Acoustic neurinomas: diagnosis and treatment

Ramina, Ricardo; Manigua, João Jarney; Meneses, Murilo Sousa; Pedrozo, Ari Antonio; Barrionuevo, Carlos Eduardo; Arruda, Walter Oleschko; Pineroli, José Carlos

doi:10.1590/S0004-282X1997000300007

Abstracts

We present our experience with 83 patients with acoustic neurinomas (January 1988 to November 1996); 81 patients underwent surgery and 2 patients with intracanalicular neurinomas received conservative therapy due to their advanced age (1 case) and patient's option (1 case). The surgical approach was retrosigmoid/ trasmeatal and the goal was total removal in one procedure with preservation of facial and cochlear nerves. Radical removal of lesion was attempted in 79 cases and it was possible in 77 patients. Subtotal tumor resection was planned in 2 cases. Facial nerve function (grades 1 to III, House and Brackman) was preseved in 90% and hearing in 58% of those with preoperative hearing. Three patients died due to postoperative complications. Early diagnosis of acoustic neurinomas is the most important factor in the prognosis and is one of the most important conquest of neurophysiology and modern neuroimaging. The management of these patients still present many controversial points. This article presents the diagnostic procedures used for acoustic neurinomas, the advantages and disadvantages of the different surgical approaches and the alternative management of these lesions.

acoustic neurinoma; vestibular schwanoma; facial nerve; hearing preservation; radiosurgery, management

Apresentamos nossa experiência no tratamento de 83 pacientes com neurinomas do acústico (Janeiro-1988 a Novembro-1996). Cirurgia foi realizada em 81 pacientes e tratamento conservador (idade avançada e escolha do paciente) em 2 casos de neurinomas intracanalicures. O objetivo da cirurgia foi ressecção radical com preservação dos nervos facial e coclear. Em 77 de 79 pacientes foi obtida remoção total. Em 2 casos foi proposta ressecção sub-total devido às más condições clínicas (1 paciente) e por tratar-se de neurofibromatose tipo 2 com lesão dos nervos facial e coclear do outro lado (1 paciente). Preservação do nervo facial (grau I a III, House e Brackman) foi possível em 90% dos casos com função facial pre-operatória normal. Dos 12 pacientes que apresentavam audição no pré-operatório, 7 mantiveram a audição. Ocorreram 3 óbitos no pós-operatório imediato. As vantagens e desvantagens dos acessos cirúrgicos mais utilizados na cirurgia do neurinoma do acústico são demonstradas. O fator mais importante no prognóstico desses pacientes é o diagnóstico precoce, possível com o desenvolvimento de novos métodos neurofisiológicos e neurorradiológicos. O tratamento no entanto pode apresentar algumas controvérsias, variando desde o simples acompanhamento clínico à remoção cirúrgica ou o uso de radiocirurgia.

neurinoma do acústico; schwanoma vestibular; nervo facial; preservação da audição; radiocirurgia

Acoustic neurinomas: diagnosis and treatment

Neurinoma do acústico: diagnóstico e tratamento

Ricardo Ramina^I; João Jarney Manigua^II; Murilo Sousa Meneses^I; Ari Antonio Pedrozo^I; Carlos Eduardo Barrionuevo^II; Walter Oleschko Arruda^III; José Carlos Pineroli^II

^ICuritiba Skull Base Foundation, Hospital das Nações, Curitiba PR, Brazil: Neurosurgeon

^IICuritiba Skull Base Foundation, Hospital das Nações, Curitiba PR, Brazil: ENT-surgeon

^IIICuritiba Skull Base Foundation, Hospital das Nações, Curitiba PR, Brazil: Neurologist

ABSTRACT

We present our experience with 83 patients with acoustic neurinomas (January 1988 to November 1996); 81 patients underwent surgery and 2 patients with intracanalicular neurinomas received conservative therapy due to their advanced age (1 case) and patient's option (1 case). The surgical approach was retrosigmoid/ trasmeatal and the goal was total removal in one procedure with preservation of facial and cochlear nerves. Radical removal of lesion was attempted in 79 cases and it was possible in 77 patients. Subtotal tumor resection was planned in 2 cases. Facial nerve function (grades 1 to III, House and Brackman) was preseved in 90% and hearing in 58% of those with preoperative hearing. Three patients died due to postoperative complications. Early diagnosis of acoustic neurinomas is the most important factor in the prognosis and is one of the most important conquest of neurophysiology and modern neuroimaging. The management of these patients still present many controversial points. This article presents the diagnostic procedures used for acoustic neurinomas, the advantages and disadvantages of the different surgical approaches and the alternative management of these lesions.

