“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.

Length of tumor–cochlear nerve contact and hearing outcome after surgery for vestibular schwannoma

2008 ◽  
Vol 108 (1) ◽  
pp. 105-110 ◽  
Author(s):  
Raymund L. Yong ◽  
Brian D. Westerberg ◽  
Charles Dong ◽  
Ryojo Akagami
Keyword(s):  
Hearing Loss ◽  
Vestibular Schwannoma ◽  
Univariate Analysis ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Magnetic Resonance Images ◽  
Auditory Evoked Potential ◽  
Cochlear Nerve ◽  
Hearing Outcome ◽  
Interpeak Latency

Object Tumor size is likely to be a major determinant of hearing preservation after surgery for vestibular schwannoma. Findings in some large case series have not supported this concept, possibly due to variation in the technique used for tumor measurement. The authors sought to determine if the length of tumor–cochlear nerve contact was predictive of hearing outcome in adults undergoing resection of a vestibular schwannoma. Methods Patients who underwent a hearing-preserving approach for resection of a vestibular schwannoma at one institution by a neurosurgeon/neurotologist team between 2001 and 2005 were screened. Patients with American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Class A or B hearing preoperatively were included. Magnetic resonance images were reviewed and used to calculate the length of tumor–cochlear nerve contact. Tumors were also measured according to AAO-HNS guidelines. Results Thirty-one patients were included, 8 (26%) of whom had hearing preservation. Univariate analysis revealed that extracanalicular length of tumor–cochlear nerve contact (p = 0.0365), preoperative hearing class (p = 0.028), I–V interpeak latency of the brainstem auditory evoked potential (p = 0.021), and the interaural I–V interpeak latency difference (p = 0.018) were predictive of hearing outcome. Multivariate analysis confirmed the predictive value of extra-canalicular length of contact and preoperative hearing class (p = 0.041 and p = 0.0235, respectively). Conclusions Vestibular schwannomas with greater lengths of tumor–cochlear nerve contact increase a patient's risk for hearing loss after surgery with attempted hearing preservation. Involvement of the internal auditory canal produces a constant risk of hearing loss. Data from the experience of a single surgical team can be used to estimate the probability of good hearing outcome for any given patient with serviceable hearing and a vestibular schwannoma.

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.

scholarly journals Cochlear Nerve Canal Stenosis: Association With MYH14 and MYH9 Genes

2021 ◽  
pp. 014556132199683
Author(s):  
Wenqi Liang ◽  
Line Wang ◽  
Xinyu Song ◽  
Fenqi Gao ◽  
Pan Liu ◽  
...  
Keyword(s):  
Hearing Loss ◽  
Next Generation Sequencing ◽  
Inner Ear ◽  
Internal Auditory Canal ◽  
Cochlear Nerve ◽  
Transverse Diameter ◽  
Congenital Hearing Loss ◽  
Canal Stenosis ◽  
Ear Anomalies ◽  
Generation Sequencing

The bony cochlear nerve canal transmits the cochlear nerve as it passes from the fundus of the internal auditory canal to the cochlea. Stenosis of the cochlear nerve canal, defined as a diameter less than 1.0 mm in transverse diameter, is associated with inner ear anomalies and severe to profound congenital hearing loss. We describe an 11-month-old infant with nonsyndromic congenital sensorineural hearing loss with cochlear nerve canal stenosis. Next-generation sequencing revealed heterozygous mutations in MYH9 and MYH14, encoding for the inner ear proteins myosin heavy chain IIA and IIC. The patient’s hearing was rehabilitated with bilateral cochlear implantation.

scholarly journals Endoscopic-assisted microsurgical resection of giant vestibular schwannoma in semi-sitting position

2021 ◽  
Vol 5 (2) ◽  
pp. V3
Author(s):  
Gang Song ◽  
Liyong Sun ◽  
Yuhai Bao ◽  
Jiantao Liang
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Residual Tumor ◽  
Nerve Function ◽  
Tumor Removal ◽  
Function Preservation ◽  
Microsurgical Resection ◽  
Dissection Technique ◽  
Total Tumor Removal ◽  
Facial Function

The main objectives of microsurgery for vestibular schwannoma are total tumor removal and preservation of facial and cochlear nerve function. For giant tumors, total tumor removal and facial nerve function preservation are challenging. The semisitting position has some advantages. In this video the authors show the removal of a giant vestibular schwannoma with the patient in a semisitting position. They demonstrate the advantages of the semisitting technique, such as the two-handed microsurgical dissection technique and a clear operative field. Finally, a small residual tumor in the internal auditory canal was removed by endoscopy. The patient’s facial function was House-Brackmann grade I at discharge. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2176

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.

