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Palavani LB, Batista S, Andreão FF, de Barros Oliveira L, Silva GM, Koester S, Barbieri JF, Bertani R, da Silva VTG, Acioly M, Paiva WS, De Andrade EJ, Rassi MS. Retrosigmoid versus middle fossa approach for hearing and facial nerve preservation in vestibular schwannoma surgery: A systematic review and comparative meta-analysis. J Clin Neurosci 2024; 124:1-14. [PMID: 38615371 DOI: 10.1016/j.jocn.2024.04.007] [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: 12/02/2023] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Vestibular schwannomas (VS) are benign tumors arising from vestibular nerve's Schwann cells. Surgical resection via retrosigmoid (RS) or middle fossa (MF) is standard, but the optimal approach remains debated. This meta-analysis evaluated RS and MF approaches for VS management, emphasizing hearing preservation and Cranial nerve seven (CN VII) outcomes stratified by tumor size. METHODS Systematic searches across PubMed, Cochrane, Web of Science, and Embase identified relevant studies. Hearing and CN VII outcomes were gauged using the American Academy of Otolaryngology-Head and Neck Surgery, Gardner Robertson, and House-Brackmann scores. RESULTS Among 7228 patients, 56 % underwent RS and 44 % MF. For intracanalicular tumors, MF recorded 38 % hearing loss, compared to RS's 54 %. In small tumors (<1.5 cm), MF showed 41 % hearing loss, contrasting RS's lower 15 %. Medium-sized tumors (1.5 cm-2.9 cm) revealed 68 % hearing loss in MF and 55 % in RS. Large tumors (>3cm) were only reported in RS with a hearing loss rate of 62 %. CONCLUSION Conclusively, while MF may be preferable for intracanalicular tumors, RS demonstrated superior hearing preservation for small to medium-sized tumors. This research underlines the significance of stratified outcomes by tumor size, guiding surgical decisions and enhancing patient outcomes.
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Affiliation(s)
| | - Sávio Batista
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, RJ, Brazil
| | - Filipi Fim Andreão
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, RJ, Brazil.
| | | | - Guilherme Melo Silva
- Federal University of Rio de Janeiro, Faculty of Medicine, Rio de Janeiro, RJ, Brazil
| | - Stefan Koester
- Vanderbilt University School of Medicine, Nashville, TN, the United States of America
| | | | - Raphael Bertani
- Department of Neurosurgery, University of Sao Paulo Medical School, SP, Brazil
| | | | - Marcus Acioly
- Division of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Wellingson S Paiva
- Department of Neurosurgery, University of Sao Paulo Medical School, SP, Brazil
| | - Erion J De Andrade
- Division of Neurosurgery, Section of Skull Base Surgery, Emory University, Atlanta, GA, the United States of America
| | - Marcio S Rassi
- Division of Neurosurgery, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, SP, Brazil
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Schwam ZG, Cosetti MK, Wanna GB. Translabyrinthine Approach for Sporadic Vestibular Schwannoma: Patient Selection, Technical Pearls, and Patient Outcomes. Otolaryngol Clin North Am 2023; 56:483-493. [PMID: 36964096 DOI: 10.1016/j.otc.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
Herein we briefly describe the translabyrinthine approach to vestibular schwannoma resection as well as a focused literature review as to the best candidates, technical recommendations, and key outcomes with respect to other approaches.
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Affiliation(s)
- Zachary G Schwam
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029, USA.
| | - Maura K Cosetti
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029, USA
| | - George B Wanna
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029, USA
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Salem N, Galal A, Piras G, Sykopetrites V, Di Rubbo V, Talaat M, Sobhy O, Sanna M. Management of Vestibular Schwannoma with Normal Hearing. Audiol Neurootol 2023; 28:12-21. [PMID: 36228574 DOI: 10.1159/000524925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/17/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION This work aimed to study the management of vestibular schwannoma (VS) patients with normal hearing (NH). METHODS A retrospective study was undertaken in a Quaternary referral center for skull base pathologies. Among 4,000 VS patients 162 met our strict audiological criteria for NH. These patients were divided into 2 management groups, wait and scan (W&S) (45/162, 25%) and operated patients (123/162, 75%), and 6 patients were included in both groups. RESULTS Our management strategy achieved the goals for treatment of VS. First goal, all tumors were completely removed except for 2 intentional residuals. Second goal, facial nerve (FN) function preservation (House Brackmann I, II, and III) was 95.9%. Third goal, possible hearing preservation (HP) attempts occurred in (50/122) (40.9%) with an HP rate in 44% of the patients. Additionally, there were only 2 cases of postoperative complications with no CSF leakage. The prospect of HP in NH patients did not differ with respect to tumor size. However, patients with normal preoperative ABR seemed to have better chances of HP and good FN function and vice versa. HP rate was superior for the MCFA as opposed to the RS + RLA. W&S group demonstrated hearing stability in 88.9% of the patients and FN function stability of HB I in 100% of the patients. CONCLUSIONS Surgical resection is a reasonable and definitive management option for VS with NH. Nevertheless, choosing to manage cases with observation remains an appropriate management option for NH patients. ABR might be considered as an adjuvant tool indicating better prognosis for HP.
