Normal Facial Function Research Articles

Outcome after Translabyrinthine Surgery for Vestibular Schwannomas: Report on 1244 Patients

The objective of this article is to study the outcome after translabyrinthine surgery for vestibular schwannomas, with special focus on the facial nerve function. The study design is a case series from a national centralized database and it is set in two University Hospitals in Denmark. Participants were 1244 patients who underwent translabyrinthine surgery during a period of 33 years from 1976 to 2009. Main outcome measures were tumor removal, intraoperative facial nerve preservation, complications, and postoperative facial nerve function. In 84% patients, the tumor was totally resected and in ~85% the nerve was intact during surgery. During 33 years, 12 patients died from complications to surgery and ~14% had cerebrospinal fluid leakage. Before surgery, 74 patients had facial paresis and 46% of these improved after surgery. In patients with normal facial function, overall ~70% had a good outcome (House-Brackmann grade 1 or 2). The chance of a good outcome was related to tumor size with a higher the chance the smaller the tumor, but not to the degree of tumor removal. In ~78% of the patients with facial paresis at discharge the paresis improved over time, in ~42% from a poor to a good function. The translabyrinthine approach is generally efficient in tumor control and with satisfactory facial nerve outcome. With larger tumors the risk of a poor outcome is evident and more data on patients managed with alternative strategies are warranted.

Parálisis de Bell, reporte de un caso

BackgroundBell's palsy is one of the most common neurological disorders affecting the cranial nerves and is certainly the most common cause of facial paralysis worldwide. Bell's palsy is a sudden, unilateral, peripheral facial paresis or paralysis with no detectable cause. This syndrome of idiopathic facial paralysis was first described more than a century ago by Sir Charles Bell, yet much controversy still surrounds its aetiology and management. ObjectiveThe objective of this report is to present a clinical case of a female patient who suffered from Belĺs palsy syndrome, her management and results. MaterialsA clinical case is presented of a 66-year-old female patient, who experienced weakness on the right side of his face and complained of facial droop and difficulty with facial expressions. The patient was treated with artificial tears, prednisone and an antiviral agent (acyclovir). ResultsThis case was handled quickly with corticoids and antiviral agent and the patient completely recovered her normal facial function. ConclusionsThe treatment used was successful.

Imaging and review of a large pre-auricular pilomatrixoma in a child

A 10-year-old girl presented with a mildly tender mass in the right preauricular region. The mass became larger, and the overlying skin turned purple. There was no clinical response to a course of either cephalexin or clarithromycin. The remainder of the head and neck examination was normal including normal facial nerve function. Lyme titers and a computed tomographic (CT) scan with contrast of the facial region were obtained. The CT scan demonstrated the lesion to be superficial to the parotid gland. The lyme titer was elevated and doxycycline was begun. The mass appeared to reduce in size after doxycycline treatment, but then grew and turned erythematous. The lesion was surgically excised and was vascular with calcification and cheesy inclusions. The mass was quite close to the skin and the clinical diagnosis at the time of surgery was a pilomatrixoma, which was corroborated on pathological evaluation.

The intraparotid facial nerve schwannoma: a diagnostic and management conundrum

ObjectivesThe aims of the study were (1) to review the management strategy and clinical outcomes of all intraparotid facial nerve (FN) schwannomas (PFNSs) treated at a single tertiary academic center from 1975 to 2010 and (2) to summarize all previously reported cases of PFNS in the international literature. Study designA retrospective cohort study and literature review. MethodsFifteen patients were diagnosed and treated at the authors' institution from 1975 to 2010. In addition, 124 published cases were systematically reviewed. ResultsThe most common presentation of PFNS was a painless parotid mass with normal FN function. Eccentric, loosely attached intraparotid tumors underwent gross total resection with nerve preservation granting satisfactory postoperative FN function, whereas “inseparable” intraparotid tumors were observed in 8 cases with stable long-term size. Lesions that extended into the fallopian canal underwent complete resection with FN sacrifice and nerve grafting in 10 cases, whereas 1 patient received subtotal resection of the intraparotid portion with stereotactic radiotherapy targeting the intratemporal component. ConclusionsIntraparotid FN schwannomas present similar to other primary salivary gland neoplasms, making an early diagnosis challenging. Intraoperative recognition of gross tumor characteristics and early histologic diagnosis with strategic biopsy are critical. Information including tumor location and extent, preoperative FN function, and the gross relationship between the tumor and the FN may guide the surgeon toward an optimal treatment plan emphasizing long-term neurologic preservation.