Preoperative Sudden Hearing Loss May Predict Hearing Preservation After Retrosigmoid Resection of Vestibular Schwannoma

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Kareem O. Tawfik ◽  
Thomas H. Alexander ◽  
Joe Saliba ◽  
Yin Ren ◽  
Bill Mastrodimos ◽  
...  
Keyword(s):  
Hearing Loss ◽  
Vestibular Schwannoma ◽  
Hearing Preservation ◽  
Sudden Hearing Loss

scholarly journals Metastatic Extrapulmonary Small Cell Carcinoma to the Cerebellopontine Angle: A Case Report and Review of the Literature

2015 ◽  
Vol 2015 ◽  
pp. 1-6
Author(s):  
Debebe Theodros ◽  
C. Rory Goodwin ◽  
Genevieve M. Crane ◽  
Jason Liauw ◽  
Lawrence Kleinberg ◽  
...  
Keyword(s):  
Cell Carcinoma ◽  
Surgical Resection ◽  
Small Cell Carcinoma ◽  
Vestibular Schwannoma ◽  
Primary Tumor ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Small Cell ◽  
Poorly Differentiated ◽  
Small Intestinal

Extrapulmonary small cell carcinomas (EPSCC) are rare malignancies with poor patient prognoses. We present the case of a 63-year-old male who underwent surgical resection of a poorly differentiated small cell carcinoma, likely from a small intestinal primary tumor that metastasized to the cerebellopontine angle (CPA). A 63-year-old male presented with mild left facial paralysis, hearing loss, and balance instability. MRI revealed a 15 mm mass in the left CPA involving the internal auditory canal consistent with a vestibular schwannoma. Preoperative MRI eight weeks later demonstrated marked enlargement to 35 mm. The patient underwent a suboccipital craniectomy and the mass was grossly different visually and in consistency from a standard vestibular schwannoma. The final pathology revealed a poorly differentiated small cell carcinoma. Postoperative PET scan identified avid uptake in the small intestine suggestive of either a small intestinal primary tumor or additional metastatic disease. The patient underwent whole brain radiation therapy and chemotherapy and at last follow-up demonstrated improvement in his symptoms. Surgical resection and radiotherapy are potential treatment options to improve survival in patients diagnosed with NET brain metastases. We present the first documented case of skull base metastasis of a poorly differentiated small cell carcinoma involving the CPA.

The Narrow Internal Auditory Canal in Children: A Contraindication to Cochlear Implants

1989 ◽  
Vol 100 (3) ◽  
pp. 227-231 ◽  
Author(s):  
Clough Shelton ◽  
William M. Luxford ◽  
Lisa L. Tonokawa ◽  
William W. M. Lo ◽  
William F. House
Keyword(s):  
High Resolution ◽  
Cochlear Implants ◽  
Cochlear Implantation ◽  
Electric Stimulation ◽  
Internal Auditory Canal ◽  
Auditory Stimulation ◽  
Cochlear Nerve ◽  
X Ray ◽  
Computed Tomographic ◽  
Auditory Response

We suggest a new explanation for the lack of auditory response to electric stimulation in children with cochlear implants: The very narrow internal auditory canal, 1 to 2 mm in diameter, and the probable absence of the cochlear nerve. This defect can be seen on high-resolution computed tomographic x-ray studies and may represent aplasia of the auditory-vestibular nerve. We report on eight children with this anomaly, three of whom have received implants and failed to respond with a sensation of sound. Identification of this problem on screening x-ray films is a contraindication to cochlear Implantation for auditory stimulation.

