Acta Oto-Laryngologica
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Translabyrinthine Surgery of Acoustic Neurinoma Mirko Tos & Jens Thomsen To cite this article: Mirko Tos & Jens Thomsen (1978) Translabyrinthine Surgery of Acoustic Neurinoma, Acta Oto-Laryngologica, 86:sup360, 45-47, DOI: 10.3109/00016487809123468 To link to this article: http://dx.doi.org/10.3109/00016487809123468
Published online: 08 Jul 2009.
Submit your article to this journal
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [McMaster University]
Date: 05 May 2016, At: 20:54
Acta Otolaryngol, Suppl. 360: 45-47, 1979 TRANSLABYRINTHINE SURGERY OF ACOUSTIC NEURINOMA Mirko Tos and Jens Thomsen From tire ENT University Clinics, Gentojte Hospital rind Rigshospitalet, Copenhagen, Denmark
In translabyrinthine and translabyrinthine-suboccipital removal of 47 acoustic tumours, the mortality rate was 2.1 %; among 18 large tumours, 5.6%. The facial nerve was preserved in 8952, and 80% had normal facial nerve function. 98%' of the tumours were removed in toto. including 17% where the tumour remnant was removed by the suboccipital approach one week after the translabyrinthine operation.
Downloaded by [McMaster University] at 20:54 05 May 2016
Ab.struct.
be removed in toto, but its size was reduced and the facial nerve was freed and marked with Silastic (Montogomery, 1973). One week later, the tumour remnant was removed via the suboccipital approach. RESULTS
After the pioneer work done by House (1964), large series of acoustic neurinomas removed by the translabyrinthine approach have been reported (House, 1968; Clemis, 1971; Montgomery, 1973; Maddox, 1977; Glasscock et al., 1978; Morrison, 1978, and others). A common feature of all these materials is a high percentage of patients with preserved function of the facial nerve, a low mortality, and good postoperative condition. The results of translabyrinthine surgery of acoustic neurinomas in Denmark on 47 patients in the course of the past 24 years are presented here.
Mortality. One patient with a large tumour died one month after the suboccipital operation (Thomsen et al., 1977). After the translabyrinthine operation there were no deaths. The total mortality was 2.1 %; among large tumours, 5.6%. Preservation of facial nerve. Two patients had preoperative facial palsy. In one of them a medium-sized tumour extended right up to the geniculate ganglion, destroying the Fallopian canal in which no nerve fibres could be identified. In the other patient, who had a large tumour, the facial nerve could be freed in the meatus and on a level with the porus acusticus
MATERIAL AND METHODS The material comprises 47 patients with acoustic neurinoma subjected to operation during the past 2 ; years. Mean age was 49 (range 18-73) years, and 12 patients were over 60. According to the classification of House (1968), one patient had a small intrameatal tumour, 28 had medium-sized, and 18 had large tumours. Among the latter the extrameatal part of 15 tumours exceeded 4 cm in diameter. All patients were primarily treated by translabyrinthine operation (House, 1964). In 8 patients with large turnours the tumour could not
Table I. Preservation of the facial nerve and postoperative normul fiinction of the facial nerve in 45 patients with acoustic neuromas
Approach, size Translabyrinthine Small ( I ) Medium (27) Large (9) Translab. + suboccipital Large (7) Total (45)
Preservation
Normal function
n
n
%
%
I 25
1 100 26 96 9 9 0
}77 4
57
40
89
%
;
36
%
100
93
;}s9 80
Downloaded by [McMaster University] at 20:54 05 May 2016
46
M . Tos and J . Thomsen
nerve was seen to be intact at the entrance to the brain stem, but later it got tom at this site. Both examples show that the facial nerve may be injured even after it has been freed. Among patients with large tumours we were able to preserve the facial nerve in 77 7%; within the total series, in 89% (Table 1). A normalfiinction of the facial nerve has so far been achieved in 80% of the patients, and in this respect there is a great difference between the translabyrinthine and the translabyrinthine-suboccipital removal (Table I). Another 5 patients ( 1 1 %) have preserved some function of the facial nerve. Total removal. 