Key words: acoustic neurinoma, vestibular schwanoma, facial nerve, hearing preservation, radiosurgery, management.

RESUMO

Apresentamos nossa experiência no tratamento de 83 pacientes com neurinomas do acústico (Janeiro-1988 a Novembro-1996). Cirurgia foi realizada em 81 pacientes e tratamento conservador (idade avançada e escolha do paciente) em 2 casos de neurinomas intracanalicures. O objetivo da cirurgia foi ressecção radical com preservação dos nervos facial e coclear. Em 77 de 79 pacientes foi obtida remoção total. Em 2 casos foi proposta ressecção sub-total devido às más condições clínicas (1 paciente) e por tratar-se de neurofibromatose tipo 2 com lesão dos nervos facial e coclear do outro lado (1 paciente). Preservação do nervo facial (grau I a III, House e Brackman) foi possível em 90% dos casos com função facial pre-operatória normal. Dos 12 pacientes que apresentavam audição no pré-operatório, 7 mantiveram a audição. Ocorreram 3 óbitos no pós-operatório imediato. As vantagens e desvantagens dos acessos cirúrgicos mais utilizados na cirurgia do neurinoma do acústico são demonstradas. O fator mais importante no prognóstico desses pacientes é o diagnóstico precoce, possível com o desenvolvimento de novos métodos neurofisiológicos e neurorradiológicos. O tratamento no entanto pode apresentar algumas controvérsias, variando desde o simples acompanhamento clínico à remoção cirúrgica ou o uso de radiocirurgia.

Palavras-chave: neurinoma do acústico, schwanoma vestibular, nervo facial, preservação da audição, radiocirurgia.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Aceite: 25-março-1997.

Dr. Ricardo Ramina - Rua Gonçalves Dias 713 - 80240-340 Curitiba PR - Brasil. Fax 041 264 1238.

