Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach

Object The choice of approach for surgical removal of large acoustic neuromas is still controversial. The authors reviewed the results in a series of patients who underwent removal of large tumors via the translabyrinthine approach. Methods The authors conducted a database analysis of 190 patients (89 men and 101 women) with acoustic neuromas 3 cm or greater in size. The mean age of these patients was 46.1 ± 15.6 years. One hundred seventy-eight patients underwent primary translabyrinthine surgical removal and 12 underwent surgery for residual tumor. Total tumor removal was accomplished in 183 cases (96.3%). The tumor was adherent to the facial nerve to some degree in 64% of the cases, but the facial nerve was preserved anatomically in 178 (93.7%) of the patients. Divided nerves were repaired by primary attachment or cable graft. Facial nerve function was assessed immediately after surgery, at the time of discharge, and at 3 to 4 weeks and 1 year after discharge. Excellent function (House-Brackmann facial nerve Grade I or II) was present in 55%, 33.9%, 38.8%, and 52.6% of the patients for each time interval, respectively, with acceptable function (Grades I–IV) in 81% at 1 year. Cerebrospinal fluid leakage that required surgical repair occurred in only 1.1% of the patients and meningitis occurred in 3.7%. There were no deaths. Conclusions Use of the translabyrinthine approach for removal of large tumors resulted in good anatomical and functional preservation of the facial nerve, with minimum incidence of morbidity and no incidence of mortality. The authors continue to recommend use of this approach for acoustic tumors larger than 3 cm and for smaller tumors when hearing preservation is not an issue.

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Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach

Journal of Neurosurgery ◽

10.3171/jns.1999.90.4.0617 ◽

1999 ◽

Vol 90 (4) ◽

pp. 617-623 ◽

Cited By ~ 133

Author(s):

Todd H. Lanman ◽

Derald E. Brackmann ◽

William E. Hitselberger ◽

Bill Subin

Keyword(s):

Facial Nerve ◽

Residual Tumor ◽

Hearing Preservation ◽

Cerebrospinal Fluid Leakage ◽

Surgical Removal ◽

Time Interval ◽

Content Type ◽

Translabyrinthine Approach ◽

Acoustic Neuromas ◽

Fine Print

Object. The choice of approach for surgical removal of large acoustic neuromas is still controversial. The authors reviewed the results in a series of patients who underwent removal of large tumors via the translabyrinthine approach.Methods. The authors conducted a database analysis of 190 patients (89 men and 101 women) with acoustic neuromas 3 cm or greater in size. The mean age of these patients was 46.1 ± 15.6 years. One hundred seventy-eight patients underwent primary translabyrinthine surgical removal and 12 underwent surgery for residual tumor. Total tumor removal was accomplished in 183 cases (96.3%). The tumor was adherent to the facial nerve to some degree in 64% of the cases, but the facial nerve was preserved anatomically in 178 (93.7%) of the patients. Divided nerves were repaired by primary attachment or cable graft. Facial nerve function was assessed immediately after surgery, at the time of discharge, and at 3 to 4 weeks and 1 year after discharge. Excellent function (House—Brackmann facial nerve Grade I or II) was present in 55%, 33.9%, 38.8%, and 52.6% of the patients for each time interval, respectively, with acceptable function (Grades I—IV) in 81% at 1 year. Cerebrospinal fluid leakage that required surgical repair occurred in only 1.1% of the patients and meningitis in 3.7%. There were no deaths.Conclusions. Use of the translabyrinthine approach for removal of large tumors resulted in good anatomical and functional preservation of the facial nerve, with minimum incidence of morbidity and no incidence of mortality. The authors continue to recommend use of this approach for acoustic tumors larger than 3 cm and for smaller tumors when hearing preservation is not an issue.

