Bone Cement Internal Auditory Canal Reconstruction to Reduce CSF Leak After Vestibular Schwannoma Retrosigmoid Approach

OBJECTIVE: Our goal was to study the occurrence and source of origin of postcraniotomy headache syndrome after removal of vestibular schwannoma via the retrosigmoid approach. METHODS: A retrospective chart analysis was conducted of all patients with headache at 3 months after removal of vestibular schwannoma from January 1981 through March 1997 and with a minimum of 24 months of follow-up. Diagnosis was made according to the headache classification and was graded using the HARNER scale. Recovery outcome was compared in selected groups of patients with and without headache. A descriptive statistical analysis was used to analyze differences between groups. RESULTS: Of the patients who underwent retrosigmoid craniotomy for removal of vestibular schwannomas, 52 of 155 patients (34%) reported having severe headache of requiring medication every day and/or feeling incapacitated 3 months after surgery. Headache was more prevalent in those who had the bone flap replaced (94% versus 27%), if there was duraplastic or direct dura closure (0% versus 100%). Laboratory-proven aseptic meningitis, most likely due to the use of fibrin glue and drilling of posterior aspect of the internal auditory canal, was mainly associated with postoperative headache (81% versus 2%). In 75% of these cases, calcifications along the brainstem had been noted. CONCLUSION: The origin of postoperative headaches after retrosigmoid vestibular schwannoma resections is not yet fully understood. Different factors may play a role in preventing or reducing headache: dural adhesions to nuchal muscles or to subcutaneous tissues and dural tension in the case of direct dural closure may explain postoperative headache from dural tension. Intradural drilling and the use of fibrin glue may be the source of aseptic meningitis as the etiology of persistent postoperative headache. Prevention of postoperative headache may include the replacement of bone flap at the end of surgery, duraplastic instead of direct dural closure, and prevention of the use of fibrin glue or extensive drilling of the posterior aspect of internal auditory canal.

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Retrosigmoid Approach for Resection of Medium-Sized Vestibular Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1677848 ◽

2019 ◽

Vol 80 (S 03) ◽

pp. S284-S284

Author(s):

Michael J. Link ◽

Colin L. W. Driscoll ◽

Yening Feng ◽

Maria Peris-Celda ◽

Christopher S. Graffeo

Keyword(s):

Vestibular Schwannoma ◽

Internal Auditory Canal ◽

Retrosigmoid Approach ◽

Gross Total Resection ◽

Instructional Video ◽

Hearing Level ◽

Facial Nerve Function ◽

Total Resection ◽

Pure Tone Average ◽

Petrous Temporal Bone

Objectives This video was aimed to describe the relevant anatomy and key surgical steps of retrosigmoid approach for gross total resection of a medium-sized vestibular schwannoma (VS). Design The procedure is described in a surgical instructional video. Setting The surgery took place at a tertiary skull base referral center. Participant Patient is a 63-year-old woman who reported with nonserviceable hearing (Pure Tone Average 60 dB Hearing level, Word Recognition Score 45%), occasional tinnitus, and a VS in the left cerebellopontine angle (CPA), extending into internal auditory canal (IAC), measuring 1.7 cm parallel to the petrous temporal bone. Main Outcome Measures The VS was resected by retrosigmoid approach. Results The surgery results gross total resection of the VS with postoperative House–Brackmann grade 1 facial nerve function and no postoperative complications. Conclusion The retrosigmoid approach is a good strategy to remove VS involving the CPA and the IAC.The link to the video can be found at: https://youtu.be/B6K_UkrKitg.

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Chances of Improvement in Cases of Vestibular Schwannoma Presenting with Facial Nerve Weakness: Presentation of Two Cases and Literature Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1661414 ◽

2018 ◽

Vol 80 (01) ◽

pp. 040-045

Author(s):

Ahmed Rizk ◽

Marcus Mehlitz ◽

Martin Bettag

Keyword(s):

Hearing Loss ◽

Facial Nerve ◽

Male Patient ◽

Vestibular Schwannoma ◽

Internal Auditory Canal ◽

Retrosigmoid Approach ◽

Neurophysiological Monitoring ◽

Facial Weakness ◽

First Case ◽

The Brain

Background and Study Aim Facial nerve (FN) weakness as a presenting feature in vestibular schwannoma (VS) is extremely rare. We are presenting two different cases of VS with significant facial weakness and reviewed the literature for similar cases. Methods and Results We are presenting two cases of VS with significant facial weakness. The first case was a 63-year-old male patient presented with 3 weeks' history of severe left-sided facial weakness (House–Brackmann [HB] grade V) and hearing loss. Magnetic resonance imaging (MRI) of the brain showed a tumor in the left internal auditory canal. Gross total removal with anatomical and physiological FN preservation was performed through a retrosigmoid approach under neurophysiological monitoring. FN function improved postoperatively to HB grade II after 16 months. The other case was 83-year-old male patient presented with sudden left-sided hearing loss and severe facial weakness (HB grade V). MRI of the brain 2.5 years before showed a left-sided (Class-T3A) cystic VS. The tumor was asymptomatic; wait-and-scan strategy was advised by the treating neurologist. Recent MRI of the brain showed approximately three times enlargement of the tumor with brain stem compression, extensive cystic changes, and suspected intratumoral hemorrhage. Surgery was performed; the tumor was subtotally removed through a retrosigmoid approach with intraoperative FN monitoring. The FN was anatomically preserved; however, physiological preservation was not possible. Severe facial weakness with incomplete lid closure persisted postoperatively. Conclusion Surgical treatment could be offered to cases of suspected VS presenting with facial weakness, as these cases may still have a chance for improvement especially in laterally located tumors.