46 tumours (98%) were removed in toto, but in 8 (17%) cases this required operation in two stages. The only patient whose tumour has not yet been removed is a 68-year-old man with bronchial asthma and in a poor cardiovascular condition, who Fig. I . EMI-scanning of the biggest acoustic turnour in the had a 5 cm large tumour. We had decided to material, totally removed in two stages. remove this tumour by the translabyrinthine approach and had already removed the greater part when cerebellar oedema restricted the acinternus, but during the suboccipital operation cess to such an extent that it was impossible in could not be followed in its most proximal to get the remainder out. On the next day the course. Indeed, both had postoperative palsy patient’s neurological status was normal and it and are not included in the calculations of seems probable that the oedema was due to facial nerve function which are based upon 45 hypoxia of the cerebellum. Owing to the poor patients. cardiovascular status, suboccipital removal of Among the 38 patients treated exclusively the tumour remnant is hardly indicated, but by translabyrinthine operation, the facial we are following the patient by EM1 scanning. nerve could be preserved in 36 (95%). In 2 Postoperutive liquorrhoea. Six patients cases the nerve was tom by unfortunate ac- (13 96) had postoperative liquorrhoea through cident: in a case of a medium-sized tumour the Eustachian tube lasting for a maximum of the entire facial nerve had been freed, and it 10 days, in one somewhat longer. This patient was intact. Thereafter, part of the nerve, on a had been discharged on the 10th day without level with the porus acusticus, was covered liquorrhoea and was feeling perfectly well. He with surgical putty. After the putty was re- started working in his garden, when the liquormoved, the nerve had been torn. However, rhoea started. After 4 weeks, the liquorrhoea via the translabyrinthine approach it could be fistula in the dura of the posterior cranial fossa sutured with two silk sutures, a procedure was closed by a large graft of fascia lata. The which Drake (1967) considered impossible. In inserted abdominal fat was vital. the case of the other tumour, which was a Cerebellar affection. After the translabyrinlarge one, the nerve was freed in the internal thine operation no patient had cerebellar afmeatus and on a level with the porus. After fection or other cranial nerve palsies, except intracapsular reduction of the tumour the for the eighth. Actci Orolrirvn~olS i r p p l 360
Translabyrinthine surgery of ucoirstic neirrinoma
Downloaded by [McMaster University] at 20:54 05 May 2016
DISCUSSION AND CONCLUSION
By close collaboration with the neurosurgeons, we have succeeded in almost completely centralizing surgery of acoustic neurinoma in Denmark. With a total population of 5.1 million, this is necessary in order to maintain a certain routine. Regardless of the size of the tumour, we commence treatment via the translabyrinthine approach and with increasing experience we are trying in more and more cases to remove even the large tumours by this route. Among the first 13 tumours, four were 3-4 cm in diameter. The remnants were removed by the suboccipital approach, and only one tumour, measuring 2: cm, was removed by the translabyrinthine route. Among the subsequent 26 tumours, we have removed by the translabyrinthine route, in tofo, six tumours measuring 3i-4 cm. Four measuring 41-7 cm (Fig. 1) were removed in two stages. Among the 8 tumours removed most recently, three were 4;-5 cm, and none needed twostage surgery. Thus, our increasing experience has clearly given more courage, so that gradually we are removing tumours up to 5 cm via the translabyrinthine approach. With respect to preserving and obtaining normal facial nerve function, there is a very striking difference between the two operations (Table I). However, it must be admitted that there will still be tumours so large (Fig. 1) that they cannot by any means be removed in toto by the translabyrinthine approach which has its spatial limitations. These results are roughly the same as those published from other clinics (House, 1968, 1978; Clemis, 1971; Glasscock et al., 1978; Morrison, 1978). Among his last 500 tumours operations, House (1978) had a mortality rate of 2.6%, and among 173 large tumours, 7%. The total removal rate was 93.2%, and total facial palsy occurred in 13.5%. Our results should encourage other otosurgeons to start using translabyrinthine surgery in dealing with
47
acoustic neurinomas. Apart from the fact that the results are better than with the suboccipital approach, translabyrinthine surgery in Denmark has afforded a great stimulus to a more active diagnosis, and a considerably larger number of especially medium-sized tumours are being diagnosed today than was the case merely 2 years ago. ZUSAMMENFASSUNG Bei translabyrintharen und translabyrinthar-suboccipitaler Entfernung der 47 Akusticustumoren war die gesamte Letalitat 2.1%, bei 18 grol3en Tumoren 5.6%. Der Fazialis wurde bei 89% der Patienten geschont und 80% hatten normale Funktion. 989%der Tumoren wurden total entfernt, doch wurde bei 17% der Tumorrest durch den suboccipitalen Zugang, eine Woche nach dem translabyrintharen entfernt.
