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Translabyrinthine Approach for Vestibular Schwannoma (Acoustic Neuroma) Resection

Contributors: Bruce E. Mickey and  J. Walter Kutz

This video highlights key steps to the translabyrinthine approach for vestibular schwannoma resection. It emphases identification of the facial nerve and the benefit of facial nerve monitoring in lateral skull base surgery.

DOI#: https://doi.org/10.17797/4w83z6uxam

Translabyrinthine Approach for Vestibular Schwannoma Resection (right ear)
1. Any size tumor accompanied by non-serviceable hearing. 2. Tumors greater than 2.0 cm regardless of hearing status. 3. Tumors with extension to the lateral internal auditory canal that are inaccessible via a retrosigmoid approach. 4. Auditory brainstem implant placement. 5. Access to other pathology (eg, meningioma, epidermoid) involving the cerebellopontine angle.
1. Desire for hearing preservation. 2. Tumor resection in an only hearing ear (relative contraindication) 3. Concurrent chronic otitis media or mastoiditis 4. High jugular bulb (relative contraindication)
- Supine position with head turned away from the surgeon. Consider use of Mayfield head frame, particularly for larger tumors. - Left lower quadrant of abdomen prepped for abdominal fat graft - Facial nerve monitoring - Head shaved 3 inches above and behind the ear - Foley catheter - Arterial line - Perioperative antibiotics - Mannitol (0.5 - 1 g per kg) - Dexamethasone - Type and screen
- Audiogram - MRI with and without gadolinium contrast - Routine laboratory studies
1. C-shaped postauricular incision two finger breadths posterior to the ear. 2. Wide cortical mastoidectomy with identification of the vertical segment of the facial nerve, sigmoid sinus, tegmen mastoideum, and posterior fossa plate. 3. Identification and removal of the incus. 4. Facial recess to enable obliteration of the Eustachian tube. 5. Removal of bone overlying the sigmoid sinus, posterior fossa dura, and middle fossa dura. In large tumors it is recommended to decompress 1.5 - 2.0 cm posterior to the sigmoid sinus. 6. Labyrinthectomy. 7. Identification of the jugular bulb. 8. Inferior and superior internal auditory canal troughs. 9. Removal of bone overlying the internal auditory canal. 10. Identification of the superior vestibular nerve and facial nerve. 11. Tumor dissection. 12. Closure. There are many different methods of closing the translabyrinthine defect that are not addressed in this video. Regardless of the specific technique, all exposed air cells must be obliterated with bone wax and the defect should be filled with abdominal fat.
Advantages: - exposure suits any tumor size - early identification of the facial nerve offers potential for improved facial nerve outcomes - no brain retraction - less postoperative headaches than the retrosigmoid approach - comparable cerebrospinal fluid leak rates Disadvantages: - hearing loss
Temporary or permanent facial nerve paralysis, cerebrospinal fluid leak, hematoma, infection, meningitis, stroke.
Temporary or permanent facial nerve paralysis, cerebrospinal fluid leak, hematoma, infection, meningitis, stroke.
None
1. House WF. Evolution of transtemporal bone removal of acoustic tumors. Arch Otolaryngol. 1964;80:731-742. 2. Lanman TH, Brackmann DE, Hitselberger WE, Subin B. Report of 190 consecutive cases of large acoustic tumors (vestibular schwannoma) removed via the translabyrinthine approach. J Neurosurg. 1999;90(4):617-623. 3. Brackmann DE, Cullen RD, Fisher LM. Facial nerve function after translabyrinthine vestibular schwannoma surgery. Otolaryngol Head Neck Surg. 2007;136(5):773-777. 4. Karampelas I, Wick C, Semaan M, Megerian CA, Bambakidis NC. Translabyrinthine resection of a small intracanalicular acoustic tumor. Neurosurg Focus. 2014;36(1 Suppl):1. doi: 10.3171/2014.V1.FOCUS13448

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