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Nair S, Baldawa SS, Gopalakrishnan CV, Menon G, Vikas V, Sudhir JB. Surgical outcome in cystic vestibular schwannomas. Asian J Neurosurg 2016; 11:219-25. [PMID: 27366248 PMCID: PMC4849290 DOI: 10.4103/1793-5482.145359] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Cystic vestibular schwannomas (VS) form a rare subgroup that differs from the solid variant clinically, radiologically, and histopathologically. These tumors also vary in their surgical outcome and carry a different risk of post-operative complications. We analyzed our series of 64 patients with cystic VS and discuss the technical difficulties related to total excision of these tumors and focus on complication avoidance. Materials and Methods: A retrospective review of cystic VS surgically managed over a span of 11 years. The case records were evaluated to record the clinical symptoms and signs, imaging findings, surgical procedure, complications, and follow-up data. Post-operative facial nerve palsy was analyzed with respect to tumor size and tumor type. Results: Progressive hearing impairment was the most common initial symptom (76.6%). Atypical initial symptoms were present in 15 patients (23.4%). Preoperatively, 78% patients had good facial nerve function (HB grade 1, 2) and 22% had intermediate (HB grade 3, 4) to poor (HB grade 5 and 6) function. Mean tumor size was 4.1 cm. Complete tumor removal was achieved in 53 patients (83%). The facial nerve was anatomically intact but thinned out after tumor excision in 38 patients (59.4%). Ninety percent patients had either intermediate or poor facial nerve function at follow-up. Poor facial nerve outcome was associated with giant tumors and peripherally located, thin-walled cystic tumors. Conclusion: Resection of cystic VS is complicated by peritumoral adhesions of the capsule to the nerve. Extensive manipulation of the nerve in order to dissect the tumor–nerve barrier results in worse facial nerve outcome. The outcome is worse in peripherally located, thin-walled cystic VS as compared to centrally located, thick-walled cystic tumors. Subtotal excision may be justified, especially in tumors with dense adhesion of the cyst wall to the facial nerve in order to preserve nerve integrity.
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Affiliation(s)
- Suresh Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sachin S Baldawa
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | | | - Girish Menon
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Vazhayil Vikas
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Jayanand B Sudhir
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Mendelsohn D, Westerberg BD, Dong C, Akagami R. Clinical and Radiographic Factors Predicting Hearing Preservation Rates in Large Vestibular Schwannomas. J Neurol Surg B Skull Base 2015; 77:193-8. [PMID: 27175312 DOI: 10.1055/s-0035-1564054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 07/22/2015] [Indexed: 01/06/2023] Open
Abstract
Objectives Postoperative hearing preservation rates for patients with large vestibular schwannomas range from 0 to 43%. The clinical and radiographic factors predicting hearing preservation in smaller vestibular schwannomas are well described; however, their importance in larger tumors is unclear. We investigated factors predicting hearing preservation in large vestibular schwannomas. Design Retrospective review. Setting Quaternary care academic center. Participants A total of 85 patients with unilateral vestibular schwannomas > 3 cm underwent retrosigmoid resections. Main Outcomes Measures Preoperative and postoperative serviceable hearing rates. Methods Clinical and radiographic data including preoperative and postoperative audiograms, preoperative symptoms, magnetic resonance imaging features, and postoperative facial weakness were analyzed. Results Hearing was preserved in 41% of patients (17 of 42) with preoperative serviceable hearing. Hypertension and diabetes increased the likelihood of preoperative hearing loss. Preoperative tinnitus predicted a lower likelihood of hearing preservation. No radiographic factors predicted hearing preservation; however, larger tumor size, smaller fourth ventricular width, and the presence of a cerebrospinal fluid cleft surrounding the tumor predicted postoperative facial weakness. Conclusion Systemic comorbidities may influence hearing loss preoperatively in patients with large vestibular schwannomas. The absence of tinnitus may reflect hearing reserve and propensity for hearing preservation. Preoperative radiographic features did not predict hearing preservation despite some associations with postoperative facial weakness.
