Translabyrinthine Approach Research Articles

Can the Risks of Cerebrospinal Fluid Leak After Vestibular Schwannoma Surgery Be Predicted?

Identifying predictive factors of cerebrospinal fluid (CSF) leak after translabyrinthine approach (TLA) for vestibular schwannoma. Retrospective study. Tertiary care center. All patients (n = 275) operated for a vestibular schwannoma by TLA between 2004 and 2013 were included. Vestibular schwannoma surgery by TLA. The rate of postoperative CSF leak considering the age, sex, body mass index (BMI), tumor staging, and duration of surgical procedure. A logistic regression model was used to identify the predictors and compute a biometric predictive model of CSF leak. Thirty-three patients (12.0%) developed a CSF leak after surgery. In a multivariable model, an increased risk of CSF leak was found for younger patients (OR 0.95, 95% CI 0.92-0.98), longer duration of surgery (OR 1.85, 95% CI 1.12-3.05), and the male sex (0 = male; 1 = female; OR 0.22, 95% CI 0.09-0.54), while also adjusting for BMI. The probability of developing a CSF leak after vestibular schwannoma surgery was calculated using a statistical prediction model, with a percentage of false negative of 7.0% and an overall correct prediction of 88.4%. The predictors of CSF leak after TLA for vestibular schwannoma are young age, male sex, longer duration of surgery, which adjusting for BMI. In this regard, the surgical team should adapt its management during pre- and postoperative period to decrease the likelihood of a leak.

Primary tumors of the facial nerve misdiagnosed: a case series and review of the literature

Conclusion: Unusual primary tumors of the facial nerve should be considered in patients with progressive facial paralysis, especially if this is accompanied by hearing loss or vertigo. Misdiagnosis could increase the difficulties of operation, diminish the chance of facial nerve reconstruction, and increase the likelihood of poor reconstructive outcomes.Objective: This paper was to determine the characteristics of facial nerve primary tumors misdiagnosed as tumor-free conditions many years prior, and to describe appropriate treatments.Methods: The cases of 11 Chinese patients with misdiagnosed primary tumors of the facial nerve were reviewed; every one had been misdiagnosed for more than 8 years. All patients presented with progressive or complete facial paralysis and hearing loss, with or without vertigo. The pre- and post-operative images (including CT scans of the temporal bone) and MRI data were reviewed.Results: All tumors were completely resected using the translabyrinthine or transmastoid approach and were confirmed to be primary tumors of the facial nerve. Facial-hypoglossal nerve anastomosis failed because fibrosis developed at the end of the facial nerve in one patient whom this study sought to manage in two stages. One patient accepted facial-hypoglossal nerve anastomosis of two-stage and patient status improved to House-Brackmann (H-B) grade V from H-B grade VI. The other nine patients chose not to undergo reconstruction.

Venous sinus compromise after pre-sigmoid, transpetrosal approach for skull base tumors: A study on the asymptomatic incidence and report of a rare dural arteriovenous fistula as symptomatic manifestation

The sigmoid sinus is routinely exposed and manipulated during pre-sigmoid, transpetrosal approaches to the skull base, but there is scant data available on the incidence of venous sinus compromise after surgery. We encountered a dural arteriovenous fistula as a result of sigmoid sinus occlusion and examined the incidence of venous sinus thrombosis or narrowing after transpetrosal surgeries. We performed a retrospective analysis of a series of patients treated by the senior surgeons (WCJ, MH, HJK), who underwent either a posterior petrosectomy or translabyrinthine approach for various skull base tumors. All available clinical and radiographic data were thoroughly examined in each patient to determine the post-operative fate of the venous sinuses. Of the 52 available patients, five patients were discovered post-operatively to have a narrowed or constricted sigmoid sinus ipsilateral to the surgery, whereas another five patients were diagnosed with asymptomatic sinus thrombosis either in the transverse or sigmoid or both. None of these patients experienced symptoms, nor were there any instance of ischemic or hemorrhagic complications. However, there was one additional patient who presented with pulsatile tinnitus 2years after surgery. His angiogram showed an occlusion of the ipsilateral sigmoid sinus and a posterior fossa dural arteriovenous fistula. A two-stage transvenous and transarterial embolization was successful in eliminating the fistula. Technical considerations to avoid sinus injuries during pre-sigmoid, transpetrosal surgery are discussed.