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Retractorless translabyrinthine approach for resection of a large acoustic neuroma: operative video and technical nuances

Neurosurgical FOCUS ◽

10.3171/2014.v1.focus13441 ◽

2014 ◽

Vol 36 (v1supplement) ◽

pp. 1 ◽

Cited By ~ 1

Author(s):

James K. Liu ◽

Robert W. Jyung

Keyword(s):

Facial Nerve ◽

Acoustic Neuroma ◽

Tumor Resection ◽

Fat Graft ◽

Cerebrospinal Fluid Leakage ◽

Dural Defect ◽

Nerve Preservation ◽

Facial Nerve Preservation ◽

Translabyrinthine Approach ◽

Acoustic Neuromas

Large acoustic neuromas, greater than 3 cm, can be technically challenging tumors to remove because of their intimate relationship with the brainstem and surrounding cranial nerves. Successful tumor resection involves functional preservation of the facial nerve and neurovascular structures. The translabyrinthine approach is useful for surgical resection of acoustic neuromas of various sizes in patients with poor preoperative hearing. The presigmoid surgical corridor allows direct exposure of the tumor in the cerebellopontine angle without any fixed cerebellar retraction. Early identification of the facial nerve at the fundus facilitates facial nerve preservation. Large acoustic tumors can be readily removed with a retractorless translabyrinthine approach using dynamic mobilization of the sigmoid sinus. In this operative video atlas report, the authors demonstrate their operative nuances for resection of a large acoustic neuroma via a translabyrinthine approach using a retractorless technique. Facial nerve preservation is achieved by maintaining a plane of dissection between the tumor capsule and the tumor arachnoid so that a layer of arachnoid protects the blood supply to the facial nerve. Multilayered closure is achieved with a fascial sling technique in which an autologous fascia lata graft is sutured to the dural defect to suspend the fat graft in the mastoidectomy defect. We describe the step-by-step technique and illustrate the operative nuances and surgical pearls to safely and efficiently perform the retractorless translabyrinthine approach, tumor resection, facial nerve preservation, and multi-layered reconstruction of the skull base dural defect to prevent postoperative cerebrospinal fluid leakage.The video can be found here: http://youtu.be/ros98UxqVMw.

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An Algorithm for the Management of Acoustic Neuromas regarding Age, Hearing, Tumor Size, and Symptoms

Otolaryngology ◽

10.1177/019459989310800101 ◽

1993 ◽

Vol 108 (1) ◽

pp. 1-10 ◽

Cited By ~ 46

Author(s):

Herbert Silverstein ◽

Seth I. Rosenberg ◽

John M. Flanzer ◽

Hayes H. Wanamaker ◽

Michael D. Seidman

Keyword(s):

Facial Nerve ◽

Acoustic Neuroma ◽

Pure Tone ◽

Hearing Preservation ◽

Subtotal Resection ◽

Residual Hearing ◽

Pure Tone Average ◽

The Past ◽

Translabyrinthine Approach ◽

Acoustic Neuromas

An algorithm has evolved for the management of patients with acoustic neuroma. Decisions as to surgery vs. observation, surgical approach, and whether hearing preservation should be attempted depend on age, patient symptoms, size of the tumor, residual hearing, and degree of facial nerve involvement at the time of surgery. Conservative management is used for patients over 65 years of age. This consists of observation or subtotal resection through a translabyrinthine approach, depending on the absence or presence of brainstem signs or symptoms. In patients under 65 years of age, hearing preservation is attempted through the retrosigmoid approach in tumors 1.5 cm or less if pure-tone average is less than 30 dB and the discrimination score is greater than 70%. The translabyrinthine approach is our preferred approach for tumors of any size when hearing is not serviceable. A near-total excision is performed when the facial nerve cannot be separated from the tumor. The rationale for this algorithm in the management of 130 cases of acoustic neuroma over the past 17 years is presented.