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Affiliation(s)
- Daniel Mendelsohn
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian D Westerberg
- Division of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles Dong
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ryojo Akagami
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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Zhang Z, Wang Z, Huang Q, Yang J, Wu H. Removal of large or giant sporadic vestibular schwannomas via translabyrinthine approach: a report of 115 cases. ORL J Otorhinolaryngol Relat Spec 2012; 74:271-7. [PMID: 23147594 DOI: 10.1159/000343791] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 08/31/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The present study was a retrospective analysis of surgical outcomes of large or giant vestibular schwannomas (VSs) via a translabyrinthine approach (TLA). METHODS One hundred and fifteen sporadic large or giant VSs (maximal diameter in the cerebellopontine angle ≥31 mm) were operated via TLA between January 2001 and December 2010. We divided patients into two groups: cystic VS (CVS) and solid VS (SVS) group. The surgical outcomes were recorded and compared. RESULTS Total, near total, and subtotal tumor removal rate was 89.6, 7.8, and 2.6%, respectively. The near total removal rate in CVS was higher than that in SVS (16.7 vs. 3.8%). The anatomical facial nerve (FN) integrity was preserved in 101 patients (87.8%). More FNs in CVS were interrupted (22.2%). There were 29.6, 56.5, and 13.9% of patients who had a short-term (1 month) FN function of House-Brackmann grade I or II, III or IV, and V or VI, respectively. The CVS had worse FN function than the SVS group. The mortality rate was 0.9%. Cerebrospinal fluid leakage occurred in 8 patients (7.0%). Four (3.5%) patients had recurrence. CONCLUSIONS Cyst formation is a crucial factor for surgical outcome of VS. With near total or subtotal tumor removal, worse functional outcomes in large or giant CVSs should be foreseen.
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Affiliation(s)
- Zhihua Zhang
- Department of Otolaryngology, Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Di Maio S, Malebranche AD, Westerberg B, Akagami R. Hearing preservation after microsurgical resection of large vestibular schwannomas. Neurosurgery 2011; 68:632-40; discussion 640. [PMID: 21164374 DOI: 10.1227/neu.0b013e31820777b1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hearing, which is often still clinically useful at presentation even with larger tumors, is a major determinant of quality of life in vestibular schwannoma (VS) patients. OBJECTIVE To present the hearing preservation rate after surgery in patients with large (>or=3 cm) VSs and identify clinical or radiologic predictors of hearing preservation. METHODS From April 2003 to March 2009, 192 patients underwent resection of a VS, including 46 large (>or=3 cm) tumors, of whom 28 had serviceable hearing preoperatively. Six of 28 patients (21.4%) had preserved hearing postoperatively. RESULTS Mean tumor diameter was 3.6 cm (range, 3.0-5.0 cm) and tumor volume was 17.2 mL (range, 6.9-45.2 mL). For patients with grade A Sanna-Fukushima hearing, the hearing preservation rate was 4 of 11 (36.4%). Complete resection was achieved in 6 of 6 cases with hearing preservation (41/47 for all patients). Six of 6 patients with preserved hearing had a cerebrospinal fluid cleft in the internal auditory canal (IAC) compared with 9 of 16 patients without preoperative hearing and 9 of 20 for patients with serviceable hearing that was lost postoperatively (P=.045). Six of 6 patients with preserved hearing had less than 35% of the tumor anterior to the longitudinal axis of the IAC compared with 13 of 20 in the serviceable hearing that was lost group (P=.036). CONCLUSION Our series demonstrates hearing preservation is possible for patients with large VSs and should be attempted in all patients with preoperative hearing. The quality of preoperative hearing, a cerebrospinal fluid cleft at the apex of the IAC, and a smaller proportion of tumor anterior to the IAC were positively associated with hearing preservation.
