Suboccipital Surgical Approach to the Cerebellopontine Angle and Internal Auditory Canal

The suboccipital craniectomy done with the patient in the prone position using modern microsurgical methods gives good anatomical exposure essential for efficient, accurate, total removal of cerebellopontine angle neoplasms and allows adjacent. uninvolved neurological structures to be spared. Modifying the anatomical exposure by varying the size and shape of the osseous craniectomy and placing the dural incision closer to the porus acousticus permits extradural retraction of the cerebellum. Thus large cerebellopontine angle neoplasms can be excised with less chance of damage to the cerebellum and smaller risk of hydrocephalus. The suboccipital craniectomy may be extended anteriorly to the facial nerve, thereby combining the suboccipital with the translabyrinthine approach. and providing a more direct angle to a large neoplasm involving the brain stem and cerebellum.

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Facial nerve preservation in patients with large acoustic neuromas treated by a combined middle fossa transtentorial translabyrinthine approach

Journal of Neurosurgery ◽

10.3171/jns.1982.57.1.0001 ◽

1982 ◽

Vol 57 (1) ◽

pp. 1-7 ◽

Cited By ~ 21

Author(s):

Charles H. Tator ◽

Julian M. Nedzelski

Keyword(s):

Facial Nerve ◽

Brain Stem ◽

Cerebellopontine Angle ◽

Middle Fossa ◽

Total Removal ◽

Content Type ◽

Translabyrinthine Approach ◽

Acoustic Neuromas ◽

The Brain ◽

Fine Print

✓ With large acoustic neuromas, the primary goal of surgery is safe total removal of the tumors, and the secondary goal is preservation of nearby neural structures, including the facial nerve. In a series of 15 consecutive patients with large cerebellopontine angle tumors, all of which were more than 2.5 cm in diameter, tumor excision was performed by a one-stage combined middle fossa-translabyrinthine approach. There were 13 acoustic neuromas, 10 of which were more than 4 cm in diameter, one petrous apex meningioma 4 cm in diameter, and one facial neuroma 3 cm in diameter. The tumors were totally removed in all 15 patients. The facial nerve was preserved in 12 of 13 evaluable patients. In the 14th patient the nerve had been transected in a previous suboccipital procedure with incomplete removal, and in the 15th patient the nerve was sutured following excision of a facial neuroma. Thus, the nerve was lost at surgery in only one patient. This combined approach provided very clear visualization of the cerebellopontine angle, including the brain stem and the lower cranial nerves. It enabled identification of both the origin of the facial nerve at the brain stem and the lateral segment of the nerve in the internal auditory canal. Anterior extensions of tumor growing through the tentorial hiatus were easily removed. The results in these 15 patients show that this approach is excellent for total removal of large acoustic neuromas with preservation of the facial nerve. It is especially suitable for large tumors with anterior extensions.

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Facial Nerve Repair in Cerebellopontine Angle Surgery

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348947808700604 ◽

1978 ◽

Vol 87 (6) ◽

pp. 772-777 ◽

Cited By ~ 24

Author(s):

Derald E. Brackmann ◽

William E. Hitselberger ◽

Jerald V. Robinson

Keyword(s):

Facial Nerve ◽

Brain Stem ◽

Cerebellopontine Angle ◽

Nerve Repair ◽

Nerve Graft ◽

Tumor Removal ◽

Stylomastoid Foramen ◽

Substitution Procedure ◽

The Brain ◽

Facial Function

Facial nerve continuity was restored during cerebellopontine angle tumor removal in nine cases. The distal facial nerve was rerouted from the stylomastoid foramen into the cerebellopontine angle. Direct suture was accomplished in seven cases while two required interposition of a greater auricular nerve graft. There was excellent return of facial function in eight of the nine cases. Overall results are superior to nerve substitution techniques. The facial nerve should be inspected for continuity following tumor removal. If one is not certain the nerve is intact, the proximal facial stump should be identified at the brain stem and facial nerve continuity reestablished. A nerve substitution procedure should be resorted to at a later time only when the proximal facial stump is not identifiable.

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Arteriovenous malformations in the posterior fossa

Journal of Neurosurgery ◽

10.3171/jns.1977.47.1.0050 ◽

1977 ◽

Vol 47 (1) ◽

pp. 50-56 ◽

Cited By ~ 47

Author(s):

Hiroshi Matsumura ◽

Yasumasa Makita ◽

Kuniyuki Someda ◽

Akinori Kondo

Keyword(s):

Arteriovenous Malformation ◽

Brain Stem ◽

Posterior Fossa ◽

Arteriovenous Malformations ◽

Cerebellopontine Angle ◽

Anterior Part ◽

Content Type ◽

The Brain ◽

Fine Print

✓ We have operated on 12 of 14 cases of arteriovenous malformation (AVM) in the posterior fossa since 1968, with one death. The lesions were in the cerebellum in 10 cases (three anteromedial, one central, three lateral, and three posteromedial), and in the cerebellopontine angle in two; in two cases the lesions were directly related to the brain stem. The AVM's in the anterior part of the cerebellum were operated on through a transtentorial occipital approach.

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

Operative Neurosurgery ◽

10.1093/ons/opab335 ◽

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.