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Simultaneous Treatment of Vestibular Schwannoma and Concurrent Middle Ear Disease Using the Enlarged Translabyrinthine Approach

Korean Journal of Otorhinolaryngology - Head and Neck Surgery ◽

10.3342/kjorl-hns.2020.00675 ◽

2021 ◽

Vol 64 (5) ◽

pp. 344-349

Author(s):

Hae Eun Noh ◽

Ho Young Lee ◽

Gina Na ◽

In Seok Moon

Keyword(s):

Middle Ear ◽

Vestibular Schwannoma ◽

Hearing Preservation ◽

Cerebrospinal Fluid Leakage ◽

Surgical Removal ◽

Simultaneous Treatment ◽

Translabyrinthine Approach ◽

Complete Treatment ◽

Middle Ear Disease ◽

Staged Treatment

Unilateral presentation of vestibular schwannoma with concurrent chronic middle ear disease or cholesteatoma is rare. We report a series of patients with ipsilateral chronic middle ear disease and vestibular schwannoma, which were simultaneously removed via the enlarged translabyrinthine approach. All tumors were near-totally removed, and middle ear disease was completely excised; there were no major postoperative complications such as cerebrospinal fluid leakage, cholesteatoma recurrence, or meningitis. If hearing preservation of the affected ear is not necessary, simultaneous surgical removal of both pathologies is more convenient than staged treatment. The enlarged translabyrinthine approach can achieve complete treatment with one corridor.

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Petrous Bone Cholesteatoma: Facial and Hearing Preservation

Ear Nose & Throat Journal ◽

10.1177/01455613211056554 ◽

2021 ◽

pp. 014556132110565

Author(s):

Annalisa Pace ◽

Irene Claudia Visconti ◽

Giannicola Iannella ◽

Alessandro Milani ◽

Valeria Rossetti ◽

...

Keyword(s):

Facial Nerve ◽

Bone Conduction ◽

Pure Tone Audiometry ◽

Hearing Preservation ◽

Petrous Bone ◽

Endoscopic Approach ◽

Surgical Removal ◽

Translabyrinthine Approach ◽

Petrous Bone Cholesteatoma

Objectives: Petrous bone cholesteatoma (PBC) is a rare condition of the petrous portion of the temporal bone. Treatment of choice consists of radical surgical removal, paying attention to protect the facial nerve and inner ear as far as possible. The aim of the present study was to evaluate the efficacy of modified translabyrinthine techniques in preserving hearing function and the use of the adjuvant endoscopic techniques in a group of PBC patients. Methods: This study comprised 16 cases of PBCs surgically treated in our Department. Pre- and post-operative hearing status was assessed with pure tone audiometry and speech discrimination and graded according to the Gardner- Robertson classification system. Facial function was based on the House Brackman (HB) classification. PBCs were grouped using Sanna’s classification. The choice of surgical technique was based on the above findings together with preoperative evidence. Post-operative follow-up ranged from 1 to 10 years and also included Computed Tomography and Magnetic Resonance Imaging assessment. Results: PBCs were classified as follows: 37.5% infralabyrinthine; 43.75% supralabyrinthine; and 18.75% massive. Preservation of the bone conduction threshold was feasible in 62.5% of patients. For supralabyrinthine PBCs a subtotal petrosetomy was performed in all cases and hearing preservation was possible in 57% of them: an adjuvant endoscopic approach was performed in 43%. Infralabyrinthine PBCs were treated using a modified translabyrinthine approach with preservation of bone conduction in 83% of patients; an adjuvant endoscopic approach was performed in 50% cases. One patient with a massive cholesteatoma was treated by modified translabyrinthine approach, preserving a serviceable level of hearing. In all massive cases, an adjuvant endoscopic approach was performed. In 2 patients with preoperative palsy, facial nerve function showed an improvement. The follow-up period revealed evidence of limited recurrence at CT imaging in 2 patients. Conclusions: The introduction of modified surgical approaches, able to preserve the anatomical-functional structures, have shown an improvement of post-operative hearing outcomes.

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One-stage Removal of Residual Intracanalicular Acoustic Neuroma and Hemihypoglossal-intratemporal Facial Nerve Anastomosis: Technical Note

Neurosurgery ◽

10.1227/01.neu.0000093830.14935.39 ◽

2003 ◽

Vol 53 (6) ◽

pp. 1444-1448 ◽

Cited By ~ 16

Author(s):

Renato Donzelli ◽

Gaetano Motta ◽

Luigi Maria Cavallo ◽

Francesco Maiuri ◽

Enrico de Divitiis

Keyword(s):