Revised Surgical Strategy to Preserve Facial Function After Resection of Facial Nerve Schwannoma

Early nerve-sparing tumor resection is designed to minimize facial deficits associated with facial nerve schwannomas. This report aimed to determine optimal treatment approaches and timing in patients with facial nerve schwannomas, especially those with good facial function. Clinical decision making is complicated in patients with good facial nerve function because classical surgical treatment consists of excision of the tumor along with the involved nerve segment, followed by grafting or primary anastomosis, which can result in permanent facial deficits. Since 1995, we have conducted a nerve-preserving technique on 15 patients with facial nerve schwannomas to obtain better results after our experience with the 10 patients who underwent tumor resection and/or facial nerve reconstruction before 1995 and evaluated the surgical outcomes of all 25 patients between 1990 and 2008. The House-Brackmann (HB) grading system for facial nerve function was used to assess preoperative and postoperative functions with follow-up magnetic resonance imaging to monitor for tumor recurrence. At the final functional assessment, 7 patients had no change in facial function, 2 had improved, and 6 had worsened. Specifically, 4 patients had normal facial function, 8 had HB Grade II, and 3 had HB Grade III. To date, no clinical or radiologic evidence of recurrence has been detected in any of the patients, all of whom underwent postoperative enhanced magnetic resonance imaging at least 3 years after surgery. Facial nerve-preserving technique is recommended for resection of facial nerve schwannomas, especially in patients with good preoperative facial function. Compared with the resection-and-reconstruction technique, this method can prevent delays in presurgical deterioration of the neural fascicle and may result in better postoperative facial function.

Lower Cranial Nerve Function Following Jugular Foramen Tumor Resection

Objective: Describe the presentation, tumor characteristics, and postoperative lower cranial nerve function following surgery for jugular foramen tumors. Method: Thirty jugular foramen tumor resections performed between 1989 and 2009 were reviewed. The mean age was 48.2 years (range, 18.6-77.7 years) at time of presentation. Surgical approaches included infratemporal fossa (70%), retrosigmoid (23%), transtemporal (20%), transcondylar (17%), and transcervical (17%). The mean follow-up was 4.6 years. Results: Combined surgical approaches were used in over 50% of the cases, and 60% underwent preoperative tumor embolization. Tinnitus was the most common presenting symptom, and middle ear or neck mass was the most common presenting sign. The most common diagnosis was paraganglioma. Six patients required tracheotomy, and 8 had feeding tubes at discharge. Fifty-seven percent of patients underwent speech or swallow therapy, 43% were treated with vocal cord injections, and 17% underwent medialization thyroplasty. Cerebrospinal fluid leak was uncommon (13%), and meningitis occurred in 1 patient. Normal or near-normal facial nerve function was maintained in 89% of patients. Conclusion: Resection of jugular foramen tumors carries a significant risk of lower cranial nerve dysfunction; however, long-term speech, airway, and swallowing morbidity can be minimized with contemporary ancillary surgical procedures.

Facial Schwannoma Treatment via Cyberknife or Decompression

Objective: Microsurgical excision of facial nerve schwannomas frequently results in facial paresis or paralysis of House-Brackmann Grade III or higher. This study’s objectives are: 1) describe alternatives to microsurgical excision of facial nerve schwannomas, specifically wide fallopian canal decompression and Cyberknife radiosurgery; and 2) describe clinical outcomes of these alternative therapies. Method: This is a case-control study of all patients undergoing excision, wide fallopian canal decompression, or Cyberknife radiosurgery at a tertiary academic referral center between 2002 and 2011. Main outcome measures were pre- and posttreatment facial nerve function, tumor control, and speech reception thresholds. Results: Eleven patients were identified (3 wide decompression, 2 Cyberknife treated, 4 observation, and 2 microsurgical excision), and mean posttreatment follow-up was 35 months. When compared with excision, all of the cases undergoing nonexcision treatments resulted in facial nerve function stable or improved, no tumor growth, and no changes in speech reception thresholds. Conclusion: While surgical excision of facial nerve schwannomas may be indicated in cases of poor facial function and impending complications, wide bony decompression, observation, and Cyberknife radiosurgery should be considered as alternative treatments to excision for patients with normal or good facial function who wish to maintain preoperative hearing thresholds.

