Middle Fossa Approach for Vestibular Schwannoma: Good Hearing and Facial Nerve Outcomes with Low Morbidity

Raheja, Amol; Bowers, Christian A.; MacDonald, Joel D.; Shelton, Clough; Gurgel, Richard K.; Brimley, Cameron; Couldwell, William T.

doi:10.1016/j.wneu.2016.04.085

Cited by 40 publications

(27 citation statements)

References 54 publications

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“…Nevertheless, the most recent guidelines on surgical management of small VSs did not give recommendation for surgery as primary treatment . The presence of a distal internal auditory canal CSF fundal cap was another prognostic factor of hearing preservation, even if some authors did not find an association with better outcome . It is fundamental to identify prognostic indicators other than tumor size in order to help clinicians in the decision‐making process.…”

Section: Discussionmentioning

confidence: 99%

Tumor growth rate: A new prognostic indicator of hearing preservation in vestibular schwannoma surgery

et al. 2019

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Background The management of small‐ to medium‐size (< 20 mm) sporadic vestibular schwannomas (VSs) continues to inspire debate. Preoperative pure tone thresholds and tumor size are recognized prognostic features of hearing preservation after surgery. Objective To investigate what preoperative characteristics were associated with nonserviceable hearing after surgery for VSs. Methods We retrospectively reviewed the audiological results of 92 patients treated with the middle cranial fossa (MCF) approach for resection of VSs (< 20 mm). Sex, age, symptoms, tumor site, tumor size, growth rate, and hearing class according to American Academy of Otolaryngology–Head and Neck Surgery guidelines were evaluated. Negative outcome was progression after surgery to nonserviceable hearing according to Gardner‐Robertson classification. We included only patients with preoperative serviceable hearing. Results After surgery, 48 patients (52.2%) had nonserviceable hearing. At univariate analysis, sex age, symptoms, tumor site, and size were not associated to hearing outcome. Tumor growth rate ≥ 2.16 mm/year (P = 0.02, odds ratio 8.5) and preoperative hearing class B (P = 0.03, OR 5.89) were statistically associated to nonserviceable hearing after VSs resection. Tumor growth rate ≥ 2.16 mm/year was also significantly associated to preoperative hearing class B (P = 0.01). At multivariate analysis, the only independent prognostic factor of progression to nonserviceable hearing in operated VSs was tumor growth rate ≥ 2.16 mm/year (P = 0.01, OR = 4.15). Conclusion We found a new prognostic indicator of hearing preservation after VS surgery with the MCF approach: the tumor growth rate. This feature should be further investigated before being considered in the decision‐making process of VS treatment. Level of Evidence 4 Laryngoscope, 129:2378–2383, 2019

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Section: Discussionmentioning

confidence: 99%

Tumor growth rate: A new prognostic indicator of hearing preservation in vestibular schwannoma surgery

et al. 2019

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“…22,53,55,62,63 There are both primary studies supporting and arguing against each of the following variables as predictors of HP: good preoperative hearing, tumor location, calorics, and other ABR parameters such as wave amplitude, latency, or interpeak interval. 22,25,39,42,45,47,51,53,55,59,60,[64][65][66][67] A literature review was performed to analyze data on hearing outcomes after MCF resection (►Table 5). While ABR was the most commonly utilized technique, a wide variety of monitoring methodologies were used.…”

Section: Discussionmentioning

confidence: 99%

Auditory Brain Stem Response Predictors of Hearing Outcomes after Middle Fossa Resection of Vestibular Schwannomas

Ren

Merna

Tawfik

et al. 2021

J Neurol Surg B Skull Base

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Objectives To analyze the relationship between preoperative and intraoperative auditory brain stem response (ABR) characteristics and hearing outcomes in patients with vestibular schwannomas (VS) undergoing hearing preservation (HP) surgery via a middle cranial fossa (MCF) approach. Design Prospective study. Setting Academic tertiary skull base referral center. Methods Pre- and postoperative pure-tone average (PTA) and word recognition score (WRS) were examined. Intraoperative ABR wave III latency, wave V latency, and amplitude were recorded. HP was defined as postoperative WRS ≥50%. Participants Adult patients with VS and WRS ≥50% who underwent MCF tumor resection between November 2017 and September 2019. Main Outcome Measures Postoperative hearing outcomes. Results Sixty patients were included. Mean tumor size was 9.2 mm (range, 3–17). HP rates were 56.7% for the cohort and 69.7% for tumors <10 mm. A complete loss of wave V was associated with an 82.9% increase in postoperative PTA (p < 0.001) and 97.2% decrease in WRS (p < 0.001), whereas a diminished wave V was correlated with 62.7% increase in PTA (p < 0.001) and 55.7% decrease in WRS (p = 0.006). A diminished or absent wave V, but not increased wave III/V latency or decreased wave V amplitude, was correlated with a decline in postoperative hearing class (r = 0.735, p < 0.001). Receiver-operating characteristic analysis demonstrated that a stable wave V has the highest accuracy in predicting HP (sensitivity of 82.6%, specificity of 84.8%). Conclusion Of the examined preoperative and intraoperative ABR characteristics, a stable wave V intraoperatively was the strongest predictor of HP after MCF resection of VS. Level of Evidence Level III.