Translabyrinthine approach to internal auditory meatus: A retrospective study

BackgroundEar and the lateral skull base surgery is challenging and yet fascinating for a Neuro-otologist. A thorough knowledge of the complex anatomy is indispensable for the surgeon in order to provide the best possible care. MethodsThe aim of the study was to highlight the present day indications for translabyrinthine approach to IAM from a Neuro-otologist perspective. ResultsThere were a total of 7 patients who underwent Translabyrinthine approach at our centre. In the present study we have reported cases of Vestibular Schwannoma, Facial nerve schwannoma, Cholesteatoma involving the IAM, Meniere's disease with refractory vertigo which were managed via translabyrinthine approach. We also encountered, probably the first reported case, tuberculoma of the IAM which was clinical suspected to be vestibular schwannoma. ConclusionThe article presents different clinical situations where this approach can be suitably utilized and has been dealt with via a retrospective study encountered at our centre.

Cost Analysis of Cerebrospinal Fluid Leaks and Cerebrospinal Fluid Leak Prevention in Patients Undergoing Cerebellopontine Angle Surgery.

To determine if cranioplasty techniques following translabyrinthine approaches to the cerebellopontine angle are cost-effective. Retrospective case series. One hundred eighty patients with available financial data who underwent translabyrinthine approaches at a single academic referral center between 2005 and 2015. Cranioplasty with a dural substitute, layered fat graft, and a resorbable mesh plate secured with screws Main Outcome Measures: billing data was obtained for each patient's hospital course for translabyrinthine approaches and postoperative cerebrospinal fluid (CSF) leaks. One hundred nineteen patients underwent translabyrinthine approaches with an abdominal fat graft closure, with a median cost of $25759.89 (range, $15885.65-$136433.07). Sixty-one patients underwent translabyrinthine approaches with a dural substitute, abdominal fat graft, and a resorbable mesh for closure, with a median cost of $29314.97 (range, $17674.28-$111404.55). The median cost of a CSF leak was $50401.25 (range, $0-$384761.71). The additional cost of a CSF leak when shared by all patients who underwent translabyrinthine approaches is $6048.15. The addition of a dural substitute and a resorbable mesh plate after translabyrinthine approaches reduced the CSF leak from 12 to 1.9%, an 84.2% reduction, and a median savings per patient of $2932.23. Applying our cohort's billing data to previously published cranioplasty techniques, costs, and leak rate improvements after translabyrinthine approaches, all techniques were found to be cost-effective. Resorbable mesh cranioplasty is cost-effective at reducing CSF leaks after translabyrinthine approaches. Per our billing data and achieving the same CSF leak rate, cranioplasty costs exceeding $5090.53 are not cost-effective.

Vestibular Schwannoma Resection with Ipsilateral Simultaneous Cochlear Implantation in Patients with Normal Contralateral Hearing

Objective: To report the hearing results of cochlear implantation simultaneous to vestibular schwannoma (VS) resection by means of a translabyrinthine approach in patients with normal contralateral hearing. Methods: This was a prospective study including adults with sporadic VS. Tumors were resected by means of a modified translabyrinthine approach with preservation of the cochlear nerve. Results: A total of 13 patients underwent cochlear implantation. At 14 months, the mean pure-tone audiogram was 56 dB. The mean speech recognition was 80%. Cochlear implantation provides monaural and binaural benefits in all the conditions tested, including sound localization. Conclusions: Cochlear implantation can be safely performed simultaneously to VS resection with satisfactory hearing results provided that the cochlear nerve is anatomically intact.

Change in Tinnitus After Acoustic Neuroma Removal Using a Translabyrinthine Approach. A Prospective Study

IntroductionTinnitus is one of the primary symptoms of vestibular schwannoma (VS) and the effect of surgery is unpredictable. Materials and methodsWe conducted a prospective study of the patients who underwent a translabyrinthine approach for the treatment of their VS (2009–2013) at our Hospital. Patients answered the Tinnitus Handicap Inventory (THI) questionnaire pre- and postoperatively. The clinical charts provided data such as age, gender, tumour size, preoperative audiometry and postoperative facial function. ResultsThe study included 39 patients. Of these, 71.8% suffered from tinnitus: 50% grade I, 17.9% grade II, 10.7% grade III, 21.4% grade IV and 0% grade V. We found no statistical association between tinnitus and the different variables measured preoperatively. Postoperatively, 48.7% of the patients suffered from tinnitus: 31.6% grade I, 36.8% grade II, 10.5% grade III, 15.8% grade IV and 5.3% grade V. The difference between mean pre- and postoperative THI was statistically significant (P=.011); this difference was greater in younger patients. We have found a significant negative correlation (r=−0.335; P=.037) between preoperative audiometry and postoperative THI. ConclusionsWe did not find any significant association between tinnitus and age, gender, tumour size and postoperative facial function. Translabyrinthine surgical removal of VS in these patients led to better THI results, with the younger patients having better outcomes. The patients with poorest preoperative audition were the ones that had the best results in the postoperative THI questionnaire.

