Hearing preservation in vestibular schwannoma surgery: what factors influence outcome?

Post, Kalmon D.; Eisenberg, Mark; Catalano, Peter J.

doi:10.3171/jns.1995.83.2.0191

Cited by 104 publications

(59 citation statements)

References 57 publications

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“…7,36,55,97 Several groups have supported this position, declaring that aggressive tumor removal as early as possible provides the greatest chance of hearing preservation. 41,50,70,76,77 Consistent with previous studies, 17,26,42,66,77 our analysis indicates improved hearing preservation with smaller tumors.…”

supporting

confidence: 80%

“…59,81 The higher incidence of facial nerve dysfunction for all patients with tumors larger than 3.0 cm is likely related to the effect of tumor size. 17,26,42,65,66,77 In summary, our analysis demonstrates the clear benefit of the retrosigmoid approach specifically for facial function among patients with tumors that are intracanalicular and 1.5-3.0 cm in size, with no difference in benefit between the middle cranial fossa and retrosigmoid approaches for patients with extrameatal tumor diameters less than 1.5 cm. For most tumor sizes, the translabyrinthine approach seems to be associated with a higher rate of facial nerve dysfunction.…”

mentioning

confidence: 94%

“…Data for facial nerve dysfunction and hearing loss were stratified based on tumor size because tumor size has been shown to be the most important predictive factor for outcome related to these variables. 17,26,42,65,66,77 Tumors were stratified as entirely IC (no extrameatal extension) or based on their extrameatal diameter (< 1.5 cm, 1.5-3.0 cm, or > 3.0 cm into the CPA). Table 1 summarizes the results for different clinical variables based on surgical approach.…”

Section: Reviewmentioning

confidence: 99%

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Surgery for vestibular schwannomas: a systematic review of complications by approach

Ansari

Terry

Cohen-Gadol

2012

FOC

251

216

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Object Various studies report outcomes of vestibular schwannoma (VS) surgery, but few studies have compared outcomes across the various approaches. The authors conducted a systematic review of the available data on VS surgery, comparing the different approaches and their associated complications. Methods MEDLINE searches were conducted to collect studies that reported information on patients undergoing VS surgery. The authors set inclusion criteria for such studies, including the availability of follow-up data for at least 3 months, inclusion of preoperative and postoperative audiometric data, intraoperative monitoring, and reporting of results using established and standardized metrics. Data were collected on hearing loss, facial nerve dysfunction, persistent postoperative headache, CSF leak, operative mortality, residual tumor, tumor recurrence, cranial nerve (CN) dysfunction involving nerves other than CN VII or VIII, and other neurological complications. The authors reviewed data from 35 studies pertaining to 5064 patients who had undergone VS surgery. Results The analyses for hearing loss and facial nerve dysfunction were stratified into the following tumor categories: intracanalicular (IC), size (extrameatal diameter) < 1.5 cm, size 1.5–3.0 cm, and size > 3.0 cm. The middle cranial fossa approach was found to be superior to the retrosigmoid approach for hearing preservation in patients with tumors < 1.5 cm (hearing loss in 43.6% vs 64.3%, p < 0.001). All other size categories showed no significant difference between middle cranial fossa and retrosigmoid approaches with respect to hearing loss. The retrosigmoid approach was associated with significantly less facial nerve dysfunction in patients with IC tumors than the middle cranial fossa method was; however, neither differed significantly from the translabyrinthine corridor (4%, 16.7%, 0%, respectively, p < 0.001). The middle cranial fossa approach differed significantly from the translabyrinthine approach for patients with tumors < 1.5 cm, whereas neither differed from the retrosigmoid approach (3.3%, 11.5%, and 7.2%, respectively, p = 0.001). The retrosigmoid approach involved less facial nerve dysfunction than the middle cranial fossa or translabyrinthine approaches for tumors 1.5–3.0 cm (6.1%, 17.3%, and 15.8%, respectively; p < 0.001). The retrosigmoid approach was also superior to the translabyrinthine approach for tumors > 3.0 cm (30.2% vs 42.5%, respectively, p < 0.001). Postoperative headache was significantly more likely after the retrosigmoid approach than after the translabyrinthine approach, but neither differed significantly from the middle cranial fossa approach (17.3%, 0%, and 8%, respectively; p < 0.001). The incidence of CSF leak was significantly greater after the retrosigmoid approach than after either the middle cranial fossa or translabyrinthine approaches (10.3%, 5.3%, 7.1%; p = 0.001). The incidences of residual tumor, mortality, major non-CN complications, residual tumor, tumor recurrence, and dysfunction of other cranial nerves were not significantly different across the approaches. Conclusions The middle cranial fossa approach seems safest for hearing preservation in patients with smaller tumors. Based on the data, the retrosigmoid approach seems to be the most versatile corridor for facial nerve preservation for most tumor sizes, but it is associated with a higher risk of postoperative pain and CSF fistula. The translabyrinthine approach is associated with complete hearing loss but may be useful for patients with large tumors and poor preoperative hearing.

