Acoustic neuroma surgery: Difference between revisions

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{{CMG}} {{AE}}{{M.B}}
{{CMG}} {{AE}}{{M.B}}
==Overview==
==Overview==
[[Surgery]] is the mainstay of treatment for acoustic neuroma. Patient with age under 65 years and/or medium to large-grade tumors and/or significant hearing loss, and/or higher headache severity scores will have more satisfying outcomes from surgery in comparison with observation. There are three main surgical approaches for the removal of an acoustic neuroma: translabyrinthine, retrosigmoid or sub-occipital, and middle [[fossa]]. Selection of a particular approach is based on several factors, including the size and location of the tumor and whether or not preservation of hearing is a goal.
[[Surgery]] is the mainstay of treatment for acoustic neuroma. [[Patient|Patients]] with age under 65 years, medium to large-grade [[Tumor|tumors]], significant [[Hearing impairment|hearing loss]], or higher [[headache]] severity scores will have more satisfying outcomes from [[surgery]] in comparison with [[observation]]. There are three main [[Surgery|surgical approaches]] for the removal of an acoustic neuroma: [[Translabyrinthine approach|translabyrinthine]], retrosigmoid or [[Occipital|sub-occipital]], and middle [[fossa]]. Selection of a particular approach is based on several factors including the size and location of the [[tumor]] and whether or not preservation of [[Hearing (sense)|hearing]] is a goal.


== Indications ==
== Indications ==
Indications for surgery for acoustic neuroma include:<ref>{{Cite journal
Indications for [[surgery]] include:<ref>{{Cite journal
<nowiki> </nowiki><nowiki>|</nowiki> author = [[Jason C. Nellis]], [[Jeff D. Sharon]], [[Seth E. Pross]], [[Lisa E. Ishii]], [[Masaru Ishii]], [[Jacob K. Dey]] & [[Howard W. Francis]]
<nowiki> </nowiki><nowiki>|</nowiki> author = [[Jason C. Nellis]], [[Jeff D. Sharon]], [[Seth E. Pross]], [[Lisa E. Ishii]], [[Masaru Ishii]], [[Jacob K. Dey]] & [[Howard W. Francis]]
  | title = Multifactor Influences of Shared Decision-Making in Acoustic Neuroma Treatment
  | title = Multifactor Influences of Shared Decision-Making in Acoustic Neuroma Treatment
Line 39: Line 39:
}}</ref>
}}</ref>
* Age < 65 years old
* Age < 65 years old
* Moderately large to large tumor
* Moderately large to large [[tumor]]
* Growing tumors
* Growing [[Tumor|tumors]]
* Significant hearing loss
* Significant [[Hearing impairment|hearing loss]]
* Higher headache severity scores
* Higher [[headache]] severity scores