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Affiliation(s)
- Nervana Salem
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza/Rome, Italy.,Department of Otorhinolaryngology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Galal
- Department of Otorhinolaryngology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Gianluca Piras
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza/Rome, Italy
| | - Vittoria Sykopetrites
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza/Rome, Italy
| | - Vittoria Di Rubbo
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza/Rome, Italy
| | - Mohamed Talaat
- Department of Otorhinolaryngology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ossama Sobhy
- Department of Otorhinolaryngology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mario Sanna
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza/Rome, Italy
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Xian-Hao J, Zhen G, Ya-Sheng Y, Wei-Dong Z. Resection of vestibular schwannoma through middle cranial fossa approach with endoscope assistance. World Neurosurg 2021; 158:e225-e230. [PMID: 34728398 DOI: 10.1016/j.wneu.2021.10.166] [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: 08/30/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To report the outcome of resection of vestibular schwannomas (VSs) originated from inferior vestibular nerve which extended into the fundus of the internal auditory canal through middle cranial fossa (MCF) approach with endoscopic assistance. METHODS Seven patients with VSs who underwent resection through MCF approach with endoscope assistance and 12 patients with conventional microsurgery in our department were enrolled in this study. These patients' characteristics were acquired and the surgical outcomes as well as postoperative complications were evaluated. RESULTS In endoscope group, the VS was first removed by a conventional microscopic procedure, then endoscope was used to find and remove any residue lesions. In 3 of seven patients, residue tumor in the space below transverse crest was found and completely removed under endoscope. 6 of 7 patients (85.7%) had House-Brackmann grade I at the time of last follow-up in endoscope group compared with 10 of 12 patients (83.3%) in conventional microsurgery group. Serviceable hearing was successfully maintained in 2 of 3 patients (66.7%) in endoscope group compared with in 6 of 10 patients (60%) in conventional microsurgery group. Total resections were achieved in all the patients (100%) in endoscope group compared with in 9 of 12 patients (75%) in conventional microsurgery group. CONCLUSIONS The use of endoscope in VS resection through MCF approach could facilitate complete removal of the lesion, meanwhile minimize the risk of hearing loss and facial paralysis. Endoscope-assisted MCF approach is especially suitable for removing intracanalicular VS with lateral extension involving the space below transverse crest.
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Affiliation(s)
- Jia Xian-Hao
- Department of Otology and Skull Base Surgery, Eye & ENT Hospital, Fudan University, Shanghai, P. R. China; Shanghai Auditory Medical Center, Shanghai, P. R. China; NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, P. R. China
| | - Gao Zhen
- Department of Otology and Skull Base Surgery, Eye & ENT Hospital, Fudan University, Shanghai, P. R. China; Shanghai Auditory Medical Center, Shanghai, P. R. China; NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, P. R. China
| | - Yuan Ya-Sheng
- Department of Otology and Skull Base Surgery, Eye & ENT Hospital, Fudan University, Shanghai, P. R. China; Shanghai Auditory Medical Center, Shanghai, P. R. China; NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, P. R. China
| | - Zhao Wei-Dong
- Department of Otology and Skull Base Surgery, Eye & ENT Hospital, Fudan University, Shanghai, P. R. China; Shanghai Auditory Medical Center, Shanghai, P. R. China; NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, P. R. China.
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Hostettler IC, Jayashankar N, Bikis C, Wanderer S, Nevzati E, Karuppiah R, Waran V, Kalbermatten D, Mariani L, Marbacher S, Guzman R, Madduri S, Roethlisberger M. Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery-A Systematic Review and Future Perspectives. Front Bioeng Biotechnol 2021; 9:659413. [PMID: 34239858 PMCID: PMC8259738 DOI: 10.3389/fbioe.2021.659413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury. Methods: A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base. Results: One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent (n = 4) or non-rodent model (n = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones. Conclusion: The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.
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Affiliation(s)
- Isabel C Hostettler
- Department of Neurosurgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Narayan Jayashankar
- Department of Oto-Rhino-Laryngology, Nanavati Super Speciality Hospital, Mumbai, India
| | - Christos Bikis
- Department of Biomedical Engineering, Biomaterials Science Center, University of Basel, Allschwil, Switzerland.,Integrierte Psychiatrie Winterthur - Zürcher Unterland, Winterthur, Switzerland
| | - Stefan Wanderer
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Edin Nevzati
- Department of Neurosurgery, Kantonsspital Luzern, Lucerne, Switzerland
| | - Ravindran Karuppiah
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia
| | - Vicknes Waran
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia
| | - Daniel Kalbermatten
- Department of Plastic Surgery, University Hospital Geneva, Geneva, Switzerland.,Department of Surgery, Biomaterials and Neuro Tissue Bioengineering, University of Geneva, Geneva, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland.,Department of Biomedicine, Brain Ischemia and Regeneration, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
| | - Srinivas Madduri
- Department of Surgery, Biomaterials and Neuro Tissue Bioengineering, University of Geneva, Geneva, Switzerland.,Department of Biomedicine, Brain Ischemia and Regeneration, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Malaya Specialist Centre, University of Malaya, Kuala Lumpur, Malaysia.,Department of Neurosurgery, University Hospital of Basel, University of Basel, Basel, Switzerland.,Department of Biomedical Engineering, Center for Bioengineering and Regenerative Medicine, University of Basel, Basel, Switzerland
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Sacchetto L, Fabbris C, Romito S, Bianconi L, Marchioni D. Facial Nerve Neurophysiologic Assessment in Vestibular Schwannoma Removal with Transcanal Approach: A Pilot Clinical Study. World Neurosurg 2020; 146:e568-e574. [PMID: 33189920 DOI: 10.1016/j.wneu.2020.10.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The transcanal transpromontorial approach has been introduced to remove vestibular schwannomas. As with other techniques, preservation of the facial nerve (FN) is challenging. This pilot study described FN outcomes of patients preoperatively and postoperatively assessed with electromyography (EMG) and blink reflex (BR). METHODS Between September 2017 and December 2018, 10 patients (5 men; 5 women; mean age, 59.8 years; age range, 25-77 years) underwent removal of vestibular schwannoma via the transcanal transpromontorial approach. FN assessment using EMG/BR and clinical evaluation with the House-Brackmann (HB) grading scale was performed preoperatively and 2 months postoperatively. If facial impairment was present postoperatively, further analysis was performed 6 months after surgery. RESULTS All 10 patients had normal FN function on preoperative EMG/BR. After 2 months, 4 patients had normal FN function on EMG/BR, 4 patients showed a slight delay of FN responses, 1 patient had moderate dysfunction, and 1 patient had consistent damage. After 6 months, among the 6 patients with a pathologic neurophysiologic study, consistent EMG/BR improvement was shown, with complete recovery in 3 cases. At the last follow-up, 8 patients had HB grade I, 1 patient had HB grade II, and 1 patient had HB grade III in 1, showing progression toward healing in 9 of 10 cases. CONCLUSIONS The transcanal transpromontorial approach is an effective procedure for vestibular schwannoma removal. EMG/BR represents an objective evaluation method to verify FN recovery after surgery and confirms the low impact of this surgical procedure on the FN.
