Clinical features and outcomes of patients with hepatocellular carcinoma complicated with bile duct invasion

BACKGROUND/AIMS: Little is known about the treatment or outcomes of hepatocellular carcinoma (HCC) complicated with bile duct invasion. METHODS: A total of 247 consecutive HCC patients with bile duct invasion at initial diagnosis were retrospectively included. RESULTS: The majority of patients had Barcelona Clinic Liver Cancer (BCLC) stage C HCC (66.8%). Portal vein tumor thrombosis was present in 166 (67.2%) patients. Median survival was 4.1 months. Various modalities of treatment were initially employed including surgical resection (10.9%), repeated transarterial chemoembolization (TACE) (42.5%), and conservative management (42.9%). Among the patients with obstructive jaundice (n=88), successful biliary drainage was associated with better overall survival rate. Among the patients with BCLC stage C, overall survival differed depending on the initial treatment for HCC; surgical resection, TACE, systemic chemotherapy, and conservative management showed overall survival rates of 11.5, 6.0 ,2.4, and 1.6 months, respectively. After adjusting for confounders, surgical resection and repeated TACE were significant prognostic factors for HCC patients with bile duct invasion (hazard ratios 0.47 and 0.39, Ps <0.001, respectively). CONCLUSIONS: The survival of HCC patients with bile duct invasion at initial diagnosis is generally poor. However, aggressive treatments for HCC such as resection or biliary drainage may be beneficial therapeutic options for patients with preserved liver function.

Long Term Speech Perception Outcomes of Cochlear Implantation in Gap Junction Protein Beta 2 Related Hearing Loss

BACKGROUND AND OBJECTIVES: The mutation of the gap junction protein beta 2 (GJB2) gene is the predominant cause of autosomal recessive non-syndromic hearing loss. The purpose of this study was to evaluate the speech perception outcome after cochlear implantation according to the presence of a GJB2 mutation. SUBJECTS AND METHODS: During the period from March 2004 to February 2005, 38 patients underwent cochlear implantation at Asan Medical Center. Genetic factors and speech perception were evaluated in all subjects, and the patients were grouped according to the presence of a GJB2 mutation. The two groups were carefully matched according to the age at cochlear implantation. We analyzed four mutations in the GJB2 gene: 35delG, 167delT, 235delC, and E114G. Speech perception outcomes were measured using the open set, 1 and 2 syllables, the comprehension test, the Meaningful Auditory Integration Scale, the categories of auditory performance, and the Speech Intelligibility Rating scores. The evaluations were performed before the operation, 6 and 12 months thereafter, and then annually up to nine years after cochlear implantation. RESULTS: Fifteen patients had bi-allelic GJB2 mutations (11 with E114G and 4 with 235delC), whereas the remaining 23 had wild type alleles. For the age-matched analysis, 14 patients were selected and divided into two groups of 7 subjects each: GJB2 mutation and no mutation (i.e., deafness of unknown origin). Overall, all patients showed improvement of speech perception outcome after cochlear implantation. There was no difference in the improvement between patients with and without GJB2 mutations at the 5-year and 9-year follow up. The pattern of improvement throughout the duration of the follow-up also showed no difference between the two groups. CONCLUSIONS: Similar outcomes of speech perception are expected after cochlear implantation in pediatric patients with or without GJB2 mutation.

Births to Parents with Asian Origins in the United States, 1992–2012

Despite a remarkable increase in Asian births in the U.S., studies on their birth outcomes have been lacking. We investigated outcomes of births to Asian parents and biracial Asian/White parents in the U.S. From the U.S. birth data (1992–2012), we selected singleton births to Korean, Chinese, Japanese, Filipino, Asian Indian, and Vietnamese. These births were divided into three groups; births to White mother/Asian father, Asian mother/White father, and births to the both ethnic Asian parents. We compared birth outcomes of these 18 subgroups to those of the White mother/White father group. Mean birthweights of births to the Asian parents were significantly lower, ranging 18 g to 295 g less than to the White parents. Compared to the rates of low birthweight (LBW) (4.6%) and preterm birth (PTB) (8.5%) in births to the White parents, births to Filipino parents had the highest rates of LBW (8.0%) and PTB (11.3%), respectively, and births to Korean parents had the lowest rates of both LBW (3.7%) and PTB (5.5%). This pattern of outcomes had changed little with adjustments of maternal sociodemographic and health factors. This observation was similarly noted also in births to the biracial parents, but the impact of paternal or maternal race on birth outcome was different by race/ethnicity. Compared to births to White parents, birth outcomes from the Asian parents or biracial Asian/White parents differed depending on the ethnic origin of Asian parents. The race/ethnicity was the strongest factor for this difference while other parental characteristics hardly explained this difference.

