The Transmastoid Retrolabyrinthine Approach in Vestibular Schwannoma Surgery

2002 ◽  
Vol 127 (5) ◽  
pp. 437-441 ◽  
Author(s):  
Ricardo Ferreira Bento ◽  
Rubens Vuono de Brito ◽  
Tanit Ganz Sanchez ◽  
Aroldo Miniti
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Prospective Analysis ◽  
Total Removal ◽  
The Right ◽  
Retrolabyrinthine Approach ◽  
Good Exposure ◽  
Audiologic Evaluation ◽  
Good Percentage

OBJECTIVE: We conducted a prospective analysis of 22 patients with small vestibular schwannoma and useful hearing who were operated on via a transmastoid retrolabyrinthine approach between January 1994 and March 1999. PATIENTS AND METHODS: The average age was 35 years, and there were 14 females and 8 males. All patients had unilateral tumors, with 10 of them occurring in the right ear and 12 occurring in the left ear. The following parameters were included in our protocol: total removal of the tumor, intraoperative difficulties or complications, immediate postoperative complications, facial score 10 days and 3 months after the surgery, and audiologic evaluation 90 days after the surgery. RESULTS: A good exposure of the internal auditory canal was possible in 19 cases. In 3 patients we had to change the approach to a translabyrinthine one to achieve total removal of the tumor in all patients. Hearing was preserved at the same preoperative levels in 31% of the cases. CONCLUSIONS: The retrolabyrinthine approach offered security to the facial nerve, no morbidity, and good percentage of hearing preservation. It is also easily changeable to a translabyrinthine approach when more exposure is necessary.

scholarly journals Retrosigmoid Approach for Vestibular Schwannoma

2018 ◽  
Vol 80 (S 03) ◽  
pp. S271-S271
Author(s):  
Mohammed Aref ◽  
Katherine Kunigelis ◽  
Stephen P. Cass ◽  
A. Samy Youssef
Keyword(s):  
Vestibular Schwannoma ◽  
Tumor Resection ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Neck Surgery ◽  
Cochlear Nerve ◽  
Management Options ◽  
Suppurative Otitis Media ◽  
History Of ◽  
The Right

Vestibular schwannoma is a benign tumor that affects 3% of the population, but accounts for 85% of tumors occurring at the cerebellopontine angle (CPA). In this case, we present a 48-year-old female with history of cholesteatoma on the right and chronic suppurative otitis media on the left who presented with an 18 month history of bilateral hearing loss, worse on the right. Investigations revealed a right sided vestibular schwannoma measuring 1.6 cm in diameter. Audiogram revealed an AAO–HNS (American Academy of Otolaryngology–Head and Neck Surgery) class C hearing on the right and class B on the left. There are several management options for this size of vestibular schwannoma including observation and radiosurgery. However, preserving cochlear nerve function remains a challenging enterprise. Furthermore, the ideal management that confers the highest chance of hearing preservation remains heavily debated. Given the patient's young age, the goal of hearing preservation and the tumor size/extension into the CPA, surgery was decided through a right retrosigmoid transmeatal approach for tumor resection with intraoperative brain auditory evoked responses monitoring. For hearing preservation, we emphasize few important dissection techniques: tumor debulking from the top first to avoid early manipulation of the cochlear nerve at the bottom of the tumor, sharp dissection from medial to lateral off the vestibular nerve which is kept intact as a tension band to minimize cochlear nerve manipulations, and limit the drilling of the posterolateral wall of the internal auditory canal (IAC) medial to the labyrinth and endolymphatic apparatus. Postoperatively, the patient was discharged home within 2 days, with imaging showing a gross total resection. Follow-up audiogram shows unchanged pure tone thresholds.The link to the Video can be found at: https://youtu.be/Z5ftkpJN5k8.

Hearing Preservation After Translabyrinthine Vestibular Schwannoma Excision: Audiometry and Electrocochleography Results

2018 ◽  
Vol 127 (8) ◽  
pp. 563-567 ◽  
Author(s):  
Kenneth Akakpo ◽  
William J. Riggs ◽  
Michael S. Harris ◽  
Edward E Dodson
Keyword(s):  
Hair Cell ◽  
Vestibular Schwannoma ◽  
Cranial Nerve ◽  
Cell Activity ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Healthy Patient ◽  
Cochlear Hair Cell ◽  
Translabyrinthine Approach ◽  
Cranial Nerve Viii

