Our Management of Vestibular Schwannomas and Review of Literatures

There is no a clear consensus provided in the literature and there remain controversial on the treatment especially for small to medium size Vestibular schwannomas (VSs). Thus the treatment technique and approach preference vary from centre to centre. This problem too exists in our centre. The purpose of this paper is to develop a consensus in our hospital among our colleagues on the treatment of our VSs patients. We have been treating VSs patient by translabyrinthine approach from time to time for the last 5 years and found it to be a very efficient approach. This approach gives the most direct route to the tumor with excellent exposure of the internal acoustic meatus, cerebropontine angle (CPA) area without the need to retract the brain with facial nerve totally in control early in the surgery. The only problem was, when there is large posterior fossa component of the tumor present. This approach is safe with direct exposure to CPA area and have minimum intraoperative or postoperative complications.

Meningioma petroclival. abordaje petroso combinado con extensión translaberíntica / Petroclival meningioma. petrosus approach combined with translabyrinthine extension

Objetivo: Presentar un caso de meningioma petroclival con extensión al cavum de Meckel, tratado quirúrgicamente a través de un abordaje petroso combinado con extensión translaberíntica. Introducción: Se define como meningioma petroclival, al que se origina en los dos tercios superiores de la fisura petroclival, y medial al nervio trigémino. Existen numerosos abordajes para estos tumores, y cada caso requiere un análisis individualizado. Descripción del caso: Paciente de 25 años que refiere cefalea de 6 meses de evolución, progresiva e invalidante, e hipoacusia derecha. Al examen físico presenta hipoestesia en territorio trigeminal derecho y desviación velopalatina a derecha. En la imagen de resonancia magnética (IRM) se evidencia voluminosa lesión expansiva petroclival derecha con extensión al cavum de Meckel. La cirugía fue programada en dos tiempos: en el primero se realizó el abordaje y en el segundo la exéresis tumoral total. En el post operatorio evolucionó con una hemiparesia izquierda transitoria y parálisis completa del tercer par derecho en recuperación. Discusión: Existen múltiples modalidades terapéuticas para los meningiomas de base de cráneo. En este caso considerando la ubicación, el tamaño, su extensión clival, al cavum de Meckel y su relación con la arteria basilar, se decidió realizar un abordaje petroso combinado, con extensión translaberíntica debido a la hipoacusia. Conclusiones: Los abordajes de base de cráneo acortan la distancia de trabajo al tumor y mejoran los ángulos de exposición, facilitando su exéresis. Su principal desventaja, que es el tiempo de realización, puede sortearse dividiendo la cirugía en 2 tiempos.

Objective: To present a patient with a right petroclival meningioma with extension into Meckel´s cave, surgically treated by combining a petrosal approach with translabyrinthine extension.Introduction: Petroclival meningiomas are tumors that arise from the upper two thirds of the petroclival fissure, medial to the trigeminal nerve. There are several treatment options, with every case warranting an individualized approach.Case description: Our patient was a 25-year-old male/female with a 6-month history of progressive, disabling headaches and right hearing loss. The physical exam revealed right trigeminal hypoesthesia and rightward deviation of the soft palate. Magnetic resonance imaging detected a huge right petroclival tumor with extension into Meckel´s cave. Two-stage surgery was planned, the first procedure to create an approach, and the second to attempt total tumor resection, which was achieved. Postoperatively, the patient had transient left hemiparesis and a complete third nerve palsy that recovered partially. Discussion: Many different surgical approaches exist for treating petroclival meningiomas. In this case, considering the tumor’s location and volume, its clival and Meckel´s cave extension and basilar artery involvement, we elected to combine a petrosal approach with translabyrinthine extension, due to the patient’s previous hearing loss. Conclusion: Skull-base approaches shorten the working distance to the tumor, improving the angle of approach and rendering total resection possible. One of the procedure’s main disadvantages is the time required; but this can be overcome by performing the procedure in two stages.

Simultaneous Translabyrinthine Tumor Removal and Cochlear Implantation in Vestibular Schwannoma Patients

Refinement of surgical techniques has allowed hearing preservation after tumor resection to be prioritized. Moreover, restoration of hearing after tumor removal can be attempted in patients with bilateral vestibular schwannomas or those with a schwannoma in the only-hearing ear. Cochlear implantation (CI) has emerged as a proper method of acoustic rehabilitation, provided that the cochlear nerve remains intact. Studies of electrical promontory stimulation in patients after vestibular schwannoma resection have demonstrated favorable results. We describe herein two cases of hearing rehabilitation via CI implemented at the time of vestibular schwannoma resection. Tumors were totally removed, and cochlear implant electrodes were successfully inserted in both cases. Also, post operative CI-aided hearing showed improved results.

