Nerve of Origin, Tumor Size, Hearing Preservation, and Facial Nerve Outcomes in 359 Vestibular Schwannoma Resections at a Tertiary Care Academic Center

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.

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Hearing Preservation and Facial Nerve Outcomes in Vestibular Schwannoma Surgery: Results Using the Middle Cranial Fossa Approach

Otology & Neurotology ◽

10.1097/01.mao.0000185153.54457.16 ◽

2006 ◽

Vol 27 (2) ◽

pp. 234-241 ◽

Cited By ~ 75

Author(s):

H Alexander Arts ◽

Steven A Telian ◽

Hussam El-Kashlan ◽

B Gregory Thompson

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Hearing Preservation ◽

Middle Cranial Fossa ◽

Middle Cranial Fossa Approach ◽

Cranial Fossa

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Intraoperative neurophysiological monitoring in vestibular schwannoma surgery: advances and clinical implications

Neurosurgical FOCUS ◽

10.3171/2009.8.focus09144 ◽

2009 ◽

Vol 27 (4) ◽

pp. E9 ◽

Cited By ~ 36

Author(s):

A. Samy Youssef ◽

Angela E. Downes

Keyword(s):

Facial Nerve ◽

Functional Outcome ◽

Vestibular Schwannoma ◽

Cranial Nerve ◽

Evoked Potential ◽

Hearing Preservation ◽

Auditory Evoked Potential ◽

Intraoperative Neurophysiological Monitoring ◽

Neurophysiological Monitoring ◽

Clinical Series

Object Intraoperative neurophysiological monitoring has become an integral part of vestibular schwannoma surgery. The aim of this article was to review the different techniques of intraoperative neurophysiological monitoring in vestibular schwannoma surgery, identify the clinical impact of certain pathognomonic patterns on postoperative outcomes of facial nerve function and hearing preservation, and highlight the role of postoperative medications in improving delayed cranial nerve dysfunction in the different reported series. Methods The authors performed a review of the literature regarding intraoperative monitoring in acoustic/vestibular schwannoma surgery. The different clinical series representing different monitoring techniques were reviewed. All the data from clinical series were analyzed in a comprehensive and comparative model. Results Intraoperative brainstem auditory evoked potential monitoring, direct cochlear nerve action potential monitoring, and facial nerve electromyography are the main tools used to assess the functional integrity of an anatomically intact cranial nerve. The identification of pathognomonic brainstem auditory evoked potential and electromyography patterns has been correlated with postoperative functional outcome. Recently, perioperative administration of intravenous hydroxyethyl starch and nimodipine as vasoactive and neuroprotective agents was shown to improve vestibular schwannoma functional outcome in few reported studies. Conclusions Recent advances in electrophysiological technology have considerably contributed to improvement in functional outcome of vestibular neuroma surgery in terms of hearing preservation and facial nerve paresis. Perioperative intravenous nimodipine and hydroxyethyl starch may be valuable additions to surgery.

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Tumor origin and hearing preservation in vestibular schwannoma surgery

Journal of Neurosurgery ◽

10.3171/2011.7.jns102092 ◽

2011 ◽

Vol 115 (5) ◽

pp. 900-905 ◽

Cited By ~ 9

Author(s):

Jens Rachinger ◽

Stefan Rampp ◽

Julian Prell ◽

Christian Scheller ◽

Alex Alfieri ◽

...

Keyword(s):

Vestibular Schwannoma ◽

Tumor Size ◽

Hearing Preservation ◽

Vestibular Nerve ◽

Cochlear Nerve ◽

Nerve Function ◽

Nerve Preservation ◽

Tumor Origin ◽

Inferior Vestibular Nerve ◽

Vs Removal

Object Preservation of cochlear nerve function in vestibular schwannoma (VS) removal is usually dependent on tumor size and preoperative hearing status. Tumor origin as an independent factor has not been systematically investigated. Methods A series of 90 patients with VSs, who underwent surgery via a suboccipitolateral route, was evaluated with respect to cochlear nerve function, tumor size, radiological findings, and intraoperatively confirmed tumor origin. All patients were reevaluated 12 months after surgery. Results Despite comparable preoperative cochlear nerve status and larger tumor sizes, hearing preservation was achieved in 42% of patients with tumor originating from the superior vestibular nerve, compared with 16% of those with tumor originating from the inferior vestibular nerve. Conclusions Tumor origin is an important prognostic factor for cochlear nerve preservation in VS surgery.

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

Otolaryngology ◽

10.1016/j.otohns.2004.09.027 ◽

2005 ◽

Vol 132 (3) ◽

pp. 459-466 ◽

Cited By ~ 29

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.

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Clinical Evaluation of CyberKnife in the Treatment of Vestibular Schwannomas

BioMed Research International ◽

10.1155/2013/297093 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 21

Author(s):

Jo-Ting Tsai ◽

Jia-Wei Lin ◽

Chien-Min Lin ◽

Yuan-Hao Chen ◽

Hsin-I Ma ◽

...