==Surgery==
==Surgery==
[[Surgery]] is the mainstay of treatment for acoustic neuroma. Selection of a particular approach is based on several factors, including the size and location of the tumor and whether or not preservation of hearing is a goal. There are three standard surgical approaches for the excision of an acoustic neuroma:<ref>{{Cite journal
[[Surgery]] is the mainstay of treatment for acoustic neuroma. Selection of a particular approach is based on several factors including the size and location of the [[tumor]] and whether or not preservation of [[Hearing (sense)|hearing]] is a goal. There are three standard [[Surgery|surgical approaches]] for the [[excision]] of an acoustic neuroma:<ref>{{Cite journal
  | author = [[Marc Bennett]] & [[David S. Haynes]]
  | author = [[Marc Bennett]] & [[David S. Haynes]]
  | title = Surgical approaches and complications in the removal of vestibular schwannomas
  | title = Surgical approaches and complications in the removal of vestibular schwannomas
Line 67: Line 67:
  | pmid = 1630831
  | pmid = 1630831
}}<nowiki></ref <ref></nowiki>{{Cite journal
}}<nowiki></ref <ref></nowiki>{{Cite journal
| author = [[Tyler Cole]], [[Anand Veeravagu]], [[Michael Zhang]], [[Tej Azad]], [[Christian Swinney]], [[Gordon H. Li]], [[John K. Ratliff]] & [[Steven L. Giannotta]]
| title = Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database
| journal = [[Cureus]]
| volume = 7
| issue = 10
| pages = e369
| year = 2015
| month = October
| doi = 10.7759/cureus.369
| pmid = 26623224
}}</ref><ref>{{Cite journal
  | author = [[Tyler Cole]], [[Anand Veeravagu]], [[Michael Zhang]], [[Tej Azad]], [[Christian Swinney]], [[Gordon H. Li]], [[John K. Ratliff]] & [[Steven L. Giannotta]]
  | author = [[Tyler Cole]], [[Anand Veeravagu]], [[Michael Zhang]], [[Tej Azad]], [[Christian Swinney]], [[Gordon H. Li]], [[John K. Ratliff]] & [[Steven L. Giannotta]]
  | title = Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database
  | title = Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database
Line 78: Line 89:
  | pmid = 26623224
  | pmid = 26623224
}}</ref>
}}</ref>
* Translabyrinthine approach
* [[Translabyrinthine approach]]
* Retromastoid suboccipital approach
* Retromastoid suboccipital approach
* Middle fossa approach
* Middle [[fossa]] approach


===Retrosigmoid/sub-occipital approach===
=== Translabyrinthine approach ===
The [[incision]] for this approach is located in a slightly different location. This approach creates an opening in the [[skull]] behind the [[mastoid]] part of the ear, near the back of the head on the side of the tumor. The surgeon exposes the tumor from its posterior (back) surface, thereby getting a very good view of the tumor in relation to the [[brainstem]]. When removing large tumors through this approach, the [[facial nerve]] can be exposed by early opening of the [[internal]] [[auditory]] canal. Any size tumor can be removed with this approach. One of the main advantages of the retrosigmoid approach is the possibility of preserving hearing. For small tumors, a disadvantage lies in the risk of long-term postoperative [[headache]].
* The [[translabyrinthine approach]] is considered for [[Tumor|tumors]] larger than 3 cm and for smaller [[Tumor|tumors]] when [[Hearing (sense)|hearing]] preservation is not a concern.  
* This method has the advantage of reduced probability of [[facial nerve]] damage.<ref>{{Cite journal
| author = [[T. H. Lanman]], [[D. E. Brackmann]], [[W. E. Hitselberger]] & [[B. Subin]]
| title = Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach
| journal = [[Journal of neurosurgery]]
| volume = 90
| issue = 4
| pages = 617–623
| year = 1999
| month = April
| doi = 10.3171/jns.1999.90.4.0617
| pmid = 10193604
}}</ref><ref>{{Cite journal
<nowiki> </nowiki><nowiki>|</nowiki> author = [[Bulent Mamikoglu]], [[Richard J. Wiet]] & [[Carlos R. Esquivel]]
| title = Translabyrinthine approach for the management of large and giant vestibular schwannomas
| journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]]
<nowiki> </nowiki><nowiki>|</nowiki> volume = 23
<nowiki> </nowiki><nowiki>|</nowiki> issue = 2
<nowiki> </nowiki><nowiki>|</nowiki> pages = 224–227
<nowiki> </nowiki><nowiki>|</nowiki> year = 2002
<nowiki> </nowiki><nowiki>|</nowiki> month = March
<nowiki> </nowiki><nowiki>|</nowiki> pmid = 11875354
}}</ref>
*