A Case of Endolymphatic Sac Tumor Removal with Modified Translabyrinthine Approach / 대한이비인후과학회지

Endolymphatic sac tumor (ELST) is a very rare tumor arising from the epithelium of the endolymphatic sac. Pathologically, ELST shows papillary growth patterns with extensive bony and soft tissue destruction. ELST commonly shows symptoms of endolymphatic hydrops such as hearing loss, vertigo and tinnitus by blocking the endolymphatic duct. As the tumor enlarges, patients experience various symptoms that include multiple cranial nerve palsy. Ten to thirty percents of ELST are related to Von Hippel Lindau (VHL) diseases. Also, bilateral tumors can develop when a patient has VHL-related ELST. The goal of treatment for ELST is total tumor eradication. The type of surgical approach is chosen by the surgeon in consideration of the tumor grade and the hearing status of the patient. In this report, we present a patient with ELST who was successfully treated with the modified translabyrinthine approach. We have also reviewed relevant literatures.

The Clinical Usefulness of Translabyrinthine Approach for Removal of the Vestibular Schwannomas

OBJECTIVE: To determine the feasibility of translabyrinthine approach in the vestibular schwannoma patients, the authors reviewed eighteen consecutive cases, focusing at their functional outcome and operative complications. MATERIALS AND METHOD: To evaluate the functional outcome, we reviewed preoperative radiological findings such as size of tumors and location of jugular bulb as well as the preoperative neurological status including audiometric analysis and cranial nerve function in 18 patients, diagnosed as vestibular schwannoma. Also the surgical outcome was evaluated according to the functional preservation of facial nerve and incidence of the surgical complication as well as the extent of surgical resection. RESULTS: The age of patients ranged from 21 to 62 years, with a mean of 50 years. Of 18 patients operated in our center by the translabyrinthine approach, wide exposure with total removal of the mass was possible in 16 cases (88.8%). The facial nerve was anatomically preserved in 88.8%. At six-month follow-up, facial nerve function was good(Grade I-II) in 15 patients(83%) and acceptable(I-IV) in all patients. Although the jugular bulb was highly placed is five patients, gross total resection was possible without facial nerve injury in all patients by the translabyrinthine approach. One patient experienced CSF leakage after surgery, but there was no patient with disabling deficit. CONCLUSION: Use of the translabyrinthine approach for removal of vestibular schwannomas resulted in good anatomical and functional preservation of the facial nerve, with minimal incidence of morbidity and no mortality. In cases of high jugular bulb impacted into mastoid bone, total removal was possible by displacing the jugular bulb with Surgicel cellulose and placement of bone wax.

A Case of Endolymphatic Sac Tumor / 대한이비인후과학회지

Endolymphatic sac tumor (ELST) is very rare but its aggressive papillary neoplasm destructs the temporal bone widely and often involves the intracranial structures. The most effective treatment is complete surgical removal, but it is very difficult because the character of tumor is very aggressive and extensive to the intracranial region. This tumor is not yet reported in Korea but we have recently experienced one case of ELST which we treated surgically by the traslabyrinthine/petrosal combined approach. We report the clinical and histological aspects of this rare tumor with a review of the literatures.

Removal of large acoustic neuromas by enlarged translabyrinthine approach / 第二军医大学学报

Objective: To investigate the surgical methods and outcomes of the enlarged translabyrinthine approach in the removal of large acoustic neuromas. Methods: A large mastoidectomy involved complete exposure of the sigmoid sinus, the dura behind the sinus for at least 1 cm, the superior petrosal sinus and the middle fossa dura. The jugular bulb was exposed and pressed downwards if necessary. The internal auditory meatus was skeletonized and uncovered for at least 270°.The debulking of the tumor began inside the anterior and inferior poles in order to find the brainstem and the facial nerve root as early as possible, and then the dissection of the nerve was done medially to laterally. Intraoperative facial nerve monitoring and postoperative CT and MRI were done in all cases. Results: Total removal was achieved in all 18 patients with tumors larger than 3 cm (mean size: 4.2 cm). There were no deaths or other complications such as intracranial infection and persistent cerebrospinal fluid leakage. There were no obvious cerebral sequelae. The facial nerve was preserved both anatomically and functionally in 14 cases, with Grade Ⅰ or Ⅱ in 8 cases, Grade Ⅲ or Ⅳ in 6 cases. Nerve interruption occurred in 4 patients who all had severe facial palsy or nerve interruption before operation. Sixteen patients resumed work within 1-3 months. Conclusion: Total removal of large acoustic neuroma could be acomplished via the translabyrinthine approach, with good preservation of facial nerve function and minimum incidence of morbidity.