Keyword(s):

Hearing Loss ◽

Prognostic Factors ◽

Clinical Evaluation ◽

Vestibular Schwannoma ◽

Tumor Size ◽

Hearing Preservation ◽

Tumor Control ◽

Auditory Function ◽

Tumor Control Rate ◽

Preservation Rate

Objective. This study assessed the posttreatment tumor control and auditory function of vestibular schwannoma (VS) patients after CyberKnife (CK) and analyzed the possible prognostic factors of hearing loss.Methods. We retrospectively studied 117 VS patients, with Gardner-Robertson (GR) classification grades I to IV, who underwent CK between 2006 and 2012. Data including radiosurgery treatment parameters, pre- and postoperative tumor size, and auditory function were collected and examined.Results. With CK, 117 patients had excellent tumor control rates (99.1%), with a mean imaging followup of 61.1 months. Excluding 52 patients (GR III-IV pretreatment), 53 (81.5%) of the remaining 65 patients (initial GR I-II) maintained GR I or II hearing after CK, with a mean audiometric followup of 64.5 months. Twelve patients experienced hearing degradation (91.6% were GR II pretreatment); they appeared to have significantly larger tumor sizes, significantly smaller cochlear sizes, and higher prescribed cochlear doses, compared to the patients with preserved hearing.Conclusion. Our data showed that CK treatment provided an excellent tumor control rate and a comparable hearing preservation rate in VS patients. Patients with pretreatment GR II hearing levels, larger tumor volumes, smaller cochlear sizes, and higher prescribed cochlear doses may have poor hearing prognoses.

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Type 2 neurofibromatosis: the need for supraregional care?

The Journal of Laryngology & Otology ◽

10.1017/s002221510012328x ◽

1993 ◽

Vol 107 (5) ◽

pp. 401-406 ◽

Cited By ~ 36

Author(s):

D. Gareth R. Evans ◽

Richard Ramsden ◽

Susan M. Huson ◽

Rodney Harris ◽

Richard Lye ◽

...

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Acoustic Neuroma ◽

Hearing Preservation ◽

Definitive Treatment ◽

Facial Nerve Function ◽

Operative Results ◽

Nerve Preservation ◽

Quality Life

The results of a U.K. study of 145 cases of type 2 neurofibromatosis has shown generally very poor operative results in terms of hearing and facial nerve preservation. Only 9 out of 118 vestibular schwannoma (acoustic neuroma) operations resulted in any clinically detectable hearing preservation and only 32 left the patient with good or normal (House grade I or II) ipsilateral facial nerve function. Although operation is still the definitive treatment of vestibular schwannoma (acoustic neuroma) and may be a lifesaving procedure, it appears that the evidence in favour of early operation is only valid when carried out in highly specialized centres. The special problems of NF2 cases who may go on to develop multiple spinal and cranial tumours making them wheelchair bound and blind as well as deaf warrants a careful experienced approach. Timing of operations may be critical for the enhancement of useful years of quality life. We therefore propose the setting up of a national NF2 register, with the management of cases at a few supraregional centres.

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Long-Term Outcomes of the Electrically Unresponsive, Anatomically Intact Facial Nerve Following Vestibular Schwannoma Surgery

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1725034 ◽

2021 ◽

Author(s):

Alireza Shoakazemi ◽

Alejandro Feria ◽

Constantine E. Kanakis ◽

Emma Stapleton ◽

Omar N. Pathmanaban ◽

...

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Tumor Size ◽

Conduction Block ◽

Extent Of Resection ◽

Nerve Grafting ◽

Long Term Outcomes ◽

Operative Notes

Abstract Objective The study aimed to determine long-term outcomes in patients with intraoperative electrical conduction block in an anatomically intact facial nerve (FN). Patients and Methods Single center retrospective review of prospectively collected database of all vestibular schwannoma surgeries between January 1, 2008 and August 25, 2015. Operative notes were reviewed and patients with anatomically intact FNs, but complete conduction block at the end of surgery were included for analysis. Results In total, 371 patients had vestibular schwannoma surgery of which 18 met inclusion criteria. Mean follow-up was 34.28 months and average tumor size was 28.00 mm. Seventeen patients had House-Brackmann Grade VI facial palsy immediately postoperatively and one patient was grade V. At 1 year, three patients remained grade VI (17%), two improved to grade V (11%), seven to grade IV (39%), six to grade III (33%), and one patient to grade II (6%). On extended follow-up, five patients (28%) had additional 1 to 2 score improvement in facial function. Subset analysis revealed no correlation of tumor size, vascularity, adherence to nerve, operative approach, extent of resection, splaying of FN, and recurrent tumor or sporadic tumors to the extent of FN recovery. Conclusion Intraoperative conduction block does not condemn a patient to permanent FN palsy. There is potential for a degree of recovery comparable with those undergoing nerve grafting. Our data do not clearly support a policy of same-surgery or early-postoperative primary nerve grafting in the event of a complete conduction block, and instead we favor monitoring for recovery in an anatomically intact nerve.

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