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Affiliation(s)
- Luca Sacchetto
- Otolaryngology, University Hospital of Verona, Verona, Italy
| | | | - Silvia Romito
- Neurology Departments, University Hospital of Verona, Verona, Italy
| | - Luca Bianconi
- Otolaryngology, University Hospital of Verona, Verona, Italy
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Ferris RL, Flamand Y, Holsinger FC, Weinstein GS, Quon H, Mehra R, Garcia JJ, Hinni ML, Gross ND, Sturgis EM, Duvvuri U, Méndez E, Ridge JA, Magnuson JS, Higgins KA, Patel MR, Smith RB, Karakla DW, Kupferman ME, Malone JP, Judson BL, Richmon J, Boyle JO, Bayon R, O'Malley BW, Ozer E, Thomas GR, Koch WM, Bell RB, Saba NF, Li S, Sigurdson ER, Burtness B. A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311. Oral Oncol 2020; 110:104797. [PMID: 32679405 DOI: 10.1016/j.oraloncology.2020.104797] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA. PATIENTS AND METHODS E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7th edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition, 10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required <10% rate of positive margins, low oropharyngeal bleeding rates, and accrual of at least one patient per 12 months. Otherwise surgeons were placed on hold and not permitted to accrue until re-credentialed using a new series of transoral resections. RESULTS 120 surgeons trained in transoral minimally invasive surgery applied for credentialing for E3311 and after peer-review, 87 (73%) were approved from 59 centers. During QA on E3311, positive final pathologic margins were reported in 19 (3.8%) patients. Grade III/IV and grade V oropharyngeal bleeding was reported in 29 (5.9%) and 1 (0.2%) of patients. CONCLUSIONS We provide proof of concept that a comprehensive credentialing process can support multicenter transoral head and neck surgical oncology trials, with low incidence of positive margins and *grade III/V oropharyngeal bleeding.
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Affiliation(s)
| | - Yael Flamand
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA, United States
| | | | | | - Harry Quon
- Johns Hopkins University, Baltimore, MD, United States
| | - Ranee Mehra
- University of Maryland, Baltimore, MD, United States
| | | | | | - Neil D Gross
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Erich M Sturgis
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | | | | | - John A Ridge
- Fox Chase Cancer Center, Philadelphia, PA, United States
| | | | | | - Mihir R Patel
- Winship Cancer Institute at Emory University, Atlanta, GA, United States
| | | | | | - Michael E Kupferman
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - James P Malone
- UPMC Pinnacle Cancer Center, Harrisburg, PA, United States
| | - Benjamin L Judson
- Yale School of Medicine and Yale Cancer Center, New Haven, CT, United States
| | - Jeremy Richmon
- Massachusetts Eye and Ear, Harvard University, Boston, MA, United States
| | - Jay O Boyle
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | | | - Enver Ozer
- The Ohio State University, Columbus, OH, United States
| | - Giovana R Thomas
- University of Miami Leonard Miller School of Medicine, Miami, FL, United States
| | - Wayne M Koch
- Johns Hopkins University, Baltimore, MD, United States
| | - R Bryan Bell
- Providence Cancer Institute, Portland, OR, United States
| | - Nabil F Saba
- Winship Cancer Institute at Emory University, Atlanta, GA, United States
| | - Shuli Li
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA, United States
| | | | - Barbara Burtness
- Yale School of Medicine and Yale Cancer Center, New Haven, CT, United States
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Master AN, Roberts DS, Wilkinson EP, Slattery WH, Lekovic GP. Endoscope-assisted middle fossa craniotomy for resection of inferior vestibular nerve schwannoma extending lateral to transverse crest. Neurosurg Focus 2019; 44:E7. [PMID: 29490550 DOI: 10.3171/2017.12.focus17663] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors describe their results using an endoscope as an adjunct to microsurgical resection of inferior vestibular schwannomas (VSs) with extension into the fundus of the internal auditory canal below the transverse crest. METHODS All patients who had undergone middle fossa craniotomy for VSs performed by the senior author between September 2014 and August 2016 were prospectively enrolled in accordance with IRB policies, and the charts of patients undergoing surgery for inferior vestibular nerve tumors, as determined either on preoperative imaging or as intraoperative findings, were retrospectively reviewed. Age prior to surgery, side of surgery, tumor size, preoperative and postoperative pure-tone average, and speech discrimination scores were recorded. The presence of early and late facial paralysis, nerve of tumor origin, and extent of resection were also recorded. RESULTS Six patients (all women; age range 40-65 years, mean age 57 years) met these criteria during the study period. Five of the 6 patients underwent gross-total resection; 1 patient underwent a near-total resection because of a small amount of tumor that adhered to the facial nerve. Gross-total resection was facilitated using the operative endoscope in 2 patients (33%) who were found to have additional tumor visible only through the endoscope. All patients had a House-Brackmann facial nerve grade of II or better in the immediate postoperative period. Serviceable hearing (American Academy of Otolaryngology-Head and Neck Surgery class A or B) was preserved in 3 of the 6 patients. CONCLUSIONS Endoscope-assisted middle fossa craniotomy for resection of inferior vestibular nerve schwannomas with extension beyond the transverse crest is safe, and hearing preservation is feasible.