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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

Operative Neurosurgery ◽

10.1093/ons/opx091 ◽

2017 ◽

Vol 14 (1) ◽

pp. 36-44 ◽

Cited By ~ 12

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.

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

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1676840 ◽

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.

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Endoscopic-assisted resection of vestibular schwannomas in high-riding jugular bulb

Neurosurgical Focus: Video ◽

10.3171/2021.7.focvid2198 ◽

2021 ◽

Vol 5 (2) ◽

pp. V4

Author(s):

Florian Roser ◽

Tanmoy Maiti ◽

Mohamed Samy Elhammady

Keyword(s):

Vestibular Schwannoma ◽

Posterior Margin ◽

Internal Auditory Canal ◽

Progression Free Survival ◽

Jugular Bulb ◽

Retrosigmoid Approach ◽

Vestibular Schwannomas ◽

Sitting Position ◽

Free Survival ◽

Dural Opening

The present surgical video demonstrates safe opening of the internal auditory canal (IAC) during vestibular schwannoma surgery via a retrosigmoid approach in the sitting position. Resection of the intrameatal portion of a tumor is important for progression-free survival. Preoperative thin-sliced CT revealed a high-riding jugular bulb obscuring the trajectory. After dural opening, the IAC was approached anteriorly and superiorly. The posterior margin of IAC drilling was above the Tubingen line. Drilling was performed under continuous jugular compression. The vein was pushed down to augment visibility. An angled endoscope was helpful. IAC can be drilled safely in a high-riding jugular bulb with the technique mentioned in the video. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2198

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Technique to prevent post-operative CSF leak in the translabyrinthine excision of vestibular schwannoma

The Journal of Laryngology & Otology ◽

10.1258/002221503322683849 ◽

2003 ◽

Vol 117 (12) ◽

pp. 965-968 ◽

Cited By ~ 12

Author(s):

M. Sanna ◽

Rohit ◽

L. J. Skinner ◽

Y. Jain

Keyword(s):

Cerebrospinal Fluid ◽

Temporal Bone ◽

Vestibular Schwannoma ◽

World Literature ◽

Internal Auditory Canal ◽

Posterior Wall ◽

Csf Leak ◽

The World ◽

Petrous Temporal Bone ◽

Vs Removal

Cerebrospinal fluid (CSF) leak following VS removal is a challenging complication. With experience, it can be seen that anatomical factors such as the extent of pneumatization of the petrous temporal bone and posterior wall of the internal auditory canal play animportant role in contributing to CSF leak. Nevertheless, the risk of post-operative CSF leak remains a major concern for both the surgeon and patient. This paper describes a technique, which we have used since 1994, and which has helped us to achieve the lowest reported rate of post-operative CSF leak in translabyrinthine excision of vestibular schwannoma in the world literature.

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Spreading of the vestibular schwannoma into porus acusticus internus. Endoscopic removal possibilities

OTORHINOLARYNGOLOGY 2-3(2) 2019 - OTORHINOLARYNGOLOGY ◽

10.37219/2528-8253-2018-1-40 ◽

2018 ◽

pp. 40-44

Author(s):

Orest Palamar ◽

Andriy Huk ◽

Dmytro Okonskyi ◽

Ruslan Aksyonov ◽

Dmytro Teslenko

Keyword(s):

Vestibular Schwannoma ◽

Internal Auditory Canal ◽

Residual Tumor ◽

Endoscopic Technique ◽

Vestibular Schwannomas ◽

Endoscopic Removal ◽

Tumor Removal ◽

Tumor Spread ◽

Microsurgical Technique ◽

Tumor Visualization

Aim: To investigate the features of the vestibular schwannoma spread into the internal auditory canal and the possibilities of endoscopic removal. Objectives: To improve tumor visualization in the internal auditory canal; to create a sufficient view angle for tumor removal during endoscopic opening of the internal auditory canal. Materials and methods: The results of surgical treatment of 20 patients with vestibular schwannomas in which the tumor spread to the internal auditory canal were analyzed. Microsurgical tumor removal was performed in 14 cases; Fully endoscopic removal of vestibular schwannomas was performed in 6 cases. The internal auditory canal opening was performed in 14 cases using microsurgical technique and in 6 cases with fully the endoscopic technique. Results: Gross total removal was achieved in 18 cases, subtotal removal in 2 cases. The tumor spread into the internal auditory canal was removed in all cases (100%). Opening the internal auditory canal using the endoscopic technique allows to increase the view angle (up to 20%) and to visualize along the axis of canal. Conclusions: 1) Endoscopic assistance technique allows to improve residual tumor visualization much more better then microsurgical technique; 2) Internal auditory canal opening using endoscopic technique is much more effective than the microsurgical technique (trepanning depth is larger); 3) Endoscopic methods for the internal auditory canal opening allows to increase canal angle view up to 20% (comparing to the microsurgical view).

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Retrosigmoid Approach for Vestibular Schwannoma Surgery

Vestibular Schwannoma Surgery ◽

10.1007/978-3-319-99298-3_4 ◽

2019 ◽

pp. 105-133

Author(s):

Pınar Eser Ocak ◽

Ihsan Dogan ◽

Sima Sayyahmelli ◽

Mustafa K. Baskaya

Keyword(s):

Vestibular Schwannoma ◽

Retrosigmoid Approach

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