Pediatric neurofibromatosis type 2: clinical and molecular presentation, management of vestibular schwannomas, and hearing rehabilitation

This study aims to describe the clinical and molecular presentation of pediatric neurofibromatosis type 2 (NF2) and the subsequent management of vestibular schwannomas (VS) and hearing rehabilitation. This is a single-center retrospective study of neurofibromatosis type 2 diagnosed before the age of 18years old from 1997. Natural history of vestibular schwannomas and surgical outcomes were evaluated using volumetric MRI, hearing, and facial nerve assessment. Patients included in chemotherapy protocols were excluded. From a database of 80 patients followed up for NF2 on a regular basis, 25 patients were eligible (11 sporadic cases, 14 inherited in five families). The mean age at diagnosis was 11.6years old. The average clinical follow-up was 6.5years. NF2 mutation was identified in 81% of the probands. The average growth rate based on the maximum linear diameter (DGR) was 1.68mm/year (n=33, average follow-up 4.22years) and 545mm3/year in volumetric assessment (VGR) for VS larger than 1cm (n=21, average follow-up 3.4years). In unoperated ears, hearing was stable in about 50% of ears. The mean change in dB HL was 9.5dB/year for pure-tone average and 3.5 for speech-recognition threshold (n=34, 5.5years 1-12). Eight children required removal through a translabyrinthine approach (mean follow-up was 4.5years), six patients were operated on for hearing preservation (mean postoperative follow-up 4.3years). Six patients were eligible for hearing rehabilitation with cochlear implantation (I), and five received placement of an auditory brainstem implant. Early diagnosis and treatment of small growing VS should be carefully discussed considering familial history and possible rehabilitation with a CI.

Advantages of Facial Nerve Rerouting in Extended Modified Translabyrinthine Approach

Advantages of Facial Nerve Rerouting in Extended Modified Translabyrinthine Approach

Surgical Treatment of Vestibular Schwannoma. Review of 420 Cases

Introduction and objectivesVestibular schwannoma is the most frequent cerebellopontine angle tumour. The aim of our study is to reflect our experience in the surgical treatment of this tumour. Material and methodsRetrospective study of 420 vestibular schwannomas operated in our hospital between 1994 and 2014. We include tumour size, preoperative hearing, surgical approaches, definitive facial and hearing functional results, and complications due to surgery. ResultsA total of 417 patients with 420 tumours were analysed, 209 female (50.1%) and 208 male (49.9%). Mean age at diagnosis was 49.8±13.2 years. The majority of the tumours were resected through a translabyrinthine approach (80.2%). Total tumour removal was achieved in 411 tumours (98.3%), and anatomic preservation of facial nerve in 404 (96.2%). Definitive facial nerve outcome was House–Brackmann grade I and II in 69.9%, and was significantly better in tumours under 20mm. Surgical complications included cerebrospinal fluid leakage in 3 patients (0.7%) and retroauricular subcutaneous collection in 16 (3.8%), 5 cases of meningitis (1.2%), 4 patients with intracraneal bleeding (0.9%), and death in 3 patients (0.7%). ConclusionsSurgery is the treatment of choice for vestibular schwannoma in the majority of patients. In our experience, the complication rate is very low and tumour size is the main factor influencing postoperative facial nerve function.

The accuracy of an electromagnetic navigation system in lateral skull base approaches.

Image-guided optical tracking systems are being used with increased frequency in lateral skull base surgery. Recently, electromagnetic tracking systems have become available for use in this region. However, the clinical accuracy of the electromagnetic tracking system has not been examined in lateral skull base surgery. This study evaluates the accuracy of electromagnetic navigation in lateral skull base surgery. Cadaveric and radiographic study. Twenty cadaveric temporal bones were dissected in a surgical setting under a commercially available, electromagnetic surgical navigation system. The target registration error (TRE) was measured at 28 surgical landmarks during and after performing the standard translabyrinthine and middle cranial fossa surgical approaches to the internal acoustic canal. In addition, three demonstrative procedures that necessitate navigation with high accuracy were performed; that is, canalostomy of the superior semicircular canal from the middle cranial fossa,1 cochleostomy from the middle cranial fossa,2 and infralabyrinthine approach to the petrous apex.3 RESULTS: Eleven of 17 (65%) of the targets in the translabyrinthine approach and five of 11 (45%) of the targets in the middle fossa approach could be identified in the navigation system with TRE of less than 0.5 mm. Three accuracy-dependent procedures were completed without anatomical injury of important anatomical structures. The electromagnetic navigation system had sufficient accuracy to be used in the surgical setting. It was possible to perform complex procedures in the lateral skull base under the guidance of the electromagnetically tracked navigation system. N/A. Laryngoscope, 2016 127:450-459, 2017.