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Lovato A, García ibañez E, García ibañez L, Filippis C. Tumor growth rate: A new prognostic indicator of hearing preservation in vestibular schwannoma surgery. Laryngoscope 2019; 129:2378-2383. [DOI: 10.1002/lary.27805] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 10/12/2018] [Accepted: 12/19/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Andrea Lovato
- Department of NeurosciencesUniversity of Padova, Audiology Unit at Treviso Hospital Treviso Italy
| | | | | | - Cosimo Filippis
- Department of NeurosciencesUniversity of Padova, Audiology Unit at Treviso Hospital Treviso Italy
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10
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Transcanal Transpromontorial Acoustic Neuroma Surgery: Results and Facial Nerve Outcomes. Otol Neurotol 2018; 39:242-249. [DOI: 10.1097/mao.0000000000001658] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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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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12
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13
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Agarwal V, Babu R, Grier J, Adogwa O, Back A, Friedman AH, Fukushima T, Adamson C. Cerebellopontine angle meningiomas: postoperative outcomes in a modern cohort. Neurosurg Focus 2014; 35:E10. [PMID: 24289118 DOI: 10.3171/2013.10.focus13367] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Tumors of the cerebellopontine angle (CPA) have always proven difficult for neurosurgeons to optimally manage. Studies investigating the natural history and treatment of vestibular schwannomas have dominated the literature in this regard. Distinguishing meningiomas from schwannomas in this location carries particular importance as each tumor type has certain prognostic and surgical considerations. In this study, the authors have characterized the outcomes of 34 patients surgically treated for CPA meningiomas and have investigated various factors that may affect postoperative neurological function. METHODS The medical records of patients with CPA meningiomas who underwent surgery from 2005 to 2013 at the Duke University Health System were reviewed. Various patient, clinical, and tumor data were gathered from the medical records including patient demographics, pre- and postoperative neurological examinations, duration of symptoms, procedural details, tumor pathology and size, and treatment characteristics. Differences in continuous variables were then analyzed using the Student t-test while categorical variables were evaluated using the chi-square test. RESULTS A total of 34 patients underwent surgical treatment for CPA meningiomas during the 8-year period. Jugular foramen invasion was seen in 17.6% of tumors, with nearly half (41.2%) extending into the internal acoustic canal. The most common presenting symptom was hearing loss (58.8%), followed by headache (52.9%) and facial numbness/pain (50.0%). The most common cranial nerve (CN) affected was CN X (11.8%), followed by CNs VI and VII (5.9%). Postoperatively, no patients experienced a decrease in hearing, with only 5.9% of patients experiencing facial nerve palsies. Patients with tumors larger than 3 cm had a significantly higher incidence of permanent CN deficits than those with smaller tumors (45.5% vs 5.9%, respectively; p = 0.011). Also, tumor extension into the jugular foramen was associated with the occurrence of lower CN deficits, none of which occurred in tumors without jugular foramen invasion. Internal acoustic canal tumor extension was not seen to be associated with postoperative complications or CN deficits. CONCLUSIONS Meningiomas of the CPA are challenging lesions to treat surgically. However, the risk of facial palsy and hearing loss is significantly lower when compared with vestibular schwannomas. Novel methods for preoperative differentiation are needed to appropriately counsel patients on surgical risks. Also, due to the significant potential for neurological deficits, further studies are needed to investigate the utility of radiotherapy for these lesions.
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Affiliation(s)
- Vijay Agarwal
- Division of Neurosurgery, Department of Surgery, and
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14
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Betka J, Zvěřina E, Balogová Z, Profant O, Skřivan J, Kraus J, Lisý J, Syka J, Chovanec M. Complications of microsurgery of vestibular schwannoma. BIOMED RESEARCH INTERNATIONAL 2014; 2014:315952. [PMID: 24987677 PMCID: PMC4058457 DOI: 10.1155/2014/315952] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/29/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to analyze complications of vestibular schwannoma (VS) microsurgery. MATERIAL AND METHODS A retrospective study was performed in 333 patients with unilateral vestibular schwannoma indicated for surgical treatment between January 1997 and December 2012. Postoperative complications were assessed immediately after VS surgery as well as during outpatient followup. RESULTS In all 333 patients microsurgical vestibular schwannoma (Koos grade 1: 12, grade 2: 34, grade 3: 62, and grade 4: 225) removal was performed. The main neurological complication was facial nerve dysfunction. The intermediate and poor function (HB III-VI) was observed in 124 cases (45%) immediately after surgery and in 104 cases (33%) on the last followup. We encountered disordered vestibular compensation in 13%, permanent trigeminal nerve dysfunction in 1%, and transient lower cranial nerves (IX-XI) deficit in 6%. Nonneurological complications included CSF leakage in 63% (lateral/medial variant: 99/1%), headache in 9%, and intracerebral hemorrhage in 5%. We did not encounter any case of meningitis. CONCLUSIONS Our study demonstrates that despite the benefits of advanced high-tech equipment, refined microsurgical instruments, and highly developed neuroimaging technologies, there are still various and significant complications associated with vestibular schwannomas microsurgery.
