• Translabyrinthine Approach for Resection of a Vestibular Schwannoma

    • Authored By:
      • Walter Jean, MD Washington,District of Columbia GEORGETOWN UNIVERSITY MEDICAL CENTER

    Case Presentation

    • 57 y.o. man with a 2-year history of left-sided tinnitus
    • Hearing on the left gradually declined over 2 years and patient presented to otolaryngologist for consultation
    • He had no other complaints except for left aural fullness
    • Neurological exam showed that he was neurological intact except for his hearing loss
    • Audiogram showed severe sensorineural hearing loss on the left with a SRT of 50 dB and speech discrimination of 72%
    • The test was repeated after a short period and the SRT had deteriorated to 62 dB and the patient felt that his left-sided hearing was no longer usable

    Alternatives

    • All three approaches commonly used for vestibular schwannomas are potentially usable in this patient
      • The middle fossa approach (green) is a "top down," hearing-preserving approach, mostly reserved for intracanalicular tumors
      • The retrosigmoid approach (brown) is "back-to-front" approach, capable of preserving hearing
      • The translabyrinthine approach is a "lateral-to-medial" approach which makes space for the surgery by removal of large amounts of temporal bone
    • Options of watchful-waiting, radiosurgery and surgical resection were presented to the patient as they were all rational options for him
    • He chose surgical resection because it was the only option with the possibility of leading to a long-term cure
    • Because of his excellent baseline health, the goal was set for total resection with preservation of his normal facial nerve
    • If the tumor was found to be adherent to the facial nerve during the operation, nerve preservation would trump degree of resection and residual would be left behind by intention

    Approach

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    Positioning

    • Position: supine, head turned to right side

    Incision

    • Incision: C-shape, behind the left auricle
    • Bone opening: mastoidectomy, drilling of the bony labyrinthine, opening of IAC
    • Durotomy: T-shape, with long limb along the axis of the tumor

    Operation

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    Post Op

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    Outcome

    • The patient's neurological exam after surgery was the same as before
    • Facial nerve function was HB I/VI on both sides
    • He was discharged from the hospital within the same week
    • His postoperative dizziness gradually disappeared over several months to baseline (i.e. none)
    • Follow up MRI over the next 4 years showed no evidence of recurrence of the tumor

    Pearls and Pitfalls

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    Discussion

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    References

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