Facial Nerve Function After Vestibular Schwannoma Surgery Following Failed Conservative Management

Because only a limited proportion of vestibular schwannomas display growth after diagnosis, an increasing number of patients are managed conservatively. Tumor growth during "wait and scan" may, however, necessitate surgery. In these cases, increased tumor size is likely to increase the risk of impaired facial nerve function after surgery. To compare facial nerve function in patients operated on soon after diagnosis with patients allocated to conservative management and the subgroup of these who later had surgery because of tumor growth. A total of 1378 consecutive patients diagnosed with a vestibular schwannoma 20 mm extrameatal or smaller were included; 419 patients were operated on soon after diagnosis, and 959 patients were initially managed conservatively. In the latter group, 161 patients were subsequently operated on owing to tumor growth. All conservatively managed patients had normal facial nerve function at the end of observation. Good facial nerve outcome was found in 87% of patients operated on at diagnosis and in 84% of patients operated on after established tumor growth. For the subgroup of small extrameatal tumors, this difference was significant. When all patients allocated primarily to conservative management were pooled, good facial function was found in 97%, which was significantly better than the result for primary operation (87%). Overall, conservative management of small to medium-sized vestibular schwannomas is the best option in terms of preservation of facial nerve function. Tumor growth during observation is found in only a minor proportion of the patients, and in these cases, surgery or irradiation should be performed immediately.

The results of temporal bone surgery for advanced or recurrent tumors of the parotid gland.

To describe the results of temporal bone surgery in managing advanced or recurrent tumors of the parotid gland. Retrospective review. Patients with advanced or recurrent tumors involving the parotid gland who underwent either mastoidectomy or temporal bone resection were reviewed for treatment outcomes. Forty-nine patients were identified who required either mastoidectomy (n = 33) or temporal bone resection (n = 16) for malignancies involving the parotid gland. Facial nerve sacrifice was required in 35 patients (71.4%). Perineural invasion was found in 51.1% of patients; and negative margins were achieved in 78.2% patients. Six of 10 patients presenting with normal facial function (House-Brackmann I) and recurrent tumors maintained normal facial function following salvage surgery. Trismus, tumors larger than 4 cm, and the need for mandibulectomy were significantly correlated with higher recurrence rates (P = .025, P = .004, and P = .002, respectively). Patients with preoperative House-Brackmann I or II had a lower risk for recurrence (P = .035) and more favorable survival at 3 years (P = .024). Patients who required parapharyngeal space dissection and those with metastatic neck disease had the poorest survival rates. The overall survival at 3 years was 72.4%. Mastoidectomy and temporal bone resection permit preservation of the facial nerve when oncologically safe; they may help to achieve negative margins, and they allow facial nerve grafting when nerve sacrifice is required. Despite the poor prognostic indicators of facial paralysis, recurrent tumors, and perineural invasion, a significant number of patients can be salvaged successfully when a temporal bone procedure is combined with parotidectomy.

Microvascular decompression may be an effective treatment for nervus intermedius neuralgia

Objective To report microvascular decompression as a possible effective treatment for patients with nervus intermedius neuralgia, and to contribute to the literature regarding both this syndrome and this specific form of treatment. Method Case report of a patient with intermedius neuralgia. The main complaint was severe otalgia in the area innervated by the nervus intermedius, possibly caused by neurovascular compression of the nervus intermedius by the anterior inferior cerebellar artery. Microvascular decompression was undertaken, with good results. Results Post-operatively, the patient felt immediate and total relief of her otalgia, with normal facial nerve function and no otological morbidity. One year post-operatively, she was still free from otalgia. Conclusion Patients with nervus intermedius neuralgia who do not respond to medical treatment may benefit from microvascular decompression.

Aberrant course of the intracranial facial nerve in cases of atresia of the internal auditory canal (IAC)

The aim of this study is to describe the morphology of the rare malformation that is atresia of the internal auditory canal (IAC) and determine the course of the facial nerve in cases of normal facial nerve function. Index cases were retrospectively selected from our electronic database in which all inner ear malformations presenting to a tertiary referral center between 1995 and 2010 are collected. Computed tomography (CT) data and magnetic resonance (MR) images were reviewed by two neuroradiologists. An otolaryngologist analyzed the patients' clinical data. Nine ears of six patients (three bilateral, three unilateral) with atresia of the IAC were identified. All patients presented with sensory neural hearing loss. Two of these unilaterally affected patients had facial nerve palsy. In the other seven cases of complete atresia of the IAC, the facial nerve was dislocated in its cisternal segment close to the trigeminal nerve. Where the nerve fibers enter the Gasserian ganglion, the facial nerve takes a sharp lateral turn and enters a minute canal by which it reaches the geniculate ganglion. In the two ears with facial nerve palsy, this pathway could not be identified. In atresia of the IAC, the facial nerve takes a ventral and superior course, with its own canal starting at the point where the trigeminal nerve enters the Gasserian ganglion. Facial nerve palsy points to absence of this aberrant temporal facial nerve canal.

