1 / 43

Acoustic neuroma surgery —Shanghai experience

Acoustic neuroma surgery —Shanghai experience. Hao Wu Department of Otolaryngology-Head and Neck Surgery Xinhua Hospital, Shanghai Second Medical University. McBumey (1891): unsuccessful Balance (1894): first successful. Cushing Era Surgical mortality: 80% Cushing –partial removal.

horace
Download Presentation

Acoustic neuroma surgery —Shanghai experience

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Acoustic neuroma surgery—Shanghai experience Hao Wu Department of Otolaryngology-Head and Neck Surgery Xinhua Hospital, Shanghai Second Medical University

  2. McBumey (1891): unsuccessful • Balance (1894): first successful

  3. Cushing Era • Surgical mortality: 80% • Cushing –partial removal

  4. Dandy Era(1917–1961) • Total removal: mortality↓(22.1%) • Atkinson (1949): AICA • Total facial paralysis

  5. 1960 • Mortality rate in California: 43.5% • Olivecrona (Sweden):414 cases • small tumors: 4.5% • large tumors: 22.5% • Facial paralysis: 50%

  6. Middle fossa approach (1961) • Traslab approach (1962) Dr. W. House(1961-)

  7. 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.

  8. 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)

  9. REASON FOR CONSULTATION Moffat et al., 1998 n = 473 . • Expected symptom: 80.7 % • (progressive HL,tinnitus,unsteadiness) • Sudden hearing loss: 9.6 % • Atypical presentation: 10 % . .

  10. 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

  11. Differential diagnosis • Other neurinomas in the CPA: 5th, 7th, or caudal cranial nerve neurinomas • Other lesions: • Most frequent: • Meningiomas • Cholesteatomas • Rare lesions :lipomas, metastases, hemangiomas, medulloblastomas etc…..

  12. Neurotological examination Audiometry+ABR+VNG Normal ABR and VNG Abnormality Age < 60 years > 60 years MRI + Gadolinium Follow-up Audio-vestibular work-up In 6 months MRI + Gadolinium Unilateral or asymetrical audio-vestibular signs : Hearing loss, vestibular syndrome, tinnitus

  13. Decisionnal factors • Tumor volume • Age • Hearing function

  14. Therapeutic options Varaiable tumor growth According to age and tumor size < 1,5 cm MRI in 6 months and then once a year • Conservative managament • Radiotherapy Gamma-knife, LINAC Volume stabilisation Hearing loss and facial paresis Under evaluation • Surgery

  15. Goals of the surgery 1- Minimal vital and neurological risks 2- Total removal 3- Facial function preservation 4- Hearing preservation

  16. Middle cranial fossa (MCF) Retrosigmoid (RS) Translabyrinthine (TL) Approaches

  17. CPA> 20 mm MCF retrosigmoid translabyrinthine Translabyrinthine or transotic Acoustic Neuromas Intracanalar or CPA <20mm < 70 years: Surgery Poor general condition: Irradiation > 70 years: Conservative management Hearing Serviceable Unserviceable

  18. I II < 15 mm III : 15-30 mm IV > 30 mm Population • 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 %

  19. Approaches • Translabyrinthine : 77 % • Transotic: 6 % • Retrosigmoid: 12 % • Middle cranial fossa: 5 % • 17% attempt to hearing preservation

  20. Intraoperative monitoring ABR

  21. Direct cochlear nerve potential

  22. Resection quality • Complete removal in 98 cases • Subtotal removal in 1 cases (1 %) • In cases with subtotal removal : • 1 MRI imagesdemonstrate to be stable (1 %) • 1 case surgically revised (1 %)

  23. Postoperative facial function in translabyrinthine or transotic approach

  24. Hearing preservation • Hearing preservation attempts by middle cranial fossa or retrosigmoid approach (n=17): Class C: 24 % Class D: 40 % Class B: 24 % Class A: 12 % Class A+B: 36%

  25. Complications • CSF leaks: 6%(all in first 39 cases) • Neurological: 3% • Infectious: 1 % • Miscellaneous: 3 %

  26. Translabyrinthine approach

  27. 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

  28. 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

  29. Fallopian bridge technique

  30. Middle fossa approach

  31. Retrosigmoid-IAM approach

  32. Facial nerve repair after interruption • end-to-ent anastomosis • Reroute technique • Bridge technique • Facial-hypolingual ana.

  33. Hearing rehabilitation in acoustic neuroma surgery NF2 and Auditory Brainstem Implant

  34. NF2 DIAGNOSIS • Bilateral vestibular schwannoma (VS) • NF2 familial history and - unilateral VS - or 2 among : meningioma, glioma, neurofibroma,schwannoma,subcapsularlens opacity

  35. NF2 • NF2 gene on chromosome 22 (1993) • Tumor suppressor gene

  36. Auditory pathway

  37. Nucleus 21 Channel Auditory Brainstem Implant Removeable magnet CI22M receiver-stimulator Monopolar reference electrode (plate) Microcoiled electrode wires T-shaped Dacron mesh Electrode array (21 platinum disks 0.7mm diameter)

  38. Bone anchored hearing aide (BAHA) • Single sided deafness; • FDA approval;

  39. 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.

  40. 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.

  41. Thanks

More Related