47POD #1. If stable, the patient is transferred to the
surgical floor on POD #1. Early ambulation is
encouraged at this point to facilitate vestibular
compensation. It is important at this point to have
all but one peripheral IV removed and to only
spot-check pulse oximetry to prevent excess lines
that impede mobilization. Incentive spirometry is
begun on POD #1 and continued until discharge.
The typical hospital course is 3–5 days.
Postoperative pain is generally mild and con-
trolled with routine analgesics. The middle fossa
approach is often associated with more severe
pain due to muscle spasms from division of the
temporalis muscle and can be associated with
mild, temporary trismus. Severe vertigo with
nausea is common in the postoperative period
due to sectioning of the vestibular nerves. Patients
with smaller tumors, such as those removed by
the middle fossa approach, often have more
severe symptoms as they had more retained ves-
tibular function going in to surgery. Control of
these symptoms is important for patient comfort,
and we have found good success with Phenergan
(promethazine), Compazine (prochlorperazine),
and Haldol (haloperidol). It is important to note
that we have seen poor symptomatic control with
Zofran (ondansetron) in this setting, unless the
nausea is related to anesthesia in the first 24 h
postoperatively only. We have found that most
patients have severe dizziness for the first 24–48 h
postoperatively. By the end of the first postopera-
tive week, they are often left with residual
unsteadiness, but most are able to ambulate with-
out assistance. Patients are to abstain from driv-
ing until no longer dizzy. We do prescribe
vestibular physical therapy for a small subset of
patients, most of who are elderly or had preoper-
ative vestibular symptoms. Patients are advised
to avoid getting their incisions wet until 7 days
after surgery and to avoid vigorous activity or
heavy lifting for 6 weeks.Outcomes
Hearing PreservationThe rate of hearing preservation has improved
over time in patients who undergo tumor resec-
tion via the middle fossa approach. In a study of
106 patients followed over 25 years published in
1989, hearing was preserved in 59% of patients
and was maintained at preoperative levels in
35% of patients [ 32 ]. Brackmann and coworkers
published their results of 333 patients followed
for 7 years in 2000 and found a hearing preser-
vation rate of 80%, with hearing preserved near
the preoperative level (within 15 dB PTA and
15% SDS) in 50% [ 26 ]. We recently evaluated
78 consecutive patients with intracanalicular
acoustic neuromas removed via middle fossa
approach. Of those with functional preoperative
hearing (AAO-HNS class A/B), 75% had func-
tional hearing postoperatively with an average
follow-up of 15 months [ 44 ]. In comparing out-
comes between hearing conservation
approaches, a recent systematic review found
the middle fossa approach to be superior to the
retrosigmoid approach for hearing preservation
in patients with tumors <1.5 cm (hearing loss in
43.6% vs 64.3%, P < 0.001). However, no dif-
ference in rate of hearing loss was found
between these two approaches for intracanalicu-
lar tumors (40.6% vs 44.3%, P = 0.492) [ 19 ].Fig. 3.12 Small tumor separated from the facial nerve.
We usually section both branches of the vestibular nerve
and the cochlear nerve (Permission to use figures from
chapters 49–50, Brackmann et al. [ 75 ]; granted by
Elsevier)
3 Middle Fossa and Translabyrinthine Approaches