Surgical management of vestibular schwannoma in elderly patients
Jordan University of Science and Technology, Irbid, Jordan. Archives of Oto-Rhino-Laryngology
(Impact Factor: 1.55).
03/2011; 269(1):17-23. DOI: 10.1007/s00405-011-1566-2
This study aimed to evaluate surgical results of vestibular schwannoma in elderly patients using a retrospective study in a Quaternary Neurotology and Skull Base Referral Center setting. The data of 232 elderly patients (above 65 years) operated on for vestibular schwannoma in the period between April 1987 and July 2009 were reviewed. Most patients were operated on via translabyrinthine approach (TLA) using transapical extension for large tumors. Other approaches used were retrosigmoid, middle cranial fossa, and transcochlear. Total tumor removal was achieved in the majority of cases, while planned subtotal removal was used in specific occasions. Postoperative complications included facial nerve palsy, other cranial nerves injury, persistent instability, intracranial hemorrhage, CSF leak, meningitis, and death. Patients were followed after surgery for tumor regrowth or occurrence of complications. The results showed low rate of morbidity and mortality. Despite that complete removal is the main target of the surgery; adoption of subtotal removal in selected cases can improve postoperative facial nerve results and reduce the duration of surgery.
Available from: PubMed Central
- "The most common techniques for facial reanimation are sural grafting and hypoglossal-facial (VII–XII) anastomosis. It has been reported that these techniques produce excellent results, as assessed by the House-Brackmann grade of facial function, but to date there has been no long-term comparison of the techniques (6). "
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ABSTRACT: The aim of this study was to compare the recovery of long-term facial nerve function between patients who received sural grafts and those who underwent hypoglossal-facial anastomosis techniques following translabyrinthine vestibular schwannoma surgery. This study included 25 patients with vestibular schwannomas treated with translabyrinthine tumor removal. All patients had large tumors with a mean tumor size of 3.12 cm. Of these patients, six had progressive tumor enlargement symptoms and had been treated previously with stereotactic irradiation. Preoperatively, all patients had normal facial functions, and total tumor removal with a translabyrinthine approach was achieved in all cases. During surgery, the facial nerve was interrupted in all 25 patients. Two types of facial reanimation were performed. Sural grafts were placed in 13 patients and hypoglossal-facial (VII-XII) anastomosis was performed in the other 12. Facial nerve function and surgical outcomes were observed upon discharge, in the short term (one year following surgery), and in the long term (three years following surgery). Total facial paresis was observed in all patients upon discharge. In the sural graft group, House-Brackmann grade III facial function was achieved in four patients upon short-term evaluation and in ten upon long-term evaluation, while House-Brackmann grade IV facial function was achieved in nine patients upon short-term evaluation and three in the long term. In the VII-XII anastomosis group, House-Brackmann grade III facial function was achieved in two patients in the short term and eight in the long term, and House-Brackmann grade IV facial function was achieved in ten patients in the short term and four in the long term. There was a statistically significant difference in the facial recovery results between the short- and long-term follow-up periods. The sural graft group exhibited a marked improvement in results compared with the VII-XII anastomosis group, but no statistically significant difference in facial function was observed between the two facial reanimation groups at either the short- or long-term follow-up. In the sural graft group, synkinesia, noted in three patients, was the most frequently observed complication. Claudication was common upon discharge (four patients), but diminished during follow-up. Disarticulation was the most common complication in the VII-XII anastomosis group (five patients); numbness of the tongue was the second most common complication (four patients). None of the patients developed dysphagia. Facial reanimation is an effective procedure for the surgical rehabilitation of static and dynamic facial nerve functions. Significant improvement in facial nerve function may occur more than three years after surgery. Despite morbidities such as synkinesia, the sural graft technique demonstrates greater improvements in facial nerve function than VII-XII anastomosis in the short and long term following surgery, but this conclusion requires confirmation by larger studies with a greater number of patients.
