Hearing improvement after conservative approach for large posterior fossa meningioma

[Retrocochlear diagnostics for acute hearing loss and successful therapy]

A 41-year-old female patient presented due to acute onset of unilateral hearing loss 3 months previously and persistent since then. Systemic therapy with oral glucocorticoids in decreasing doses had been performed beforehand, but did not lead to any improvement. In the course of audiological diagnostics, based on subjective and objective methods, a retrocochlear hearing disorder was suspected. A meningioma was diagnosed by diagnostic imaging. Subsequent surgical removal achieved a significant hearing improvement.

Treated large posterior fossa vestibular schwannoma and meningioma: Hearing outcome and willingness-to-accept brain implant for unilateral deafness

Background/Objective

To compare functional hearing and tinnitus outcomes in treated large (~ 3 cm) vestibular schwannoma (VS) and posterior fossa meningioma cohorts, and construct willingness-to-accept profiles for an experimental brain implant to treat unilateral hearing loss.

Methods

A two-way MANOVA model with two independent variables (tumor type; time from treatment) and three dependent variables (hearing effort of tumor ear; abbreviated Speech, Spatial, and Qualities of Hearing scale (SSQ12); Tinnitus Functional Index (TFI)) was used to analyze data from VS (N = 32) and meningioma (N = 50) patients who were treated at a tertiary care center between 2010 and 2020. A query to probe acceptance of experimental treatment for hearing loss relative to expected benefit was used to construct willingness-to-accept profiles.

Results

Tumor type was statistically significant on the combined dependent variables analysis (F[3, 76] = 19.172, p < .0005, Wilks' Λ = 0.569). Meningioma showed better outcome for hearing effort (F[1, 76] = 14.632, p < .0005) and SSQ12 (F[1, 76] = 16.164, p < .0005), but not for TFI (F[1, 76] = 1.247, p = .268) on univariate two-way ANOVA analyses. Superior hearing effort and SSQ12 indices in the short-term (< 2 years) persisted in the long-term (> 2 years) (p ≤ .017). At the 60% speech understanding level, 77% of respondents would accept an experimental brain implant.

Conclusion

Hearing outcome is better for posterior fossa meningioma compared to VS. Most patients with hearing loss in the tumor ear would consider a brain implant if the benefit level would be comparable to a cochlear implant.

Level of Evidence

2.

Hearing recovery after surgical resection of non-vestibular schwannoma cerebellopontine angle tumors

PURPOSE

Post-operative outcomes for hearing after resection surgery to remove cerebellopontine angle (CPA) tumors other than vestibular schwannomas (VS) are not well understood. This study presents a series of patients with significant post-operative hearing recovery, trying to define the incidence among all patients operated on for removal of non-VS CPA tumors.

METHODS

This is a retrospective observational case series of 8 patients among 69 operated on for removal of non-VS CPA tumors between 2012 and 2020. All patients had pre- and post-operative hearing measurement with pure-tone average (PTA) and speech discrimination score (SDS), according to the American Academy of Otolaryngology-Head and Neck Surgery recommendations, auditory brainstem response (ABR) measurements and imaging.

RESULTS

Six meningiomas and two lower cranial nerve schwannomas operated on with a retrosigmoid approach were included for analysis. The mean pre-operative PTA and SDS were 58 ± 20.7 dB and 13 ± 17.5%, respectively. All patients had pre-operative class D hearing and asynchronous ABRs. They all showed significant hearing recovery, with an improvement of 36 ± 22.2 dB (p = 0.0025) and 85 ± 16.9% (p = 0.0001) in PTA and SDS, respectively, with mean follow-up of 21 ± 23.5 months. Seven patients recovered to a class A hearing level and one patient to class B. The ABRs became synchronous for three patients. The incidence of auditory recovery was 13% for patients operated on with a conservative approach (n = 60).

CONCLUSION

A significant post-operative improvement in hearing could be a reasonable expectation in non-VS tumors extending into the CPA and a retrosigmoid approach should always be considered regardless of pre-operative hearing status.

Cochlear Dysfunction is not Common in Human Meningioma of the Internal Auditory Canal

HYPOTHESIS

Cochlear dysfunction is not common in human meningioma of the internal auditory canal.