Removal of large acoustic neuromas by enlarged translabyrinthine approach / 第二军医大学学报

Objective: To investigate the surgical methods and outcomes of the enlarged translabyrinthine approach in the removal of large acoustic neuromas. Methods: A large mastoidectomy involved complete exposure of the sigmoid sinus, the dura behind the sinus for at least 1 cm, the superior petrosal sinus and the middle fossa dura. The jugular bulb was exposed and pressed downwards if necessary. The internal auditory meatus was skeletonized and uncovered for at least 270°.The debulking of the tumor began inside the anterior and inferior poles in order to find the brainstem and the facial nerve root as early as possible, and then the dissection of the nerve was done medially to laterally. Intraoperative facial nerve monitoring and postoperative CT and MRI were done in all cases. Results: Total removal was achieved in all 18 patients with tumors larger than 3 cm (mean size: 4.2 cm). There were no deaths or other complications such as intracranial infection and persistent cerebrospinal fluid leakage. There were no obvious cerebral sequelae. The facial nerve was preserved both anatomically and functionally in 14 cases, with Grade Ⅰ or Ⅱ in 8 cases, Grade Ⅲ or Ⅳ in 6 cases. Nerve interruption occurred in 4 patients who all had severe facial palsy or nerve interruption before operation. Sixteen patients resumed work within 1-3 months. Conclusion: Total removal of large acoustic neuroma could be acomplished via the translabyrinthine approach, with good preservation of facial nerve function and minimum incidence of morbidity.

Removal of large acoustic neuromas by enlarged translabyrinthine approach / 第二军医大学学报

Objective: To investigate the surgical methods and outcomes of the enlarged translabyrinthine approach in the removal of large acoustic neuromas. Methods: A large mastoidectomy involved complete exposure of the sigmoid sinus, the dura behind the sinus for at least 1 cm, the superior petrosal sinus and the middle fossa dura. The jugular bulb was exposed and pressed downwards if necessary. The internal auditory meatus was skeletonized and uncovered for at least 270°.The debulking of the tumor began inside the anterior and inferior poles in order to find the brainstem and the facial nerve root as early as possible, and then the dissection of the nerve was done medially to laterally. Intraoperative facial nerve monitoring and postoperative CT and MRI were done in all cases. Results: Total removal was achieved in all 18 patients with tumors larger than 3 cm (mean size: 4.2 cm). There were no deaths or other complications such as intracranial infection and persistent cerebrospinal fluid leakage. There were no obvious cerebral sequelae. The facial nerve was preserved both anatomically and functionally in 14 cases, with Grade Ⅰ or Ⅱ in 8 cases, Grade Ⅲ or Ⅳ in 6 cases. Nerve interruption occurred in 4 patients who all had severe facial palsy or nerve interruption before operation. Sixteen patients resumed work within 1-3 months. Conclusion: Total removal of large acoustic neuroma could be acomplished via the translabyrinthine approach, with good preservation of facial nerve function and minimum incidence of morbidity.

The enlarged translabyrinthine removal of large acoustic neuromas: 18 cases report / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the surgical methods and results of enlarged translabyrinthine approachin the removal of large acoustic neuromas. Method:A large mastoidectomy involved complete exposure of sigmoidsinus, the dura behind the sinus for at least lcm, the superior petrosal sinus and the middle fossa dura. Thejugular bulb was exposed and pressed downwards if necessary. The internal auditory meatus was skeletonizedand uncovered for at least 270°. The debulking of the tumor began inside the anterior and inferior poles in orderto find the brainstem and the facial nerve root as early as possible, then the dissection of the nerve was performedmedially to laterally. Intraoperative facial nerve monitoring and postoperative CT and MRI were performed in allcases. Result:Total removal was achieved in all 18 patients with tumors larger than 3 cm (mean size:4.2 cm).There were no death as well as other complications such as intracranial infection and persistent cerebrospinalfluid leakage. There were no obvious cerebral sequela. The facial nerve was preserved both anatomically andfunctionally in 14 cases, with Grade Ⅰ or Ⅱ in 8 cases,Grade Ⅲ or Ⅳ in 6 cases. Nerve interruption occurred in4 cases who all had severe facial paralysis or nerve interruption before operation. 16 patients returned to workwithin 1～3 months. Conclusion: Total removal of large acoustic neuroma could be acomplished via thetranslabyrinthine approach, with good result of facial nerve function and minimum incidence of morbidity.