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Causes of Facial Nerve Paresis after Translabyrinthine Surgery for Acoustic Neuroma

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348949210101004 ◽

1992 ◽

Vol 101 (10) ◽

pp. 821-826 ◽

Cited By ~ 18

Author(s):

Mirko Tos ◽

Jens Thomsen ◽

Mahmoud Youssef ◽

Suat Turgut

Keyword(s):

Facial Nerve ◽

Brain Stem ◽

Acoustic Neuroma ◽

Facial Palsy ◽

Cerebellopontine Angle ◽

Patient Records ◽

Nerve Function ◽

Facial Nerve Function ◽

Common Site ◽

Nerve Paresis

Forty-six consecutive video-recorded translabyrinthine operations at Gentofte Hospital, for tumors of 5 to 25 mm, were investigated for possible damage to the facial nerve from cauterization, suction, stretching, pushing, and other instrumental trauma at the following regions: fundus, internal meatus, porus, cerebellopontine angle, and brain stem. House-Brackmann grading of the postoperative facial nerve function was determined from the patient records for the 1st, 3rd, and 10th days and 3 months and 6 months postoperatively, as well as the final status. Suction on the nerve seems to be the most important factor for perioperative facial nerve damage. The most common site of damage was the porus region. This investigation shows thermic drilling lesions to be very relevant. There was no correlation between the degree and character of damage and the postoperative facial nerve function. In eight patients we cannot explain the postoperative facial palsy.

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Facial Nerve Neuromas: Report of 10 Cases and Review of the Literature

Neurosurgery ◽

10.1097/00006123-200203000-00004 ◽

2002 ◽

Vol 50 (3) ◽

pp. 450-456 ◽

Cited By ~ 8

Author(s):

Jonathan D. Sherman ◽

Elias Dagnew ◽

Myles L. Pensak ◽

Harry R. van Loveren ◽

John M. Tew

Keyword(s):

Facial Nerve ◽

Cerebellopontine Angle ◽

Internal Auditory Canal ◽

Hearing Preservation ◽

Outpatient Basis ◽

Nerve Sheath Tumor ◽

Facial Paresis ◽

Presenting Symptoms ◽

Nervus Intermedius

Abstract OBJECTIVE: This study reviewed the management and outcomes of facial neuromas during the past decade at our institution. The goal was to analyze differences in presentation on the basis of location of the facial neuroma, review facial nerve function and hearing preservation postoperatively, and understand the characteristics of patients with tumors limited to the cerebellopontine angle or internal auditory canal. We also report an unusual case of a facial neuroma limited to the nervus intermedius. METHODS: Nine patients with facial neuromas and one with Jacobson's nerve neuroma underwent surgery, and total resection was accomplished in nine patients. A chart review for pre- and postoperative data was performed, after which all patients were evaluated on an outpatient basis. RESULTS: The mean age of the patients was 47 years; mean follow-up time was 33.1 months. The most common presenting symptoms were hearing loss (six patients) and facial paresis (five patients). A total of five patients had progressive (four patients) or recurrent (one patient) facial paresis. No patient experienced worsened hearing as a result of surgery, and one experienced improvement in a conductive hearing deficit. Five patients required cable graft repair of the facial nerve; four improved to House-Brackmann Grade 3 facial paresis. Four of five patients with preserved anatomic continuity of the facial nerve regained normal facial function. There were no surgical complications. No tumors have recurred during follow-up. We report the second nerve sheath tumor limited to the nervus intermedius. CONCLUSION: This series documents that facial neuromas can be resected safely with preservation of facial nerve and hearing function. Preservation of anatomic continuity of the facial nerve should be attempted, and it does not seem to lead to frequent recurrence. Tumors limited to the cerebellopontine angle/internal auditory canal are a unique subset of facial neuromas with characteristics that vary greatly from facial neuromas in other locations, and they are indistinguishable clinically from acoustic neuromas.

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Hemifacial Spasm: Treatment by Microsurgical Facial Nerve Decompression

Neurosurgery ◽

10.1227/00006123-198308000-00006 ◽

1983 ◽

Vol 13 (2) ◽

pp. 141-146 ◽

Cited By ~ 96

Author(s):

John D. Loeser ◽

James Chen

Keyword(s):

Facial Nerve ◽

Brain Stem ◽

Surgical Therapy ◽

Hemifacial Spasm ◽

Surgical Patients ◽

Facial Weakness ◽

Nerve Decompression ◽

The Brain ◽

Facial Nerve Decompression

Abstract The literature on hemifacial spasm and its surgical therapy is reviewed, and the authors' experiences with 20 patients are described. Vascular cross compression of the facial nerve adjacent to the brain stem is seen in 90% of the surgical patients. Mobilizing the offending vessel will cure or significantly improve approximately 80% of the patients. Complications occur in 25% of the patients and usually involve decreased hearing or facial weakness. Mortality is virtually zero, and this operation is vastly superior to any other medical or surgical therapy for hemifacial spasm. The pathophysiology is not yet understood.

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Transvestibular Approach to the Internal Auditory Canal

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348947508400201 ◽

1975 ◽

Vol 84 (2) ◽

pp. 145-151 ◽

Cited By ~ 2

Author(s):

F. Antoli-Candela ◽

F. Alvarez de Cozar ◽

F. Antoli-Candela

Keyword(s):

Facial Nerve ◽

Surgical Approach ◽

Diagnostic Procedure ◽

Operative Procedure ◽

Internal Auditory Canal ◽

Ménière’S Disease ◽

Acoustic Neurinoma ◽

Nerve Decompression ◽

Vestibular Response ◽

Facial Nerve Decompression

A surgical approach to the internal auditory canal is presented which has proved useful in the following circumstances: 1) as a destructive procedure in Ménière's disease, 2) as a diagnostic procedure in patients in whom an acoustic neurinoma is suspected and a labyrinthectomy is indicated. In this situation the tumor may be removed during the same operative procedure, 3) for the removal of small, mobile, intracanalicular neurinomas, and 4) for complete facial nerve decompression in patients with no vestibular response and no serviceable hearing.

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