Early complications and symptoms of cerebellopontine angle tumor surgery: a prospective analysis

Our objective is to prospectively report very early complications and outcomes of cerebellopontine angle (CPA) surgery. Between January and August 2007, 72 patients were operated on by different transpetrosal approaches in a tertiary referral center. During preoperative assessment, facial nerve function (House-Brackmann grading system), the presence of vertigo or tinnitus and caloric test results were recorded and correlated with complications and symptoms occurring daily from day (D) 1 to D 8. The overall number of complications did not differ from those of former retrospective studies; nevertheless, the prospective feature of this study prompts several comments. Even slight (grade II) preoperative facial impairments increased the risk of severe postoperative facial dysfunction. Keratitis was frequent (42%) even in patients with normal facial function. Thrombo-embolic complications only occurred after long air-travel (≥5 h). Preoperative caloric test status was predictive of postoperative vestibular disturbance occurrence. With respect to the activity recovery; younger patients (<40 years old) displayed faster central compensations than the older (>60 years old) patients. This study highlights several features that may be used for preoperative patient counseling and complication management. In particular, the practitioner has to pay attention to even minor preoperative clinical signs of facial dysfunction to properly inform the patient of facial outcome. Routine ophthalmologic evaluation should be practiced, even when facial function is normal or subnormal. 1b.

Microvascular decompression may be an effective treatment for nervus intermedius neuralgia

To report microvascular decompression as a possible effective treatment for patients with nervus intermedius neuralgia, and to contribute to the literature regarding both this syndrome and this specific form of treatment. Case report of a patient with intermedius neuralgia. The main complaint was severe otalgia in the area innervated by the nervus intermedius, possibly caused by neurovascular compression of the nervus intermedius by the anterior inferior cerebellar artery. Microvascular decompression was undertaken, with good results. Post-operatively, the patient felt immediate and total relief of her otalgia, with normal facial nerve function and no otological morbidity. One year post-operatively, she was still free from otalgia. Patients with nervus intermedius neuralgia who do not respond to medical treatment may benefit from microvascular decompression.

Fundus Obliteration and Facial Nerve Outcome in Vestibular Schwannoma Surgery

The major objectives in vestibular schwannoma (VS) surgery have evolved from reducing mortality to functional preservation of the facial nerve and hearing. Absence of fluid between the lateral end of the VS and the internal auditory canal fundus on magnetic resonance imaging (MRI) appeared to have a negative influence on hearing outcome. Our goal was to study the prognostic significance of fundus obliteration on facial nerve function after VS surgery in patients with clinically normal facial function. We performed a retrospective review in a tertiary referral neurotology unit or 110 consecutive patients with a surgically removed VS and normal preoperative facial nerve function. Facial nerve function was evaluated at 1 month and 1 year by using the House-Brackmann (HB) scale and correlated to fundus obliteration on MRI. Facial nerve function was intact preoperatively in 114 of 123 patients (92.7%). We noticed a statistically significant difference and worse short-term outcome when the fundus was obliterated: 29.7% had HB 3 or more versus 13.0% if no fundus obliteration was seen. This statistically significant difference disappeared at 1 year. Fundus obliteration has a negative prognostic influence on short-term facial nerve function after VS surgery in patients with clinically normal facial function preoperatively.