Microsurgical resection of an acoustic neuroma via the translabyrinthine approach

Microsurgical resection of an acoustic neuroma via the translabyrinthine approach

Middle Fossa Approach for Vestibular Schwannoma: Good Hearing and Facial Nerve Outcomes with Low Morbidity

The middle fossa approach (MFA) is not used as frequently as the traditional translabyrinthine and retrosigmoid approaches for accessing vestibular schwannomas (VSs). Here, MFA was used to remove primarily intracanalicular tumors in patients in whom hearing preservation is a goal of surgery. A retrospective chart review was performed to identify consecutive adult patients who underwent MFA for VS. Demographic profile, perioperative complications, pre- and postoperative hearing, and facial nerve outcomes were analyzed with linear regression analysis to identify factors predicting hearing outcome. Among 78 identified patients (mean age, 49 years; 53% female; mean tumor size, 7.5 mm), 78% had functional hearing preoperatively (American Academy of Otolaryngology-Head and Neck Surgery class A/B). Follow-up audiologic data were available for 60 patients overall (mean follow-up, 15.1 months). The hearing preservation rate was 75.5% (37/49) at last known follow-up for patients with functional hearing preoperatively. Other than preoperative hearing status (P < 0.001), none of the factors assessed, including demographic profile, size of tumor, and fundal fluid cap, predicted hearing preservation (P > 0.05). Good functional preservation of the facial nerve (House-Brackmann class I/II) was achieved in 90% of patients. The only operative complications were 3 wound infections (3.8%). Preliminary results from this single-center retrospective study of patients undergoing MFA for resection of VS showed that good hearing preservation and facial nerve outcomes could be achieved with few complications. These results suggest that resection via the MFA is a rational alternative to watchful waiting or stereotactic radiosurgery.

Surgical treatment for markedly advanced petrous apex cholesteatoma via the translabyrinthine and trans-sphenoidal approach

Surgical treatment for markedly advanced petrous apex cholesteatoma via the translabyrinthine and trans-sphenoidal approach

Estudio prospectivo de la evolución del acúfeno tras exéresis por vía translaberíntica del neurinoma del acústico

IntroductionTinnitus is one of the primary symptoms of vestibular schwannoma (VS) and the effect of surgery is unpredictable. Materials and methodsWe conducted a prospective study of the patients who underwent a translabyrinthine approach for the treatment of their VS (2009-2013) at our Hospital. Patients answered the Tinnitus Handicap Inventory (THI) questionnaire pre- and postoperatively. The clinical charts provided data such as age, gender, tumour size, preoperative audiometry and postoperative facial function. ResultsThe study included 39 patients. Of these, 71.8% suffered from tinnitus: 50% grade I, 17.9% grade II, 10.7% grade III, 21.4% grade IV and 0% grade V. We found no statistical association between tinnitus and the different variables measured preoperatively. Postoperatively, 48.7% of the patients suffered from tinnitus: 31.6% grade I, 36.8% grade II, 10.5% grade III, 15.8% grade IV and 5.3% grade V. The difference between mean pre- and postoperative THI was statistically significant (P=.011); this difference was greater in younger patients. We have found a significant negative correlation (r=–0.335; P=.037) between preoperative audiometry and postoperative THI. ConclusionsWe did not find any significant association between tinnitus and age, gender, tumour size and postoperative facial function. Translabyrinthine surgical removal of VS in these patients led to better THI results, with the younger patients having better outcomes. The patients with poorest preoperative audition were the ones that had the best results in the postoperative THI questionnaire.