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“…VS size was found to be strongly associated with likelihood for post-operatively FN palsy with smaller tumors having a lower likelihood (Cerullo et al, 1993;Kazim et al, 2011). The traditional paradigm of GTR of CPA tumors to minimize disease recurrence has to be balanced against the frequent occurrence of a permanent FN paresis/paralysis (King and Morrison, 1980;Gantz et al, 1986;Nadol et al, 1987Nadol et al, , 1992Bentivoglio et al, 1988;Moulin et al, 1995;Mass et al, 1999;Bento et al, 2002;Elsmore and Mendoza, 2002;Magnan et al, 2002;Couloigner et al, 2003;Mangham, 2004;Samii et al, 2006Samii et al, , 2010Seol et al, 2006;Yang et al, 2008;Gerganov et al, 2009Gerganov et al, , 2010Silva et al, 2012;Sharma et al, 2013;Wang et al, 2013;Setty et al, 2015;Aristegui Ruiz et al, 2016;Raheja et al, 2016;Roessler et al, 2016;Taddei et al, 2016;D'Amico et al, 2017;Hoshide et al, 2018; Tables 1, 5, 6). FN preservation surgery is justifiable, when acceptable extent-of-resection and good long-term control tumor rates are achievable (Seol et al, 2006;D'Amico et al, 2017;Bernardeschi et al, 2018;Zumofen et al, 2018).…”

Section: Causes Of Intracranial Facial Nerve Injury After Cpa-tumor Surgerymentioning

confidence: 99%

“…Eighty percent of them improved on follow-up to some degree and again, out of those, 28% experienced a complete recovery of their FN function. Only two studies (Gantz et al, 1986 ; Raheja et al, 2016 ) report to have achieved complete GTR-rates exclusively via the MCF approach in n = 121 individuals, 34% of which suffered from post-operative FN impairment. Ten studies (Tator and Nedzelski, 1982 ; Kirkpatrick et al, 1993 ; Magliulo et al, 1998 ; Fenton et al, 2002 ; Colletti and Fiorino, 2003 ; Isaacson et al, 2005 ; Neff et al, 2005 ; Esquia-Medina et al, 2009 ; Matsui, 2012 ; Torres et al, 2017 ) report on complete GTR-rates in n = 734 individuals using a selected variation of surgical approaches.…”

Section: Systematic Review Of the Literaturementioning

confidence: 99%

Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery–A Systematic Review and Future Perspectives

Hostettler

Jayashankar

Bikis

et al. 2021

Front. Bioeng. Biotechnol.

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Background and purpose: Tumorous lesions developing in the cerebellopontine angle (CPA) get into close contact with the 1st (cisternal) and 2nd (meatal) intra-arachnoidal portion of the facial nerve (FN). When surgical damage occurs, commonly known reconstruction strategies are often associated with poor functional recovery. This article aims to provide a systematic overview for translational research by establishing the current evidence on available clinical studies and experimental models reporting on intracranial FN injury.Methods: A systematic literature search of several databases (PubMed, EMBASE, Medline) was performed prior to July 2020. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Included clinical studies were reviewed and categorized according to the pathology and surgical resection strategy, and experimental studies according to the animal. For anatomical study purposes, perfusion-fixed adult New Zealand white rabbits were used for radiological high-resolution imaging and anatomical dissection of the CPA and periotic skull base.Results: One hundred forty four out of 166 included publications were clinical studies reporting on FN outcomes after CPA-tumor surgery in 19,136 patients. During CPA-tumor surgery, the specific vulnerability of the intracranial FN to stretching and compression more likely leads to neurapraxia or axonotmesis than neurotmesis. Severe FN palsy was reported in 7 to 15 % after vestibular schwannoma surgery, and 6% following the resection of CPA-meningioma. Twenty-two papers reported on experimental studies, out of which only 6 specifically used intracranial FN injury in a rodent (n = 4) or non-rodent model (n = 2). Rats and rabbits offer a feasible model for manipulation of the FN in the CPA, the latter was further confirmed in our study covering the radiological and anatomical analysis of perfusion fixed periotic bones.Conclusion: The particular anatomical and physiological features of the intracranial FN warrant a distinguishment of experimental models for intracranial FN injuries. New Zealand White rabbits might be a very cost-effective and valuable option to test new experimental approaches for intracranial FN regeneration. Flexible and bioactive biomaterials, commonly used in skull base surgery, endowed with trophic and topographical functions, should address the specific needs of intracranial FN injuries.

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Middle Fossa Approach for Vestibular Schwannoma: Good Hearing and Facial Nerve Outcomes with Low Morbidity

Cited by 40 publications

References 54 publications

Tumor growth rate: A new prognostic indicator of hearing preservation in vestibular schwannoma surgery

Tumor growth rate: A new prognostic indicator of hearing preservation in vestibular schwannoma surgery

Auditory Brain Stem Response Predictors of Hearing Outcomes after Middle Fossa Resection of Vestibular Schwannomas

Clinical Studies and Pre-clinical Animal Models on Facial Nerve Preservation, Reconstruction, and Regeneration Following Cerebellopontine Angle Tumor Surgery–A Systematic Review and Future Perspectives

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