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Hearing preservation surgery for vestibular schwannomas via the retrosigmoid transmeatal approach: surgical tips

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Abstract

Maximum tumor extirpation with preservation of the facial and cochlear nerve function is the goal of surgery for vestibular schwannoma. To preserve cochlear nerve function, the surgeon must employ a detailed knowledge of microanatomy, precise microsurgical techniques, and persistence. This paper describes the “pearls” of surgical techniques based on the anatomical study inside the mastoid from the view of the retrosigmoid transmeatal approach. A total of 592 consecutive patients underwent surgical removal of unilateral vestibular schwannoma (VS) between January 1994 and December 2009. The hearing preservation rate was 53.7 % for large vestibular schwannomas (>20 mm in diameter) and 74.1 % for tumors of all sizes. The key procedures for hearing preservation surgery are as follows: bloodless microdissection, sufficient coring-debulking, capsular elevation to locate the facial and cochlear nerves both electrophysiologically and by visual observation, sharp dissection of the facial and cochlear nerves, and avoidance of heat and mechanical injury to the nerves, the internal auditory artery, and the brain stem. Besides these techniques, appropriate instruments are essential to preserve hearing. The function of the facial and cochlear nerves should be the foremost concern. Meticulous techniques and the knowledge of microsurgical anatomy lead to hearing preservation with maximum tumor removal.

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References

  1. Briggs RJ, Fabinyi G, Kaye AH (2000) Current management of acoustic neuromas: review of surgical approaches and outcomes. J Clin Neurosci 7:521–526

    Article  CAS  PubMed  Google Scholar 

  2. Buchman CA, Chen DA, Flannagan P, Wilberger JE, Maroon JC (1996) The learning curve for acoustic tumor surgery. Laryngoscope 106:1406–1411

    Article  CAS  PubMed  Google Scholar 

  3. Darrouzet V, Martel J, Enee V, Bebear JP, Guerin J (2004) Vestibular schwannoma surgery outcomes: our multidisciplinary experience in 400 cases over 17 years. Laryngoscope 114:681–688

    Article  PubMed  Google Scholar 

  4. Di Maio S, Malebranche AD, Westerberg B, Akagami R (2011) Hearing preservation after microsurgical resection of large vestibular schwannomas. Neurosurgery 68:632–640, discussion 640

    Article  PubMed  Google Scholar 

  5. Elsmore AJ, Mendoza ND (2002) The operative learning curve for vestibular schwannoma excision via the retrosigmoid approach. Br J Neurosurg 16:448–455

    Article  CAS  PubMed  Google Scholar 

  6. Fahlbusch R, Neu M, Strauss C (1998) Preservation of hearing in large acoustic neurinomas following removal via suboccipito-lateral approach. Acta Neurochir (Wien) 140:771–777, discussion 778

    Article  CAS  Google Scholar 

  7. Gormley WB, Sekhar LN, Wright DC, Kamerer D, Schessel D (1997) Acoustic neuromas: results of current surgical management. Neurosurgery 41:50–58, discussion 58–60

    Article  CAS  PubMed  Google Scholar 

  8. Hecht CS, Honrubia VF, Wiet RJ, Sims HS (1997) Hearing preservation after acoustic neuroma resection with tumor size used as a clinical prognosticator. Laryngoscope 107:1122–1126

    Article  CAS  PubMed  Google Scholar 

  9. Jacob A, Robinson LL Jr, Bortman JS, Yu L, Dodson EE, Welling DB (2007) Nerve of origin, tumor size, hearing preservation, and facial nerve outcomes in 359 vestibular schwannoma resections at a tertiary care academic center. Laryngoscope 117:2087–2092

    Article  PubMed  Google Scholar 

  10. Magliulo G, Parrotto D, Stasolla A, Marini M (2004) Modified translabyrinthine approach and hearing preservation. Laryngoscope 114:1133–1138

    Article  PubMed  Google Scholar 

  11. Maw AR, Coakham HB, Ayoub O, Butler SR (2003) Hearing preservation and facial nerve function in vestibular schwannoma surgery. Clin Otolaryngol Allied Sci 28:252–256

    Article  CAS  PubMed  Google Scholar 

  12. McElveen JT Jr, Hitselberger WE (1989) The neural dissector. Otolaryngology—head and neck surgery. Off J Am Acad Otolaryngol-Head Neck Surg 101:513

    Google Scholar 

  13. McElveen JT Jr, Belmonte RG, Fukushima T, Bullard DE (2000) A review of facial nerve outcome in 100 consecutive cases of acoustic tumor surgery. Laryngoscope 110:1667–1672

