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__NOTOC__
{{Acoustic neuroma}}
{{Acoustic neuroma}}
{{CMG}}
{{CMG}} {{AE}}{{M.B}}
==Overview==
==Overview==
Because these neuromata grow so slowly, a physician may opt for conservative treatment beginning with an observation period. In such a case, the tumor is monitored by annual [[MRI]] to monitor growth. Records suggest that about 45% of acoustic neuromata do not grow detectably over the 3-5 years of observation. In rare cases, acoustical neuromata have been known to shrink spontaneously. Often people with acoustic neuromata [[death|die]] of other causes before the neuroma becomes life-threatening. (This is especially true of [[old age|elderly]] people possessing a small neuroma.)
[[Surgery]] is the mainstay of treatment for acoustic neuroma. [[Patient|Patients]] with age under 65 years, medium to large-grade [[Tumor|tumors]], significant [[Hearing impairment|hearing loss]], or higher [[headache]] severity scores will have more satisfying outcomes from [[surgery]] in comparison with [[observation]]. There are three main [[Surgery|surgical approaches]] for the removal of an acoustic neuroma: [[Translabyrinthine approach|translabyrinthine]], retrosigmoid or [[Occipital|sub-occipital]], and middle [[fossa]]. Selection of a particular approach is based on several factors including the size and location of the [[tumor]] and whether or not preservation of [[Hearing (sense)|hearing]] is a goal.


Since the growth rate of an acoustic neuroma rarely accelerates, annual observation is sufficient. Acoustic neuromata may cause either gradual or—less commonly—sudden [[hearing impairment|hearing loss]] and [[tinnitus]].
== Indications ==
 
Indications for [[surgery]] include:<ref>{{Cite journal
==Radiation therapy==
<nowiki> </nowiki><nowiki>|</nowiki> author = [[Jason C. Nellis]], [[Jeff D. Sharon]], [[Seth E. Pross]], [[Lisa E. Ishii]], [[Masaru Ishii]], [[Jacob K. Dey]] & [[Howard W. Francis]]
It is done in a variety of ways, but mainly by two methods: [[gamma knife]] [[radiosurgery]] or fractionated stereotactic [[radiotherapy]]. In the gamma knife approach, 201 beams of [[gamma radiation]] are focused on the tumor in a single session. The damage to the tumor at the convergence point may cause it to stop growing but usually does not cause it to shrink in the long term.  It may cause short-term shrinkage due to necrosis in the tumor. The damage may be to the tumor cells and/or to the tumor [[vasculature]].
  | title = Multifactor Influences of Shared Decision-Making in Acoustic Neuroma Treatment
 
| journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]]
It is not clear what percentage of tumors are controlled by this method for long periods. In earlier times when higher radiation doses were used, the failure rate was about 12% (which then required surgery). Most surgeons feel that these tumors are much more difficult to remove after radiation treatment. Radiation does not remove the tumor, and when irradiated tumors are surgically removed, it is often found that they have growing tumor cells in them.  
<nowiki> </nowiki><nowiki>|</nowiki> volume = 38
 
<nowiki> </nowiki><nowiki>|</nowiki> issue = 3
Two risks of radiation treatment are [[carcinogenic]] progression of the acoustic neuroma (conversion from [[benign]] to[[malignant]]) or induction of other tumors (such as [[glioblastoma]]) in the nearby irradiated brain tissue. The incidence of these events appears to be low, and it is often said to be one in one thousand or less. (However, the incidence is markedly higher in patients with neurofibromatosis type 2.) This calculation is done by dividing the number of obvious cases of[[tumorigenesis|tumorigenic]] progression or secondary tumor reported in the medical literature by the estimated number of gamma knife procedures done in the world to date. This is not a scientifically valid method of estimating the carcinogenic risk of medical radiation exposures, and involves a list of very questionable assumptions.
<nowiki> </nowiki><nowiki>|</nowiki> pages = 392–399
 
<nowiki> </nowiki><nowiki>|</nowiki> year = 2017
The proper and scientifically valid way to estimate such risks can be found at the web site of the Health Physics Society (http://www.hps.org/), where estimates of the risks of CT scans and other procedures can be found. These calculations have never been made for gamma knife radiosurgery.  
<nowiki> </nowiki><nowiki>|</nowiki> month = March
 