1. Atkinson WJ Jr. Anterior inferior cerebellar artery: its variation, pontine distribution, and significance in surgery of the cerebello-pontine angle tumours. J Neurol Neurosurg Psychiatry 1949;12:137-151.
2. Ballance CA. Some points in the surgery of the brain and its membranes. London: Macmillan, 1907.
3. Briggs RJS, Luxford WM, Atkins JS Jr, Hitselberger WE. Translabyrinthine removal of large acoustic neuromas. Neurosurgery 1994;34:5,785-791.
4. Cushing H. Tumors of the nervus acusticus and the syndrome of the cerebellopontine angle. Philadelphia: WB Saunders, 1917: 244-287.
5. Dandy WE. An operation for the total removal of cerebellopontine (acoustic) tumors. Surg Gynecol Obstet 1925;41:129-148.
6. Dandy WE. Results of removal of acoustic tumors by the unilateral approach. Arch Surg 1941;42:1026-1033.
7. Deen HG, Ebersold MJ, Harner SG, Beatty CW, Marion MS, Wharen RG, Green JA, Quart L. Conservative management of acoustic neuroma:an outcome study. Neurosurgery 1996;39:260-266.
8. Ducatman BS, Scheithauer BW. Postirradiation neurofibrosarcoma. Cancer 1983; 51:1028-1033.
9. Gardner G, Robertson JH. Hearing preservation in unilateral acoustic neuroma surgery. Ann Otol Rhinol Laryngol 1988;97:55-66.
10. Goel A, Sekhar LN, Langheinrich W, Kamen D, Hirsch B. Late course of preserved hearing and tinnitus after acoustic neurilemoma surgery. J Neurosurg 1992;77:685-689.
11. Haines SJ, Levine SC. Intracanalicular acoustic neuroma: early surgery for preservation of hearing. J Neurosurg 1993;79:515-520.
12. House WF. Monograph I: Transtemporal bone microsurgical removal of acoustic neurinomas. Arch Otolaryngol 1964;80:597-756.
13. House WF, Brackman DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-147.
14. House WF, Waluch V, Jackler RK. Magnetic ressonance imaging in acoustic neuroma diagnosis. Ann Otol Rhinol Laryngol 1986;95:16-20.
15. Irwing RM, Nofffat DA, Hardy DG, Barton DE, Xuereb JH, Maher ER. Molecular genetic analysis of the mechanism of tumorgenesis in acoustic neuroma. Arch Otolaryngol Head Neck Surg 1993;119:1222-1228.
16. Jannetta PJ, Mõller AR, Moller MB. Technique of hearing preservation in small acoustic neuromas. Ann Surg 1984;200:513-523.
17. Koos WT, Perneczky A. Suboccipital approach to acoustic neurinomas with emphasis on preservation of facial nerve and cochlear nerve function. In Rand W (ed) Microneurosurgery. St Louis: CV Mosby, 1985: 335-365.
18. Leksell L. A note on the treatment of acoustic tumors. Acta Chir Scand 1971;137:763-765.
19. Lindskay ME, Lunsford DL, Flidanger JC. Tumor control after stereotatic radiosurgery in neurofibromatosis patients with bilateral acoustic tumors. Neurosurgery 1992;31:829-839.
20. Mangham CA. Complications of translabyrinthine vs suboccipital approach for acoustic tumor surgery. Otolaryngol Head Neck Surg 1988;99:396-400.
21. Maniglia AJ, Fenstermaker RA, Ratcheson RA. Preservation of hearing in the surgical removal of cerebellopontine angle tumors. Otolaryngol Clin North Am 1989;22:211-232.
22. Mõller AR, Janetta PJ. Preservation of facial function during removal of acoustic neuromas. J Neurosurg 1984;61:757-760.
23. Noren G, Arndt I, Hindmarsh T. Stereotactic radiosurgery in cases of acoustic neurinoma: further experiences. Neurosurgery 1988;13: 12-22.
24. Noren G, Greitz D, Hirsch A, Lax I. Gamma knife radiosurgery in acoustic neurinomas. In Tos M, Thomsen J (eds). Proceedings of the first international conference on acoustic neuroma. Amsterdam: Kugler, 1992: 289-292.
25. Ojemann RG. Management of acoustic neuromas (vestibular schwannomas). Clin Neurosurg 1993;40:498-535.
26. Ojemann RG, Martuza RL. Acoustic neuroma. In Youmas JR (ed). Neurological surgery. Ed 3. Philadelphia: Saunders, 1990:3316-3350.
27. Olivecrona H. Acoustic tumors. J Neurol Neurosurg Psychiatry 1940;3:141-146.
28. Pensak ML, Tew JM, Keoth RW, Van Loveren HR. Management of the acoustic in an only hearing ear. Skull Base Surg 1991;1:93-96.
29. Pollock BE, Lunsford DL, Kondziolka D, Flickinger JC, Bissonette DJ, Kelsey SF, Jannetta PJ. Outcome analysis of acoustic neuroma management: comparison of microsurgery and stereotatic radiosurgery. Neurosurgery 1995;36:215-229.
30. Ramina R, Maniglia JJ, Barrionuevo CE. Surgical excision of petrous apex lesions. In Sekhar LN, Janecka P (eds). Surgery of cranial base tumors:a color atlas. New York: Raven Press, 1993: 291-305.
31. Rand R, Kurze T. Microneurosurgical resection of acoustic tumors by a transmeatal posterior fossa approach. Bull Los Angeles Neurol Soc 1965;30:17-20.
32. Rand R, Kurze T. Preservation of vestibular, cochlear and facial nerves during microsurgical removal of acoustic tumors: report of two cases. J Neurosurg 1968;28:158-161.
33. Rhoton AL Jr. Microsurgical anatomy of acoustic neuromas. In Sekhar LN, Janecka IP (eds). Surgery of cranial base tumors: a color atlas. New York: Raven Press, 1993: 687-713.
34. Roswell E, Dilys P. Summary: vestibular schwannoma (acoustic neuroma) consensus development conference, conference proceedings. Neurosurgery 1992;30:962-964.
35. Samii M. Tumors of the internal auditory canal and cerebellopontine angle, acoustic neuroma. In: Samii M, Draf W (eds). Surgery of the skull base: an interdisciplinary approach. Berlin: Springer-Verlag, 1988: 377-395.
36. Samii M, Mathies C, Tatagiba M. Intracanaiicuiar acoustic neurinomas. Neurosurgery 1991;29:189-199.
37. Samii M, Tatagiba M, Mathies C. Acoustic neurinoma in the elderly: factors predictive of postoperative outcome. Neurosurgery 1992;31:615-620.
38. Sterkers JM, Desgeorges M, Sterkers O, Corlieu O. Our present approach to acoustic neuroma surgery. Adv Otorhinolaryngol 1984;34:160-163.
39. Strasnick L, Glasscock III ME, Haynes D, McMenome SD, Minor FB. The natural history of untreated acoustic neurinomas. Laryngoscope 1994;104:1115-1119.
40. Tos M, Thomsen J. Cerebrospinal fluid leak after translabyrinthine surgery for acoustic neuroma. Laryngoscope 1985;95:351-354.
41. Valvanori GE, Shannon M. Natural history of acoustic neuromas. Skull Base Surg 1991;1:165-167.
42. Wiegand DA, Fickel V. Acoustic neuroma- the patient's perspective: subjective assessment of symptoms, diagnosis, therapy and outcome in 541 patients. Laryngoscope 1989;99:179-187.

