Abstract
ObjectiveWe retrospectively evaluated the oncological and functional effectiveness of revision surgery for recurrent or remnant vestibular schwannoma (rVS).MethodsWe included 29 consecutive patients with unilateral hearing loss (16 women; mean age: 42.2 years) that underwent surgery for rVS. Previous surgeries included gross total resections (GTRs, n=11) or subtotal resections (n=18); mean times to recurrence were 9.45 and 4.15 years, respectively. House–Brackmann (HB) grading of facial nerve (FN) weakness (grades II-IV) indicated that 22 (75.9%) patients had deep, long-lasting FN paresis (HB grades: IV-VI). The mean recurrent tumor size was 23.3 mm (range: 6 to 51). Seven patients had neurofibromatosis type 2.ResultsAll patients received revision GTRs. Fourteen small- to medium-sized tumors located at the bottom of the internal acoustic canal required the translabyrinthine approach (TLA); 12 large and small tumors, predominantly in the cerebellopontine angle, required the retrosigmoid approach (RSA); and 2 required both TLA and RSA. One tumor that progressed to the petrous apex required the middle fossa approach. Fifteen patients underwent facial neurorrhaphy. Of these, 11 received hemihypoglossal–facial neurorrhaphies (HHFNs); nine with simultaneous revision surgery. In follow-up, 10 patients (34.48%) experienced persistent deep FN paresis (HB grades IV-VI). After HHFN, all patients improved from HB grade VI to III (n=10) or IV (n=1). No tumors recurred during follow-up (mean, 3.46 years).ConclusionsAggressive microsurgical rVS treatment combined with FN reconstruction provided durable oncological and neurological effects. Surgery was a reasonable alternative to radiosurgery, particularly in facial neurorrhaphy, where it provided a one-step treatment.
Highlights
Vestibular schwannoma (VS) surgery has changed beyond recognition since the early 20th century, when it was associated with mortality rates as high as 86% [1]
The translabyrinthine approach (TLA) was used for 14 small- to mediumsized tumors that arose from the bottom of the internal acoustic canal (IAC)
The retrosigmoid approach (RSA) was used for larger tumors and for smaller tumors (n=12) that were predominantly located in the cerebellopontine angle (CPA)
Summary
Vestibular schwannoma (VS) surgery has changed beyond recognition since the early 20th century, when it was associated with mortality rates as high as 86% [1]. Contemporary skull base surgery includes gross total resections (GTRs), and aims for a good functional outcome, mostly by preserving facial nerve (FN) and other cranial nerve functions [3,4,5,6] in addition to reducing the mortality rate [7, 8]. Treatment options for VS include observation, surgery, via a retrosigmoid approach (RSA) [9,10,11], middle fossa approach [12], or translabyrinthine approach (TLA) [13], and stereotactic radiosurgery (SRS) [14,15,16,17]. Some physicians prefer a combination of treatment methods, including an intentional partial resection, followed by SRS [18,19,20]. Some patients experience tumor progression after a subtotal resection or recurrence after a GTR. Regrowth of a residual tumor occurs in up to 44% of cases [22]
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