<nowiki> </nowiki><nowiki>|</nowiki> doi = 10.1097/MAO.0000000000001292
Due to the possibility of regrowth and the possibility of tumorigenic progression or secondary tumors, it is essential that radiation treatments for acoustic neuromas be followed by yearly MRI for the rest of the patient's life. MRI at this time (2007) cost about 300€. Long-term secondary effects (for instance [[cognitive]] effects) on a scale of 10-20 years are not yet established for gamma knife surgery.
<nowiki> </nowiki><nowiki>|</nowiki> pmid = 27930442
 
}}</ref><ref>{{Cite journal
Fractionated stereotactic therapy involves a beam of [[ionizing]] radiation focused on the tumor from a moving gantry. The beam is wider and less accurate than that of the gamma knife. The total dose is also much higher than that used in gamma knife radiosurgery, but the fractionation of the dose (done on many different days) spares normal tissue. This method has not been done on as many patients as gamma knife procedures and there have not been as many years of follow-up study. This means that the tumor control by this method is not yet established, and the incidence of secondary effects of the radiation are not yet known.
<nowiki> </nowiki><nowiki>|</nowiki> author = [[D. M. Kaylie]], [[E. Gilbert]], [[M. A. Horgan]], [[J. B. Delashaw]] & [[S. O. McMenomey]]
| title = Acoustic neuroma surgery outcomes
| journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]]
<nowiki> </nowiki><nowiki>|</nowiki> volume = 22
<nowiki> </nowiki><nowiki>|</nowiki> issue = 5
<nowiki> </nowiki><nowiki>|</nowiki> pages = 686–689
<nowiki> </nowiki><nowiki>|</nowiki> year = 2001
<nowiki> </nowiki><nowiki>|</nowiki> month = September
<nowiki> </nowiki><nowiki>|</nowiki> pmid = 11568680
}}</ref><ref>{{Cite journal
| author = [[A. Wright]] & [[R. Bradford]]
| title = Management of acoustic neuroma
| journal = [[BMJ (Clinical research ed.)]]
| volume = 311
| issue = 7013
| pages = 1141–1144
| year = 1995
| month = October
| pmid = 7580712
}}</ref>
* Age < 65 years old
* Moderately large to large [[tumor]]
* Growing [[Tumor|tumors]]
* Significant [[Hearing impairment|hearing loss]]
* Higher [[headache]] severity scores


==Surgery==
==Surgery==
Removal of acoustic neuromas may be performed using several approaches. Each approach has its advantages and disadvantages. Microsurgery for acoustic neuroma is the only technique that removes the tumor.  Radiation treatment (discussed in another section) does not remove the tumor, but has the potential to slow or stop its growth.  Surgery is the only treatment that will definitively treat balance symptoms associated with tumor growth, as the vestibular nerves are removed at surgery.
[[Surgery]] is the mainstay of treatment for acoustic neuroma. Selection of a particular approach is based on several factors including the size and location of the [[tumor]] and whether or not preservation of [[Hearing (sense)|hearing]] is a goal. There are three standard [[Surgery|surgical approaches]] for the [[excision]] of an acoustic neuroma:<ref>{{Cite journal
 
| author = [[Marc Bennett]] & [[David S. Haynes]]
Choice of surgical approach is based on the patient's age, medical condition, size of tumor, and preoperative hearing thresholds and speech discrimination, as well as other tests such as electronystagmography, imaging, and auditory brainstem response testing. With large tumors, the patient is usually deaf at presentation.  Surgery is still indicated to prevent further compression of posterior fossa structures.  The patient's and surgeon's preferences also play a significant role.
  | title = Surgical approaches and complications in the removal of vestibular schwannomas
 
| journal = [[Otolaryngologic clinics of North America]]
During removal of the tumor, the tumor along with the superior and inferior vestibular nerves are removed. This results in an acute loss of vestibular input to the brain from the operated side. However, vestibular function improves rapidly due to compensation by the other ear and other balance mechanisms.  
| volume = 40
 
| issue = 3
Surgery carries risk to the facial nerve which is therefore monitored during the procedure. Best results (normal or near normal facial function) are more likely with small acoustic neuromas.  
| pages = 589–609
 