Neonatal and Infant Mortality in Korea, Japan, and the U.S.: Effect of Birth Weight Distribution and Birth Weight-Specific Mortality Rates

Difference in crude neonatal and infant mortality rates (NMR and IMR) among different countries is due to the differences in its two determinants: birth weight distribution (BWD) and birth weight-specific mortality rates (BW-SMRs). We aimed to determine impact of BWD and BW-SMRs on differences in crude NMR and IMR among Korea, Japan, and the U.S. Our study used the live birth data of the period 2009 through 2010. Crude NMR/IMR are the lowest in Japan, 1.1/2.1, compared to 1.8/3.2, in Korea, and 4.1/6.2, in the U.S., respectively. Japanese had the best BW-SMRs of all birth weight groups compared to the Koreans and the U.S. The U.S. BWD was unfavorable with very low birth weight (< 1,500 g) rate of 1.4%, compared to 0.6% in Korea, and 0.8% in Japan. If Koreans and Japanese had the same BWD as in the U.S., their crude NMR/IMR would be 3.9/6.1 for the Koreans and 1.5/2.5 for the Japanese. If both Koreans and Japanese had the same BW-SMRs as in the U.S., the crude NMR/IMR would be 2.0/3.8 for the Koreans and 2.7/5.0 for the Japanese. In conclusion, compared to the U.S., lower crude NMR or IMR in Japan is mainly attributable to its better BW-SMRs. Koreans had lower crude NMR and IMR, primarily from its favorable BWD. Comparing crude NMR or IMR among different countries should include further exploration of its two determinants, BW-SMRs reflecting medical care, and BWD reflecting socio-demographic conditions.

Birth Outcomes of Koreans by Birthplace of Infants and Their Mothers, the United States versus Korea, 1995-2004

The acculturation effect of immigrant women on birth outcomes varies by race. We examined birth outcomes of three groups of births for the period 1995-2004, USA births to the USA-born Korean mothers, USA births to the non-USA-born Korean mothers, and births in Korea. In singleton USA births to both Korean parents, average birth weight was 3,294 g for the USA-born Korean mothers and 3,323 g for the non-USA-born Korean mothers. However, this difference was not significant, once controlled for other maternal sociodemographic, obstetric and medical factors. Low birth weight and prematurity prevalence were not different by maternal nativity between these two singleton groups. Average birth weight of all births including multiplets in Korea was 3,270 g, compared to 3,297 g for all USA-born infants including multiplets and births either to both or one Korean parents. This difference might have reflected a significantly lower educational attainment of mothers in Korea compared to Korean mothers in the USA. Low birth weight rate was consistently lower in infants born in Korea compared to the USA-born, but this difference became less, 4.2% and 4.6% respectively by 2004. These observations suggest that in the USA acculturation effect of Korean immigrants on birth outcomes is negligible.

Results of Primary Malleostapedotomy in Stapes Fixation / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to analyze the results of malleostapedotomy as primary surgical procedure in stapes fixation. SUBJECTS AND METHOD: This study was a retrospective chart review of 12 patients who underwent primary malleostapedotomy for conductive hearing loss. The intraoperative findings, surgical outcomes including audiologic data and complications were analyzed. RESULTS: Nine patients had ossicular fixation with ossicular anomalies and 3 patients had ossicular fixation alone. The median length of piston wire was 5.5 mm in total length. The preoperative mean bone and air-conduction thresholds were 57.5+/-8.8 (mean+/-SD) dB, 19.7+/-10.3 dB, respectively, and the mean air-bone gap (ABG) was 44.6+/-13.2 dB. After malleostapedotomy, hearings were improved and mean postoperative ABG was 11.1+/-11.3 dB. In eight patients (66.7%), ABG was reduced to 20 dB or less. There was no intraoperative or postoperative complication except for mild postoperative vertigo for 1 or 2 days. CONCLUSION: Malleostapedotomy can be a safe and effective surgical procedure as an alternative of incus stapedotomy in certain cases of absence or anomalous incus long process, and/or immobile incus in patients with stapes fixation.

