• Retrosigmoid approach for vestibular schwannoma

    Case Presentation

    • 45-year-old woman presents with progressive hearing loss and dizziness.

    Alternatives

    • Conservative medical management with serial observation

    Approach

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    Positioning

    • Supine/Flat
    • Turning
      • RIGHT

    Incision

    • A curvilinear skin incision was made 1-2 cm behind the pinna through the asterion to the mastoid tip.

    Operation

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    Post Op

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    Outcome

    • Postoperative course was initially uneventful, and the patient was discharged POD 3.
    • The patient developed delayed facial weakness HB grade 3 on POD 5, which resolved slowly over 6 weeks to normal facial function.

    Pearls and Pitfalls

    • If possible, the course of the facial nerve should be recognized early in the case to aid in anatomic preservation.
    • Once the facial nerve course is identified, internal debulking can usually be performed rapidly.
    • Intradural drilling of the IAC allows for distal facial nerve identification.
    • Delayed facial weakness is not uncommon but may take several weeks to resolve.

    Discussion

    • In retrosigmoid approaches to vestibular schwannomas with significant intracanalicular extension, it is important to drill off the posterior aspect of the IAC. Care must be taken to avoid injury to adjacent otologic structures.
    • Delayed facial palsy is not an uncommon occurrence after vestibular schwannoma resection, with a reported rate of 16% in a single institution study.
    • Development of facial palsy occurs at a mean of POD 12 but typically resolves by POD 33.
    • Patients with a gross total tumor resection or undergoing a retrosigmoid approach may be at higher risk of delayed facial palsy, but they recover normal or near-normal function.

    References

    • Carlstrom LP, Copeland WR 3rd, Neff BA, Castner ML, Driscoll CL, Link MJ. Incidence and risk factors of delayed facial palsy after vestibular schwannoma resection. Neurosurgery 2016. 78(2):251-5.
    • Surgery of the Cerebellopontine Angle. Nicholas C. Bambakidis, Cliff A. Megerian, Robert Friedrich Spetzler. PMPH-USA, 2009

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