| year = 2007
Three surgical approaches are commonly used. The first is the [[translabyrinthine approach]], which destroys hearing in the affected ear. Thus, it is often employed in patients who have poor speech discrimination in the affected ear. Any size tumor may be removed with this approach. There is no brain retraction with this approach, so it is often considered the safest route to remove the tumor.  In patients with neurofibromatosis type 2 who undergo auditory brainstem implantation, this technique is used as it provides the most direct path of access to the [[lateral recess]] and [[cochlear nucleus]], where the device is placed.
| month = June
| doi = 10.1016/j.otc.2007.03.007
| pmid = 17544697
}}</ref><ref>{{Cite journal
  | author = [[D. E. Brackmann]] & [[J. D. Green]]
| title = Translabyrinthine approach for acoustic tumor removal
| journal = [[Otolaryngologic clinics of North America]]
| volume = 25
| issue = 2
| pages = 311–329
| year = 1992
| month = April
| pmid = 1630831
}}<nowiki></ref <ref></nowiki>{{Cite journal
| author = [[Tyler Cole]], [[Anand Veeravagu]], [[Michael Zhang]], [[Tej Azad]], [[Christian Swinney]], [[Gordon H. Li]], [[John K. Ratliff]] & [[Steven L. Giannotta]]
  | title = Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database
| journal = [[Cureus]]
| volume = 7
| issue = 10
| pages = e369
| year = 2015
| month = October
  | doi = 10.7759/cureus.369
| pmid = 26623224
}}</ref><ref>{{Cite journal
| author = [[Tyler Cole]], [[Anand Veeravagu]], [[Michael Zhang]], [[Tej Azad]], [[Christian Swinney]], [[Gordon H. Li]], [[John K. Ratliff]] & [[Steven L. Giannotta]]
| title = Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database
| journal = [[Cureus]]
| volume = 7
| issue = 10
| pages = e369
  | year = 2015
  | month = October
  | doi = 10.7759/cureus.369
  | pmid = 26623224
}}</ref>
* [[Translabyrinthine approach]]
* Retromastoid suboccipital approach
* Middle [[fossa]] approach


The two other approaches (suboccipital retrosigmoid and middle fossa) are hearing preservation approaches, which have a chance of preserving some or all of the hearing in the affected ear.  Neurosurgeons often prefer the retrosigmoid approach, as they are frequently more familiar with it from training.  
=== Translabyrinthine approach ===
* The [[translabyrinthine approach]] is considered for [[Tumor|tumors]] larger than 3 cm and for smaller [[Tumor|tumors]] when [[Hearing (sense)|hearing]] preservation is not a concern.
* This method has the advantage of reduced probability of [[facial nerve]] damage.<ref>{{Cite journal
| author = [[T. H. Lanman]], [[D. E. Brackmann]], [[W. E. Hitselberger]] & [[B. Subin]]
  | title = Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach
| journal = [[Journal of neurosurgery]]
| volume = 90
| issue = 4
| pages = 617–623
| year = 1999
| month = April
| doi = 10.3171/jns.1999.90.4.0617
| pmid = 10193604
}}</ref><ref>{{Cite journal
<nowiki> </nowiki><nowiki>|</nowiki> author = [[Bulent Mamikoglu]], [[Richard J. Wiet]] & [[Carlos R. Esquivel]]
| title = Translabyrinthine approach for the management of large and giant vestibular schwannomas
| journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]]
<nowiki> </nowiki><nowiki>|</nowiki> volume = 23
<nowiki> </nowiki><nowiki>|</nowiki> issue = 2
<nowiki> </nowiki><nowiki>|</nowiki> pages = 224–227
<nowiki> </nowiki><nowiki>|</nowiki> year = 2002
<nowiki> </nowiki><nowiki>|</nowiki> month = March
<nowiki> </nowiki><nowiki>|</nowiki> pmid = 11875354
}}</ref>
*


The middle fossa approach is used for tumors typically less than 2cm in greatest dimension, where hearing conservation is to be attempted. This approach has the advantage over the retrosigmoid approach in its direct access to the lateral end of the internal auditory canal. Multiple reports have shown that the retrosigmoid approach cannot reach the lateral end of the internal auditory canal without violating the posterior semicircular canal, and hence destroying the hearing.
===Retromastoid Suboccipital Approach===
* The [[Occipital|suboccipital]] approach is considered for all acoustic [[Tumor|tumors]] with or without the concern of [[Hearing (sense)|hearing]] preservation.
* Any size [[tumor]] can be removed with this approach.<ref>{{Cite journal
| author = [[Pk Nayak]] & [[Rvs Kumar]]
| title = Retromastoid-sub occipital: A novel approach to cerebello pontine angle in acoustic neuroma surgery-our experience in 21 cases
| journal = [[Journal of neurosciences in rural practice]]
| volume = 2
| issue = 1
| pages = 23–26
| year = 2011
| month = January
| doi = 10.4103/0976-3147.80084
| pmid = 21716801
}}</ref>