BACKGROUND

Meningiomas arising from the cerebellopontine angle and internal auditory canal typically cause hearing loss. Cochlear dysfunction is known to contribute to sensorineural hearing loss induced by vestibular schwannoma, the most common tumor of the internal auditory canal. Detailed cochlear histopathology in meningioma has not been reported.

METHODS

Retrospective analysis of cochlear histopathology in five unoperated and five operated meningiomas of the internal auditory canal identified after screening human temporal bone collections from three academic medical centers.

RESULTS

While some dysfunction of all analyzed cochlear cell types was identified, a predominant or exclusive loss of hair cells was not observed in any meningioma. Only 14.3% of temporal bones showed significantly more hair cell damage on the side of the tumor when compared with the contralateral ear; cochlear neuronal damage was more prevalent in meningiomas. The incidence of hydrops, perilymphatic precipitate, or endolymphatic precipitate was low.

CONCLUSIONS

Substantial cochlear damage in human meningioma of the internal auditory canal is not common. This may explain the anecdotal hearing improvement observed after surgical resection of meningioma. Our findings underline the importance of developing therapeutic strategies to prevent cochlear neuronal degeneration due to tumors of the internal auditory canal.

Bilateral hearing loss due to a meningioma located in the left posterior fossa: a case report

We report the case of a 39-year-old woman with a left side meningioma, suffering from bilateral sensorineural hearing loss, who recovered audiometric hearing in both ears after surgery. A preoperative pure tone audiogram (PTA) revealed a bilateral sensorineural hearing loss. Several examinations for sensorineural hearing loss indicated cochlear and retrocochlear hearing loss in the left ear and cochlear hearing loss in the right ear. After the operation, bilateral hearing loss due to a left posterior fossa meningioma gradually improved. One year after surgery, with the exception of hearing at frequencies of 4 and 8 kHz in the left ear, the postoperative audiogram had improved to an almost normal level. We speculate that hearing loss in the left ear may have been induced by the indirect compression of the cochlear nerve caused by the tumor's edema, whereas that in the right ear may have resulted from changes in CSF pressure caused by the mass effects of the tumor.

Facial and Cochlear Nerve Function after Surgery of Cerebellopontine Angle Meningiomas

OBJECTIVE:

Meningiomas of the cerebellopontine angle (CPA) share a common location, but their site of dural origin and their relationship to surrounding neurovascular structures of the CPA are variable. The clinical presentation and outcome after surgical resection are different because of the diversity of this tumor entity. We report on a series of 421 patients with CPA meningiomas, with special emphasis on the analysis of the preoperative and postoperative facial and cochlear nerve function in relation to the site of dural attachment and main tumor location in the CPA cistern.

METHODS:

Among 421 patients, the charts of 347 patients with complete clinical data, including the history and audiograms, imaging studies, surgical records, discharge letters, histological records, and follow-up records, were reviewed retrospectively. Data about preoperative and postoperative facial nerve function were available in 334 patients, and audiometric analysis was conducted in 333 patients. Patients with neurofibromatosis Type 2 were excluded from the study.

RESULTS:

There were 270 women and 77 men, with a mean age of 53.4 years (range, 17.6–84 yr). Among these patients, 32.9% of the tumors originated at the petrous ridge anterior to the inner auditory canal (IAC) (Group 1), 22.2% showed involvement of the IAC (Group 2), 20.2% were located superior to the IAC (Group 3), 11.8% were inferior to the IAC (Group 4), and 12.9% were posterior to the IAC, originating between the IAC and the sigmoid sinus (Group 5). Patients presented with disturbance of Cranial Nerves V–VIII, the lower cranial nerves, and ataxia, depending on the main tumor location. Tumor resection was performed through a suboccipital-retrosigmoidal approach in the semisitting position in 95% of the patients. A combined supratentorial-infratentorial presigmoidal approach was performed in 5%. Total tumor removal (Simpson Grade 1 and 2) was achieved in 85.9% and subtotal removal in 14.1%. The best initial postoperative facial and auditory nerve function was observed in tumors belonging to Groups 3 and 5. Recovery from preoperative deafness was observed in 1.8% of patients. On long-term follow-up, good facial nerve function (House-Brackmann Grade 1 or 2) was observed in 88.9% of patients. Hearing preservation among patients with preoperative functional hearing was documented in 90.8% on long-term follow-up.