===Middle fossa approach===
===Retromastoid Suboccipital Approach===
This approach is in a slightly different [[incision]] location and is utilized primarily for the purpose of hearing preservation in patients with small tumors, typically confined to the internal auditory canal. A small wind of bone is removed above the ear canal to allow exposure of the tumor from the upper surface of the internal auditory canal, preserving the inner ear structures.
* The [[Occipital|suboccipital]] approach is considered for all acoustic [[Tumor|tumors]] with or without the concern of [[Hearing (sense)|hearing]] preservation.
* Any size [[tumor]] can be removed with this approach.<ref>{{Cite journal
| author = [[Pk Nayak]] & [[Rvs Kumar]]
| title = Retromastoid-sub occipital: A novel approach to cerebello pontine angle in acoustic neuroma surgery-our experience in 21 cases
| journal = [[Journal of neurosciences in rural practice]]
| volume = 2
| issue = 1
| pages = 23–26
| year = 2011
| month = January
| doi = 10.4103/0976-3147.80084
| pmid = 21716801
}}</ref>


===Advantages of surgery===
===Middle Fossa Approach===
*Tumor is completely removed and risk of recurrence is less than 0.1%
* The middle [[fossa]] approach is considered for [[Tumor|tumors]] smaller than 1.5 cm when [[Hearing (sense)|hearing]] preservation is optimal.
*One follow-up [[MRI]] is needed
* This approach can preserve the [[inner ear]] structures.<ref>{{Cite journal
*Hearing is preserved and it is stable over time
| author = [[William F. House]] & [[Clough Shelton]]
 
| title = Middle fossa approach for acoustic tumor removal. 1992
===Disadvantages of surgery===
| journal = [[Neurosurgery clinics of North America]]
*In some cases, hearing cannot be saved
| volume = 19
*Long period of recovery, 4-6 day of hospital stay and 4-6 weeks to regain strength and balance
| issue = 2
*Leakage and [[infection]] of cerebrospinal fluid through the wound
| pages = 279–288
*Hearing loss
| year = 2008
*Facial [[numbness]] and [[weakness]]
| month = April
*Ringing in the ear
| doi = 10.1016/j.nec.2008.02.009
*Balance problems
  | pmid = 18534340
*Persistent [[headaches]]
}}</ref>
*[[Stroke]] or [[brain]] [[bleeding]]
 
===Stereotactic radiosurgery===
In single dose treatments, many hundreds of small beams of radiation are aimed at the tumor. This results in a high dose of radiation to the tumor and very little to any surrounding [[brain]] structures. Many patients have been treated this way with high success rates. Facial [[weakness]] or [[numbness]], in the hands of experienced radiation physicians, occurs in only a small percent of cases. This can be performed with either the linear accelerator or [[gamma]] knife. [[Radiosurgery]] is a treatment option for patients with smaller tumors (<3 cm) or for patients with enlarging tumors who are not candidates for [[surgery]].
*Complications of stereotactic radiosurgery include:
**Post [[radiation]] [[tumor]] expansion
**Local [[tissue]] scarring
**[[Cystic]] degeneration
**[[Malignant]] transformation