A less common approach is minimally invasive endoscopic surgery. This approach is available in specialized centers. This technique is not widely used due to concerns over bleeding and the inability to remove tumors from the internal auditory canal with this method.
===Middle Fossa Approach===
* The middle [[fossa]] approach is considered for [[Tumor|tumors]] smaller than 1.5 cm when [[Hearing (sense)|hearing]] preservation is optimal.  
* This approach can preserve the [[inner ear]] structures.<ref>{{Cite journal
| author = [[William F. House]] & [[Clough Shelton]]
| title = Middle fossa approach for acoustic tumor removal. 1992
| journal = [[Neurosurgery clinics of North America]]
| volume = 19
| issue = 2
| pages = 279–288
| year = 2008
| month = April
| doi = 10.1016/j.nec.2008.02.009
| pmid = 18534340
}}</ref>


Acoustic neuroma surgery is highly technically demanding, and patients are advised to seek out surgical teams with extensive experience.
Below table summarizes and simplifies approaches for the management of acoustic neuroma:
{| class="wikitable"
! style="background-color: #0080FF; font-weight: bold;" | Tumor Size
! style="background-color: #0080FF; font-weight: bold;" | Treatment line
! style="background-color: #0080FF; font-weight: bold;" | Treatment
|-
| style="background-color: #819FF7; font-weight: bold;" | Tumor < 1 to 1.5 cm
| colspan="2" |
|-
! rowspan="2" |No [[tumor]] growth
| First
| [[Observation]]
|-
| Second
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
! rowspan="3" | With [[tumor]] growth
| First
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
| Adjunct
| Salvage [[Radiation therapy|radiation]] or [[surgery]]
|-
| Second
| [[Observation]]
|-
| style="background-color: #819FF7; font-weight: bold;" | Tumor 1.5 to 3cm
| colspan="2" |
|-
! rowspan="3" | No [[tumor]] growth
| First
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
| Adjunct
| Salvage [[Radiation therapy|radiation]] or [[surgery]]
|-
| Second
| [[Observation]]
|-
! rowspan="3" | With [[tumor]] growth
| First
| Focused [[Radiation therapy|radiation]] or [[surgery]]
|-
| Adjunct
| Salvage [[Radiation therapy|radiation]] or [[surgery]]
|-
| Second
| [[Observation]]
|-
| style="background-color: #819FF7; font-weight: bold;" | Tumor > 3cm
| colspan="2" |
|-
| rowspan="3" |
| First
| [[Surgery]]
|-
| Second
| [[Observation]]
|}


==References==
==References==


{{reflist|2}}
{{reflist|2}}
{{Nervous tissue tumors}}
[[de:Akustikusneurinom]]
[[fr:Neurinome#Neurinome acoustique]]
[[nl:Brughoektumor]]


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Latest revision as of 20:08, 26 April 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohsen Basiri M.D.

Overview

Surgery is the mainstay of treatment for acoustic neuroma. Patients with age under 65 years, medium to large-grade tumors, significant hearing loss, or higher headache severity scores will have more satisfying outcomes from surgery in comparison with observation. There are three main surgical approaches for the removal of an acoustic neuroma: translabyrinthine, retrosigmoid or sub-occipital, and middle fossa. Selection of a particular approach is based on several factors including the size and location of the tumor and whether or not preservation of hearing is a goal.