Objectives: To describe a case of inadvertent hearing preservation following a classical translabyrinthine resection of a vestibular schwannoma of the internal auditory canal in an otherwise healthy patient. Methods: Herein, we describe the case of an otherwise healthy patient who underwent resection of an intracanalicular vestibular schwannoma via a translabyrinthine approach. Furthermore, as part of an ongoing study aimed at characterizing hearing changes due to intraoperative events, cochlear hair cell and nerve activity were monitored using electrocochleography throughout surgery. Unexpectedly, the patient maintained serviceable hearing following surgery. As a result, we are able to provide electrophysiologic evidence of cochlear hair cell activity at various stages of this surgery. Results: Hair cell responses across tested frequencies were detectable prior to and following completion of the translabyrinthine procedure. Neural integrity of the auditory division of cranial nerve VIII was maintained throughout. Lastly, postoperative audiometric testing supported the patient’s subjective assertion of serviceable hearing in the surgical ear. Conclusion: Our results suggest that some degree of hair cell and neural integrity can be maintained throughout the course of the translabyrinthine approach, and if preservation of the auditory division of cranial nerve VIII is feasible, a functional amount of hearing preservation is attainable.

Modified translabyrinthine approach and hearing preservation: imaging evaluation

2007 ◽  
Vol 121 (8) ◽  
pp. 736-741 ◽  
Author(s):  
G Magliulo ◽  
A Stasolla ◽  
D Parrotto ◽  
M Marini
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Ct Scans ◽  
Successful Outcome ◽  
Imaging Evaluation ◽  
Translabyrinthine Approach ◽  
Hearing Function ◽  
Mri Scans ◽  
Magnetic Resonance Imaging Mri

AbstractAim:To establish if the computed tomography (CT) and magnetic resonance imaging (MRI) appearances of the vestibule, after the removal of vestibular schwannoma by a modified translabyrinthine approach, correlate with a successful outcome, defined as hearing preservation.Materials and methods:Our study group consisted of 16 patients with vestibular schwannoma. All patients' pre-operative hearing was graded as class one or two according to the Gardner–Robertson scale. On MRI scans, the schwannoma, including the intracanalicular segment, were less than 2 cm in size in all the patients. The intracanalicular portion involved the fundus of the internal auditory canal in seven patients. In the remaining nine patients, the schwannoma had spread to involve two-thirds of the meatus, sparing its lateral third. The state of the labyrinth, in particular the integrity of the vestibule, was evaluated by CT scans and MRI prior to and following surgery.Results:The schwannoma was completely removed in all patients. None showed any signs of persistence or tumoral relapse on the post-operative MRI. The final follow up showed that seven patients had maintained their hearing function (i.e. four patients with class one hearing and three with class two). The MRI vestibular signal on the T2-weighted images was well depicted only in patients with hearing preservation. Bony vestibular integrity was observed in the CT scans of all cases with hearing preservation, and also in three cases with failure of hearing preservation.Conclusion:Our results confirm that total isolation and maintenance of an anatomically intact vestibule, as depicted by MRI examination, is one of the fundamental factors for successful preservation of hearing function following modified translabyrinthine approach schwannoma removal.

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.

scholarly journals Retrosigmoid Transmeatal Endoscope-Assisted Approach in Semi-Sitting Position for Resection of Vestibular Schwannoma: 2-D operative Video

2018 ◽  
Vol 79 (S 05) ◽  
pp. S385-S386
Author(s):  
Rocio Evangelista-Zamora ◽  
Stefan Lieber ◽  
Florian Ebner ◽  
Marcos Tatagiba
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Sitting Position ◽  
Speech Discrimination ◽  
Endoscopic Assistance ◽  
Set Up ◽  
One Year ◽  
The Right ◽  
Neurovascular Structures

We present a case of a mid-sized vestibular schwannoma (T3b according to the Hannover classification) that was resected through a retrosigmoid transmeatal approach in semi-sitting position under endoscopic assistance. The patient is a 52-year-old male with acute loss of functional hearing on the right side. Audiometry confirmed a loss of up to 60 dB and lost speech discrimination, there were no associated symptoms such as tinnitus or vertigo. This 2D video demonstrates positioning, OR set-up, anatomical and surgical nuances of the skull base approach and the operative technique for microdissection of the tumor from the critical neurovascular structures, especially the facial and cochlear nerves. A gross total resection was achieved and the patient discharged home after four days with unaltered function of the facial nerve (HB I). At one year follow up there was no indication of residual or recurrence.In summary, the retrosigmoid transmeatal approach is an important and powerful tool in the armamentarium for the microsurgical management of all kinds of vestibular schwannomas. Provided the necessary anesthesiological precautions and intraoperative procedures the semi-sitting position is safe and effective. If needed, the approach can be complemented by the use of an endoscope for visualization of the distal internal auditory canal.The link to the video can be found at: https://youtu.be/pPKT4_5nIn0.

