative tinnitus continued to experience tinnitus in follow-up. Episodic vertigo continued in 3 of the 11 patients who presented with vertigo. CONCLUSION Gamma knife radiosurgery (using conformal dose planning, small-beam geometry, and < or = 14 Gy to the margin) prevents tumor growth and achieves excellent hearing preservation rates.
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Affiliation(s)
- A Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania 15213, USA
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Rowed DW. Hearing preservation in vestibular schwannoma surgery. J Neurosurg 1999; 90:374-6. [PMID: 9950515 DOI: 10.3171/jns.1999.90.2.0374a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Colletti V, Fiorino FG. Retrosigmoid-transmeatal en bloc removal of small to medium-sized acoustic neuromas. Otolaryngol Head Neck Surg 1999; 120:122-8. [PMID: 9914562 DOI: 10.1016/s0194-5998(99)70382-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
One hundred three subjects with acoustic neuroma (AN) underwent surgery--involving a retrosigmoid-transmeatal approach--between January 1990 and December 1995. All the intracanalar tumors (n = 18) and 70 of the intra- and extracanalar neuromas with an extracanalar neuroma size less than 25 mm--a total of 88 patients--constituted the final study population. The first 48 patients were operated on with the use of classic procedures described in the literature, characterized by limited exposure of the internal auditory canal and removal of the tumor after debulking. Surgery in the next 40 subjects was conducted according to the technique of en bloc removal of the tumor. The main features of this technique are continuous direct recording of cochlear and facial-nerve action potentials, wide opening of the internal auditory canal with lateral extension to the fundus, and removal of the tumor following the capsular lining without debulking. Statistical analysis of the results of the en bloc removal, compared with the previously used debulking technique, showed improvement in postoperative outcome for both auditory and facial-nerve function.
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Affiliation(s)
- V Colletti
- Ear-Nose-Throat Department, University of Verona, Italy
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Irving RM, Jackler RK, Pitts LH. Hearing preservation in patients undergoing vestibular schwannoma surgery: comparison of middle fossa and retrosigmoid approaches. J Neurosurg 1998; 88:840-5. [PMID: 9576251 DOI: 10.3171/jns.1998.88.5.0840] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT The goal of this retrospective study was to evaluate hearing preservation after surgery for vestibular schwannoma in which the middle fossa (MF) or retrosigmoid (RS) approaches were used. Hearing preservation in vestibular schwannoma surgery can be achieved by using either the MR or RS approach. Comparative outcome data between these approaches are lacking, and, as a result, selection has generally been determined by the surgeon's preference. METHODS The authors have compared removal of small vestibular schwannomas via MF and RS approaches with regard to hearing preservation and facial nerve function. The study group was composed of consecutively treated patients with vestibular schwannoma, 48 of whom underwent operation via an MF approach and 50 of whom underwent the same number of RS operations. Tumors were divided into size-matched groups. Hearing results were recorded according to the American Academy of Otolaryngology-Head and Neck Surgery criteria, and facial nerve outcome was recorded as the House-Brackmann grade. Overall, 26 (52%) of the patients treated via the MF approach achieved a Class B or better hearing result compared with seven (14%) of the RS group. Some hearing was preserved in 32 (64%) of the patients in the MF group and in 17 (34%) of the RS group. The results obtained by using the MF approach were superior for intracanalicular tumors (p=0.009, t-test), and for tumors with a cerebellopontine angle (CPA) component measuring 0.1 to 1 cm (p=0.006, t-test). For tumors in the CPA that were 1.1 to 2 cm in size, our data were inconclusive because of the small sample size. Facial weakness was seen more frequently after MF surgery in the early postoperative period, but results were equal at 1 year. CONCLUSIONS The results of this study have demonstrated a more favorable hearing outcome for patients with intracanalicular tumors and tumors extending up to 1 cm into the CPA that were removed via the MF when compared with the RS approach.
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Affiliation(s)
- R M Irving
- Department of Otolaryngology, University of California at San Francisco, 94117, USA
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