=== Stereotactic radiosurgery and fractionated stereotactic radiotherapy ===
Below table summarizes and simplifies approaches for the management of acoustic neuroma:
Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (SRT) represent comparable noninvasive treatments for acoustic neuromas. Studies demonstrated at 1-year follow-up, a significantly higher rate of serviceable hearing preservation was achieved in SRT sporadic tumor patients and may therefore be preferable to alternatives including [[surgery]], SRS, or possibly [[observation]] in patients with serviceable hearing .<ref>{{Cite journal|last=DAVID W. ANDREWS, M.D., OSCAR SUAREZ, M.D., H. WARREN GOLDMAN, M.D., PH.D., M. BEVERLY DOWNES, M.S., GREG BEDNARZ, PH.D., BENJAMIN W. CORN, M.D., MARIA WERNER-WASIK, M.D., JEFFREY ROSENSTOCK., M.D. AND WALTER J. CURRAN, JR., M.D.|first=|date=2001|title=STEREOTACTIC RADIOSURGERY AND FRACTIONATED STEREOTACTIC RADIOTHERAPY FOR THE TREATMENT OF ACOUSTIC SCHWANNOMAS: COMPARATIVE OBSERVATIONS OF 125 PATIENTS TREATED AT ONE INSTITUTION|url=|journal=Elsevier Science|volume=|pages=|via=}}</ref><ref>{{Cite journal|last=STEPHANIE E. COMBS, M.D., THOMAS WELZEL, M.D., DANIELA SCHULZ-ERTNER, M.D., PETER E. HUBER, M.D., PH.D., AND JURGEN DEBUS, M.D., PH.D.|first=|date=2010|title=DIFFERENCES IN CLINICAL RESULTS AFTER LINAC-BASED SINGLE-DOSE RADIOSURGERY VERSUS FRACTIONATED STEREOTACTIC RADIOTHERAPY FOR PATIENTS WITH VESTIBULAR SCHWANNOMAS|url=|journal=Int. J. Radiation Oncology Biol. Phys|volume=76|pages=193|via=}}</ref>
{| class="wikitable"
! style="background-color: #0080FF; font-weight: bold;" | Tumor Size
! style="background-color: #0080FF; font-weight: bold;" | Treatment line
! style="background-color: #0080FF; font-weight: bold;" | Treatment
|-
| style="background-color: #819FF7; font-weight: bold;" | Tumor < 1 to 1.5 cm
| colspan="2" |
|-
! rowspan="2" |No [[tumor]] growth
| First
| [[Observation]]
|-
| Second
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
! rowspan="3" | With [[tumor]] growth
| First
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
| Adjunct
| Salvage [[Radiation therapy|radiation]] or [[surgery]]
|-
| Second
| [[Observation]]
|-
| style="background-color: #819FF7; font-weight: bold;" | Tumor 1.5 to 3cm
| colspan="2" |
|-
! rowspan="3" | No [[tumor]] growth
| First
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
| Adjunct
| Salvage [[Radiation therapy|radiation]] or [[surgery]]
|-
| Second
| [[Observation]]
|-
! rowspan="3" | With [[tumor]] growth
| First
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
| Adjunct
| Salvage [[Radiation therapy|radiation]] or [[surgery]]
|-
| Second
| [[Observation]]
|-
| style="background-color: #819FF7; font-weight: bold;" | Tumor > 3cm
| colspan="2" |
|-
| rowspan="3" |
| First
| [[Surgery]]
|-
| Second
| [[Observation]]
|}


==References==
==References==

Latest revision as of 20:08, 26 April 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohsen Basiri M.D.

Overview

Surgery is the mainstay of treatment for acoustic neuroma. Patients with age under 65 years, medium to large-grade tumors, significant hearing loss, or higher headache severity scores will have more satisfying outcomes from surgery in comparison with observation. There are three main surgical approaches for the removal of an acoustic neuroma: translabyrinthine, retrosigmoid or sub-occipital, and middle fossa. Selection of a particular approach is based on several factors including the size and location of the tumor and whether or not preservation of hearing is a goal.

Indications

Indications for surgery include:[1][2][3]

Surgery

Surgery is the mainstay of treatment for acoustic neuroma. Selection of a particular approach is based on several factors including the size and location of the tumor and whether or not preservation of hearing is a goal. There are three standard surgical approaches for the excision of an acoustic neuroma:[4][5][6]

Translabyrinthine approach

Retromastoid Suboccipital Approach

  • The suboccipital approach is considered for all acoustic tumors with or without the concern of hearing preservation.
  • Any size tumor can be removed with this approach.[9]

Middle Fossa Approach

  • The middle fossa approach is considered for tumors smaller than 1.5 cm when hearing preservation is optimal.
  • This approach can preserve the inner ear structures.[10]

Below table summarizes and simplifies approaches for the management of acoustic neuroma:

Tumor Size Treatment line Treatment
Tumor < 1 to 1.5 cm
No tumor growth First Observation
Second Focused radiation or surgery
With tumor growth First Focused radiation or surgery
Adjunct Salvage radiation or surgery
Second Observation
Tumor 1.5 to 3cm
No tumor growth First Focused radiation or surgery
Adjunct Salvage radiation or surgery
Second Observation
With tumor growth First Focused radiation or surgery
Adjunct Salvage radiation or surgery
Second Observation
Tumor > 3cm
First Surgery
Second Observation

References

  1. ↑ {{Cite journal | author = Jason C. Nellis, Jeff D. Sharon, Seth E. Pross, Lisa E. Ishii, Masaru Ishii, Jacob K. Dey & Howard W. Francis | title = Multifactor Influences of Shared Decision-Making in Acoustic Neuroma Treatment | journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]] | volume = 38 | issue = 3 | pages = 392–399 | year = 2017 | month = March | doi = 10.1097/MAO.0000000000001292 | pmid = 27930442 }}
  2. ↑ {{Cite journal | author = D. M. Kaylie, E. Gilbert, M. A. Horgan, J. B. Delashaw & S. O. McMenomey | title = Acoustic neuroma surgery outcomes | journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]] | volume = 22 | issue = 5 | pages = 686–689 | year = 2001 | month = September | pmid = 11568680 }}
  3. ↑ A. Wright & R. Bradford (1995). "Management of acoustic neuroma". BMJ (Clinical research ed.). 311 (7013): 1141–1144. PMID 7580712. Unknown parameter |month= ignored (help)
  4. ↑ Marc Bennett & David S. Haynes (2007). "Surgical approaches and complications in the removal of vestibular schwannomas". Otolaryngologic clinics of North America. 40 (3): 589–609. doi:10.1016/j.otc.2007.03.007. PMID 17544697. Unknown parameter |month= ignored (help)
  5. ↑ D. E. Brackmann & J. D. Green (1992). "Translabyrinthine approach for acoustic tumor removal". Otolaryngologic clinics of North America. 25 (2): 311–329. PMID 1630831. Unknown parameter |month= ignored (help)</ref <ref>Tyler Cole, Anand Veeravagu, Michael Zhang, Tej Azad, Christian Swinney, Gordon H. Li, John K. Ratliff & Steven L. Giannotta (2015). "Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database". Cureus. 7 (10): e369. doi:10.7759/cureus.369. PMID 26623224. Unknown parameter |month= ignored (help)
  6. ↑ Tyler Cole, Anand Veeravagu, Michael Zhang, Tej Azad, Christian Swinney, Gordon H. Li, John K. Ratliff & Steven L. Giannotta (2015). "Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database". Cureus. 7 (10): e369. doi:10.7759/cureus.369. PMID 26623224. Unknown parameter |month= ignored (help)
  7. ↑ T. H. Lanman, D. E. Brackmann, W. E. Hitselberger & B. Subin (1999). "Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach". Journal of neurosurgery. 90 (4): 617–623. doi:10.3171/jns.1999.90.4.0617. PMID 10193604. Unknown parameter |month= ignored (help)
  8. ↑ {{Cite journal | author = Bulent Mamikoglu, Richard J. Wiet & Carlos R. Esquivel | title = Translabyrinthine approach for the management of large and giant vestibular schwannomas | journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]] | volume = 23 | issue = 2 | pages = 224–227 | year = 2002 | month = March | pmid = 11875354 }}
  9. ↑ Pk Nayak & Rvs Kumar (2011). "Retromastoid-sub occipital: A novel approach to cerebello pontine angle in acoustic neuroma surgery-our experience in 21 cases". Journal of neurosciences in rural practice. 2 (1): 23–26. doi:10.4103/0976-3147.80084. PMID 21716801. Unknown parameter |month= ignored (help)
  10. ↑ William F. House & Clough Shelton (2008). "Middle fossa approach for acoustic tumor removal. 1992". Neurosurgery clinics of North America. 19 (2): 279–288. doi:10.1016/j.nec.2008.02.009. PMID 18534340. Unknown parameter |month= ignored (help)


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