Four Cases of Large Cerebellopontine Angle Tumors Removed by Translabyrinthine Approach / 대한이비인후과학회지

Several approaches to the cerebellopontine angle and internal auditory canal have been described for the removal of large acoustic tumors. Of these, the translabyrinthine removal of the large cerebellopontine angle tumors requires extensive removal of bones in order to manage the low-lying tegmen, the anterior sigmoid sinus, and the high jugular bulb. We removed 4 large cerebellopontine angle tumors by the translabyrinthine approach alone. All tumors were totally removed with acceptable facial nerve function. There was a case of CSF leak which was repaired at the revision surgery.

Neurotologic Analysis of Cerebellopontine Angle Tumor / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The authors performed seven removal operations cerebellopontine angle tumor, six of which were acoustic neuroma. The purpose of this research is to analyze different cases of cerebellopontine angle tumor, determine their clinical characteristics, and evaluate the efficacy of various surgical approaches. MATERIALS AND METHODS: We performed neurotological analysis of both clinical characteristics and the results of each surgical approach for seven patients who have been treated for cerebellopontine angle tumor. RESULTS: The most frequent symptom was the complaint of hearing disturbance, where the mean PTAs measured were 66 dB, and the mean speech discrimination score was 35%. The average size of tumors measured by MRI was 3.9 cm. The following surgical approaches were used: translabyrinthine in 4 cases, modified translabyrinthine in 2 cases, transcochlear in one case. Complete removal of the tumor was possible in six patients. Facial nerve was preserved anatomically in six patients, and hearing preservation was possible in one patient for whom we performed the modified translabyrinthine approach. CONCLUSION: Early diagnosis and treatment is important in order to improve the facial nerve function after the operation. The modified translabyrinthine approach is worth performing for hearing preservation.

A Case of Neurofibromatosis Type II / 대한이비인후과학회지

Neurofibromatosis affects primarily cell growth of neural tissues and can cause tumors to grow on nerves at any time and any location. it is a heritable disease that is transmitted as an autosomal-dominant trait. Neurofibromatosis type II is characterized by bilateral acoustic neuromas with high incidence of other tumors. Hearing loss is the most common symptom in patients with neurofibromatosis type II. The other symptoms may be tinnitus, facial weakness, and dizziness. Audiometric test and MRI are essential to diagnose neurofibromatosis type II. Most cases of neurofibromatosis type II may need for surgical procedures. We experienced a case of neurofibromatosis type II having cervical spinal cord neuroma, multiple intracranial meningiomas, and bilateral acoustic neuromas. There was positive family history. Her two brothers also had neurofibromatosis type II, confined by MRI. Her acoustic neuroma on left side was removed successfully via translabyrinthine approach and cervical spinal cord neuroma by cervical laminectomy was removed.

A Case of Huge Clival Meningioma: Case Report

Meningiomas in the clival region are not common. These tumors present some of the most formidable challenges in skull base surgery. Total removal of clival meningoma has carried a significant mortality and morbidity. Several approches and combinations of approaches have been used remove clival meningiomas. Transpetrosal operations have been shown to offer distinct advantages over traditional operations in approaching lesions of the clival area. The authors report a case of a huge clival meningioma that was totally removed using posterior transpetrosal translabyrinthine approach.

The Translabyrinthine Approach for Removal of the Acoustic Neurinomas: Comparison with the Suboccipital Approach

The result of a series of thirteen translabyrinthine removals of acoustic neurinomas are reported. From 1990 March to 1993 May, thirteen patients with acoustic neuromas underwent translabyrinthine removal at Seoul National University Hospital with cooperation of Department of Neurosurgery and Otolaryngology. In four patients with the medium-sized(11-20 mm) tumors, complete removal with preservation of the facial nerve was possible. In nine patients with the large(21-40 mm) tumors, complete removal of the tumor was possible in seven. Preservation of the facial nerve was possible in all but one, whose facial nerve was incidentally transected at the distal intracanalicular portion and was anastomosed end-to-endly. In one, postoperative leakage of cerebrospinal fluid required reoperation. The results of translabyrinthine approaches were compared with those of suboccipital approaches performed during the same period. In medium-sized or large acoustic tumors, translabyrinthine approach was comparable with suboccipital approach in the rate of total tumors removal, preservation of the facial nerves, and complication.