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Affiliation(s)
- Jan Betka
- Department of Otorhinolaryngology, Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Charles University in Prague, V Uvalu 84, Prague 5, 150 06 Prague, Czech Republic
| | - Eduard Zvěřina
- Department of Otorhinolaryngology, Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Charles University in Prague, V Uvalu 84, Prague 5, 150 06 Prague, Czech Republic
| | - Zuzana Balogová
- Department of Otorhinolaryngology, Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Charles University in Prague, V Uvalu 84, Prague 5, 150 06 Prague, Czech Republic
- Department of Auditory Neuroscience, Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Videnska 1083, Prague 4, 142 20 Prague, Czech Republic
| | - Oliver Profant
- Department of Otorhinolaryngology, Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Charles University in Prague, V Uvalu 84, Prague 5, 150 06 Prague, Czech Republic
- Department of Auditory Neuroscience, Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Videnska 1083, Prague 4, 142 20 Prague, Czech Republic
| | - Jiří Skřivan
- Department of Otorhinolaryngology, Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Charles University in Prague, V Uvalu 84, Prague 5, 150 06 Prague, Czech Republic
| | - Josef Kraus
- Department of Pediatric Neurology, 2nd Faculty of Medicine, Faculty Hospital Motol, Charles University in Prague, V Uvalu 84, Prague 5, 150 06 Prague, Czech Republic
| | - Jiří Lisý
- Department of Imaging Methods, 2nd Faculty of Medicine, Faculty Hospital Motol, Charles University, V Uvalu 84, Prague 5 150 06, Prague, Czech Republic
| | - Josef Syka
- Department of Auditory Neuroscience, Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Videnska 1083, Prague 4, 142 20 Prague, Czech Republic
| | - Martin Chovanec
- Department of Otorhinolaryngology, Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Charles University in Prague, V Uvalu 84, Prague 5, 150 06 Prague, Czech Republic
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Nonaka Y, Fukushima T, Watanabe K, Friedman AH, Sampson JH, Mcelveen JT, Cunningham CD, Zomorodi AR. Contemporary surgical management of vestibular schwannomas: analysis of complications and lessons learned over the past decade. Neurosurgery 2013; 72:ons103-15; discussion ons115. [PMID: 23037828 DOI: 10.1227/neu.0b013e3182752b05] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery. OBJECTIVE To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications. METHODS Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1-116 months; mean, 32.7 months). RESULTS Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were <20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors <20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%. CONCLUSION Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.
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Affiliation(s)
- Yoichi Nonaka
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
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Bernardo A, Evins AI, Visca A, Stieg PE. The intracranial facial nerve as seen through different surgical windows: an extensive anatomosurgical study. Neurosurgery 2013. [PMID: 23190637 DOI: 10.1227/neu.0b013e31827e5844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The facial nerve has a short intracranial course but crosses critical and frequently accessed surgical structures during cranial base surgery. When performing approaches to complex intracranial regions, it is essential to understand the nerve's conventional and topographic anatomy from different surgical perspectives as well as its relationship with surrounding structures. OBJECTIVE To describe the entire intracranial course of the facial nerve as observed via different neurosurgical approaches and to provide an analytical evaluation of the degree of nerve exposure achieved with each approach. METHODS Anterior petrosectomies (middle fossa, extended middle fossa), posterior petrosectomies (translabyrinthine, retrolabyrinthine, transcochlear), a retrosigmoid, a far lateral, and anterior transfacial (extended maxillectomy, mandibular swing) approaches were performed on 10 adult cadaveric heads (20 sides). The degree of facial nerve exposure achieved per segment for each approach was assessed and graded independently by 3 surgeons. RESULTS The anterior petrosal approaches offered good visualization of the nerve in the cerebellopontine angle and intracanalicular portion superiorly, whereas the posterior petrosectomies provided more direct visualization without the need for cerebellar retraction. The far lateral approach exposed part of the posterior and the entire inferior quadrants, whereas the retrosigmoid approach exposed parts of the superior and inferior quadrants and the entire posterior quadrant. Anterior and anteroinferior exposure of the facial nerve was achieved via the transfacial approaches. CONCLUSION The surgical route used must rely on the size, nature, and general location of the lesion, as well as on the capability of the particular approach to better expose the appropriate segment of the facial nerve.
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Affiliation(s)
- Antonio Bernardo
- Department of Neurological Surgery, Weill Cornell Medical College, Cornell University, New York, NY 10021, USA.
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Seo JH, Jun BC, Jeon EJ, Chang KH. Predictive factors influencing facial nerve outcomes in surgery for small-sized vestibular schwannoma. Acta Otolaryngol 2013; 133:722-7. [PMID: 23768057 DOI: 10.3109/00016489.2013.776178] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION The most important predictive factor of facial nerve outcome in surgery for small-sized vestibular schwannoma (VS) is the adhesion between the tumor and the facial nerve. OBJECTIVES To compare the facial nerve outcomes between middle cranial fossa (MCF) and translabyrinthine (TL) approaches, and to analyze the preoperative and intraoperative factors influencing facial nerve outcome after small VS surgery in our neurotologic department. METHODS A total of 29 patients were retrospectively analyzed, with 16 in the MCF group and 13 in the TL group. Facial function was serially evaluated according to the House-Brackmann classification at 7 days, 1 month, 3 months, 6 months, and 1 year postoperatively. The effects of variables such as the surgical approach, tumor size, nerve origin, extrameatal extension, intraoperative tumor adhesion to the facial nerve, and facial nerve displacement were determined. RESULTS Early and late facial nerve outcomes showed no significant correlation with surgical approach, tumor origin, tumor size, extrameatal extension, or facial nerve displacement pattern. However, a significant correlation was observed with tumor adhesion to the facial nerve and facial nerve outcomes.