Left-sided retrosigmoid craniotomy for the resection of a vestibular schwannoma

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1 ◽  
Author(s):  
Peter S. Amenta ◽  
Jacques J. Morcos
Keyword(s):  
Vestibular Schwannoma ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Patient Positioning ◽  
Standard Technique ◽  
Hearing Preservation ◽  
Surgical Access ◽  
Wide Range ◽  
Primary Means

The cerebellopontine angle is the site for a wide-range of neoplastic and vascular pathologies. The retrosigmoid craniotomy remains the primary means by which to gain surgical access to this anatomically complex region. We present our standard technique for the completion of a retrosigmoid craniotomy and the resection of a left-sided vestibular schwannoma. Anatomy pertinent to the approach, including, the transverse and sigmoid sinuses, cranial nerves, and internal auditory canal (IAC) is displayed. Special emphasis is placed on patient positioning, adequate bone removal, and tumor resection. The drilling of the IAC and tumor dissection from the VII-VIII complex is also highlighted. Hearing preservation was achieved.The video can be found here: http://youtu.be/FFZju5vcBi0.

Nerve origin of vestibular schwannoma: a prospective study

2007 ◽  
Vol 122 (2) ◽  
pp. 128-131 ◽  
Author(s):  
T Khrais ◽  
G Romano ◽  
M Sanna
Keyword(s):  
Vestibular Schwannoma ◽  
Tumour Size ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Middle Cranial Fossa ◽  
Vestibular Nerve ◽  
Case Review ◽  
Explanatory Factors ◽  
Inferior Vestibular Nerve ◽  
A Prospective Study

AbstractObjective:The origin of vestibular schwannoma has always been a matter of debate. The aim of our study was to identify the nerve origin of this tumour.Study design:Prospective case review. This study was conducted at Gruppo Otologico, a private referral centre for neurotology and skull base surgery.Methods:A total of 200 cases of vestibular schwannoma were included in the study. All the tumours were removed surgically utilising the translabyrinthine approach. The origin of the tumour was sought at the fundus of the internal auditory canal.Results:A total of 200 consecutive cases was included in the study. The origin of the tumour was limited to one nerve at the fundus in 152 cases (76 per cent). Out of these cases, the tumour originated from the inferior vestibular nerve in 139 cases (91.4 per cent), from the superior vestibular nerve in nine cases (6 per cent), from the cochlear nerve in two cases (1.3 per cent) and from the facial nerve in two cases (1.3 per cent).Conclusion:The vast majority of vestibular schwannomas originate from the inferior vestibular nerve; the incidence of involvement of this nerve increases as the tumour size increases. An origin of vestibular schwannoma from the inferior vestibular nerve can be considered as one of the explanatory factors for the poor functional outcome of the extended middle cranial fossa approach, and probably accounts also for the better hearing preservation rate reported in some series for the retrosigmoid approach.

Retrolabyrinthine Meatotomy as Part of Retrosigmoid Approach to Expose the Whole Internal Auditory Canal: Rationale, Technique, and Outcome in Hearing Preservation Surgery for Vestibular Schwannoma

2017 ◽  
Vol 14 (1) ◽  
pp. 36-44 ◽  
Author(s):  
Antonio Mazzoni ◽  
Elisabetta Zanoletti ◽  
Luca Denaro ◽  
Alessandro Martini ◽  
Domenico d’ Avella
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Residual Tumor ◽  
Hearing Preservation ◽  
Retrosigmoid Approach ◽  
Long Term Results ◽  
Consecutive Series ◽  
Unfavorable Condition ◽  
Hearing Preservation Surgery

Abstract BACKGROUND Vestibular schwannoma extending to the fundus of the internal auditory canal is currently considered an unfavorable condition for hearing preservation surgery via a retrosigmoid approach because the lateral end of the canal is hard to view directly during microsurgery. OBJECTIVE To present an improved retrolabyrinthine meatotomy (RLM) technique that enables the full length of the cochlear and facial nerves to be inspected up to their orifices on the fundus. Long-term results are briefly reported. METHODS A consecutive series of 100 cases with various degrees of fundus involvement underwent surgery via a retrosigmoid approach and RLM. The follow-up ranged from 4 to 14 yr. Outcomes on hearing and facial nerve function were recorded, and preoperative MRI findings of the tumor on the fundus were correlated with the surgical findings and the long-term radicality of the tumor resection. RESULTS Residual tumor on the fundus was identified in 3 cases, all belonging to the group with tumors adhering to the fundus. The functional results were in line with the best reported outcomes of this surgery. CONCLUSION RLM via a retrosigmoid approach seemed adequate for the purposes of hearing preservation surgery and enabled the full course of the facial and cochlear nerves through the internal auditory canal to be exposed to direct view. Tumors adhering to the vestibular quadrant of the fundus were more difficult to remove, and there were a few cases of local residual tumor.