Outcome After Microsurgery for Meningiomas Involving the Internal Auditory Canal

The subset of patients suffering from meningiomas truly originating in or extending into the internal auditory canal is not well described in the literature. To evaluate postoperative facial motor and hearing outcomes in patients undergoing resection of meningiomas originating in or extending into the internal auditory canal. Chart reviews were done of 19 consecutive patients undergoing surgery for meningiomas originating in or extending into the internal auditory canal at the Mayo Clinic, Rochester, with emphasis on clinical exam and audiometry. Median follow-up for the entire group was 29 months. Seventy-four percent of patients had stable facial nerve function. One patient experienced improvement. Postoperative cochlear nerve function was unchanged in 74% of patients and worsened in 21% of patients. One patient with a sudden preoperative hearing loss improved to full hearing at 3 months. Every attempt should be made to preserve hearing and facial motor function in surgical removal of posterior fossa meningiomas that originate in or extend into the internal auditory canal. Normal or nearly normal facial nerve function can be preserved in 88% of patients presenting with normal facial nerve function; serviceable hearing can be preserved in 92% of patients who present with normal hearing. A standard retrosigmoid craniotomy with drilling of the posterior canal wall of the internal auditory canal worked well in the majority of cases.

Prognostic factors for the incidence and recovery of delayed facial nerve palsy after vestibular schwannoma resection

Preservation of facial nerve function in vestibular schwannoma (VS) resections remains a significant operative challenge. Delayed facial palsy (DFP) is one specific challenge yet to be fully elucidated. The aim of this study was to evaluate DFP among VS resection cases to identify significant prognostic factors associated with its incidence and clinical recovery. This investigation involves a retrospective review of 104 cases of VS resection that occurred between December 2005 and May 2007. Patients who developed DFP were compared with patients exhibiting no facial palsy postoperatively with regard to surgical approach, severity and day of palsy onset, tumor size, intraoperative facial nerve monitoring, and postoperative recovery and treatment. Patients who demonstrated immediate facial palsy (IFP) following VS resection were also analyzed. Furthermore, specific analyses were performed in 2 distinct DFP patient groups: those who developed DFP after postoperative Day 3 ("late onset DFP"), and those whose palsy worsened after initial DFP identification ("deteriorators"). Of the 104 patients who underwent VS resection, 25.0% developed DFP and 8.6% demonstrated IFP postoperatively. The DFP group did not differ significantly in any measure when compared with patients with no postoperative facial palsy. However, patients with DFP presented with significantly smaller tumor sizes than patients with IFP. This IFP group averaged significantly smaller intraoperative facial nerve responses than patients without facial palsy, and larger tumor sizes than both the DFP and no facial palsy groups. Within the DFP group, patients with late onset DFP showed diminished intraoperative facial nerve responses when compared with the total DFP patient population. In total, 25 (96.2%) of 26 patients with DFP and 7 (77.8%) of 9 patients with IFP recovered to normal or near-normal facial function (House-Brackmann Grade I or II) at longest clinical follow-up. Although patients with DFP did not exhibit any distinguishable characteristics when compared with patients without postoperative facial palsy, our analysis identified significant differences in patients with palsy presenting immediately postoperatively. Further study of patients with DFP should be undertaken to predict its incidence following VS resection.

Electrophysiologic Assessment of the Subclinical Changes in Facial Functions After Parotidectomy

Our objective was to evaluate whether there was a subclinical change in the functions of the facial nerve after parotidectomy. Facial nerve functions of 21 patients who had parotidectomy between January 1999 and December 2003 were assessed using electromyography (EMG) at least 5 years after the surgery. There was no significant difference between both sides of the face in the EMG amplitudes (P > 0.05) except for the amplitudes obtained from the site of nasolabial sulcus (P < 0.05). In the patients who underwent total parotidectomy, the EMG amplitudes were significantly different for both sides of the face (P < 0.05). No significant difference was found in the comparison of other measurements performed by EMG. Tumor histopathologic type (benign or malignant) and type of parotidectomy (superficial or total) do not cause a subclinical dysfunction of the facial nerve after parotidectomy in the patients who also have clinically normal facial functions. The only exception to this contention is the subclinical dysfunction in nasal branches of the facial nerve in total parotidectomy cases.