    Article  PubMed  Google Scholar 

  14. Moffat DA, da Cruz MJ, Baguley DM, Beynon GJ, Hardy DG (1999) Hearing preservation in solitary vestibular schwannoma surgery using the retrosigmoid approach. Otolaryngology—head and neck surgery. Off J Am Acad Otolaryngol-Head Neck Surg 121:781–788

    Article  CAS  Google Scholar 

  15. Mohr G, Sade B, Dufour JJ, Rappaport JM (2005) Preservation of hearing in patients undergoing microsurgery for vestibular schwannoma: degree of meatal filling. J Neurosurg 102:1–5

    Article  PubMed  Google Scholar 

  16. Moriyama T, Fukushima T, Asaoka K, Roche PH, Barrs DM, McElveen JT Jr (2002) Hearing preservation in acoustic neuroma surgery: importance of adhesion between the cochlear nerve and the tumor. J Neurosurg 97:337–340

    Article  PubMed  Google Scholar 

  17. Nonaka Y, Fukushima T, Watanabe K, Friedman AH, Sampson JH, McElveen JT, Jr., Cunningham CD, 3rd, Zomorodi AR (2012) Contemporary surgical management of vestibular schwannomas: analysis of complications and lessons learned over the past decade. Neurosurgery

  18. Rachinger J, Rampp S, Prell J, Scheller C, Alfieri A, Strauss C (2011) Tumor origin and hearing preservation in vestibular schwannoma surgery. J Neurosurg 115:900–905

    Article  PubMed  Google Scholar 

  19. Rowed DW, Nedzelski JM (1997) Hearing preservation in the removal of intracanalicular acoustic neuromas via the retrosigmoid approach. J Neurosurg 86:456–461

    Article  CAS  PubMed  Google Scholar 

  20. Samii M, Matthies C (1997) Management of 1000 vestibular schwannomas (acoustic neuromas): hearing function in 1000 tumor resections. Neurosurgery 40:248–260, discussion 260–242

    Article  CAS  PubMed  Google Scholar 

  21. Samii M, Gerganov V, Samii A (2006) Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients. J Neurosurg 105:527–535

    Article  PubMed  Google Scholar 

  22. Sanna M, Karmarkar S, Landolfi M (1995) Hearing preservation in vestibular schwannoma surgery: fact or fantasy? J Laryngol Otol 109:374–380

    Article  CAS  PubMed  Google Scholar 

  23. Shelton C, Hitselberger WE, House WF, Brackmann DE (1990) Hearing preservation after acoustic tumor removal: long-term results. Laryngoscope 100:115–119

    CAS  PubMed  Google Scholar 

  24. Slattery WH 3rd, Brackmann DE, Hitselberger W (1997) Middle fossa approach for hearing preservation with acoustic neuromas. Am J Otology 18:596–601

    PubMed  Google Scholar 

  25. Wanibuchi M, Fukushima T, McElveen JT Jr, Friedman AH (2009) Hearing preservation in surgery for large vestibular schwannomas. J Neurosurg 111:845–854

    Article  PubMed  Google Scholar 

  26. Wanibuchi M, Fukushima T, Zomordi AR, Nonaka Y, Friedman AH (2012) Trigeminal schwannomas: skull base approaches and operative results in 105 patients. Neurosurgery 70:132–143, discussion 143–134

    Article  PubMed  Google Scholar 

  27. Welling DB, Slater PW, Thomas RD, McGregor JM, Goodman JE (1999) The learning curve in vestibular schwannoma surgery. Am J Otology 20:644–648

    CAS  PubMed  Google Scholar 

  28. Wiet RJ, Mamikoglu B, Odom L, Hoistad DL (2001) Long-term results of the first 500 cases of acoustic neuroma surgery. Otolaryngology—head and neck surgery. Off J Am Acad Otolaryngol-Head Neck Surg 124:645–651

    Article  CAS  Google Scholar 

  29. Yong RL, Westerberg BD, Dong C, Akagami R (2008) Length of tumor-cochlear nerve contact and hearing outcome after surgery for vestibular schwannoma. J Neurosurg 108:105–110

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Sapporo Medical University School of Medicine, South 1, West 16 Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan

    Masahiko Wanibuchi, Yukinori Akiyama, Takeshi Mikami, Satoshi Iihoshi, Tomohiro Murakami, Toshiya Sugino & Nobuhiro Mikuni

  2. Division of Neurosurgery, Duke University Medical Center, Durham, USA

    Takanori Fukushima, Allan H. Friedman & Kentaro Watanabe

  3. Carolina Neuroscience Institute, Raleigh, USA

    Takanori Fukushima & Kentaro Watanabe

Authors
  1. Masahiko Wanibuchi
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  2. Takanori Fukushima
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  3. Allan H. Friedman
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  4. Kentaro Watanabe
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  5. Yukinori Akiyama
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  6. Takeshi Mikami
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  7. Satoshi Iihoshi
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  8. Tomohiro Murakami
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  9. Toshiya Sugino
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  10. Nobuhiro Mikuni
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Correspondence to Masahiko Wanibuchi.