Publication Dates

Publication in this collection
18 Oct 2010
Date of issue
Sept 1997

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Atkinson WJ Jr. Anterior inferior cerebellar artery: its variation, pontine distribution, and significance in surgery of the cerebello-pontine angle tumours. J Neurol Neurosurg Psychiatry 1949;12:137-151.

[2] 2. Ballance CA. Some points in the surgery of the brain and its membranes. London: Macmillan, 1907.

[3] 3. Briggs RJS, Luxford WM, Atkins JS Jr, Hitselberger WE. Translabyrinthine removal of large acoustic neuromas. Neurosurgery 1994;34:5,785-791.

[4] 4. Cushing H. Tumors of the nervus acusticus and the syndrome of the cerebellopontine angle. Philadelphia: WB Saunders, 1917: 244-287.

[5] 5. Dandy WE. An operation for the total removal of cerebellopontine (acoustic) tumors. Surg Gynecol Obstet 1925;41:129-148.

[6] 6. Dandy WE. Results of removal of acoustic tumors by the unilateral approach. Arch Surg 1941;42:1026-1033.

[7] 7. Deen HG, Ebersold MJ, Harner SG, Beatty CW, Marion MS, Wharen RG, Green JA, Quart L. Conservative management of acoustic neuroma:an outcome study. Neurosurgery 1996;39:260-266.

[8] 8. Ducatman BS, Scheithauer BW. Postirradiation neurofibrosarcoma. Cancer 1983; 51:1028-1033.

[9] 9. Gardner G, Robertson JH. Hearing preservation in unilateral acoustic neuroma surgery. Ann Otol Rhinol Laryngol 1988;97:55-66.

[10] 10. Goel A, Sekhar LN, Langheinrich W, Kamen D, Hirsch B. Late course of preserved hearing and tinnitus after acoustic neurilemoma surgery. J Neurosurg 1992;77:685-689.

[11] 11. Haines SJ, Levine SC. Intracanalicular acoustic neuroma: early surgery for preservation of hearing. J Neurosurg 1993;79:515-520.

[12] 12. House WF. Monograph I: Transtemporal bone microsurgical removal of acoustic neurinomas. Arch Otolaryngol 1964;80:597-756.

[13] 13. House WF, Brackman DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-147.

[14] 14. House WF, Waluch V, Jackler RK. Magnetic ressonance imaging in acoustic neuroma diagnosis. Ann Otol Rhinol Laryngol 1986;95:16-20.

[15] 15. Irwing RM, Nofffat DA, Hardy DG, Barton DE, Xuereb JH, Maher ER. Molecular genetic analysis of the mechanism of tumorgenesis in acoustic neuroma. Arch Otolaryngol Head Neck Surg 1993;119:1222-1228.

[16] 16. Jannetta PJ, Mõller AR, Moller MB. Technique of hearing preservation in small acoustic neuromas. Ann Surg 1984;200:513-523.

[17] 17. Koos WT, Perneczky A. Suboccipital approach to acoustic neurinomas with emphasis on preservation of facial nerve and cochlear nerve function. In Rand W (ed) Microneurosurgery. St Louis: CV Mosby, 1985: 335-365.

[18] 18. Leksell L. A note on the treatment of acoustic tumors. Acta Chir Scand 1971;137:763-765.

[19] 19. Lindskay ME, Lunsford DL, Flidanger JC. Tumor control after stereotatic radiosurgery in neurofibromatosis patients with bilateral acoustic tumors. Neurosurgery 1992;31:829-839.

[20] 20. Mangham CA. Complications of translabyrinthine vs suboccipital approach for acoustic tumor surgery. Otolaryngol Head Neck Surg 1988;99:396-400.