Comparison of Re-evaluated Disability Grades with the First Registered Grade in the Seoul-living Disabled for National Registration for Disability

OBJECTIVE: To compare the disability grades previously evaluated and registered, with the re-evaluated ones for individuals with disability living in Seoul. METHOD: Thee hundred and eleven people with disability living in Seoul were selected by the hierarchical systematic extraction method. Their disability grade was re-evaluated in the otolaryngology, ophthalmology, rehabilitation outpatient clinic or via home visit. And the disability level of each person was evaluated by the Korean Activities of Daily Living (K-ADL). RESULTS: Two hundred and twenty nine people with disability were re-evaluated on their disability grades. One hundred and thirty four (58.5%) cases had the same disability grade as initially evaluated. Thirty three cases were re-adjusted to a higher disability grade and sixty two cases to a lower grade. The K-ADL scores of people with brain lesion and spine/spinal cord injury were higher than those of other type of disability, which indicated a higher level of disability. CONCLUSION: When disability grades were re-evaluated, discrepancy rate was 41.5%. For proper management in the process of disability registration, it is imperative to implement a policy, which ensures the re-evaluation of the disability grade at a regular interval, the clear guidelines for grading as well as the competency of the evaluators.

A Case of Typhoid Fever to Failed Ciprofloxacin, Infected in Korea / 감염과화학요법

Typhoid fever caused by Salmonella enterica serovar Typhi (S. typhi) and usually ciprofloxacin is first used for treatment. However, the incidence of fluoroquinolone resistance or reduced susceptibility in S. typhi has been increased in Asia over the past decade and there have been reports of failed treatment with ciprofloxacin. Recently, if typhoid fever does not improved with ciprofloxacin treatment, S. typhi with reduced susceptibility to ciprofloxacin should be considered. We experienced a case of nalidixic acid-resistant S. typhi infection that was refractory to treatment with ciprofloxacin in Korea. A 47-year-old woman presented with fever and headache for 14 days. Blood culture revealed the presence of S. typhi that was susceptible to ciprofloxacin. However, she remained feverish and new symptoms of abdominal pain and bloody diarrhea developed after 5 days treatment with ciprofloxacin and subsequent testing showed that isolate was resistant to nalidixic acid.

Acute Arsine (AsH3) Intoxication / 대한신장학회지

The present report describes a case of arsine intoxication. A 36-year-old male technician who handled gas in a semiconductor laboratory was admitted with severe abdominal pain and dark-red-colored urine. He was exposed to arsine gas while changing a gas bomb, since he mistook an arsine bomb for another, a different kind of a bomb. About 30 minutes after exposure, he suffered colicky abdominal pain, nausea, vomiting and dizziness. He noticed gross hematuria one hour later. On hospital in-patient day 2, the 24 h urine arsenic level was >1,000 microgram/day, and the serum arsenic level was 309.4 microgram/L. Since BUN/ creatinine level had risen to 33/2.0 mg/dL at this stage, a hemoperfusion was performed. And then hydration was used to maintain urine output at 2 mL/kg/h. His condition had improved, although he complained of a severe headache which was a neuropathic sequela of arsenic exposure. He was discharged with a normal blood arsine level. To our knowledge, this is the second report of arsine poisoning in Korea but somewhat different from the first case.

A Phase II Study of Leucovorin, 5-FU and Docetaxel Combination Chemotherapy in Patients with Inoperable or Postoperative Relapsed Gastric Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: To estimate the effect and toxicity of bimonthly low-dose leucovorin (LV) and fluorouracil (5-FU) bolus plus continuous infusion(LV5FU2) with docetaxel combination chemotheraphy in patients with inoperable or postoperative relapsed gastric cancer. MATERIALS AND METHODS: Total 27 patients are enrolled in this study. LV 20 mg/m2 (bolus), 5FU 400 mg/m2 (bolus), 5-FU 600 mg/m2 (24-hour continuous infusion) on day 1, 2, 15, and 16, docetaxel 60 mg/m2 (1-hour infusion) on day 15 every 4 weeks. RESULTS: Total of 141 cycles were administered and response rate were 36.8% with 2 complete response (10.5%) and 5 partial response (26.3%) in 19 evaluable patients. The median response duration is 8.1 months (95% CI, 4.0~12.1). The median progression-free survival time is 6.7 months (95% CI, 5.0~8.5) and the median overall survival time is 11.9 months (95% CI, 4.8~19.1). The grade 3-4 toxcity of neutropenia (24.8%) and anemia (11.3%), neutropenic fever (2.8%) is observed. The grade 1 toxcity of injection site reaction is observed all patients and the grade 1-2 toxcity of alopecia is observed 60%. CONCLUSIONS: LV5FU2 with docetaxel combination chemotheraphy is effective and tolerable in patients with inoperable or postoperative relapsed gastric cancer.