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Affiliation(s)
- Jae-Hyun Seo
- Department of Otolaryngology-HNS, The Catholic University of Korea, Seoul, South Korea
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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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Outcome on hearing and facial nerve function in microsurgical treatment of small vestibular schwannoma via the middle cranial fossa approach. Eur Arch Otorhinolaryngol 2012; 270:1209-16. [DOI: 10.1007/s00405-012-2074-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Accepted: 05/31/2012] [Indexed: 11/25/2022]
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20
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Thirumala PD, Mohanraj SK, Habeych M, Wichman K, Chang YF, Gardner P, Snyderman C, Crammond DJ, Balzer J. Value of free-run electromyographic monitoring of lower cranial nerves in endoscopic endonasal approach to skull base surgeries. J Neurol Surg B Skull Base 2012; 73:236-44. [PMID: 23904999 DOI: 10.1055/s-0032-1312712] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 01/27/2012] [Indexed: 10/28/2022] Open
Abstract
Objective The main objective of this study was to evaluate the value of free-run electromyography (f-EMG) monitoring of cranial nerves (CNs) VII, IX, X, XI, and XII in skull base surgeries performed using endoscopic endonasal approach (EEA) to reduce iatrogenic CN deficits. Design We retrospectively identified 73 patients out of 990 patients who had EEA in our institution who had at least one CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as group I and those who did not as group II. Results We monitored a total of 342 CNs. A total of 62 nerves had SG f-EMG activity including CN VII = 18, CN IX = 16, CN X = 13, CN XI = 5, and CN XII = 10. No nerve deficit was found in the nerves that had significant activity during procedure. A total of five nerve deficits including (CN IX = 1, CN X = 2, CN XII = 2) were observed in the group that did not display SG f-EMG activity during surgery. Conclusions f-EMG seems highly sensitive to surgical manipulations and in locating CNs. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of lower CNs during EEA procedures need to be done with both f-EMG and triggered EMG.
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Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States ; Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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What really decides the facial function of vestibular schwannoma surgery? Clin Exp Otorhinolaryngol 2011; 4:168-73. [PMID: 22232710 PMCID: PMC3250579 DOI: 10.3342/ceo.2011.4.4.168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 12/21/2010] [Accepted: 05/16/2011] [Indexed: 11/08/2022] Open
Abstract
Objectives To find the main cause of facial nerve dysfunction in vestibular schwannoma (VS) surgery and review the prognosis of facial function in relation to tumor size, preoperative facial function and surgical approach. Methods We reviewed the surgical outcome of 134 patients with VS treated in our department between 1994 and 2008. All patients included in the study had postoperative facial paralysis after surgical management of their VS. There were 14 women and 7 men. The mean age was 48.5 years, with a mean follow-up period of 57 months. Results Twenty-one patients (sustained facial palsy, 4; newly developed facial palsy, 17) had facial nerve paralysis after surgery: ten patients in large VS and eleven patients in small VS. In large VS group, 4 patients had facial nerve function of HB grade II, 3 patients had HB grade III, and 3 patients had HB grade IV. In small VS group, 9 patients had HB grade II and 2 patients had HB grade IV. Middle cranial fossa approach rather than translabyrinthine approach for the preservation of hearing, led to facial nerve deterioration and the patients who had facial nerve paralysis perioperatively,
had resulted in permanent facial paralysis. Conclusion The tumor size in VS is certainly one of the most important prognostic factors. However, VS tumor size alone should not be considered a unique prognostic indicator. The surgical approach used, which may be related to tumor size, based on the surgeon's experience, can be a deciding factor, and the status of the facial nerve injured by the tumor can influence postoperative facial nerve function.
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22
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Gjuric M, Rudic M. What is the best tumor size to achieve optimal functional results in vestibular schwannoma surgery? Skull Base 2011; 18:317-25. [PMID: 19240831 DOI: 10.1055/s-0028-1086056] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To analyze our own functional results to delineate a critical vestibular schwannoma size for middle cranial fossa (MCF) surgery with the best possible outcome. STUDY DESIGN Retrospective chart review. SETTING Academic tertiary referral center. METHODS Tumors were divided into intracanalicular, tumors 1 to 5, 6 to 10, and 11 to 15 mm in the cerebellopontine angle (CPA). Patients were evaluated at 2 months, 1 year, and 5 years after surgery. RESULTS At 1 year, House-Brackmann score of I or II was obtained in 100% of intracanalicular and in 96%, 86%, and 85% with tumors up to 5, 10, and 15 mm in the CPA, respectively. Class I hearing was postoperatively preserved in 61%, 41%, 29%, and 20%, and measurable word recognition in 67%, 51%, 35%, and 21% of patients, respectively. CONCLUSION The outcome is predominantly a function of tumor size, and these changes influence MCF surgery at an earlier stage than in the translabyrinthine or retrosigmoid approach. For the facial nerve, there is a cutoff at 5-mm extracanalicular extension. Also, chances for successful hearing preservation decrease rapidly with size, and in tumors beyond 1.5 cm are below 20%. Consequently, although an expectant policy with small tumors may be reasonable in some instances, it is not so for MCF candidates.
