Hearing preservation following suboccipital removal of acoustic neuromas

Advances in the diagnosis and intraoperative management of acoustic neuromas have greatly reduced the incidence of neurologic deficits following their removal. Ninety-three patients underwent acoustic tumor removal during a 41/2-year period, and hearing preservation was attempted in 20 cases. Hearing was preserved in 65% of the entire series, and excellent results were obtained in tumors less than 1.5 cm. No patient with a tumor greater than 1.5 cm had serviceable hearing preserved when total tumor removal was performed. Two patients, one with neurofibromatosis and one with an acoustic neuroma in an only-hearing ear, had planned partial tumor removal with preservation of hearing. Preoperative auditory brainstem response results were not predictive of postoperative hearing preservation. Intraoperative auditory brainstem response monitoring demonstrated that loss of wave V consistently correlated with loss of hearing postoperatively, whereas persistence of wave V (with a latency prolongation not exceeding 3.00 ms) was predictive of successful hearing preservation regardless of latency increases.     

Translabyrinthine removal of large acoustic neuromas in young adults

OBJECTIVE: the authors reviewed the clinical manifestations and the surgical outcomes in a series of young patients who underwent removal of large acoustic neuromas via the translabyrinthine approach. METHODS: 40 young adults who underwent a translabyrinthine removal of acoustic neuromas 3 cm or greater in size were analyzed. The patient's age ranged from 17 to 30 years. The mean size of tumor was 4.25 cm. RESULTS: the primary symptoms are similar to those in adult but usually less intense. The average interval time between the primary symptom and the diagnosis was 17 months. A high percentage of preoperative normal hearing (35%) and good facial function (100%) were noted. Translabyrinthine approach was used in all cases. Total removal was realised in 39 patients (97.5%). The facial nerve was anatomically preserved in 37 patients (92.5%). Twenty-six patients (65%) had a good facial function (House-Brackmann grade I or II) immediately or at 1 month after surgery, 11 patients (28%) achieved grade III or IV. Three patients underwent an immediate nerve repair after tumor removal. All of them recovered to grade III or IV 1 year after surgery. Postoperative complications were minimal. CONCLUSIONS: young adults may have a rapid growth rate but usually have minimal symptoms even with a large acoustic neuroma. The translabyrinthine approach has been used successfully in removal of large acoustic tumors of young patients, with the good result of facial nerve preservation and long-term tumor control.     

The translabyrinthine approach for the removal of large acoustic neuromas

The results and the sequelae are reported from a series of consecutive 400 translabyrinthine removals of acoustic neuromas comprising almost all such tumors in Denmark during a 12-year period from 1976 to 1988. There were two intrameatal, 137 median-sized, 112 large and 149 advanced tumors, the latter having a diameter exceeding 40 mm. The mortality rate in the overall series was 2%. The incidence of cerebrospinal fluid leak occurred in 11%, and persisted for more than 2 weeks in 4%. Facial nerve function was completely normal in 67% of the patients, while only 5% required a nerve anastomosis.     

The translabyrinthine approach for the removal of large acoustic neuromas

Summary The results and the sequelae are reported from a series of consecutive 400 translabyrinthine removals of acoustic neuromas comprising almost all such tumors in Denmark during a 12-year period from 1976 to 1988. There were two intrameatal, 137 mediansized, 112 large and 149 advanced tumors, the latter having a diameter exceeding 40 mm. The mortality rate in the overall series was 2%. The incidence of cerebrospinal fluid leak occurred in 11%, and persisted for more than 2 weeks in 4%. Facial nerve function was completely normal in 67% of the patients, while only 5% required a nerve anastomosis.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29 September 1988     

扩大迷路进路切除大听神经瘤18例报告

目的：探讨通过扩大的迷路进路切除大听神经瘤的方法和效果。方法：充分暴露乙状窦及其后方硬脑膜、岩上窦、颅中窝硬脑膜,暴露并下压颈静脉球,内听道周转骨质２７０℃以上切除。肿瘤切除从前下极处开始,以早期暴露脑干及脑干表面面神经,随后即从内侧向外侧解剖面神经。结果：１８例直径在３ｃｍ以上的听神经瘤（平均直径４．２ｃｍ）,均手术全切,脑组织无明显损伤。２例术后一过性脑脊液漏自愈,无颅内感染。面神经解剖及功能     