A Case of Typhoid Fever to Failed Ciprofloxacin, Infected in Korea / 감염과화학요법

Typhoid fever caused by Salmonella enterica serovar Typhi (S. typhi) and usually ciprofloxacin is first used for treatment. However, the incidence of fluoroquinolone resistance or reduced susceptibility in S. typhi has been increased in Asia over the past decade and there have been reports of failed treatment with ciprofloxacin. Recently, if typhoid fever does not improved with ciprofloxacin treatment, S. typhi with reduced susceptibility to ciprofloxacin should be considered. We experienced a case of nalidixic acid-resistant S. typhi infection that was refractory to treatment with ciprofloxacin in Korea. A 47-year-old woman presented with fever and headache for 14 days. Blood culture revealed the presence of S. typhi that was susceptible to ciprofloxacin. However, she remained feverish and new symptoms of abdominal pain and bloody diarrhea developed after 5 days treatment with ciprofloxacin and subsequent testing showed that isolate was resistant to nalidixic acid.

A Case of Candida Bursitis Associated with Etanercept Treatment in a Patient with Rheumatoid Arthritis / 대한류마티스학회지

Tumor necrosis factor (TNF)-alpha blockade has been well proved to significantly improve the disease course of rheumatoid arthritis. However, since TNF-alpha plays an important role in the immune system against external infectious organisms, it was reported that TNF-alpha blockade could increase the frequency of serious opportunistic infections such as tuberculosis. Fungal bursitis is a rare infectious disease following sever infections, malignancies and immune deficiencies. Moreover, there was no report on fungal bursitis occurring after administration of TNF-alpha blockade in Korea to date. Recently we experienced a 58-year-old female patient with rheumatoid arthritis who presented soft buttock mass after treatment with etanercept and was finally diagnosed as fungal bursitis by Candida parapsilosis.

Clinical Comparison of the Auditory Steady-State Response with the Click Auditory Brainstem Response in Infants

OBJECTIVES: Our goal was to determine the effectiveness of using the auditory steady state response (ASSR) as a measure of hearing thresholds in infants who are suspected of having significant hearing loss, as compared with using the click-auditory brainstem response (C-ABR). METHODS: We retrospectively analyzed the audiologic profiles of 76 infants (46 boys and 30 girls, a total of 151 ears) who ranged in age from 1 to 12 months (average age: 5.7 months). The auditory evaluations in 76 infants who were suspected of having hearing loss were done via the C-ABR and ASSR. In addition, for reference, the mean ASSR thresholds were compared to those of 39 ears of infants and 39 ears of adults with normal hearing at 0.5, 1, 2, and 4 kHz. RESULTS: The highest correlation between the C-ABR and ASSR thresholds was observed at an average of 2-4 kHz (r=0.94). On comparison between the hearing of infants and adults at 0.5, 1, 2, and 4 kHz, the mean ASSR threshold in infants was 12, 7, 8, and 7 dB higher, respectively, than that in adults. CONCLUSION: ASSR testing may provide additional audiometric information for accurately predicting the hearing sensitivity, and this is essential for the management of infants with severe to profound hearing loss.