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Affiliation(s)
- Mislav Gjuric
- Department of Otorhinolaryngology, KBC Zagreb, University of Zagreb, Zagreb, Croatia
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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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Sriskandan N, Connor S. The role of radiology in the diagnosis and management of vestibular schwannoma. Clin Radiol 2011; 66:357-65. [DOI: 10.1016/j.crad.2010.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 10/25/2010] [Accepted: 10/28/2010] [Indexed: 10/18/2022]
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Sughrue ME, Yang I, Aranda D, Rutkowski MJ, Fang S, Cheung SW, Parsa AT. Beyond audiofacial morbidity after vestibular schwannoma surgery. J Neurosurg 2011; 114:367-74. [DOI: 10.3171/2009.10.jns091203] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectOutcomes following vestibular schwannoma (VS) surgery have been extensively described; however, complication rates reported in the literature vary markedly. In addition, the majority of reports have focused on outcomes related to cranial nerves (CNs) VII and VIII. The objective of this study was to analyze reported morbidity unrelated to CNs VII and VIII following the resection of VS.MethodsThe authors performed a comprehensive search of the English language literature, identifying and aggregating morbidity and death data from patients who had undergone microsurgical removal of VSs. A subgroup analysis based on surgical approach and tumor size was performed to compare rates of CSF leakage, vascular injury, neurological deficit, and postoperative infection.ResultsOne hundred articles met the inclusion criteria, providing data for 32,870 patients. The overall mortality rate was 0.2% (95% CI 0.1–0.3%). Twenty-two percent of patients (95% CI 21–23%) experienced at least 1 surgically attributable complication unrelated to CNs VII or VIII. Cerebrospinal fluid leakage occurred in 8.5% of patients (95% CI 6.9–10.0%). This rate was markedly increased with the translabyrinthine approach but was not affected by tumor size. Vascular complications, such as ischemic injury or hemorrhage, occurred in 1% of patients (95% CI 0.75–1.2%). Neurological complications occurred in 8.6% of cases (95% CI 7.9–9.3%) and were less likely with the resection of smaller tumors (p < 0.0001) and the use of the translabyrinthine approach (p < 0.0001). Infections occurred in 3.8% of cases (95% CI 3.4–4.3%), and 78% of these infections were meningitis.ConclusionsThis study provides statistically powerful data for practitioners to advise patients about the published risks of surgery for VS unrelated to compromised CNs VII and VIII.
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Affiliation(s)
| | - Isaac Yang
- 1Departments of Neurological Surgery and
| | | | | | | | - Steven W. Cheung
- 2Otolaryngology-Head and Neck Surgery, University of California at San Francisco, California
| | - Andrew T. Parsa
- 1Departments of Neurological Surgery and
- 2Otolaryngology-Head and Neck Surgery, University of California at San Francisco, California
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Hearing preservation rates after microsurgical resection of vestibular schwannoma. J Clin Neurosci 2010; 17:1126-9. [DOI: 10.1016/j.jocn.2010.01.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Revised: 01/23/2010] [Accepted: 01/31/2010] [Indexed: 11/18/2022]
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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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Kameda K, Shono T, Hashiguchi K, Yoshida F, Sasaki T. Effect of tumor removal on tinnitus in patients with vestibular schwannoma. J Neurosurg 2010; 112:152-7. [PMID: 19480542 DOI: 10.3171/2009.3.jns081053] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Tinnitus is one of the most common symptoms in patients with vestibular schwannomas (VSs), but the effect of surgery on this symptom has not been fully evaluated. The aim of this study was to define the effect on tinnitus of tumor removal, cochlear nerve resection, and useful hearing preservation in patients with VSs. METHODS The authors retrospectively analyzed the status of tinnitus before and after surgery in 242 patients with unilateral VSs who underwent surgery via the retrosigmoid lateral suboccipital approach. RESULTS Of 242 patients, 171 (70.7%) complained of tinnitus before surgery; the symptom disappeared in 25.2%, improved in 33.3%, remained unchanged in 31.6%, and worsened in 9.9% of these cases after tumor removal. In the 171 patients with preoperative tinnitus, the cochlear nerve was resected in 85 (49.7%) and preserved in 86 (50.3%), but there was no significant difference in the incidence of postoperative tinnitus between these 2 groups (p = 0.293). In the 71 patients without preoperative tinnitus, the symptom developed postoperatively in 6 cases (8.5%). Among those without preoperative tinnitus, the cochlear nerve was resected in 45 cases (63.4%) and tinnitus appeared postoperatively in 3 (6.7%). The authors also analyzed the association between postoperative tinnitus and useful hearing preservation, but could not find any statistically significant association between the 2 factors (p = 0.153). CONCLUSIONS Tumor removal via the retrosigmoid lateral suboccipital approach may provide some chance for improvement of tinnitus in patients with VSs; however, neither cochlear nerve resection nor useful hearing preservation affects the postoperative development of tinnitus.
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Affiliation(s)
- Katsuharu Kameda
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Do facial nerve displacement pattern and tumor adhesion influence the facial nerve outcome in vestibular schwannoma surgery? Otol Neurotol 2009; 30:392-7. [PMID: 19318891 DOI: 10.1097/mao.0b013e3181967874] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the nerve facial displacement by a vestibular schwannoma and nerve adhesion to tumor as predictive factors of facial function outcome. STUDY DESIGN A prospective cohort study. SETTING Tertiary referral center. PATIENTS Ninety-six patients undergoing a solitary vestibular schwannoma surgery during 2005 were included. Data concerning tumor size (Stage 1, intracanalicular; Stage 2, < or =15 mm in the cerebellopontine angle [CPA]; Stage 3, 15-30 mm in the CPA; and Stage 4, >30 mm in the CPA), intraoperative facial nerve displacement (Type 1, anterior to the tumor; Type 2, anterior and superior to the tumor and separated from the cochlear nerve; Type 3, superior to the tumor; and Type 4, posterior to the tumor), degree of tumor adhesion (weak, intermediate, and strong) and postoperative facial function according to the House and Brackmann classification at days 10, 30, 90 and 180 were collected. RESULTS A good facial function (Grade 1 or 2) was reported in 73% at postoperative Day 180. Univariate analysis showed that facial outcome was better in small tumors, in displacement Types 1 and 2 (Type 1, 46%; Type 2, 34%; and Type 3, 20%), and in tumors with weak and intermediate adhesion (weak, 10%; intermediate, 38%; and strong, 52%). Facial nerve displacement and adhesion were related to tumor stage. The combination of tumor stage, adhesion, and nerve displacement in a logistic regression model was highly predictive of postoperative facial function. CONCLUSION Facial nerve displacement and nerve adhesion to tumor are significant predictive factors of facial function outcome after vestibular schwannoma surgery in addition to tumor size.
