112
patients with CPA meningiomas that were
resected with a retrosigmoid approach and
achieved total removal in 91% of patients with
facial nerve preservation in 91% of patients and
hearing preservation in 83% [ 3 ]. A recent series
advocated for subtotal resection followed by
Gamma Knife radiosurgery for residual or small
tumors with the goal of preserving facial nerve
function, and they achieved similar functional
results to Samii, with only 10% of patients hav-
ing decreased facial function postoperatively
but had a much lower rate of total resection
(67%) [ 5 ]. Another recent smaller series that
focused on functional preservation reported a
low rate of facial deficits (5.9%) and no new
hearing deficits in 34 patients [ 1 ]. Finally, a
recent large Chinese series of 193 patients with
CPA meningiomas found that gross total resec-
tion was markedly lower in tumors involving
the IAC (30%) compared to no IAC involve-
ment (71%) but did not report facial nerve or
hearing outcomes.
The decision to treat with microsurgery or
radiotherapy/radiosurgery depends on patient and
tumor-specific factors. All patients with middle
and posterior petrous face meningiomas should
have preoperative audiometry to evaluate hearing.
Observation with serial imaging is an option for
asymptomatic small tumors. For tumors <2.5 cm
in diameter, radiotherapy can be considered as an
upfront treatment option and has excellent out-
comes with regard to tumor growth arrest and
preservation of cranial nerve function and avoids
the morbidity of open surgery [ 5 ]. However, for
larger tumors or symptomatic tumors, surgical
resection is considered the standard of care and
can lead to excellent outcomes, even in elderly
patients [ 11 ]. Approach selection is determined
by surgeon comfort and facility with the different
approaches; however, most tumors can be resected
via a retrosigmoid or modified far lateral approach
as discussed above. The presence of a neuro-otol-
ogist to assist with petrous drilling through the
retrosigmoid approach has been very useful in
our hands. Finally, patient preference must be
taken into consideration, and a mutual decision
on management should be made by the patient
and surgeon.
In conclusion, petrous face meningiomas can
be separated into three categories based on loca-
tion, anterior, middle, and posterior. They present
with distinct size and symptoms based on loca-
tion. They can be resected via retrosigmoid or
modified far lateral approaches, and surgical
resection should be focused on maximal safe
resection with preservation of facial and hearing
function. Adjuvant postoperative radiotherapy or
radiosurgery can be performed for small residu-
als with excellent tumor control (Table 8.1).References
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Table 8.1 Petrous face meningiomas: tumor size, clinical syndromes, and approaches
APFM MPFM PPFM
Presentation size Small or medium Medium Small, medium, or large
Symptom complex Trigeminal neuropathy/neuralgia Audiovestibular Small^ – audiovestibular
Large – ataxia, elevated ICP
Surgical approach Retrosigmoid – suprameatal Retrosigmoid Small – retrosigmoid
Large – modified far lateralS.T. Magill et al.