CONCLUSION:

Although the outcome of facial and cochlear nerve function is different in CPA meningiomas, depending on the topographic classification of these tumors, preservation of the cochlear nerve is possible in every tumor group and should be attempted in every patient with CPA meningioma. It has to be kept in mind that recovery of hearing was also observed in patients with preoperative profound hearing deficits.

The evolution of surgical approaches for posterior fossa meningiomas

OBJECTIVE

To evaluate surgical outcomes for the treatment of posterior fossa meningiomas at the House Ear Clinic from 1987 to 2001. We review our current treatment algorithm and present our postoperative outcomes with attention to facial and auditory neural preservation.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care center.

PATIENTS

Medical records of 71 patients who underwent posterior fossa meningioma surgery at the House Ear Clinic were reviewed.

INTERVENTION

All patients had surgical removal of their meningioma via translabyrinthine, transcochlear, retrosigmoid, extended middle fossa, or combined petrosal approaches by House Ear Clinic neurotologists and neurosurgeons.

MAIN OUTCOME MEASURES

Preoperative and postoperative auditory and facial nerve function data were collected. Patient and tumor characteristics including presenting symptoms, completion of tumor resection, and complications secondary to surgery were also recorded.

RESULTS

The most common presenting symptoms in this series were otologic, with hearing loss (61%), tinnitus (58%), and imbalance (58%) as the three most common. Gross total resection was achieved in 67 (94%) patients. Hearing-preservation surgery was attempted in 37 (52%) patients (68% via extended middle fossa or combined approach). Twenty-one patients with preoperative Class A hearing had follow-up audiometric data and 18 (86%) had serviceable hearing preserved. Excluding transcochlear craniotomies, 85% of patients had normal facial nerve function postoperatively. Cerebrospinal fluid leak (6%) was the most common complication.

CONCLUSIONS

Advances in microsurgical techniques have greatly changed our management of patients with posterior fossa meningiomas. These changes have reduced postoperative morbidity. Specifically, use of the anterior and posterior petrosal approaches has facilitated facial and auditory neural preservation while not compromising the extent of tumor excision.

Hearing restoration from deafness after resection of a large cerebellopontine angle meningioma--case report

A 61-year-old man presented with a large cerebellopontine angle meningioma manifesting as a 1-year history of deafness on the right side, in whom hearing was restored from the deaf state immediately after tumor resection. Neuroimaging demonstrated a large mass in the right cerebellopontine angle, originating at the region adjacent to the jugular foramen. Audiometry showed his hearing was off-scale (> 105 dB) on the right. The tumor was successfully removed through the retrosigmoid approach, and the integrity of the 7th and 8th cranial nerves was maintained. The patient regained hearing on the day after the operation, which continued to improve until near-normal. The 8th cranial nerve function may recover dramatically after removal of non-acoustic tumors, even if preoperative hearing loss is profound. To maximize the opportunity to regain hearing, approaches which devastate cochlear function should be avoided and more meticulous manipulation during tumor removal is needed.

Meningiomas of the cerebellopontine angle

BACKGROUND

Meningiomas of the cerebellopontine angle (CPA), although uniform in location, are diverse with regard to the site of dural origin and displacement of neurovascular structures. A study of patients with CPA meningiomas was undertaken to gain more information regarding the relationship between site of dural attachment, clinical presentation, operative approach, and outcome.

METHODS

In this report, we retrospectively review 40 patients with CPA meningiomas managed surgically.

RESULTS

Common clinical presentations were hearing loss, unsteadiness, and dysequilibrium. Findings upon physical examination included hearing loss (73%), cerebellar signs (32%), trigeminal neuropathy (16%), and facial nerve dysfunction (16%). The most common site of dural origin was the petrous ridge (anterior to the IAC [26%], posterior [21%], superior [18%], and inferior [16%]). Less common sites of dural origin included the tentorium (31%), the clivus (15%), the IAC (10%), and the jugular foramen (8%). Site of dural origin determined the direction of displacement of the facial/vestibulocochlear nerve bundle. The most common microsurgical complication was facial nerve dysfunction (30%). Gross total resection was achieved in 82% of cases, whereas 18% underwent subtotal resection. Two patients died. Follow-up ranged from three months to 13 years with three recurrences.

