51venous infarcts, seizures, or persistent cerebellar
dysfunction. When grouped together, they found
these occurred at a rate of 2.4% in the middle
fossa approach and 2.6% in the translabyrinthine
approach (P = 0.512) [ 19 ]. Seizures are more
commonly seen following the middle fossa
approach and are thought to be related to tempo-
ral lobe retraction. Limiting the time of temporal
lobe retraction to 60–90 min can help to avoid
this complication [ 3 ].
Summary
With the development of the operating micro-
scope and microsurgical techniques, the approach
to removing acoustic neuromas has evolved and
improved over the years. Continued technical
refinements have led to a low rate of complica-
tions and rare mortality. The incorporation of
routine gadolinium-enhanced MRI has facilitated
early diagnosis of small lesions and made hear-
ing conservation surgery a possibility in these
cases.
The primary considerations when deciding on
the surgical approach are preoperative hearing sta-
tus and tumor size. In patients with small lesions
and serviceable hearing, use of the middle fossa
approach can lead to preservation of preoperative
hearing in up to 80% of patients with as many as
95% of patients being left with a normal or near-
normal facial nerve function. In patients with poor
preoperative hearing and/or large acoustic neuro-
mas, the translabyrinthine approach has excellent
exposure and has shown to be safe. As tumors
increase in size, the rate of postoperative compli-
cations and facial nerve dysfunction increases. In
acoustic neuromas larger than 2.5 cm, consider-
ation can be given to subtotal tumor resection and
facial nerve preservation, knowing that this may
result in tumor regrowth over time.
References
- Parry RH. A case of tinnitus and vertigo treated by
division of the auditory nerve. 1904. J Laryngol Otol.
1991;105(12):1099–100.
2. House WF. Surgical exposure of the internal audi-
tory canal and its contents through the middle, cranial
fossa. Laryngoscope. 1961;71:1363–85.
3. Brackmann DE, Shelton C, House WF. Middle fossa
approach. In: Shelton C, Brackmann D, Arriaga
MA, editors. Otologic surgery. 4th ed. Philadelphia:
Elsevier; 2016. p. 512–9.
4. Shelton C, Hitselberger WE. The treatment of
small acoustic tumors: now or later? Laryngoscope.
1991;101(9):925–8.
5. Wade PJ, House W. Hearing preservation in patients
with acoustic neuromas via the middle fossa approach.
Otolaryngol Head Neck Surg. 1984;92(2):184–93.
6. Kurze T, Doyle JB Jr. Extradural intracranial (mid-
dle fossa) approach to the internal auditory canal.
J Neurosurg. 1962;19:1033–7.
7. Brackmann D. Middle cranial fossa approach. In:
House W, Luetje C, editors. Acoustic tumors manage-
ment, vol. 2. Baltimore: University Park Press; 1979.
8. Glasscock ME, Poe DS, Johnson GD. Hearing
preservation in surgery of cerebellopontine angle
tumors. In: Fisch U, Valavanis A, Yasargil MG, edi-
tors. Neurological surgery of the ear and skullbase.
Amsterdam: Kugler & Ghedini; 1989.
9. House F, Hitselberger WE. The middle fossa
approach for removal of small acoustic tumors. Acta
Otolaryngol. 1969;67(4):413–27.
10. Minor LB, Solomon D, Zinreich JS, Zee DS. Sound-
and/or pressure-induced vertigo due to bone dehis-
cence of the superior semicircular canal. Arch
Otolaryngol Head Neck Surg. 1998;124(3):249–58.
11. Baugh RF, Basura GJ, Ishii LE, Schwartz SR,
Drumheller CM, Burkholder R, et al. Clinical practice
guideline: bell’s palsy. Otolaryngol Head Neck Surg.
2013;149(3 Suppl):S1–27.
12. Cannon RB, Gurgel RK, Warren FM, Shelton C. Facial
nerve outcomes after middle fossa decompression for
Bell’s palsy. Otol Neurotol. 2015;36(3):513–8.
13. Cannon RB, Thomson RS, Shelton C, Gurgel
RK. Long-term outcomes after middle fossa approach
for traumatic facial nerve paralysis. Otol Neurotol.
2016;37:799–804.
14. House WF. Transtemporal bone microsurgical
removal of acoustic neuromas. Evolution of trans-
temporal bone removal of acoustic tumors. Arch
Otolaryngol. 1964;80:731–42.
15. House WF. Translabyrinthine approach. In: House
WF, Luetje C, editors. Acoustic tumors manage-
ment, vol. 2. Baltimore: University Park Press; 1979.
p. 43–87.
16. Goddard JC, McRackan TR, House
JW. Translabyrinthine approach. In: Brackmann DE,
Shelton C, Arriaga MA, editors. Otolgoic surgery. 4th
ed. Philadelphia: Elsevier; 2016. p. 520–30.
17. Hitselberger WE, House WF. A warning regarding
the sitting position for acoustic tumor surgery. Arch
Otolaryngol. 1980;106(2):69.
18. Jackler R, Sim D. Retrosigmoid approach to tumours
of the cerebellopontine angle. In: Brackmann DE,
3 Middle Fossa and Translabyrinthine Approaches