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Comments

Venelin Gerganov, Hannover, Germany

The authors of this nicely written manuscript present their technique for function-preserving vestibular schwannoma surgery. Using this technique in a relatively large series of patients, they could achieve excellent functional results: the hearing preservation rate was 54 % for vestibular schwannomas >20 mm and 74 % for tumors of all sizes. The facial nerve functional outcome corresponds also to the highest current treatment standards. One should highlight explicitly their surgical philosophy, which I completely share: the patient’s preoperative hearing level is the sole criterion for attempting hearing preservation surgery and the size of the tumor is irrelevant.

Whatever operative technique one applies in his practice, the detailed description of the technique developed and used by the senior authors, is highly valuable. It does not differ essentially from the operative technique that we use (developed by M. Samii). Still, there are some minor differences, such as the preoperative placement of spinal drainage catheter, the dural incision, or the closure of the internal auditory canal (IAC). Other differences are more important and need to be mentioned.

We prefer the semisitting positioning of the patient, which allows for two-hand tumor dissection because there is no need for constant suction. Moreover, this position obviates the need for frequent bipolar coagulation that may be very dangerous for the nervous structures. In this point, I disagree with the view of the authors on the necessity to keep a “bloodless surgical field.” Only the major bleeding arteries need to be coagulated. The blood is “washed-out” by irrigation, and the CSF, blood, and fluids drain out spontaneously.

We prefer to open the IAC prior to tumor debulking (with the exception of giant VS) thereby avoiding the spread of bone dust. Importantly, the canal should always be widely opened—for approximately 180°—in order to provide an unobstructed view to the tumor. The extent of lateral opening, however, is determined by the tumor extension, which is assessed at surgery: the preoperative MR imaging may be misleading in this regard.

The constant auditory brain stem monitoring is essential because it provides constant feedback on the cochlear nerve function. Thus, surgical manipulations and actions could be modified accordingly.

Once the intracanalicular tumor portion is removed, the extracanalicular is approached. Tumor debulking should proceed systematically in all directions. Then, the remaining tumor part is pulled slightly into the operative field and its capsule is dissected in the arachnoid plane. In larger VS, these steps are repeated alternatively in all directions. The dissection of the nerves should always be performed in the arachnoid plane, usually by using just two instruments: to hold the tumor capsule and to pealing off the arachnoid. Thus, the microvasculature running in the arachnoid that is essential for the hearing can be preserved.

At the end, we plug the IAC with fat pieces harvested from the incisional area and seal them with fibrin glue.

Ricardo Ramina and Luis Fernando M Silva, Curitiba, Brazil

The authors describe step-by-step tips for preservation of the cochlear nerve function in a large series of 592 unilateral vestibular schwannomas. The retrosigmoid transmeatal approach was used in 70 % of the cases. Maximum tumor removal with preservation of facial and cochlear nerve function was the aim of surgery. Hearing preservation was attempted in patients with preoperative hearing levels of class A, B, C, or D (pure tone average (PTA) <60 dB and speech discrimination score (SDS) >50 %). They emphasizes the importance of intraoperative monitoring, not opening the vestibule or the posterior semicircular canal during drilling the wall of the IAC, and sharp dissection of the nerves avoiding heat and mechanical injury. Employing these surgical strategies, the authors achieved a high rate of hearing preservation (74.1 %) for tumors of all sizes and 53.7 % for large vestibular schwannomas (>20 mm in diameter). However, gross total removal was performed in only 74.6 % of cases. Functional facial nerve preservation (grades I and II on the House–Brackmann scale) was 90.7 % for large tumors and 92.7 % for tumors of all sizes. CSF leak was observed in 3 of 54 patients with larger tumors. No mortality associated with the surgery was reported. This article highlights the importance of functional preservation of the involved cranial nerves in vestibular schwannomas surgery and provides valuable surgical tips for hearing preservation.

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Wanibuchi, M., Fukushima, T., Friedman, A.H. et al. Hearing preservation surgery for vestibular schwannomas via the retrosigmoid transmeatal approach: surgical tips. Neurosurg Rev 37, 431–444 (2014). https://doi.org/10.1007/s10143-014-0543-9

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  • DOI: https://doi.org/10.1007/s10143-014-0543-9

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