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Dogru S, Van Daele D, Hansen MR. Retrograde labeling of the rat facial nerve with carbocyanine dyes to enhance intraoperative identification. Ann Otol Rhinol Laryngol 2008; 117:753-8. [PMID: 18998504 DOI: 10.1177/000348940811701009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Removal of head and neck neoplasms, especially those of the parotid gland and those of the internal auditory canal and cerebellopontine angle, often requires microdissection of the facial nerve. Displacement or splaying of the nerve can make it difficult to identify facial nerve fibers and/or distinguish them from surrounding tissues. Here we tested a method of labeling the facial nerve with fluorescent lipophilic dyes as a method of providing intraoperative visual confirmation of nerve fibers. METHODS The facial nerves of adult rats were retrogradely labeled with 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate (DiI), 3,3'-dioctadecyloxacarbocyanine perchlorate (DiO), or 3,3'-dilinoleyloxacarbocyanine perchlorate (Fast DiO) either by direct application to the nerve sheath or by microinjection into the facial muscles. The nerves were examined 30 days after dye application by means of a dissecting stereomicroscope equipped with epifluorescence filters. RESULTS Of the dyes tested, Fast DiO proved to be the most effective, providing labeling of the nerve sufficient to be seen with combined fluorescent and bright field stereomicroscopy. Nerve conduction studies indicated that fluorescent labeling did not adversely affect nerve function. CONCLUSIONS These results raise the possibility of using fluorescent lipophilic dyes to label nerves as a method of enhancing identification and distinguishing nerve fibers during surgery.
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Affiliation(s)
- Salim Dogru
- Dept of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, IA 52242, USA
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Surgical Approaches and Complications in the Removal of Vestibular Schwannomas. Neurosurg Clin N Am 2008; 19:331-43, vii. [DOI: 10.1016/j.nec.2008.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nerve of Origin, Tumor Size, Hearing Preservation, and Facial Nerve Outcomes in 359 Vestibular Schwannoma Resections at a Tertiary Care Academic Center. Laryngoscope 2007; 117:2087-92. [DOI: 10.1097/mlg.0b013e3181453a07] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bennett M, Haynes DS. Surgical approaches and complications in the removal of vestibular schwannomas. Otolaryngol Clin North Am 2007; 40:589-609, ix-x. [PMID: 17544697 DOI: 10.1016/j.otc.2007.03.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Vestibular schwannomas are benign tumors that usually originate from the balance portion of cranial nerve VIII. The treatment options currently available for vestibular schwannomas include observation with serial imaging, stereotactic radiation, and microsurgical removal. Although the ultimate goal in treatment of vestibular schwannomas is preservation of life, the best option for each patient depends on symptoms, tumor size, tumor location, and the patient's general health and age. Surgical exposure of the cerebellopontine angle for removal of vestibular schwannomas can be performed safely via a translabyrinthine, retrosigmoid, and middle fossa approach. Each approach has its advantages and disadvantages. The goal of surgery is complete eradication of tumor with preservation of hearing and facial nerve function when possible.
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Affiliation(s)
- Marc Bennett
- The Otology Group of Vanderbilt, 300 20th Avenue North, Suite 502, Nashville, TN 37203, USA
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Isaacson B, Kutz JW, Roland PS. Lesions of the petrous apex: diagnosis and management. Otolaryngol Clin North Am 2007; 40:479-519, viii. [PMID: 17544693 DOI: 10.1016/j.otc.2007.03.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Management of petrous apex pathology poses a unique challenge even to the most seasoned skull base surgeons. The central location in the skull base with adjacent critical neurovascular structures makes access to this region more than a trivial matter. Significant advances in diagnostic imaging have greatly facilitated the diagnosis of petrous apex lesions. The introduction of modern skull base surgery techniques also has provided skull base surgeons with numerous avenues to the petrous apex while significantly decreasing morbidity. The latest diagnostic and management strategies are discussed and an update of some of the more common pathologic entities is provided.
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Affiliation(s)
- Brandon Isaacson
- Department of Otolaryngology-Head and Neck Surgery, The University of Texas-Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9035, USA.
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Doherty JK, Friedman RA. Controversies in building a management algorithm for vestibular schwannomas. Curr Opin Otolaryngol Head Neck Surg 2006; 14:305-13. [PMID: 16974142 DOI: 10.1097/01.moo.0000244186.72645.d4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The present review examines the various mainstream treatment options, benefits and risks, and controversies involved in developing a management algorithm for treatment of vestibular schwannoma. RECENT FINDINGS Advances in microsurgery and radiosurgery have made tremendous contributions to management of vestibular schwannoma; however, considerable controversy still exists. The auditory and facial nerve functional outcomes have improved with use of intraoperative monitoring for vestibular schwannoma removal and with lower radiosurgery doses; however, risks to the facial and auditory nerves still exist. Observing vestibular schwannomas for growth with serial magnetic resonance imaging is an increasingly popular option for small vestibular schwannomas that allows patients to enjoy hearing and facial function. SUMMARY The risks and benefits of each treatment option must be weighed for each patient, and management decisions regarding vestibular schwannomas should be individualized for each patient depending on tumor anatomy, patient preferences, and symptoms.
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Affiliation(s)
- Joni K Doherty
- House Clinic and House Ear Institute, Los Angeles, California 90057, USA
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