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supporting

confidence: 80%

mentioning

confidence: 94%

Section: Reviewmentioning

confidence: 99%

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Surgery for vestibular schwannomas: a systematic review of complications by approach

Ansari

Terry

Cohen-Gadol

2012

FOC

251

216

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“…[1,2,11,[14][15][16][17]19] Given the medical, psychological, and functional sequelae of facial nerve weakness, [13,23] close attention has been paid to factors that influence facial nerve outcome, and a number of authors have reported on their experience with these complex tumors. [1,11,17,18,21] In recent years, the phenomenon of delayed facial nerve palsy has become evident.…”

mentioning

confidence: 99%

Late-onset facial nerve degeneration after vestibular schwannoma surgery: incidence, putative mechanisms, and prevention

Sampath

Rhines²,

Holliday³

et al. 1998

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Delayed facial nerve dysfunction after vestibular schwannoma surgery is a poorly understood phenomenon that has been reported to occur in 15 to 29% of patients undergoing microsurgery. It is a condition characterized by spontaneous deterioration of facial nerve function in a patient who has otherwise normal or near-normal facial function in the immediate postoperative period. This delayed paralysis is generally reported to occur in the first few days postsurgery, with the majority of patients eventually recovering their immediate postoperative facial function. However, infrequently, it can also occur more than 1 week after surgery (so-called late-onset facial nerve palsy). The authors reviewed facial nerve outcome in 611 patients who underwent microsurgery between 1973 and 1994. The facial nerve was anatomically preserved in 596 patients (97.5%), and 90% of patients had House-Brackmann[6] Grade 1 or 2 function 1 year after surgery. Late-onset facial dysfunction was seen in 13 patients (2.1%). All of these had significant deterioration in facial nerve function between 1 and 4 weeks postoperatively, and all showed improvement by 1 year. In this study, the focus on these patients who developed late-onset facial palsy. The incidence, treatment strategies, and outcomes will be discussed with emphasis on possible pathophysiological mechanisms that contribute to this relatively rare condition.

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“…In most centers around the world, patients undergo this surgery in a supine (flat or slight reverse Trendelenberg) position, with the head turned or in a lateral position. 2 Patients with hydrocephalus, even those with modestly elevated intracranial pressure (ICP), at induction of anesthesia can have their ICP severely elevated, and this may be obviated in the sitting position. Modest or marked elevation of the ICP will often make it more difficult to perform the surgical procedure safely and to accomplish the removal of the entire tumor while sparing the critical cranial nerves.…”

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confidence: 99%

Editorial: Acoustics and hydrocephalus

Becker¹

2011

JNS

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This retrospective study regarding management options in patients with hydrocephalus associated with vestibular schwannomas (VSs) comes from a center with a remarkably large surgical experience treating this tumor type.1 Their surgical technique has been exquisitely developed over many years, and is uniform among colleagues in their institution. They receive worldwide referrals and treat a greater than usual number of larger VSs. This helps to account for their significant experience with hydrocephalus in patients with this specific tumor; that is, larger tumors often present for a longer than usual period of time. Their consecutive series of 400 patients was collected over a 6-year period (an average of more than 66 cases per year). Their overall results with complete tumor removal and percentage of saved facial nerve function and preserved hearing is among the best reported in the medical literature. 3In evaluating the superb results herein reported ("The general and functional outcome of surgery showed no correlation to the presence of preoperative hydrocephalus."), the above statements and the fact that these patients undergo operation in the semisitting position, with very experienced neuroanesthesiologists performing the anesthesia, must be taken into account. In most centers around the world, patients undergo this surgery in a supine (flat or slight reverse Trendelenberg) position, with the head turned or in a lateral position.2 Patients with hydrocephalus, even those with modestly elevated intracranial pressure (ICP), at induction of anesthesia can have their ICP severely elevated, and this may be obviated in the sitting position. Modest or marked elevation of the ICP will often make it more difficult to perform the surgical procedure safely and to accomplish the removal of the entire tumor while sparing the critical cranial nerves.My own recommendation (and I believe the procedures that are followed in most centers where patients are not operated on in the sitting position) would be as follows: 1) patients with symptomatic hydrocephalus accompanied by elevated ICP would have an external ventricular drain (EVD) placed, and when the ICP normalized in 1 or 2 days, they would be taken to surgery. The EVD would be left in place postoperatively, and then the patient would be gradually weaned from the drain. If weaning was not possible (as the authors recommend), a ventriculoperitoneal shunt would be placed. 2) Patients with asymptomatic hydrocephalus and those with normalpressure hydrocephalus (NPH) symptomatology would have an EVD placed at the beginning of anesthesia, the pressure would be kept in a normal range during the operation to mitigate elevated pressure transmission to the posterior fossa, and then after surgery the drain would be left in, and then usually removed in 1-2 days, as long as the clamped pressure permitted this. With this approach, the incidence of permanent hydrocephalus (obstructive or communicating), and CSF leakage would probably be similar to that reported herein. The authors empha...

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Hearing preservation in vestibular schwannoma surgery: what factors influence outcome?

Cited by 104 publications

References 57 publications

Surgery for vestibular schwannomas: a systematic review of complications by approach

Surgery for vestibular schwannomas: a systematic review of complications by approach

Late-onset facial nerve degeneration after vestibular schwannoma surgery: incidence, putative mechanisms, and prevention

Editorial: Acoustics and hydrocephalus

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