Available from: Rodrigo Ramos-Zúñiga
- "That is why, experimental procedures such as this should be part of the elementary training procedures in otoneurosurgery through approaches that combine effectively with endoscopic and microsurgical strategies for the treatment of pathologies affecting the cerebello-pontine angle. "
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ABSTRACT: Experimental procedures will continue to be a key element while going through the learning curve in the use of the endoscope and minimally invasive procedures. We describe the technical procedure of an experimental approach to middle ear in New Zealand rabbits through external auditory canal and its relevance as an ideal model to study graft materials and serve as a training tool for potential applications in otoneurology.
A group of 28 adult New Zealand rabbits were subjected to an experimental myringoplasty, combining the transmeatal and retroauricular approach with endoscopic assistance and microsurgical technique. The different anatomical steps and systematization of the complete experimental procedure are described.
An experimental approach to middle ear live model and basic anatomic description was successfully used, standardizing the ideal technique. The eardrum could regenerate with no complications and with functional preservation in all the myringoplasty cases. This strategy involves a safe combined approach to the tympanic membrane and others neurosurgical as transcochlear and translaberyntic approaches and is useful as a test of other experimental procedures to evaluate biomaterials to repair the eardrum currently studied. This experimental myringoplasty model also facilitates functional tests such as impedanciometry and the endoscopic follow-up of the whole process.
The method described to perform an experimental myringoplasty (type I tympanoplasty) in a New Zealand rabbit is an option to be used as a basic model to study the behavior of the graft in the tympanic membrane. Also, basic concepts for the use of combined instrumentation are established in the treatment of eardrum lesions, as a refinement of the technical training application in microsurgery and assisted endoscopy in the transcochlear and translaberintic approaches and otoneurology areas.
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The authors' objective was 2-fold: 1) to compare outcomes of microsurgical resection for vestibular schwannoma (VS) between patients aged 70 years or older and patients younger than 70 years and 2) to test the hypothesis that symptomatic tumors in elderly patients represent a more aggressive variant of VS than those in younger adults, resulting in increased morbidity and a higher rate of recurrence after subtotal resection (STR).
A retrospective matched cohort study was conducted. Patients aged 70 years or older who had undergone microsurgical resection of VS were matched to adult patients younger than 70 years; the matching was performed on the basis of surgical approach, completeness of resection, and tumor size. Associations between clinical, radiographic, and surgical data and postoperative outcome were analyzed using conditional logistic regression.
Twenty patients aged 70 years or older (mean age ± SD 75.9 ± 5.3, range 70-86 years) were identified and matched to a cohort of younger adult patients (mean age ± SD 55.7 ± 13.8, range 25-69 years). The mean tumor size in both groups was approximately 3 cm. Overall, the elderly patients had a poorer preoperative American Society of Anesthesiology physical status score (p = 0.038), were more likely to report imbalance (OR 9.61, p = 0.016), and more commonly exhibited compromised balance and coordination (OR 9.61, p = 0.016) than patients in the younger cohort. There were no differences between the 2 cohorts in perioperative complications (p = 0.26) or facial nerve function (p > 0.5) at any time. The elderly patients were 13 times more likely to have long-term postoperative imbalance (OR 13.00, p = 0.013) than the younger patients. Overall, 9 tumors recurred among 32 patients undergoing STR; 6 of these patients underwent additional interventions (stereotactic radiosurgery in 5 patients and microsurgery in 1) and showed no evidence of tumor progression at the last follow-up. The median growth rate of the recurrent tumor in the 6 elderly patients was 4.8 mm/year (range 2.1-14.9 mm/year) and, in the 3 control patients, 2.2 mm/year (range 1.9-4.0 mm/year). Overall, the mortality data showed a trend toward statistical significance (p = 0.068) with a higher risk of death in the elderly.
As the number of elderly patients with VS increases, microsurgical resection will remain an important management option for these patients. Despite a poorer preoperative physical status in elderly patients, their morbidity profiles are similar to those in adult patients younger than 70 years. However, elderly patients may require longer convalescence due to prolonged postoperative imbalance. Not surprisingly, overall diminished functional reserve and advanced comorbidities may increase the mortality risk associated with surgical intervention in the elderly patients. Finally, there was a high risk of further tumor growth following STR in the elderly patients (6 [37.5%] of 16), underscoring the need for close postoperative radiological surveillance and consideration of early stereotactic radiosurgery for the tumor remnant following the STR.
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