Experiences from Auditory Brainstem Implantation (ABIs) in four paediatric patients

Introduction: Indications for auditory brainstem implants (ABIs) have been widened from patients with neurofibromatosis type 2 (NF2) to paediatric patients with congenital cochlear malformations, cochlear nerve hypoplasia/aplasia, or cochlear ossification after meningitis. We present four ABI surgeries performed in children at Uppsala University Hospital in Sweden since 2009.Methods: Three children were implanted with implants from Cochlear Ltd. (Lane Cove, Australia) and one child with an implant from MedEl GMBH (Innsbruck, Austria). A boy with Goldenhar syndrome was implanted with a Cochlear Nucleus ABI24M at age 2 years (patient 1). Another boy with CHARGE syndrome was implanted with a Cochlear Nucleus ABI541 at age 2.5 years (patient 2). Another boy with post-ossification meningitis was implanted with a Cochlear Nucleus ABI24M at age 4 years (patient 3). A girl with cochlear aplasia was implanted with a MedEl Synchrony ABI at age 3 years (patient 4). In patients 1, 2, and 3, the trans-labyrinthine approach was used, and in patient 4 the retro-sigmoid approach was used.Results: Three of the four children benefited from their ABIs and use it full time. Two of the full time users had categories of auditory performance (CAP) score of 4 at their last follow up visit (6 and 2.5 years postoperative) which means they can discriminate consistently any combination of two of Ling's sounds. One child has not been fully evaluated yet, but is a full time user and had CAP 2 (responds to speech sounds) after 3 months of ABI use. No severe side or unpleasant stimulation effects have been observed so far. There was one case of immediate electrode migration and one case of implant device failure after 6.5 years.Conclusion: ABI should be considered as an option in the rehabilitation of children with similar diagnoses.

Successful endovascular management of venous sinus thrombosis complicating trans-labyrinthine removal of vestibular schwanomma

Cerebral venous sinus thrombosis (CVST) is a rare complication of surgical treatment of vestibular schwanomma. We present a rare case of extensive venous sinus thrombosis after trans-labyrinthine approach that was refractory to systemic anti-coagulation. Mechanical aspiration thrombectomy was utilized to re-canalize the venous sinuses and resulted in successful resolution of neurological symptoms. Indications of utilizing endovascular approaches are discussed that will enable skull base surgeons to address this uncommon yet potentially fatal complication.

Table of contents

The LaryngoscopeVolume 126, Issue S3 p. S3-S3 Issue InformationFree Access Table of contents First published: 23 January 2016 https://doi.org/10.1002/lary.25887AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume126, IssueS3Supplement: Retrosigmoid Versus Translabyrinthine Approach to Acoustic Neuroma Resection: A Comparative Cost-Effectiveness AnalysisFebruary 2016Pages S3-S3 RelatedInformation

Surgery for sporadic vestibular schwannoma. Part II. Complications (not related to facial and auditory nerves)

IntroductionThe aim of this study was to analyze the frequency and consequences of postoperative complications (PC) after surgery for sporadic vestibular schwannoma and to find factors that increase the risk of PC occurrence. Materials and methodsThe study included 220 consecutive patients (134 women, 86 men; age ranged from 18 to 74) operated on with the retrosigmoid (217) or translabyrinthine (3) approach. Complicated postoperative period was defined as an occurrence of at least one of: cerebrospinal fluid (CSF) leakage, hematoma in the tumor bed, intracerebellar hematoma, cerebellar swelling, brainstem stroke, hydrocephalus (HCP), healing problems, meningitis and cranial nerves (excluding VII–VIII) palsies or cerebellar symptoms. Correlation studies and multivariate regression analysis were performed. ResultsPC occurred in 55 patients (25%). PC included lower cranial nerve (LCN) palsy (8.2%), cerebellar symptoms (7.3%), CSF leakage (5.9%), HCP (5%), CNVI palsy (3.1%), meningitis (1.8%), cerebellar swelling (1.4%), CNV dysfunction (0.9%), intracerebellar hematoma (0.5%) and lethal brainstem stroke (0.5%). In long term follow-up, LCN deficit was present in 2 patients (0.9%), cerebellar syndrome in 4(1.8%) and facial hypoesthesia in 2(0.9%). One patient (0.5%) developed bilateral blindness, secondary to preoperative optic nerve atrophy. As a result of PC, 10 patients (4.5%) required 11 additional surgical procedures. In statistical analysis, PC were independently related to preoperative cerebellar syndrome (p=0.002) and tumor size (>30mm vs.<30mm, p<0.05). The risk of PC diminished significantly with the increased number of performed procedures from 40% at the beginning to 16.4% in the last 55 cases. ConclusionsTumor size, cerebellar syndrome at presentation and experience of the team were the three most important risk factors for PC occurrence. Permanent deficit secondary to PC remained in only 4% of the patients.

Facial nerve preservation in vestibular schwannoma surgery by translabyrinthine approach

Facial nerve preservation in vestibular schwannoma surgery by translabyrinthine approach