CONCLUSIONS

CPA meningiomas displace the seventh and eighth cranial nerves in various directions depending on the site of dural origin. Total surgical excision can be accomplished in the majority of cases with acceptable morbidity.

Recovery of useful hearing after posterior fossa surgery: the role of otoacoustic emissions: case report

OBJECTIVE AND IMPORTANCE

Hearing preservation has become an important issue in surgical procedures involving the cerebellopontine angle (CPA). Although several prognostic factors for hearing preservation in patients with "useful" preoperative hearing have been described, it is difficult to predict which patients have the potential for hearing preservation or recovery. Otoacoustic emission measurement is a new technique that allows recording of sounds produced by the cochlear outer hair cells as a normal byproduct of the receptor process and can be used to assess cochlear involvement in patients with hearing loss.

CLINICAL PRESENTATION

We present the case of a 53-year-old patient with a recurrent arachnoid cyst of the CPA. She had noticed progressive severe hearing loss ipsilateral to the cyst that was confirmed by preoperative audiogram.

TECHNIQUE

Otoacoustic emissions were obtained and were within normal limits on the involved side, suggesting that the cochlear outer hair cells were still intact and that the patient had the potential for hearing recovery. The CPA was decompressed by marsupialization of the cyst. Postoperative audiogram demonstrated a dramatic recovery of hearing to a normal level.

CONCLUSION

Otoacoustic emissions clearly provide valuable information about the potential for hearing preservation/recovery after CPA surgery and have significant implications for the current neurosurgical management of these lesions.

Meningiomas of the cerebellopontine angle

Meningiomas of the cerebellopontine angle (CPA) represent a clinically and surgically interesting entity. The opportunity of complete surgical excision and the incidence of impairment of nerval structures largely depend on the tumour biology that either leads to displacement of surrounding structures by an expansive type of growth or to an enveloping of nerval and vascular structures by an en plaque type of growth. As the origin and the direction of growth are very variable, the exact tumour extension in relation to the nerval structures and the tumour origin can be identified sometimes only at the time of surgery. Out of a series of 230 meningiomas of the posterior skull base operated between 1978 and 1993, data of 134 meningiomas involving the cerebellopontine angle are presented. There were 20% male and 80% female patients, age at the time of surgery ranging from 18 to 76 years, on the average 51 years. The clinical presentation was characterized by a predominant disturbance of the cranial nerves V (19%), VII (11%), VIII (67%) and the caudal cranial nerves (6%) and signs of ataxia (28%). 80% of the meningiomas were larger than 30 mm in diameter, 53% led to evident brainstem compression or dislocation and 85% extended anteriorly to the internal auditory canal. Using the lateral suboccipital approach in the majority of cases and a combined presigmoidal or combined suboccipital and subtemporal approaches in either sequence in 5%, complete tumour removal (Simpson I and II) was accomplished in 95% and subtotal tumour removal in 5%. Histologically the meningiotheliomatous type was most common (49%) followed by the mixed type (19%), fibroblastic (16%), psammomatous (7%), hemangioblastic (7%) and anaplastic (2%) types. Major post-operative complications were CSF leakage (8%) requiring surgical revision in 2% and hemorrhage (3%) requiring revision in 2%. While the majority of neurological disturbances showed signs of recovery, facial nerve paresis or paralysis was encountered in 17%, and facial nerve reconstruction was necessary in 7%. Hearing was preserved in 82% with improvement of hearing in 6%. The variability of tumour extension, the implications and limitations for complete surgical excision are discussed along with the experiences from the literature.

Management of posterior cranial fossa meningiomas

Posterior cranial fossa meningiomas are relatively common extra-axial tumors with important relationships to the cochleovestibular system, facial nerve, and/or cranial base. Nevertheless, objective reporting of auditory and vestibular function is rare for this patient population, and a full discussion of the nonsurgical management is all but totally discounted in the otolaryngology literature. Nine cases (8 operative cases) are presented, with the purpose of correlating neurotologic function with precise anatomic tumor location, available by magnetic resonance imaging and computed tomography. The usefulness of this information for diagnosis and meaningful scrutiny of the operative results is discussed. A comprehensive review of posterior fossa meningiomas in terms of epidemiology, etiology, and pathology, as well as nonsurgical treatment alternatives, is provided.