Hearing preservation in patients with vestibular schwannoma treated with Gamma Knife surgery

2013 ◽  
Vol 118 (3) ◽  
pp. 571-578 ◽  
Author(s):  
Andrew M. Baschnagel ◽  
Peter Y. Chen ◽  
Dennis Bojrab ◽  
Daniel Pieper ◽  
Jack Kartush ◽  
...  
Keyword(s):  
Hearing Loss ◽  
Gamma Knife ◽  
Vestibular Schwannoma ◽  
Hearing Preservation ◽  
Gamma Knife Surgery ◽  
Speech Discrimination ◽  
Before And After ◽  
Nerve Dysfunction ◽  
Preservation Rate

Object Hearing loss after Gamma Knife surgery (GKS) in patients with vestibular schwannoma has been associated with radiation dose to the cochlea. The purpose of this study was to evaluate serviceable hearing preservation in patients with VS who were treated with GKS and to determine if serviceable hearing loss can be correlated with the dose to the cochlea. Methods Forty patients with vestibular schwannoma with serviceable hearing were treated using GKS with a median marginal dose of 12.5 Gy (range 12.5–13 Gy) to the 50% isodose volume. Audiometry was performed prospectively before and after GKS at 1, 3, and 6 months, and then every 6 months thereafter. Hearing preservation was based on pure tone average (PTA) and speech discrimination (SD). Serviceable hearing was defined as PTA less than 50 dB and SD greater than 50%. Results The median cochlear maximum and mean doses were 6.9 Gy (range 1.6–16 Gy) and 2.7 Gy (range 0.7–5.0 Gy), respectively. With a median audiological follow-up of 35 months (range 6–58 months), the 1-, 2-, and 3-year actuarial rates of maintaining serviceable hearing were 93%, 77%, and 74%, respectively. No patient who received a mean cochlear dose less than 2 Gy experienced serviceable hearing loss (p = 0.035). Patients who received a mean cochlear dose less than 3 Gy had a 2-year hearing preservation rate of 91% compared with 59% in those who received a mean cochlear dose of 3 Gy or greater (p = 0.029). Those who had more than 25% of their cochlea receiving 3 Gy or greater had a higher rate of hearing loss (p = 0.030). There was no statistically significant correlation between serviceable hearing loss and age, tumor size, pre-GKS PTA, pre-GKS SD, pre-GKS Gardner-Robertson class, maximum cochlear dose, or the percentage of cochlear volume receiving 5 Gy. On multivariate analysis there was a trend toward significance for serviceable hearing loss with a mean cochlear dose of 3 Gy or greater (p = 0.074). Local control was 100% at 24 months. No patient developed facial or trigeminal nerve dysfunction. Conclusions With a median mean cochlear dose of 2.7 Gy, the majority of patients with serviceable hearing retained serviceable hearing 3 years after GKS. A mean cochlear dose less than 3 Gy was associated with higher serviceable hearing preservation.

Preservation of hearing in patients undergoing excision of acoustic neuromas and other cerebellopontine angle tumors

1985 ◽  
Vol 63 (2) ◽  
pp. 168-174 ◽  
Author(s):  
Charles H. Tator ◽  
Julian M. Nedzelski
Keyword(s):  
Tumor Size ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Hearing Preservation ◽  
Cochlear Nerve ◽  
Consecutive Series ◽  
Speech Discrimination ◽  
Content Type ◽  
Acoustic Neuromas ◽  
Fine Print

✓ Microsurgical techniques have made it possible to identify and preserve the cochlear nerve from its origin at the brain stem and along its course through the internal auditory canal in patients undergoing removal of small or medium-sized acoustic neuromas or other cerebellopontine angle (CPA) tumors. In a consecutive series of 100 patients with such tumors operated on between 1975 and 1981, an attempt was made to preserve the cochlear nerve in 23. The decision to attempt to preserve hearing was based on tumor size and the degree of associated hearing loss. In cases of unilateral acoustic neuroma, the criteria for attempted preservation of hearing were tumor size (2.5 cm or less), speech reception threshold (50 dB or less), and speech discrimination score (60% or greater). In patients with bilateral acoustic neuromas or tumors of other types, the size and hearing criteria were significantly broadened. All patients were operated on through a suboccipital approach. Hearing was preserved postoperatively in six (31.6%) of the 19 patients with unilateral acoustic neuromas, although the cochlear nerve was preserved in 16. Of the six patients with postoperative hearing, three retained excellent hearing, and the other three had only sound awareness and poor discrimination. Hearing was preserved in three cases with other CPA tumors, including an epidermoid cyst and small petrous meningiomas in the internal auditory canal. Of the two cases with bilateral tumors, hearing was preserved in one. Of the 23 patients in whom hearing preservation was attempted, nine (39.1%) had some postoperative hearing, which in six was equal to or better than the preoperative level. Thus, it is worthwhile to attempt hearing preservation in selected patients with CPA tumors.

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