The Management of Peripheral Facial Nerve Palsy

Conservative management of idiopathic or herpetic acute peripheral facial palsy (herpes zoster oticus, HZO) often leads to a favorable outcome. However, recent multicenter studies have challenged the necessity of antivirals. Whereas large numbers of patients are required to reveal statistical differences in a disease with an overall positive outcome, surprisingly few studies differentiate between patients with paresis and paralysis. Analyzing our own prospective cohort of patients and reviewing the current literature on conservative treatment of Bell's palsy and HZO, we reveal the importance of initial baseline assessment of the disease course to predict the outcome and to validate the impact of medical treatment options. STUDY DESIGN AND DATA SOURCE: Prospective analysis of consecutive patients referred to 2 tertiary referral centers and research on the Cochrane Library for current updates of their previous reviews and search of MEDLINE (1976-2009) for randomized trials on conservative treatment of acute facial palsy were conducted. One hundred ninety-six patients with Bell's palsy or HZO were followed up prospectively until complete recovery or at least for 12 months. The numeric Fisch score (FS) was used to classify facial function, and patients were separated between incomplete palsy (=paresis) and complete paralysis. Electroneuronography (ENoG) was used to further subdivide patients with paralysis. The treatment protocol was independent of the ongoing investigation including prednisone and valacyclovir in most patients. A total of 250 previous studies on facial palsy outcome were evaluated regarding their distinction between different severity scores at baseline and its impact on treatment outcome. Trials not making the distinction between paresis and paralysis at baseline and with an insufficient follow-up of less than 12 months were excluded. In the Bell's and HZO paresis group, all except 1 patient recovered completely, most of them within 3 months, independent of the treatment regimen. In the Bell's paralysis group, 38 patients (70%) recovered completely after 1 year, including 94% of patients with a denervation by ENoG of less than 90%. Thirty percent of Bell's paralysis patients recovered incompletely, revealing the worst outcome in patients with a 100% denervation on ENoG. None of the 4 patients with HZO and ENoG denervation of more than 90% recovered to normal facial function. We found a highly significant difference regarding the time course and final outcome in patients with incomplete palsies versus total paralysis; however, only 3 of 250 studies make this distinction. The time course for improvement and the extent of recovery is significantly different in patients presenting with an incomplete facial nerve paresis compared with patients with a total paralysis. Whereas the term "palsy" includes both entities, the term "paralysis" should only be used to describe total loss of nerve function. Patients with incomplete acute Bell's palsy (paresis) should start to improve their facial function early (1-2 wk after onset) and are expected to recover completely within 3 months. These patients do not benefit from antiviral medications and most likely do not profit from systemic steroids. Mixing patients with different severity of palsies will always lead to controversial results.

Diagnosis and management of intraparotid facial nerve schwannoma

Our objective was to provide the management guidelines for facial nerve schwannomas (FNSs) presenting as a parotid mass. The study is a case report and literature review. Four clinical cases of patients with an asymptomatic parotid mass diagnosed as FNS are presented. The patient's presentation, the diagnostic algorithm and surgical rationale are discussed. A review of the literature on FNSs is presented. Intraparotid FNSs are an extremely rare entity and are rarely diagnosed preoperatively. Intraoperatively, conservative biopsy in a non-functional part of the lesion can be used to make the diagnosis. Most of the FNSs of patients with normal facial nerve function could be dissected off the nerve trunk without losing FN function. FNS patients with preoperatively abnormal FN function should be managed conservatively or undergo reconstruction with nerve graft after tumour resection.

Transcochlear Approach to Cerebellopontine Angle and Clivus Lesions

Evaluate transcochlear (TC)/transotic (TO) approaches surgery for midline intradural lesions arising from the clivus and cerebellopontine angle masses arising anterior to the internal auditory canal. Retrospective chart review. Tertiary referral neurotologic practice. Forty patients who underwent TC/TO approach surgery. Patients were grouped by whether the facial nerve was mobilized (TC, n = 15) or not (TO, n = 25). Indications, postoperative outcomes, and complications including tumor removal and facial nerve status (House-Brackmann grade). Forty percent of all TC patients were meningiomas, whereas 36% of all TO patients were cochlear neuromas. The remainder included tumors associated with NF2, acoustic tumors, malignancies, and other lesions. Complete removal was achieved in 92.5% of tumors. Of all patients, 42% and 55% had normal facial nerve function at the time of hospital discharge and follow up, respectively. Moreover, 22% underwent a facial nerve reanastomosis procedure. Early and late complications occurred in 11 and 14%, respectively. There was one surgery-related death. Complications included cerebrospinal fluid leak (9%) and unsteadiness (9%). The TC and TO approaches provide access to midline intradural lesions, intradural petroclival tumors, and cerebellopontine angle tumors and cholesteatomas arising anterior to the internal auditory canal, without using brain retractors. Total tumor removal, including its base and blood supply, is possible. Facial weakness is frequent when the facial nerve is rerouted, but excellent facial nerve results are accomplished with the TO approach. With these approaches, recurrence israre when all tumor has been removed. Their safety and efficacy encourage their use in extensive lesions.