[21] 21. Maniglia AJ, Fenstermaker RA, Ratcheson RA. Preservation of hearing in the surgical removal of cerebellopontine angle tumors. Otolaryngol Clin North Am 1989;22:211-232.

[22] 22. Mõller AR, Janetta PJ. Preservation of facial function during removal of acoustic neuromas. J Neurosurg 1984;61:757-760.

[23] 23. Noren G, Arndt I, Hindmarsh T. Stereotactic radiosurgery in cases of acoustic neurinoma: further experiences. Neurosurgery 1988;13: 12-22.

[24] 24. Noren G, Greitz D, Hirsch A, Lax I. Gamma knife radiosurgery in acoustic neurinomas. In Tos M, Thomsen J (eds). Proceedings of the first international conference on acoustic neuroma. Amsterdam: Kugler, 1992: 289-292.

[25] 25. Ojemann RG. Management of acoustic neuromas (vestibular schwannomas). Clin Neurosurg 1993;40:498-535.

[26] 26. Ojemann RG, Martuza RL. Acoustic neuroma. In Youmas JR (ed). Neurological surgery. Ed 3. Philadelphia: Saunders, 1990:3316-3350.

[27] 27. Olivecrona H. Acoustic tumors. J Neurol Neurosurg Psychiatry 1940;3:141-146.

[28] 28. Pensak ML, Tew JM, Keoth RW, Van Loveren HR. Management of the acoustic in an only hearing ear. Skull Base Surg 1991;1:93-96.

[29] 29. Pollock BE, Lunsford DL, Kondziolka D, Flickinger JC, Bissonette DJ, Kelsey SF, Jannetta PJ. Outcome analysis of acoustic neuroma management: comparison of microsurgery and stereotatic radiosurgery. Neurosurgery 1995;36:215-229.

[30] 30. Ramina R, Maniglia JJ, Barrionuevo CE. Surgical excision of petrous apex lesions. In Sekhar LN, Janecka P (eds). Surgery of cranial base tumors:a color atlas. New York: Raven Press, 1993: 291-305.

[31] 31. Rand R, Kurze T. Microneurosurgical resection of acoustic tumors by a transmeatal posterior fossa approach. Bull Los Angeles Neurol Soc 1965;30:17-20.

[32] 32. Rand R, Kurze T. Preservation of vestibular, cochlear and facial nerves during microsurgical removal of acoustic tumors: report of two cases. J Neurosurg 1968;28:158-161.

[33] 33. Rhoton AL Jr. Microsurgical anatomy of acoustic neuromas. In Sekhar LN, Janecka IP (eds). Surgery of cranial base tumors: a color atlas. New York: Raven Press, 1993: 687-713.

[34] 34. Roswell E, Dilys P. Summary: vestibular schwannoma (acoustic neuroma) consensus development conference, conference proceedings. Neurosurgery 1992;30:962-964.

[35] 35. Samii M. Tumors of the internal auditory canal and cerebellopontine angle, acoustic neuroma. In: Samii M, Draf W (eds). Surgery of the skull base: an interdisciplinary approach. Berlin: Springer-Verlag, 1988: 377-395.

[36] 36. Samii M, Mathies C, Tatagiba M. Intracanaiicuiar acoustic neurinomas. Neurosurgery 1991;29:189-199.

[37] 37. Samii M, Tatagiba M, Mathies C. Acoustic neurinoma in the elderly: factors predictive of postoperative outcome. Neurosurgery 1992;31:615-620.

[38] 38. Sterkers JM, Desgeorges M, Sterkers O, Corlieu O. Our present approach to acoustic neuroma surgery. Adv Otorhinolaryngol 1984;34:160-163.

[39] 39. Strasnick L, Glasscock III ME, Haynes D, McMenome SD, Minor FB. The natural history of untreated acoustic neurinomas. Laryngoscope 1994;104:1115-1119.

[40] 40. Tos M, Thomsen J. Cerebrospinal fluid leak after translabyrinthine surgery for acoustic neuroma. Laryngoscope 1985;95:351-354.

[41] 41. Valvanori GE, Shannon M. Natural history of acoustic neuromas. Skull Base Surg 1991;1:165-167.

[42] 42. Wiegand DA, Fickel V. Acoustic neuroma- the patient's perspective: subjective assessment of symptoms, diagnosis, therapy and outcome in 541 patients. Laryngoscope 1989;99:179-187.