51
venous 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.
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