Is the middle fossa approach the treatment of choice for intracanalicular vestibular schwannoma?

2005 ◽  
Vol 132 (3) ◽  
pp. 459-466 ◽  
Author(s):  
Vittorio Colletti ◽  
Francesco Fiorino
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Selection Criteria ◽  
Surgical Techniques ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Class A ◽  
Longitudinal Investigation

OBJECTIVES: To compare the 2 surgical techniques most commonly used during vestibular schwannoma (VS) surgery, i.e., the middle fossa (MF) and the retrosigmoid-transmeatal (RS-TM) routes, when hearing preservation is attempted. STUDY DESIGN: A longitudinal study of a series of consecutive patients operated on with the 2 techniques by the same surgeon was conducted. Selection criteria included tumor confined to the internal auditory canal (IAC) with a length ranging from 4 to 12 mm and hearing class A or B. Patients were alternately assigned to 1 of the 2 groups regardless of auditory class and distance of the tumor from the IAC fundus. Thirty-five subjects were operated on with the RS-TM technique and 35 via the MF route. RESULTS: No significant differences in auditory and facial nerve function results between the 2 techniques were observed. The RS-TM approach, however, showed better facial nerve results at discharge. VS size, IAC enlargement, and, particularly, the distance from the IAC fundus were found to influence the postoperative results more than the type of approach itself. CONCLUSIONS: The MF approach has been described as being the better technique for VS surgery in terms of auditory results. However, this claim lacks statistical substantiation because no prospective studies are to be found in the literature. The present longitudinal investigation shows that the MF approach does not afford any particular advantages over the RS-TM route in terms of auditory results in intracanalicular VS, with the exception of tumors reaching the IAC fundus.

Hearing Preservation Using the Middle Fossa Approach for the Treatment of Vestibular Schwannoma

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. 334-341 ◽  
Author(s):  
Joe Walter Kutz ◽  
Tyler Scoresby ◽  
Brandon Isaacson ◽  
Bruce E. Mickey ◽  
Christopher J. Madden ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Academic Medical Center ◽  
Hearing Preservation ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Class A ◽  
Facial Function ◽  
Grade Iii

Abstract BACKGROUND: The incidence of small vestibular schwannomas in patients with serviceable hearing is increasing because of the widespread use of MRI. The middle fossa approach provides the patient with an opportunity for tumor removal with hearing preservation. OBJECTIVE: To determine the rate of hearing preservation and facial nerve outcomes after removal of a vestibular schwannoma with the use of the middle fossa approach. METHODS: A retrospective case review at a tertiary, academic medical center was performed identifying patients from 1998 through 2008 that underwent removal of a vestibular schwannoma by the middle fossa approach. Preoperative and postoperative audiograms were compared to determine hearing preservation rates. In addition, facial nerve outcomes at last follow-up were recorded. RESULTS: Forty-six patients underwent a middle fossa craniotomy for the removal of a vestibular schwannoma. Of the 38 patients that had class A or class B hearing preoperatively, 24 (63.2%) retained class A or B hearing and 29 (76.3%) retained class A, B, or C hearing. When tumors were 10 mm or less in patients with class A or B preoperative hearing, 22 of 30 patients (73.3%) retained class A or B hearing. When the tumor size was greater than 10 mm in patients with class A or B preoperative hearing, 2 of 8 patients (25%) retained class A or B hearing. At most recent follow-up, 76.1% of patients had House-Brackmann grade I facial function, 13.0% had House-Brackmann grade II facial function, and 10.9% had House-Brackmann grade III facial function. CONCLUSION: Hearing preservation rates are excellent using the middle fossa approach, especially for smaller tumors. No patient experienced long-term facial nerve function worse than House-Brackmann grade III.

Hearing preservation surgery for vestibular schwannoma: experience with the middle fossa approach

2012 ◽  
Vol 33 (3) ◽  
pp. E10 ◽  
Author(s):  
Franco DeMonte ◽  
Paul W. Gidley
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Nerve Function ◽  
Middle Fossa ◽  
Facial Nerve Function ◽  
Middle Fossa Approach ◽  
Class A ◽  
Csf Leakage ◽  
Class B ◽  
Class C