A case of valproic acid-induced hyperammonemic encephalopathy with normal liver function / 대한내과학회지

Valproic acid is an effective anticonvulsant used in neurology and psychiatry. Valproic acid-induced hyperammonemic encephalopathy is an unusual complication characterized by a decreasing level of consciousness, the development of progressive confusional states and, sometimes, a coexisting increase in the frequency of seizures after the onset of valproic acid treatment. It can lead to death, but can be reversed if a swift diagnosis is made. We report the case of a 58-year-old woman with an intracerebral hemorrhage and normal liver function who presented with valproic acid-induced hyperammonemic encephalopathy. After valproic acid treatment, she developed encephalopathy and became comatose, with seizures and a markedly elevated serum ammonia level. Her neurologic manifestations and hyperammonemia improved after discontinuing the valproic acid.

Long Term Changes of Electrical Stimulation Levels in Children with Cochlear Implant / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The goal of mapping after cochlear implantation (CI) is to find a proper range of acoustic signals for the implantees. In young children or infants, however, it is more difficult to obtain reliable responses during mapping procedure. The purpose of this study was to observe the changes of the proper electrical stimulation levels (threshold levels, comfortable levels and dynamic range) in children with the Nucleus 24 cochlear implant system by analyzing postoperative mapping results. SUBJECTS AND METHOD: The maps of 23 children with normal inner ear who received CI were examined at 7 time intervals (1, 6, 12, 24, 36, 48 and 60 months post-connection). RESULTS: The mean value of C levels and DR of 23 children gradually increased according to time from 1 month to 60 months post-connection. The value of T level increased up to 6 months post-connection and then stabilized. CONCLUSION: This study emphasized the need for frequent mapping in the first 6 months of implant use in children. Protocol for regular mapping schedule from 1 year to 5 year post-connection would be necessary.

The Validity Using Two-stage Automated Auditory Brainstem Response as a Universal Newborn Hearing Screening Protocol : Experiences in Asan Medical Center / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Universal newborn hearing screening is widely accepted due to socioeconomic harm of congenital hearing loss. The aim of this study was to assess whether two-stage automated auditory brainstem response (AABR) is acceptable method for newborn hearing screening and to check the presence of potential false negative cases by using another criterion considering sweep number. SUBJECTS AND METHOD: Among 3761 neonates who were born from March 2004 to December 2005, 3053 healthy neonates (81.18%) whose parents agreed to hearing screening protocol were screened with AABR. Failed neonates ('refer') at first stage test and neonates showing high sweep number (>4000) on repeated test were received second stage retest within 24 hours from the first test. Neonates whose retest AABR results were failed or high sweep number continuously were tested with conventional ABR as a confirmative study within 3 months. RESULTS: 94 neonates (3.08%) were failed and 180 neonates (5.89%) showed high sweep number on first stage AABR test. On second stage AABR test, neonates with 'final refer' result were 46 (1.51%) and neonates with 'final high sweep number' result were 44 (1.44%). Neonates with threshold of over 30 dB at ABR were 14 among final refer group and 5 among final high sweep number group. Three bilateral profound hearing loss cases were detected and proper management was done. Nine false negative cases were detected and of these, 3 neonates showed moderate hearing loss. There is no clear relationship between predicting false negative case and sweep number. CONCLUSION: Our current two stage AABR test is useful tool for newborn hearing screening with acceptable referral rate and positive predictive value. False negative cases detected through our protocol have no clear relationship with high sweep number.

Cochlear Implantation in the Cochlear Nerve Hypoplasia or Aplasia as Suggested by Temporal Bone Magnetic Resonance Imaging / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Identifying cochlear nerve hypoplasia or aplasia is dependent on temporal bone magnetic resonance imaging (TBMRI) providing information on the cochlea, internal auditory canal, and the cochlear nerve. The purpose of this study was to review the results of cochlear implantation (CI) in ears with cochlear nerve hypoplasia or aplasia as suggested by TBMRI. SUBJECTS AND METHOD: From April 1999 to April 2005, 321 patients were fitted with cochlear implants in our department by two surgeons. The present study focused on four prelingual patients who underwent CI in ears with cochlear nerve hypoplasia or aplasia as suggested by TBMRI. The perceptive and linguistic results were evaluated based on speech perception and production at preimplantation and at 1, 3, 6, 9, 12, and 24 months postimplantation. RESULTS: Pre-operative auditory brainstem responses were absent at 90 dB nHL in all patients. At least 10 months after implantation all patients were able to detect consonants and vowels in 100% and their categories of auditory performance scores were 4 or above. CONCLUSION: We confirmed cochlear nerve presence in cases of cochlear nerve hypoplasia or aplasia as suggested by TBMRI and made their auditory habilitation possible with cochlear implantation. However, even in cases of cochlear nerve hypoplasia or aplasia suggested by TBMRI, physicians need to confirm cochlear nerve presence before implantation and to predict the outcome of cochlear implantation.