并发慢性中耳乳突炎的大听神经瘤经扩大迷路进路二期手术切除

目的：探讨经扩大迷路进路摘除伴发慢性中耳乳突炎的大听神经瘤的手术方法。方法：先一期手术彻底清除鼓室乳突病灶，术毕封闭中耳乳突腔；2周后行二期手术，经一期径路进行听神经瘤切除术。结果：2例并发慢性中耳炎的大听神经瘤均得到全切，术后面神经功能正常，切口一期愈合。随访半年以上无感染发生。结论：并发慢性中耳乳突炎的大听神经瘤同样可经扩大迷路进路进行手术切除。     

Suboccipital approach in the removal of acoustic neuromas

Modern expertise by neurosurgeons has made the suboccipital route the approach of choice in removal of acoustic neuromas. In addition to assisting the neurosurgeon, the role of the otolaryngologist should now be extended to provide re-education of physicians in order to achieve earlier referral and consequent early diagnosis.     

Medical treatment of headache after suboccipital acoustic tumor removal

Objectives: Suboccipital craniotomy is a frequently used surgical approach for removal of cerebellopontine angle (CPA) tumors. A frequently cited consequence, however, is the high incidence of postoperative headaches. Much has been written regarding prevention of these headaches, but little has been written of their treatment. The authors review their extensive experience in suboccipital tumor removal and the medical management of postoperative headache, highlighting the recent use of a regimen of divalproex sodium and verapamil. Study Design: Retrospective chart review. Methods: The charts of a consecutive series of patients having suboccipital craniotomies for CPA tumors were reviewed. Presence, duration, and severity of headache were noted. Medical treatments and their effectiveness were also noted. Results: Between 1980 and 1997, 228 patients underwent suboccipital craniotomy for removal of CPA tumors. Of these patients, 124 (54.4%) complained of headache. For 62 (27.2%) the headaches persisted for more than a year after surgery. Twenty-nine patients (12.7%) received no relief from any medication. Ten of these patients received a regimen of divalproex sodium and verapamil, with all patients obtaining significant relief. Conclusion: Headache is a significant problem with the suboccipital approach for acoustic tumor removal. The majority of patients that complain of headache can be adequately treated with nonsteroidal anti-inflammatory drugs (NSAIDs). If pain is unrelieved by NSAIDs, treatment becomes problematic. The authors' early experience with divalproex sodium/verapamil is encouraging and deserves further investigation as a treatment for these refractory cases.     

Facial nerve function after suboccipital removal of acoustic neurinoma

Summary The recovery of facial nerve function after suboccipital removal of 91 acoustic neurinomas is presented. The results after anatomical preservation of the nerve (60 cases), direct anastomosis of the nerve (7 cases), nerve grafting (16 cases), and facial hypoglossal anastomosis (8 cases) are presented after a follow-up period of 31.2 months. A simplified classification was used to describe motor function. The results are compared to those in the literature.     

Facial nerve function after suboccipital removal of acoustic neurinoma

The recovery of facial nerve function after suboccipital removal of 91 acoustic neurinomas is presented. The results after anatomical preservation of the nerve (60 cases), direct anastomosis of the nerve (7 cases), nerve grafting (16 cases), and facial hypoglossal anastomosis (8 cases) are presented after a follow-up period of 31.2 months. A simplified classification was used to describe motor function. The results are compared to those in the literature.     

肌电图监护下大型听神经瘤的显微手术及面神经保留

目的 介绍经枕下-乙状窦后入路大型听神经瘤显微手术切除及面神经保留技巧。方法对32例大型听神经瘤在面肌肌电图监护下行显微手术切除。结果所有32例病人均行肿瘤全切，面神经解剖保留率为96．88％。根据House-Brackmann面神经功能分级标准，面神经功能保留率术后6个月为Ⅱ级52．38％、Ⅲ级42．86％、Ⅳ级4．76％；术后1年为Ⅱ级66．67％、Ⅲ级28．57％、Ⅳ级4．76％。结论对大型听神经瘤，在面肌肌电图监护下通过显微手术技术，可以全切肿瘤同时保留面神经解剖的完整。     

Suboccipital removal of acoustic neuromas. Results of 125 operations.