Object In the early 1960s William F. House developed the middle fossa approach for the removal of small vestibular schwannomas (VSs) with the preservation of hearing. It is the best approach for tumors that extend laterally to the fundus of the internal auditory canal, although it does have the potential disadvantage of increased facial nerve manipulation, especially for tumors arising from the inferior vestibular nerve. The aim of this study was to monitor the hearing preservation and facial nerve outcomes of this approach. Methods A prospective database was constructed, and data were retrospectively reviewed. Results Between December 2004 and January 2012, 30 patients with small VSs underwent surgery via a middle fossa approach for hearing preservation. The patients consisted of 13 men and 17 women with a mean age of 46 years. Tumor size ranged from 7 to 19 mm. Gross-total resection was accomplished in 25 of 30 patients. Preoperative hearing was American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Class A in 21 patients, Class B in 5, Class C in 3, and undocumented in 1. Postoperatively, hearing was graded as AAO-HNS Class A in 15 patients, Class B in 7, Class C in 1, Class D in 2, and undocumented in 5. Facial nerve function was House-Brackmann (HB) Grade I in all patients preoperatively. Postoperatively, facial nerve function was HB Grade I in 28 patients, Grade III in 1, and Grade IV in 1. There were 3 complications: CSF leakage in 1 patient, superficial wound infection in 1, and extradural hematoma (asymptomatic) in 1. The overall hearing preservation rate of at least 73% and HB Grade I facial nerve outcome of 93% in this cohort are in keeping with other contemporary reports. Conclusions The middle fossa approach for the resection of small VSs with hearing preservation is a viable and relatively safe option. It should be considered among the various options available for the management of small, growing VSs.

scholarly journals Hearing preservation middle fossa approach for intracanalicular vestibular schwannoma in a NF2 patient

2021 ◽  
Vol 5 (2) ◽  
pp. V13
Author(s):  
Claudio H. F. Vidal ◽  
Yoav Hahn ◽  
Mariana C. Leal ◽  
Kiara Medeiros ◽  
Gabriela F. Hazin ◽  
...  
Keyword(s):  
Vestibular Schwannoma ◽  
Postoperative Period ◽  
Internal Auditory Canal ◽  
Decisive Role ◽  
Hearing Preservation ◽  
Vestibular Schwannomas ◽  
Individual Experience ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Potential Benefits

Hearing preservation is a cornerstone in the management of intracanalicular vestibular schwannomas. This video demonstrates a middle fossa approach to an intracanalicular schwannoma and highlights some technical and anatomical nuances relevant to the procedure. The patient had sustained hearing preservation in the postoperative period. There are potential benefits in favor of the middle fossa when the tumor reaches the fundus of the internal auditory canal, but the surgeon’s individual experience plays a decisive role in the choice of approach. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21121

scholarly journals Resection of a Dumbbell-Shaped Facial Nerve Schwannoma With Preservation of Facial Nerve Function Through the Extended Middle Fossa Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kaith K Almefty ◽  
Wenya Linda Bi ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Facial Nerve ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Growth Patterns ◽  
Geniculate Ganglion ◽  
Nerve Function ◽  
Middle Fossa ◽  
Facial Nerve Function ◽  
Large Tumor ◽  
Middle Fossa Approach

Abstract Facial nerve schwannomas are rare and can arise from any segment along the course of the facial nerve.1 Their location and growth patterns present as distinct groups that warrant specific surgical management and approaches.2 The management challenge arises when the facial nerve maintains good function (House-Brackmann grade I-II).3 Hence, a prime goal of management is to maintain good facial animation. In large tumors, however, resection with facial nerve function preservation should be sought and is achievable.4,5  While tumors originating from the geniculate ganglion grow extradural on the floor of the middle fossa, they may extend via an isthmus through the internal auditory canal to the cerebellopontine angle forming a dumbbell-shaped tumor. Despite the large size, they may present with good facial nerve function. These tumors may be resected through an extended middle fossa approach with preservation of facial and vestibulocochlear nerve function.  The patient is a 62-yr-old man who presented with mixed sensorineural and conductive hearing loss and normal facial nerve function. Magnetic resonance imaging (MRI) revealed a large tumor involving the middle fossa, internal auditory meatus, and cerebellopontine angle.  The tumor was resected through an extended middle fossa approach with a zygomatic osteotomy and anterior petrosectomy.6 A small residual was left at the geniculate ganglion to preserve facial function. The patient did well with hearing preservation and intact facial nerve function. He consented to the procedure and publication of images.  Image at 1:30 © Ossama Al-Mefty, used with permission. Images at 2:03 reprinted from Kadri and Al-Mefty,6 with permission from JNSPG.

Preservation of Facial, Cochlear, and other Nerve Functions in Acoustic Neuroma Treatment

1994 ◽  
Vol 110 (2) ◽  
pp. 146-155 ◽  
Author(s):  
Jean-Marc Sterkers ◽  
Gavin A. J. Morrison ◽  
Olivier Sterkers ◽  
Mohamed M. K. Badr El-Dine
Keyword(s):  
Facial Nerve ◽  
Cranial Nerves ◽  
Surgical Excision ◽  
Hearing Preservation ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Translabyrinthine Approach ◽  
Number Of Patients ◽  
Facial Nerve Monitoring ◽  
Facial Function

