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Acoustic neuroma surgeryShanghai experience Hao Wu Department of Otolaryngology-Head and Neck Surgery Xinhua Hospital, Shanghai Second Medical University.

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Presentation on theme: "Acoustic neuroma surgeryShanghai experience Hao Wu Department of Otolaryngology-Head and Neck Surgery Xinhua Hospital, Shanghai Second Medical University."— Presentation transcript:

1 Acoustic neuroma surgeryShanghai experience Hao Wu Department of Otolaryngology-Head and Neck Surgery Xinhua Hospital, Shanghai Second Medical University

2 McBumey (1891): unsuccessful Balance (1894): first successful

3 Cushing Era Surgical mortality: 80% Cushing –partial removal

4 Dandy Era 1917–1961 Total removal: mortality(22.1%) Atkinson (1949): AICA Total facial paralysis

5 1960 Mortality rate in California: 43.5% Olivecrona (Sweden) 414 cases –small tumors: 4.5% –large tumors: 22.5% –Facial paralysis: 50%

6 Dr. W. House Middle fossa approach (1961) Traslab approach (1962)

7 Origin Development in the internal acoustic meatus from the schwann cells of the vestibular ganglion (Sterkers JM et al., Acta Otolaryngol., 1987) Arachnoid sheet enveloping the tumour during its expansion to the CPA.

8 Epidemiology 6 to 8 % of all intracranial tumours The most frequent (80 to 90%) of the CPA tumours Sporadic, and solitary in 95 % of cases Associated with NF2 in 5 % of cases Estimated incidence in USA and Western Europe: 1 for 100,000 individuals per year (Kurlan et al., J neurosurg, 1958 ; Nestor JJ et al., Arch Otlaryngol Head Neck Surg, 1988)

9 REASON FOR CONSULTATION Expected symptom: 80.7 % (progressive HL,tinnitus,unsteadiness) Sudden hearing loss: 9.6 % Atypical presentation: 10 %... Moffat et al., 1998 n = 473

10 MRI diagnosis Isosignal on T1, and variable aspect en T2 views Constant gadolinium enhancement Intratumoral cysts in large neurinomes No adjascent meningeal enhancement Enlarged IAM Extension predominantly posterior to IAM

11 Differential diagnosis Other neurinomas in the CPA: 5th, 7th, or caudal cranial nerve neurinomas Other lesions: Most frequent: Meningiomas Cholesteatomas Rare lesions :lipomas, metastases, hemangiomas, medulloblastomas etc…..

12 Unilateral or asymetrical audio-vestibular signs : Hearing loss, vestibular syndrome, tinnitus MRI + Gadolinium Follow-up Audio-vestibular work-up In 6 months Neurotological examination Audiometry+ABR+VNG Age < 60 years> 60 years AbnormalityNormal ABR and VNG

13 Decisionnal factors 1.Tumor volume 2.Age 3.Hearing function

14 Therapeutic options Varaiable tumor growth According to age and tumor size < 1,5 cm MRI in 6 months and then once a year Gamma-knife, LINAC Volume stabilisation Hearing loss and facial paresis Under evaluation Conservative managament Surgery Radiotherapy

15 Goals of the surgery 1- Minimal vital and neurological risks 2- Total removal 3- Facial function preservation 4- Hearing preservation

16 Approaches Retrosigmoid (RS) Translabyrinthine (TL) Middle cranial fossa (MCF)

17 Acoustic Neuromas Intracanalar or CPA < 20 mm > 70 years: Conservative management < 70 years: Surgery Poor general condition: Irradiation CPA> 20 mm Translabyrinthine or transotic translabyrinthineMCF retrosigmoid Hearing ServiceableUnserviceable

18 II < 15 mm III : mm IV > 30 mm I : 100 VS operated on Mean age: 49 years (range: 20-79) Sex ratio: 0.8 Tumor stages : –Stage 1: 3 % –Stage 2: 11 % –Stage 3 : 71 % –Stage 4 : 15 % Population

19 Approaches Translabyrinthine : 77 % Transotic: 6 % Retrosigmoid: 12 % Middle cranial fossa: 5 % 17% attempt to hearing preservation

20 ABR Intraoperative monitoring

21 Direct cochlear nerve potential

22 Resection quality Complete removal in 98 cases Subtotal removal in 1 cases (1 %) In cases with subtotal removal : 1 MRI images demonstrate to be stable (1 %) 1 case surgically revised (1 %)

23 Postoperative facial function in translabyrinthine or transotic approach StagesCases Facial function

24 Hearing preservation Hearing preservation attempts by middle cranial fossa or retrosigmoid approach (n=17): Class D: 40 % Class A: 12 % Class C: 24 % Class B: 24 % Class A+B: 36%

25 Complications CSF leaks: 6%(all in first 39 cases) Neurological: 3% Infectious: 1 % Miscellaneous: 3 %

26 Translabyrinthine approach

27 Translabyrinthine removal of VS after radiosurgery 5 cases Difficult in facial nerve dissection Results total removal in all cases facial function: grade II in 1 case grade III in 2 cases grade IV in 2 cases grade VI in 1 case

28 Transotic removal of VS with chronic middle ear infection 3 cases Results total removal in all cases facial function: all with gradeI-II no postoperative infection

29 Fallopian bridge technique

30 Middle fossa approach


32 Retrosigmoid-IAM approach

33 Facial nerve repair after interruption end-to-ent anastomosis Reroute technique Bridge technique Facial-hypolingual ana.

34 NF2 and Auditory Brainstem Implant Hearing rehabilitation in acoustic neuroma surgery

35 NF2 DIAGNOSIS Bilateral vestibular schwannoma (VS) NF2 familial history and - unilateral VS - or 2 among : meningioma, glioma, neurofibroma,schwannoma,subcapsular lens opacity

36 NF2 NF2 gene on chromosome 22 (1993) Tumor suppressor gene

37 Auditory pathway

38 Nucleus 21 Channel Auditory Brainstem Implant CI22M receiver-stimulator Monopolar reference electrode (plate) Microcoiled electrode wires Electrode array (21 platinum disks 0.7mm diameter) T-shaped Dacron mesh Removeable magnet


40 Bone anchored hearing aide (BAHA) Single sided deafness; FDA approval;

41 Conclusions 1 In spite of modern image techniques, large VS acounts for most diagnosed cases in China. The translabyrinthine app. could be used in even largest VS with minival invasion.

42 Conclusions 2 The facial function is aceptable in most patients. The hearing preservation result should still be improved. Hearing rehabilitation techniques are available after tumor removal.

43 Thanks

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