Two-handed endoscopic-directed vestibular nerve sectioning: case series and review of the literature

Abstract

<jats:sec><jats:title>Object</jats:title><jats:p>Vestibular nerve sectioning is an accepted surgical treatment option for patients with medically refractory Ménière disease. In this paper the authors introduce and evaluate a 2-handed endoscopic-directed technique for vestibular nerve section.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Eleven patients underwent a retrosigmoid craniectomy for endoscopic-directed vestibular nerve sectioning as treatment for intractable vertigo associated with Ménière disease. In all patients, identification and dissection of the cranial nerve VII/VIII complex was performed entirely under endoscopic guidance. The authors used the specially designed Frazee II neuroendoscope, consisting of a traditional endoscope lens with a microsuction attachment.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Vestibular nerve sectioning was completed in all 11 patients. Postoperative improvement in vertiginous episodes was achieved in 10 patients (91%). Auditory function was noted to be worse postoperatively in only 1 patient (9%). The same patient also developed a House-Brackmann Grade III facial nerve palsy, which improved gradually over time. There were no further complications, including no delayed CSF leaks.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>The endoscopic-directed approach represents a safe and effective method for performing vestibular nerve sectioning. Until now, the endoscope has been used primarily as an adjunct to the operating microscope in surgery at the cerebellopontine angle. In addition, previous endoscopic techniques typically require a third hand to manipulate the endoscope. With the 2-handed endoscopic-directed technique, however, the endoscope is used as the primary means of visualization, and the unique design of this endoscope allows for a bimanual procedure without the requirement of a cosurgeon. Advantages of using this technique compared with the microscope include superior brightness at close distances, greater depth of field, increased maneuverability within small regions, and an improved ability to visualize objects not in a direct line of sight. Among other things, this allows for minimally invasive openings, decreased cerebellar retraction, and better identification of nerve cleavage planes and vascular anatomy.</jats:p></jats:sec>

Fully Endoscopic Retrosigmoid Vestibular Nerve Section for Refractory Meniere Disease

“…[36][37][38][39][40][41][42][43][44][45] In 2012, Culter et al described a technique of fully endoscopic VNS in a series of 11 patients. 25 To our knowledge, this was the first fully endoscopic VNS report, however, the operative microscope was brought in for 5 of the 11 patients in this study. Nonetheless, 10 out of the 11 patients (91%) had improvement in vertiginous symptoms at follow-up with 1 patient (9%) suffering from a facial nerve palsy, HB 3/6, after surgery.…”

“…As a result, surgeons are provided with improved visualization, while eliminating all cerebellar retraction, minimizing soft tissue dissection and reducing the size of the craniotomy. 25 Despite its potential, the fully endoscopic VNS procedure has scarcely been reported. We present our results of the fully endoscopic VNS technique in patients with refractory Meniere disease in what is, to our knowledge, the largest reported series to date.…”

Endoscopic Resection of Vestibular Schwannomas

“…Utilizing the findings of previous authors, several surgeons began implementing the endoscope into CPA surgery via the endoscopic-assisted technique. Reports of this procedure demonstrated successful results in microvascular decompression, [17][18][19][20][21][22][23][24][25] vestibular neurectomy, 23,26,27 and resection of various tumors such as epidermoid cysts 28 and vestibular schwannomas. 23,[29][30][31] The endoscope allowed for full visualization of the CPA from cranial nerve IV at the level of the incisura to the foramen magnum as well as from the cerebellar hemisphere to the petrous portion of the temporal bone.…”

Endoscopic and Microscopic Microvascular Decompression

“…Some surgeons have attached a microsuction device to the endoscope to facilitate one-handed surgery, although there are inherent issues with image motion with any attempt to locally suction. 25 Despite these limitations, endoscopy remains a useful adjunct for surgeons who heavily rely on the microscope within their practice.…”