Acoustic neuroma surgery —Shanghai experience
description
Transcript of Acoustic neuroma surgery —Shanghai experience
![Page 1: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/1.jpg)
Acoustic neuroma surgery—Shanghai experience
Hao WuDepartment of Otolaryngology-Head and Neck Surgery
Xinhua Hospital, Shanghai Second Medical University
![Page 2: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/2.jpg)
• McBumey (1891): unsuccessful
• Balance (1894): first successful
![Page 3: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/3.jpg)
Cushing Era
• Surgical mortality: 80%
• Cushing –partial removal
![Page 4: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/4.jpg)
Dandy Era( 1917–1961)• Total removal: mortality↓(22.1%)
• Atkinson (1949): AICA
• Total facial paralysis
![Page 5: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/5.jpg)
1960
• Mortality rate in California: 43.5%
• Olivecrona (Sweden): 414 cases– small tumors: 4.5%
– large tumors: 22.5%
– Facial paralysis: 50%
![Page 6: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/6.jpg)
Dr. W. House ( 1961-)
•Middle fossa approach (1961)
•Traslab approach (1962)
![Page 7: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/7.jpg)
Origin
Development in the internal acoustic meatus from the schwann cells of the vestibular ganglion (Sterkers JM et al., Acta Otolaryngol., 1987)
Arachnoid sheet enveloping the tumour during its expansion to the CPA.
![Page 8: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/8.jpg)
Epidemiology• 6 to 8 % of all intracranial tumours• The most frequent (80 to 90%) of the
CPA tumours• Sporadic, and solitary in 95 % of cases• Associated with NF2 in 5 % of cases• Estimated incidence in USA and
Western Europe: 1 for 100,000 individuals per year (Kurlan et al., J neurosurg, 1958 ; Nestor JJ et al., Arch Otlaryngol Head Neck Surg, 1988)
![Page 9: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/9.jpg)
REASON FOR CONSULTATION
Expected symptom: 80.7 %(progressive HL,tinnitus,unsteadiness) Sudden hearing loss: 9.6 %Atypical presentation: 10 %
.
..
Moffat et al., 1998n = 473
![Page 10: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/10.jpg)
MRI diagnosis
Isosignal on T1, and variable aspect en T2 views
Constant gadolinium enhancement
Intratumoral cysts in large neurinomes
No adjascent meningeal enhancement
Enlarged IAM
Extension predominantly posterior to IAM
![Page 11: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/11.jpg)
Differential diagnosis
Other neurinomas in the CPA: 5th, 7th, or caudal cranial nerve neurinomasOther lesions:
Most frequent:MeningiomasCholesteatomas
Rare lesions :lipomas, metastases, hemangiomas, medulloblastomas etc…..
![Page 12: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/12.jpg)
Unilateral or asymetrical audio-vestibular signs :Hearing loss, vestibular syndrome, tinnitus
MRI + GadoliniumMRI + Gadolinium Follow-upAudio-vestibular work-up
In 6 months
Neurotological examinationAudiometry+ABR+VNG
Age
< 60 years > 60 years
Abnormality Normal ABR and VNG
![Page 13: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/13.jpg)
Decisionnal factors
1. Tumor volume
2. Age
3. Hearing function
![Page 14: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/14.jpg)
Therapeutic options
Varaiable tumor growth
According to age and tumor size < 1,5 cm
MRI in 6 months and then once a year
Gamma-knife, LINACVolume stabilisationHearing loss and facial paresisUnder evaluation
• Conservative managament
• Surgery
• Radiotherapy
![Page 15: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/15.jpg)
Goals of the surgery
1- Minimal vital and neurological risks
2- Total removal
3- Facial function preservation
4- Hearing preservation
![Page 16: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/16.jpg)
Approaches
Retrosigmoid (RS)
Translabyrinthine (TL)
Middle cranial fossa (MCF)
![Page 17: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/17.jpg)
Acoustic Neuromas
Intracanalar or CPA < 20 mm
> 70 years:Conservativemanagement
< 70 years:Surgery
Poor general condition:Irradiation
CPA> 20 mm
Translabyrinthine or transotictranslabyrinthineMCFretrosigmoid
Hearing
Serviceable Unserviceable
![Page 18: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/18.jpg)
II < 15 mmIII : 15-30 mm
IV > 30 mm
I
• 1999.1-2004.3: 100 VS operated on • Mean age: 49 years (range: 20-79)• Sex ratio: 0.8• Tumor stages :
– Stage 1: 3 %
– Stage 2: 11 %
– Stage 3 : 71 %
– Stage 4 : 15 %
Population
![Page 19: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/19.jpg)
Approaches
•Translabyrinthine : 77 %
•Transotic: 6 %
