A systematic approach to the surgical management of acoustic neuroma

Glasscock, Michael E.; Kveton, John F.; Jackson, C. Gary; Levine, Samuel C.; Mckennan, Kevin X.

doi:10.1288/00005537-198610000-00008

Cited by 146 publications

(78 citation statements)

References 9 publications

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“…In 1993, Glasscock et al 38 decried the "disarray of data" in the VS literature regarding outcome reporting. Although there are available standard metrics for reporting tumor size, hearing, and facial function, some authors do not adhere to these metrics, providing nonuniform data that are difficult to compare across studies.…”

Section: Limitations Of the Study And Future Directionsmentioning

confidence: 99%

“…This approach may be poorly tolerated by the elderly, as extradural dissection of the adherent dura may be difficult. 85 The middle cranial fossa corridor is suggested for younger patients with smaller tumors 7,38,81 in the IAC with less involvement of the CPA, specifically the tumors that involve the fundus of the IAC, a location to which access and visualization are restricted during the retrosigmoid approach. 20 This route is also indicated for patients with useful preoperative hearing (although the definition of "useful" is still open to debate).…”

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confidence: 99%

“…43 The retrosigmoid approach is a versatile route for tumors of any size regardless of the preoperative hearing status. 28 The translabyrinthine approach precludes the possibility of hearing preservation but allows removal of a tumor of almost any size, with early identification of the facial nerve, 38,79,89,93 and some argue that the translabyrinthine approach permits good preservation of all CNs. 54 It also provides very good visualization of the lateral IAC and fundus, whereas the exposure of these in the retrosigmoid approach is limited due to the risk of damaging the vestibule and cochlea; therefore the translabyrinthine approach may allow for a more complete removal of tumor from these areas.…”

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confidence: 99%

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

Ansari

Terry

Cohen-Gadol

2012

FOC

260

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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Section: Limitations Of the Study And Future Directionsmentioning

confidence: 99%

mentioning

confidence: 99%

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confidence: 99%

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

Ansari

Terry

Cohen-Gadol

2012

FOC

260

216

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“…In two other large series, Sindou et al [6] and Knosp et al [7] reported a trigeminal and visual cranial nerve deficit incidence of between 14 and 58%. Similarly, even with microsurgical resection with intra-operative monitoring, facial nerve dysfunction occurs in up to 7% of patients [26][27][28][29] and hearing loss is universally observed in most acoustic neuromas exceeding 2-3 cm in diameter [30][31][32]. Hence, radiation therapy has been a preferred choice for such tumors with preserved neurological function.…”

Section: Hypofractionatedmentioning

confidence: 99%

Clinical outcome after Hypofractionated Stereotactic Radiotherapy (HSRT) for benign skull base tumors

Mahadevan¹,

Floyd²,

Wong

et al. 2011

Computer Aided Surgery

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“…4,36 For small and medium-sized tumors, long-term facial nerve preservation rates are reported to be more than 90%, but this rate is substantially lower for large tumors. 20,29 Series of large VSs frequently have been published as distinct clinical entities, because large tumors present a greater challenge to surgeons regarding total removal, cranial nerve preservation, and other postoperative complications. 32,49 Due to the paucity of data for such large tumors, a systematic literature review of all the available reports would be greatly beneficial in determining optiFacial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?…”

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Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

Gurgel

Doğru

Amdur³

et al. 2012

FOC

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Object The object of this study was to evaluate facial nerve outcomes in the surgical treatment of large vestibular schwannomas (VSs; ≥ 2.5 cm maximal or extrameatal cerebellopontine angle diameter) based on both the operative approach and extent of tumor resection. Methods A PubMed search was conducted of English language studies on the treatment of large VSs published from 1985 to 2011. Studies were then evaluated and included if they contained data regarding the size of the tumor, surgical approach, extent of resection, and postoperative facial nerve function. Results Of the 536 studies initially screened, 59 full-text articles were assessed for eligibility, and 30 studies were included for analysis. A total of 1688 tumor resections were reported. Surgical approach was reported in 1390 patients and was significantly associated with facial nerve outcome (ϕ= 0.29, p < 0.0001). Good facial nerve outcomes (House-Brackmann Grade I or II) were produced in 62.5% of the 555 translabyrinthine approaches, 65.2% of the 601 retrosigmoid approaches, and 27.4% of the 234 extended translabyrinthine approaches. Facial nerve outcomes from translabyrinthine and retrosigmoid approaches were not significantly different from each other, but both showed significantly more good facial nerve outcomes, compared with the extended translabyrinthine approach (OR for translabyrinthine vs extended translabyrinthine = 4.43, 95% CI 3.17–6.19, p < 0.0001; OR for retrosigmoid vs extended translabyrinthine = 4.98, 95% CI 3.57–6.95, p < 0.0001). There were 471 patients for whom extent of resection was reported. There was a strong and significant association between degree of resection and outcome (ϕ= 0.38, p < 0.0001). Of the 80 patients receiving subtotal resections, 92.5% had good facial nerve outcomes, compared with 74.6% (n = 55) and 47.3% (n = 336) of those who received near-total resections and gross-total resections, respectively. In the 2-way comparison of good versus suboptimal/poor outcomes (House-Brackmann Grade III–VI), subtotal resection was significantly better than near-total resection (OR = 4.21, 95% CI 1.50–11.79; p = 0.004), and near-total resection was significantly better than gross-total resection (OR = 3.26, 95% CI 1.71–6.20; p = 0.0002) in producing better facial nerve outcomes. Conclusions In a pooled patient population from studies evaluating the treatment of large VSs, subtotal and near-total resections were shown to produce better facial nerve outcomes when compared with gross-total resections. The translabyrinthine and retrosigmoid surgical approaches are likely to result in similar rates of good facial nerve outcomes. Both of these approaches show better facial nerve outcomes when compared with the extended translabyrinthine approach, which is typically reserved for especially large tumors. The reported literature on treatment of large VSs is extremely heterogeneous and minimal consistency in reporting outcomes was observed.

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A systematic approach to the surgical management of acoustic neuroma

Cited by 146 publications

References 9 publications

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

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

Clinical outcome after Hypofractionated Stereotactic Radiotherapy (HSRT) for benign skull base tumors

Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

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