Facial Nerve ◽

Acoustic Neuroma ◽

Facial Palsy ◽

Residual Tumor ◽

Surgical Removal ◽

Translabyrinthine Approach ◽

One Stage ◽

Incomplete Removal ◽

Nerve Anastomosis ◽

Suboccipital Approach

Abstract OBJECTIVE AND IMPORTANCE Incomplete removal of residual intracanalicular tumor and injury to the facial nerve are the main problems associated with surgery of large acoustic neuromas via the retromastoid suboccipital approach. In patients with residual or recurrent intracanalicular neuromas, the translabyrinthine approach is the preferred surgical route, allowing complete tumor removal; it may eventually also be used for exposure of the intratemporal portion of the facial nerve for a hemihypoglossal-facial nerve anastomosis when a postoperative facial palsy exists This one-stage procedure has not been described previously. CLINICAL PRESENTATION Three patients with postoperative facial palsy and residual intracanalicular tumor after surgical removal of a large acoustic neuroma via the retromastoid suboccipital approach underwent reoperation via the translabyrinthine approach and one-stage removal of the residual tumor and hemihypoglossal-facial nerve anastomosis. All three patients had a complete facial palsy of House-Brackmann Grade VI and a residual tumor of 8 to 12 mm. TECHNIQUE A classic translabyrinthine approach was used to open the internal auditory canal and remove the residual intracanalicular tumor. The facial nerve was exposed in its mastoid and tympanic parts, mobilized, and transected; then, the long nerve stump was transposed into the neck and used for an end-to-side anastomosis into the hypoglossal nerve. The operation resulted in variable improvement of the facial muscle function up to Grade III (one patient) and Grade IV (two patients). CONCLUSION Reoperation via the translabyrinthine approach is indicated for removal of residual intracanalicular acoustic neuroma and realization of a hypoglossal-facial nerve anastomosis in a single procedure. It is suggested that this type of anastomosis may also be used during the initial operation for acoustic neuroma removal when the facial nerve is inadvertently sectioned.

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Translabyrinthine Approach for Acoustic Neuroma

Neurosurgery ◽

10.1227/01.neu.0000103668.26590.5a ◽

2004 ◽

Vol 54 (2) ◽

pp. 391-396 ◽

Cited By ~ 30

Author(s):

John Diaz Day ◽

Douglas A. Chen ◽

Moises Arriaga

Keyword(s):

Surgical Treatment ◽

Acoustic Neuroma ◽

Cerebellopontine Angle ◽

Hearing Preservation ◽

Retrosigmoid Approach ◽

The Past ◽

Translabyrinthine Approach ◽

Acoustic Neuromas

Abstract THE TRANSLABYRINTHINE APPROACH has been popularized during the past 30 years for the surgical treatment of acoustic neuromas. It serves as an alternative to the retrosigmoid approach in patients when hearing preservation is not a primary consideration. Patients with a tumor of any size may be treated by the translabyrinthine approach. The corridor of access to the cerebellopontine angle is shifted anteriorly in contrast to the retrosigmoid approach, resulting in minimized retraction of the cerebellum. Successful use of the approach relies on a number of technical nuances that are outlined in this article.

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How I Do It: The Role of Flexible Hand-held 2μ-Thulium Laser Fiber in Microsurgical Removal of Acoustic Neuromas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1598202 ◽

2017 ◽

Vol 78 (04) ◽

pp. 301-307 ◽

Cited By ~ 8

Author(s):

Guglielmo Cacciotti ◽

Raffaele Roperto ◽

Maria Tonelli ◽

Ettore Carpineta ◽

Luciano Mastronardi

Keyword(s):