Surgical Outcome of Revision Stapedotomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study is to analyze the causes of recurrent conductive hearing loss following stapedotomy, and then the final hearing results. SUBJECTS AND METHOD: This study was a retrospective chart review of 6 patients who underwent revision stapedotomy for recurrent or persistent conductive hearing loss after primary stapedotomy. The intraoperative findings, surgical outcome including audiologic data and complications were noted. RESULTS: Obstruction of oval window fenestration was demonstrated in 5 patients (83.3%), short prosthesis in 4 patients (66.7%), incus erosion in two patients (33.3%) and granulation around prosthesis and stapes in one patient. Successful hearing improvements, air-bone gap (ABG) reduced to 20 dB or less, were achieved in 5 ears (83.3%). There were no patients who noted sensorineural hearing loss and other significant complications after surgery. CONCLUSION: More than 83% of revision stapedotomy cases have had successful closure of their ABG. The most common problem was obstruction of oval window fenestration (83.3%).

Postoperative Complications Following Cochlear Implantation in Patients with Inner Ear Anomalies / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Cochlear implantation is regarded as a safe and effective treatment for patients with profound sensorineural hearing loss. However, a few patients, especially with inner ear anomalies, suffer from complications with variable degrees after operation. This study reports various complications encountered in patients with inner ear anomalies undergoing cochlear implantation in 3rd referreral center. SUBJECTS AND METHOD: We retrospectively analyzed 342 patients who had cochlear implantation between April 1999 and December 2005. There were 70 patients with various inner ear anomalies. Immediate and delayed complications were defined according to their onset which happened within or over 1 week. Minor and Major complications were defined according to their severity which needed further operation or management. RESULTS: Among 342 patients, there were 35 cases (10.2%) with various postoperative complications. In patients with inner ear anomalies, the total number of complications was 20 cases (28.6%). There were 4 cases (5.7%) of major complications including facial nerve palsy, recurrent meningitis, device failure, and cerebrospinal fluid leakage. Reimplantation was performed in 3 cases (4.3%). CONCLUSION: Although the rate of postoperative complications in patients with inner ear anomalies was higher than in patients with normal inner ear, most of them were minor and could be managed with conservative treatments. The tolerable rate of major complications suggests that cochlear implantation is a safe operation even for patients with inner ear anomalies.

Clinical Features and Comparison of the Results according to Surgical Methods in Patients with Intrameatal Vestibular Schwannoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Modern imaging and surgical techniques have made intrameatal vestibular schwannoma (IMVS) surgery safe and have allowed for good outcomes with respect to facial nerve function and hearing outcome. This study aimed to analyze clinical features and to compare the results of the middle fossa approach (MFA) and translabyrinthine approach (TLA) used during IMVS surgery. SUBJECTS AND METHOD: We reviewed retrospectively 10 patients who were operated for IMVS from November 1995 to May 2005. This study analyzed chief complaint, size of tumor, audiological studies, caloric test, imaging study, and treatment modality. RESULTS: The main symptom for IMVS patients is vertigo. But, in our study, patients having only vertigo was rare ; most cases had vertigo with tinnitus or hearing disturbance. Patients with vertigo and tinnitus had mild hearing disturbance in PTA and unilateral weakness in the Caloric test. In terms of mean operation time, it took 7.5 hours in MFA and 4 hours in TLA. Postoperative hearing loss and facial nerve palsy occurred in early MFA operation cases. With respect to facial nerve function, the MF approach group had a higher rate of development of facial neuropathy than did the TL approach group. CONCLUSION: We think patients with vertigo and tinnitus will progress to hearing loss. We should suspect IMVS if patients complain of vertigo and tinnitus. But, further evaluation should be needed. If postoperative hearing preservation is not important, the TLA technique has made IMVS surgery safe and has allowed for good outcomes with respect to facial nerve function preservation. To use the MFA method, otolaryngologic surgeons need more direct and indirect experiences, considering the low incidence of acoustic schwannoma surgery and that the MFA method requires longer mean operation time than TLA.