Indications

Indications for surgery include:[1][2][3]

Surgery

Surgery is the mainstay of treatment for acoustic neuroma. Selection of a particular approach is based on several factors including the size and location of the tumor and whether or not preservation of hearing is a goal. There are three standard surgical approaches for the excision of an acoustic neuroma:[4][5][6]

Translabyrinthine approach

Retromastoid Suboccipital Approach

  • The suboccipital approach is considered for all acoustic tumors with or without the concern of hearing preservation.
  • Any size tumor can be removed with this approach.[9]

Middle Fossa Approach

  • The middle fossa approach is considered for tumors smaller than 1.5 cm when hearing preservation is optimal.
  • This approach can preserve the inner ear structures.[10]

Below table summarizes and simplifies approaches for the management of acoustic neuroma:

Tumor Size Treatment line Treatment
Tumor < 1 to 1.5 cm
No tumor growth First Observation
Second Focused radiation or surgery
With tumor growth First Focused radiation or surgery
Adjunct Salvage radiation or surgery
Second Observation
Tumor 1.5 to 3cm
No tumor growth First Focused radiation or surgery
Adjunct Salvage radiation or surgery
Second Observation
With tumor growth First Focused radiation or surgery
Adjunct Salvage radiation or surgery
Second Observation
Tumor > 3cm
First Surgery
Second Observation

References

  1. ↑ {{Cite journal | author = Jason C. Nellis, Jeff D. Sharon, Seth E. Pross, Lisa E. Ishii, Masaru Ishii, Jacob K. Dey & Howard W. Francis | title = Multifactor Influences of Shared Decision-Making in Acoustic Neuroma Treatment | journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]] | volume = 38 | issue = 3 | pages = 392–399 | year = 2017 | month = March | doi = 10.1097/MAO.0000000000001292 | pmid = 27930442 }}
  2. ↑ {{Cite journal | author = D. M. Kaylie, E. Gilbert, M. A. Horgan, J. B. Delashaw & S. O. McMenomey | title = Acoustic neuroma surgery outcomes | journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]] | volume = 22 | issue = 5 | pages = 686–689 | year = 2001 | month = September | pmid = 11568680 }}
  3. ↑ A. Wright & R. Bradford (1995). "Management of acoustic neuroma". BMJ (Clinical research ed.). 311 (7013): 1141–1144. PMID 7580712. Unknown parameter |month= ignored (help)
  4. ↑ Marc Bennett & David S. Haynes (2007). "Surgical approaches and complications in the removal of vestibular schwannomas". Otolaryngologic clinics of North America. 40 (3): 589–609. doi:10.1016/j.otc.2007.03.007. PMID 17544697. Unknown parameter |month= ignored (help)
  5. ↑ D. E. Brackmann & J. D. Green (1992). "Translabyrinthine approach for acoustic tumor removal". Otolaryngologic clinics of North America. 25 (2): 311–329. PMID 1630831. Unknown parameter |month= ignored (help)</ref <ref>Tyler Cole, Anand Veeravagu, Michael Zhang, Tej Azad, Christian Swinney, Gordon H. Li, John K. Ratliff & Steven L. Giannotta (2015). "Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database". Cureus. 7 (10): e369. doi:10.7759/cureus.369. PMID 26623224. Unknown parameter |month= ignored (help)
  6. ↑ Tyler Cole, Anand Veeravagu, Michael Zhang, Tej Azad, Christian Swinney, Gordon H. Li, John K. Ratliff & Steven L. Giannotta (2015). "Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database". Cureus. 7 (10): e369. doi:10.7759/cureus.369. PMID 26623224. Unknown parameter |month= ignored (help)
  7. ↑ T. H. Lanman, D. E. Brackmann, W. E. Hitselberger & B. Subin (1999). "Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach". Journal of neurosurgery. 90 (4): 617–623. doi:10.3171/jns.1999.90.4.0617. PMID 10193604. Unknown parameter |month= ignored (help)
  8. ↑ {{Cite journal | author = Bulent Mamikoglu, Richard J. Wiet & Carlos R. Esquivel | title = Translabyrinthine approach for the management of large and giant vestibular schwannomas | journal = [[Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology]] | volume = 23 | issue = 2 | pages = 224–227 | year = 2002 | month = March | pmid = 11875354 }}
  9. ↑ Pk Nayak & Rvs Kumar (2011). "Retromastoid-sub occipital: A novel approach to cerebello pontine angle in acoustic neuroma surgery-our experience in 21 cases". Journal of neurosciences in rural practice. 2 (1): 23–26. doi:10.4103/0976-3147.80084. PMID 21716801. Unknown parameter |month= ignored (help)
  10. ↑ William F. House & Clough Shelton (2008). "Middle fossa approach for acoustic tumor removal. 1992". Neurosurgery clinics of North America. 19 (2): 279–288. doi:10.1016/j.nec.2008.02.009. PMID 18534340. Unknown parameter |month= ignored (help)


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