scholarly journals Microsurgical and Endoscope Assisted Resection of a Right Intracanalicular Vestibular Schwannoma Two-Dimensional Operative Video

2019 ◽  
Vol 80 (S 03) ◽  
pp. S288-S289
Author(s):  
Chun-Yu Cheng ◽  
Zeeshan Qazi ◽  
Laligam N. Sekhar
Keyword(s):  
Vestibular Schwannoma ◽  
Coming Out ◽  
Internal Auditory Canal ◽  
Brain Magnetic Resonance Imaging ◽  
Hearing Preservation ◽  
Retrosigmoid Approach ◽  
Two Dimensional ◽  
Speech Discrimination ◽  
Far Lateral Approach ◽  
Hearing Test

A 36-year-old lady presented with tinnitus and hearing loss for 1 year which was progressively worsening. A hearing test revealed pure tone average (PTA) between 48 to 65 dB and speech discrimination of 56% at 95 dB. Brain magnetic resonance imaging (MRI) showed a right vestibular schwannoma 5 × 8 mm (Fig. 1) which extended far laterally to the fundus of internal auditory canal (IAC). A translabyrinthine approach was suggested by another neurosurgeon/neurotologist team, but the patient decided to undergo operation by retrosigmoid approach with attempted hearing preservation.She underwent a right retrosigmoid craniotomy, craniectomy, and mastoidectomy with far lateral approach. We performed petrous transcanalicular microsurgical approach with the assistance of neuroendoscope. Intraoperatively, the internal auditory artery was looping into the IAC between cranial nerves VII and VIII, and coming out inferiorly. The IAC was opened by the diamond drill, ultrasonic bone curette, and fine rongeurs. The tumor was grayish in color with filling the lateral aspect of the IAC. After circumferential dissection of the tumor capsule, the tumor was removed completely. It was arising from the inferior vestibular nerve which was stretched. The patient had vertigo and nausea postoperatively but it is steadily improving. Her hearing test has improved to a PTA of 22 dB and speech discrimination of 100% at 70 dB at 6 weeks. The postoperative MRI showed total resection.This two-dimensional video shows the technical nuances of microsurgical retrosigmoid approach and endoscopic assisted resection of an intracanalicular vestibular schwannoma and the value of attempting hearing preservation in all vestibular schwannomas (Fig. 2).The link to the video can be found at: https://youtu.be/KHrO_iDI2tw.

“Save the Nerve”: Technical Nuances for Hearing Preservation and Restoration in Vestibular Schwannoma Surgery: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Rami O Almefty ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Hearing Loss ◽  
Cochlear Implants ◽  
Surgical Resection ◽  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Cochlear Nerve ◽  
Severe Hearing Loss ◽  
Significant Disability ◽  
Microsurgical Resection

Abstract Hearing loss is a significant disability that inflects dysfunction and affects the patient quality of life. Consequently, hearing preservation and the potential of hearing restoration are prized quests in the management of vestibular schwannoma.1 Although small intracanalicular vestibular schwannomas are commonly observed, progressive hearing loss occurs despite the absence of tumor growth; hence, surgical resection can be performed with the sole aim of hearing preservation in well-informed and eager patients. Hearing preservation by surgical resection has proven to be durable.1-4 In this group of patients, we concur with Yamakami et al2 that vascularized meatal flap to reconstruct the canal helps prevent scarring of the cochlear nerve and provides cerebrospinal fluid (CSF) bathing to the cochlear nerve, yielding better long-term hearing preservation.  With larger tumors and more severe hearing loss at presentation, microsurgical resection should aim at preserving the cochlear nerve, a goal frequently achievable, which offers the potential for hearing restoration with cochlear implants.3 The results of cochlear implants in restoration of severe hearing loss have been to say the least most impressive.5 We demonstrate these 2 frequently encountered clinical situations with 2 surgical videos showing specific surgical tenets, including intra-arachnoidal dissection, medial to lateral manipulation of the tumor, preservation of the labyrinthine artery, as well as reconstruction of the internal auditory canal.2,3,6,7 The patients consented to the surgery and to the publication of their picture in a surgical video.  Illustration in video © 1997 O. Al-Mefty. Used with permission. All rights reserved.

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