•Retrosigmoid: 12 %
•Middle cranial fossa: 5 %
17% attempt to hearing preservation
![Page 20: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/20.jpg)
ABRIntraoperative monitoring
![Page 21: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/21.jpg)
Direct cochlear nerve potential
![Page 22: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/22.jpg)
Resection quality
Complete removal in 98 cases Subtotal removal in 1 cases (1 %)
In cases with subtotal removal :1 MRI images demonstrate to be stable (1 %)1 case surgically revised (1 %)
![Page 23: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/23.jpg)
Postoperative facial function in translabyrinthine or transotic
approach
Stages Cases Facial function
1 2 3 4 5 6
总计 83 31 15 13 12 8 4
![Page 24: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/24.jpg)
Hearing preservation
Hearing preservation attempts by middle cranial fossa or retrosigmoid approach (n=17):
Class D: 40 %
Class A: 12 %
Class C: 24 %
Class B: 24 %
Class A+B: 36%
![Page 25: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/25.jpg)
Complications
• CSF leaks: 6%(all in first 39 cases)
Neurological: 3%
Infectious: 1 %
Miscellaneous: 3 %
![Page 26: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/26.jpg)
Translabyrinthine approach
![Page 27: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/27.jpg)
Translabyrinthine removal of VS after radiosurgery
• 5 cases;• Difficult in facial nerve dissection;• Results: total removal in all cases
facial function: grade II in 1 case
grade III in 2 cases
grade IV in 2 cases
grade VI in 1 case
![Page 28: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/28.jpg)
Transotic removal of VS with chronic middle ear infection
• 3 cases;• Results: total removal in all cases
facial function: all with gradeI-II
no postoperative infection
![Page 29: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/29.jpg)
Fallopian bridge technique
![Page 30: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/30.jpg)
Middle fossa approach
![Page 31: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/31.jpg)
![Page 32: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/32.jpg)
Retrosigmoid-IAM approach
![Page 33: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/33.jpg)
Facial nerve repair after interruption
• end-to-ent anastomosis
• Reroute technique
• Bridge technique
• Facial-hypolingual ana.
![Page 34: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/34.jpg)
NF2 and Auditory Brainstem Implant
Hearing rehabilitation in acoustic neuroma surgery
![Page 35: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/35.jpg)
NF2 DIAGNOSIS
• Bilateral vestibular schwannoma (VS)
• NF2 familial history
and
- unilateral VS
- or 2 among : meningioma, glioma, neurofibroma,schwannoma,subcapsular lens opacity
![Page 36: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/36.jpg)
NF2
• NF2 gene on chromosome 22 (1993)
• Tumor suppressor gene
![Page 37: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/37.jpg)
Auditory pathway
Me dia l g e nic ula te bo dy
Infe rio r c o llic ulus
La te ra l le mnisc us
Supe rio r & a c c e sso ry o live a re a
Do rsa l c o c hle a r nuc le usVe ntra l c o c hle a r nuc le us
(Ada pte d fro m "Ne uro to lo g y",Ja c kle r a nd Bra c kma nn)
Co c hle a r
Audito ry c o rte x
VIIIth ne rve
Co c hle a rImpla nt
Audito ryBra inste m
Impla nt
![Page 38: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/38.jpg)
Nucleus 21 Channel Auditory Brainstem Implant
CI22M receiver-stimulator
Monopolarreference electrode
(plate)
Microcoiled electrodewires
Electrode array(21 platinum disks0.7mm diameter)
T-shapedDacronmesh
Removeablemagnet
![Page 39: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/39.jpg)
![Page 40: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/40.jpg)
Bone anchored hearing aide (BAHA)
• Single sided deafness;• FDA approval;
![Page 41: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/41.jpg)
Conclusions 1• In spite of modern image techniques, large VS acounts for most diagnosed cases in China.
•The translabyrinthine app. could be used in even largest VS with minival invasion.
![Page 42: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/42.jpg)
Conclusions 2• The facial function is aceptable in most patients.•The hearing preservation result should still be improved.•Hearing rehabilitation techniques are available after tumor removal.
![Page 43: Acoustic neuroma surgery —Shanghai experience](https://reader036.fdocuments.net/reader036/viewer/2022081722/56814325550346895daf8db6/html5/thumbnails/43.jpg)
Thanks