The surgical results obtained in 125 patients with acoustic neuromas, using the suboccipital approach, are reported. These results do not differ from those obtained in other neurosurgical materials, with the same distribution of tumour size, and the same surgical approach. The material consists of 20 medium size tumours, and 105 large. However, the results, regarding both mortality, postoperative facial paralysis as well as post-operative condition in general are unsatisfactory. A historical review of the development of the surgical treatment of acoustic neuromas is given, and the necessity of a closer neurosurgical-otologic cooperation is stressed, both with regard to diagnosis of the neuromas as well as the surgical treatment.     

Cystic acoustic neuromas

Predominantly cystic acoustic neuromas are rare and they usually present with clinical and radiological features different from their more common solid counterparts. Two cases of cystic acoustic neuromas are reported here.     

Bilateral acoustic neuromas

This article reviews 12 patients with bilateral acoustic neuromas. The sex incidence was equal and the mean age at diagnosis was 26.2 years. The family history was positive in nine of the patients. Five patients have had incomplete surgical removal of acoustic neuromas on both sides. Two of them are completely deaf and the other three have severe sensorineural hearing loss in one ear and no hearing in the other ear. In five patients the tumour on one side has been operated on and the other side is being observed with at least short-term preservation of good hearing. The remaining two patients died of intra-cranial complications, one of them post-operatively. Four patients developed facial palsy immediately following surgery and one developed facial weakness 6 months after surgery. Guidelines are discussed for the care of these patients including the timing of surgery and alternative treatment options (observation, radio-surgery adn chemotherapy). This is essentially a group of young individuals who have had multiple operations for bilateral acoustic tumours and associated manifestations and for whom the disease and the sequelae of treatment can be tragic.     

双侧听神经瘤

目的探讨双侧听神经瘤的临床表现、生长特性及治疗。方法回顾性分析１９８７年６月～１９９７年５月间收治５例双侧听神经瘤的临床资料。结果本病约占全部听神经瘤患者的５％（５／９２）。５例的首发症状均为耳鸣伴听力减退。来诊时除位听神经症状外,有多个颅神经和脑干受累的临床表现。２例有孤立的浅褐色皮肤色素斑,５例有数量不等、分布不一的其它神经纤维瘤。５例中４例行一侧听神经瘤切除术,其中１例术后因脑水肿、高颅压、脑疝死亡。对１例术前、术后颅脑冠状位和轴位ＭＲＩ检查表明,其肿瘤平均每年朝上下、左右方向各生长１．１ｃｍ和０．７ｃｍ。结论双侧听神经瘤的治疗与单侧听神经瘤有不同。     

Complications of the translabyrinthine approach for the removal of acoustic neuromas.

OBJECTIVE: To report the complications that occurred during a large series of surgical procedures for the removal of acoustic neuromas using the translabyrinthine approach. DESIGN: Retrospective analysis. SETTING: Neuro-otology practice with academic affiliation. Procedures were performed at either a university medical center or a community hospital in conjunction with a neurosurgery team. PATIENTS: A total of 258 patients (142 men, 116 women; mean age, 51 years) underwent the translabyrinthine approach during a 14-year period. All patients had a histologically proven diagnosis of acoustic neuroma. RESULTS: There were no deaths. There were 3 cases (1.1%) of neurovascular compromise. There were 20 cases (7.8%) of cerebrospinal fluid leak, 16 (80%) of which presented as rhinorrhea and 4 (20%) as incisional leaks. The leaks at the incision responded to conservative management, while rhinorrhea usually required more aggressive means of closure. Four patients (1.6%) were diagnosed as having bacterial meningitis. Complete gross tumor removal was not achieved in 4 patients (1.6%). Facial nerve function, as measured by the House-Brackmann system, was recorded in all patients at 1 year: 76% had a score of I or II; 18%, a score of III or IV; and 6%, a score of V or VI. Other complications included 3 cases of pneumonia, 1 case of severe gastric hemorrhage, and 1 case of wound infection. CONCLUSIONS: The results of this series generally agree with those of other large series and demonstrate the safety and effectiveness of the translabyrinthine approach in excising acoustic neuromas.