Facial Nerve ◽

Tumor Resection ◽

Hearing Preservation ◽

Matched Pair ◽

Nerve Preservation ◽

Acoustic Neuromas ◽

Laser Fiber ◽

Laser Focusing ◽

Preservation Rate

Aims We performed a retrospective nonrandomized study to analyze the results of microsurgery of acoustic neuromas (AN) using 2μ-thulium flexible hand-held laser fiber (Revolix jr). Methods From September 2010 to September 2015, 89 patients suffering from AN have been operated on with microsurgical technique via retrosigmoid approach. In 37 cases, tumor resection was performed with the assistance of 2μ-thulium flexible hand-held laser fiber (L-group). Eight cases operated on with the assistance of CO2 hand-held flexible laser fiber were excluded from this study. A total of 44 patients, operated on without laser assistance during the same period, were used as comparison group (C-group) (matched pair technique). Facial nerve function was assessed with the House–Brackmann (HB) scale preoperatively, and 1 week and 6 months postoperatively. Results Overall time from incision to skin suture changed in relation to size of tumor (165–575 minutes) and was not affected by the use of laser. In 7 out of 81 cases, a preoperative facial nerve palsy HB2 and in 1 case, HB4 (permanent) were observed. In the remaining 80 cases, at 6-month follow-up, facial nerve preservation rate (HB1) was 92.5%. Hearing preservation rate (AAO-HNS A/B classes) was 68.2% (26 out of 36). Adopting a 0 to 3 scale, the mean surgeon satisfaction rate of usefulness of laser fiber was 2.7. Conclusion The use of 2μ-thulium hand-held flexible laser fiber in AN microsurgery seems to be safe and subjectively facilitates tumor resection especially in “difficult” conditions (e.g., highly vascularized and hard tumors). In this limited retrospective trial, the good functional outcome following conventional microsurgery had not further improved, nor the surgical time reduced by laser. Focusing its use on “difficult” (large and vascularized) cases may lead to different results in future.

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Preservation of Facial, Cochlear, and other Nerve Functions in Acoustic Neuroma Treatment

Otolaryngology ◽

10.1177/019459989411000202 ◽

1994 ◽

Vol 110 (2) ◽

pp. 146-155 ◽

Cited By ~ 82

Author(s):

Jean-Marc Sterkers ◽

Gavin A. J. Morrison ◽

Olivier Sterkers ◽

Mohamed M. K. Badr El-Dine

Keyword(s):

Facial Nerve ◽

Cranial Nerves ◽

Surgical Excision ◽

Hearing Preservation ◽

Middle Fossa ◽

Middle Fossa Approach ◽

Translabyrinthine Approach ◽

Number Of Patients ◽

Facial Nerve Monitoring ◽

Facial Function

Between March 1966 and September 1992, 1400 acoustic neuromas were treated in Paris, France, by surgical excision. The findings over the last 7 years are presented. The translabyrinthine approach has been used in more than 85% of cases. Where hearing preservation is attempted, the middle fossa approach has been adopted for intracanilicular tumors and the retrosigmoid approach for small tumors extending into the cerebellopontine angle, in which the fundus of the internal meatus is free of tumor. The main goal is to achieve a grade I or II result in facial function within 1 month of surgery. Results improved during 1991 after the introduction of continuous facial nerve monitoring and the use of the Beaver mini-blade for dissection of tumor from nerve. With these techniques, facial function at grade I or II at 1 month improved from 20% to 52% for large tumors (larger than 3 cm), from 42% to 81% for medium tumors (2 to 3 cm), and from 70% to 92% for small tumors (up to and including 2 cm extracanalicular). The facial nerve was at greater risk using the retrosigmoid or middle fossa approaches than by the translabyrinthine route. Since 1985, success in hearing preservation has changed little, with useful hearing being preserved in 38.2% of cases operated on by means of the retrosigmoid route and 36.4% of cases after the middle fossa approach. In older patients with good hearing and small tumors, observation with periodic MRI scanning is recommended. Despite earlier diagnosis, the number of patients suitable for hearing preservation surgery remains very limited and careful selection is required. Trigeminal nerve signs were present in 20% of cases preoperativey, in 10% postoperatively, and recovered spontaneously. Palsies of the other cranial nerves after surgery were much rarer and were as follows: sixth nerve (abducens), 0.5%; ninth nerve (glossopharyngeal), 1.4%; and tenth nerve (vagus), 0.7%. The importance of preservation of function of the nervus intermedius of Wrisberg is stressed. These results emphasize the advantages of the translabyrinthine approach, offering greater security to the facial nerve and lower morbidity.

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