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Affiliation(s)
- Salvatore Di Maio
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vanvouver, British Columbia, Canada
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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: 50] [Impact Index Per Article: 3.3] [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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Mehrotra N, Behari S, Pal L, Banerji D, Sahu RN, Jain VK. Giant vestibular schwannomas: focusing on the differences between the solid and the cystic variants. Br J Neurosurg 2009; 22:550-6. [DOI: 10.1080/02688690802159031] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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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Yates PD, Jackler RK, Satar B, Pitts LH, Oghalai JS. Is it worthwhile to attempt hearing preservation in larger acoustic neuromas? Otol Neurotol 2003; 24:460-4. [PMID: 12806299 DOI: 10.1097/00129492-200305000-00017] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the hearing outcome in patients undergoing surgery via the retrosigmoid approach for acoustic neuromas with a substantial component in the cerebellopontine angle. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS The medical records of all patients undergoing acoustic neuroma removal via the retrosigmoid approach at a tertiary referral center were retrospectively reviewed. Sixty-four patients with both cerebellopontine angle component >or=15 mm and preoperative audiometry of class A or B (American Academy of Otolaryngology-Head and Neck Surgery) were identified. MAIN OUTCOME MEASURES Postoperative average pure tone threshold and word recognition scores, categorized according to the classification of the American Academy of Otolaryngology-Head and Neck Surgery, were used to assess hearing outcome. RESULTS Overall, only 6.3% (4 of 63) retained good hearing (class A or B) postoperatively. Hearing preservation rate in the smallest (15- to 19-mm) group was 17.6% (3 of 17), which was better than that for the larger groups. No successful hearing preservation was achieved in tumors with >or=25 mm cerebellopontine angle component (0 of 23). CONCLUSIONS Surgeon and patient alike would always choose a hearing preservation technique if there was no potential for increased morbidity in making the attempt. When compared with the non-hearing preservation translabyrinthine approach, the retrosigmoid approach had a higher incidence of persistent headache. In addition, efforts to conserve the auditory nerve prolong operating time, increase the incidence of postoperative vestibular dysfunction, and carry a slightly higher risk of tumor recurrence. Nevertheless, even though the probability of success is disappointingly small, when excellent hearing is present we favor offering the option of a hearing conservation attempt when the patient has been well informed of the pros and cons of the endeavor. Factors weighing against undertaking this effort include larger cerebellopontine angle component (>or=25 mm), deep involvement of the fundus, wide erosion of the porus, and marginal residual hearing.
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Affiliation(s)
- Philip D Yates
- Departments of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California 94143-0342, USA
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Hecht CS, Honrubia VF, Wiet RJ, Sims HS. Hearing preservation after acoustic neuroma resection with tumor size used as a clinical prognosticator. Laryngoscope 1997; 107:1122-6. [PMID: 9261019 DOI: 10.1097/00005537-199708000-00021] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Three hundred sixty-four patients referred to the Chicago Otology Group for acoustic tumor removal between 1981 and 1995 were reviewed in a retrospective fashion. Of this group, 60 patients were candidates for hearing preservation surgery and thus underwent one of two surgical approaches to remove the tumor and preserve hearing. Eighteen patients had tumor removal via the middle cranial fossa approach, and 42 patients had tumor removed via the retrosigmoid approach. Of the 42 patients who underwent retrosigmoid removal, 33% had hearing preserved overall. Of the 18 patients in the middle fossa group, 44% had hearing preserved overall. The average tumor size of patients with preserved hearing in the retrosigmoid group was 1.4 cm, and in the middle fossa group was 0.74 cm. Of significance was the fact that in both groups of patients with a tumor of 1.5 cm or less there was a 50% chance of hearing preservation. In the group of patients with tumors larger than 1.5 cm there was only a 16% chance of preserving hearing. We propose that these data can be used for better counseling of patients preoperatively as to the chances of hearing preservation and the type of approach appropriate for each case.
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Affiliation(s)
- C S Hecht
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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