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Long-term facial nerve function evaluation following surgery for large acoustic neuromas via retrosigmoid transmeatal approach

  • Clinical Article
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Abstract

Purpose

By evaluating the postoperative facial nerve function of large acoustic neuromas, the purpose of this study was to analyze the factors that influence the facial nerve function outcome and to explore the surgical strategy for large acoustic neuromas.

Methods

A retrospective study of surgical outcome was performed on 89 patients with large acoustic neuromas. All operations were performed via the retrosigmoid transmeatal approach using the intraoperative electrophysiological monitoring.

Results

Gross total resection was performed in 38 (42.7%) of the 89 patients, near total resection in 35 (39.3%), and subtotal resection in 16 (18.0%). The facial nerve was anatomically intact at the end of surgery in 83 (93.3%) patients. At 1 year after surgery, 48 (53.9%) patients had good facial nerve function (House–Brackmann (HB) Grades I–II), 23 (25.8%) patients had regular facial nerve function (HB Grades III–IV), and 18 (20.2%) patients had poor facial nerve function (HB Grades V–VI).

Conclusions

For large acoustic neuromas, the goal of complete tumor resection and preservation of acceptable facial nerve function can be attained via the retrosigmoid transmeatal approach, using the intraoperative facial nerve monitoring. The surgical strategy of near total resection is indicated for the large acoustic neuromas with severe adherence or inclusion in order to preserve facial nerve function.

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Authors and Affiliations

  1. Department of Neurosurgery, the Second Hospital of Shandong University, 247# Beiyuan Road, Jinan, Shandong Province, 250033, China

    Xu Zhao, Zhigang Wang, Yong Ji, Chengwei Wang, Rui Yu, Xuan Ding & Shengcheng Wei

Authors
  1. Xu Zhao
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  2. Zhigang Wang
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  3. Yong Ji
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  4. Chengwei Wang
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  5. Rui Yu
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  6. Xuan Ding
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  7. Shengcheng Wei
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Corresponding author

Correspondence to Zhigang Wang.

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Comment

The reporting of this clinical series of large vestibular schwannomas operated on by the sub occipital route has some virtues.

It demonstrates the continued usefulness of this classical surgical approach in the treatment of these tumors, one that has stood the test of time in comparison with other surgical routes also in use. It is a fast, clean, and very safe surgical approach, which creates a wide surgical corridor to work along. It provides an excellent view of all the pertinent anatomy, without the need to increase the amount of bone work (and the possible risks associated with it) required by other routes. In our experience, it also does without the need for cerebellar retraction.

The authors present us the numbers of the morbidity resulting from the resection of large (> 4cm) vestibular schwannomas in yet another large-volume center around the world. Their report is essentially centered on the function of the facial nerve. The authors have systematically used intraoperative EMG monitoring and state that they have privileged facial function over extent of resection. Indeed in the days when tumor control can be achieved with alternative methods such as radiosurgery, surgery must secure a very low risk of facial function loss. Any alternative is better than a facial palsy.

In this series, the authors had 93.3% of anatomical preservation of the facial nerve, but poor function occurred in a non-negligible 29% of patients’ immediately postoperative anatomical preservation coming down to 20% at 1 year. This discrepancy is worth commenting. Did the cases of anatomical preservation of VII also have a preserved EMG function at the end of the operation? If not, what was then the rationale to continue the resection when the EMG recording was admittedly getting worse? In the light of the author's philosophy (with which we condone) it would seem more appropriate to opt for leaving some tumor behind and preserving more facial function.

It also seems appropriate to include a word about postoperative face function restoration. The authors apparently do not advocate the use of VII/XII anastomosis for patients with irreversible complete facial palsy. Grave complications are to be expected regarding eye function among the disastrous cosmetic and functional consequences of a complete facial paralysis. The authors should be encouraged to demonstrate how they have been able to control this situation making do with only conservative measures such as drugs, acupuncture, and physical therapy.

Manuel Cunha e Sa

Almada, Portugal

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Zhao, X., Wang, Z., Ji, Y. et al. Long-term facial nerve function evaluation following surgery for large acoustic neuromas via retrosigmoid transmeatal approach. Acta Neurochir 152, 1647–1652 (2010). https://doi.org/10.1007/s00701-010-0705-7

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  • DOI: https://doi.org/10.1007/s00701-010-0705-7

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