Between March 1966 and September 1992, 1400 acoustic neuromas were treated in Paris, France, by surgical excision. The findings over the last 7 years are presented. The translabyrinthine approach has been used in more than 85% of cases. Where hearing preservation is attempted, the middle fossa approach has been adopted for intracanilicular tumors and the retrosigmoid approach for small tumors extending into the cerebellopontine angle, in which the fundus of the internal meatus is free of tumor. The main goal is to achieve a grade I or II result in facial function within 1 month of surgery. Results improved during 1991 after the introduction of continuous facial nerve monitoring and the use of the Beaver mini-blade for dissection of tumor from nerve. With these techniques, facial function at grade I or II at 1 month improved from 20% to 52% for large tumors (larger than 3 cm), from 42% to 81% for medium tumors (2 to 3 cm), and from 70% to 92% for small tumors (up to and including 2 cm extracanalicular). The facial nerve was at greater risk using the retrosigmoid or middle fossa approaches than by the translabyrinthine route. Since 1985, success in hearing preservation has changed little, with useful hearing being preserved in 38.2% of cases operated on by means of the retrosigmoid route and 36.4% of cases after the middle fossa approach. In older patients with good hearing and small tumors, observation with periodic MRI scanning is recommended. Despite earlier diagnosis, the number of patients suitable for hearing preservation surgery remains very limited and careful selection is required. Trigeminal nerve signs were present in 20% of cases preoperativey, in 10% postoperatively, and recovered spontaneously. Palsies of the other cranial nerves after surgery were much rarer and were as follows: sixth nerve (abducens), 0.5%; ninth nerve (glossopharyngeal), 1.4%; and tenth nerve (vagus), 0.7%. The importance of preservation of function of the nervus intermedius of Wrisberg is stressed. These results emphasize the advantages of the translabyrinthine approach, offering greater security to the facial nerve and lower morbidity.

Middle Fossa Approach for Vestibular Schwannoma: Good Hearing and Facial Nerve Outcomes with Low Morbidity

2016 ◽  
Vol 92 ◽  
pp. 37-46 ◽  
Author(s):  
Amol Raheja ◽  
Christian A. Bowers ◽  
Joel D. MacDonald ◽  
Clough Shelton ◽  
Richard K. Gurgel ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Middle Fossa ◽  
Middle Fossa Approach

Influence of Vestibular Schwannoma Morphology on Hearing Preservation in Patients Operated by the Middle Fossa Approach

Skull Base ◽  
2007 ◽  
Vol 17 (S 1) ◽  
Author(s):  
Kazimierz Niemczyk ◽  
Krzysztof Morawski ◽  
Andrzej Marchel ◽  
Antoni Bruzgielewicz ◽  
Arkadiusz Nowak ◽  
...  
Keyword(s):  
Vestibular Schwannoma ◽  
Hearing Preservation ◽  
Middle Fossa ◽  
Middle Fossa Approach

scholarly journals Middle Fossa Approach for Resection of an Intracanalicular Vestibular Schwannoma

2019 ◽  
Vol 80 (S 03) ◽  
pp. S287-S287
Author(s):  
Walter C. Jean ◽  
Kyle Mueller ◽  
H. Jeffrey Kim
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Middle Cranial Fossa ◽  
Petrous Bone ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Nerve Preservation ◽  
Greater Superficial Petrosal Nerve ◽  
Cranial Fossa ◽  
Video Case Report

Objective This video was aimed to demonstrate the middle fossa approach for the resection of an intracanalicular vestibular schwannoma. Design Present study is a video case report. Setting The operative video is showing a microsurgical resection. Participant The patient was a 59-year-old man who presented with worsening headache and right-side hearing loss. He was found to have a right intracanalicular vestibular schwannoma. After weighing risks and benefits, he chose surgery to remove his tumor. Since his hearing remained “serviceable,” a middle fossa approach was chosen. Main Outcome Measures Pre- and postoperative patient photographs evaluated the muscles of facial expression as a marker for facial nerve preservation. Results A right middle fossa craniotomy was performed which allowed access to the floor of the middle cranial fossa. The greater superficial petrosal nerve (GSPN) and arcuate eminence were identified. Using these two landmarks, the internal acoustic canal (IAC) was localized. After drilling the petrous bone, the IAC was unroofed. The facial nerve was identified by stimulation and visual inspection and the tumor was separated from it with microsurgical dissection. In the end, the tumor was fully resected. Both the facial and cochlear nerves were preserved. Postoperatively, the patient experienced no facial palsy and his hearing is at baseline. Conclusion With radiosurgery gaining increasing popularity, patients with intracanalicular vestibular schwannomas are frequently treated with it, or are managed with observation. The middle fossa approach is therefore becoming a “lost art,” but as demonstrated in this video, remains an effective technique for tumor removal and nerve preservation.The link to the video can be found at: https://youtu.be/MD6o3DF6jYg.

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