REFERENCES Clemis. J . D. 1971. Microsurgical treatment of acoustic neurinomas (results and complications). Laryngoscope 81. 1191. Drake, C. G. 1967. Surgical treatment of acoustic neuroma with preservation or reconstruction of t h e facial nerve. J Neurosiirg 26, 459. Glasscock, M. E., Hays, J. W . . Miller, G . W., Drake, F. D. & Kanok, M. M. 1978. Preservation of hearing in tumors of the internal auditory canal and cerebellopontine angle. Luryngoscope 88, 43. House, W. F. 1964. Transtemporal bone microsurgical removal of acoustic neuromas. Arch Otolaryngol 80, 599. House, W. F. 1968. Monograph 11. Acoustic neuroma. Arch Otoluryngol88. House, W. F. 1978. Personal communication. Maddox, H. E. 1977. The lateral approach to acoustic tumors. Luryngoscope 87, 1572. Montgomery, W. W. 1973. Surgery for acoustic neuroma. Ann Otol Rhino1 Luryngol82, 428. Morrison, A. W. 1978. Translabyrinthine surgical approach to the internal acoustic meatus. J Roy Soc Med 71. 269. Thomsen, J., Tos, M., Harmsen, A , , Riishede. J. & Thornval, G. 1977. Surgery of acoustic neuromas. Preliminary experience with a translabyrinthine approach. Arta Neiirol Scand 56. 277. M. Tos, M.D. ENT University Clinic Gentofte Hospiiul Copenhagen Denmark
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Translabyrinthine Surgery of Acoustic Neurinoma Mirko Tos & Jens Thomsen To cite this article: Mirko Tos & Jens Thomsen (1978) Translabyrinthine Surgery of Acoustic Neurinoma, Acta Oto-Laryngologica, 86:sup360, 45-47, DOI: 10.3109/00016487809123468 To link to this article: http://dx.doi.org/10.3109/00016487809123468
Published online: 08 Jul 2009.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [McMaster University]
Date: 05 May 2016, At: 20:54
Acta Otolaryngol, Suppl. 360: 45-47, 1979 TRANSLABYRINTHINE SURGERY OF ACOUSTIC NEURINOMA Mirko Tos and Jens Thomsen From tire ENT University Clinics, Gentojte Hospital rind Rigshospitalet, Copenhagen, Denmark
In translabyrinthine and translabyrinthine-suboccipital removal of 47 acoustic tumours, the mortality rate was 2.1 %; among 18 large tumours, 5.6%. The facial nerve was preserved in 8952, and 80% had normal facial nerve function. 98%' of the tumours were removed in toto. including 17% where the tumour remnant was removed by the suboccipital approach one week after the translabyrinthine operation.
Downloaded by [McMaster University] at 20:54 05 May 2016
Ab.struct.
be removed in toto, but its size was reduced and the facial nerve was freed and marked with Silastic (Montogomery, 1973). One week later, the tumour remnant was removed via the suboccipital approach. RESULTS
After the pioneer work done by House (1964), large series of acoustic neurinomas removed by the translabyrinthine approach have been reported (House, 1968; Clemis, 1971; Montgomery, 1973; Maddox, 1977; Glasscock et al., 1978; Morrison, 1978, and others). A common feature of all these materials is a high percentage of patients with preserved function of the facial nerve, a low mortality, and good postoperative condition. The results of translabyrinthine surgery of acoustic neurinomas in Denmark on 47 patients in the course of the past 24 years are presented here.
Mortality. One patient with a large tumour died one month after the suboccipital operation (Thomsen et al., 1977). After the translabyrinthine operation there were no deaths. The total mortality was 2.1 %; among large tumours, 5.6%. Preservation of facial nerve. Two patients had preoperative facial palsy. In one of them a medium-sized tumour extended right up to the geniculate ganglion, destroying the Fallopian canal in which no nerve fibres could be identified. In the other patient, who had a large tumour, the facial nerve could be freed in the meatus and on a level with the porus acusticus
MATERIAL AND METHODS The material comprises 47 patients with acoustic neurinoma subjected to operation during the past 2 ; years. Mean age was 49 (range 18-73) years, and 12 patients were over 60. According to the classification of House (1968), one patient had a small intrameatal tumour, 28 had medium-sized, and 18 had large tumours. Among the latter the extrameatal part of 15 tumours exceeded 4 cm in diameter. All patients were primarily treated by translabyrinthine operation (House, 1964). In 8 patients with large turnours the tumour could not
Table I. Preservation of the facial nerve and postoperative normul fiinction of the facial nerve in 45 patients with acoustic neuromas
Approach, size Translabyrinthine Small ( I ) Medium (27) Large (9) Translab. + suboccipital Large (7) Total (45)
Preservation
Normal function
n
n
%
%
I 25
1 100 26 96 9 9 0
}77 4
57
40
89
%
;
36
%
100
93
;}s9 80
Downloaded by [McMaster University] at 20:54 05 May 2016
46
M . Tos and J . Thomsen
nerve was seen to be intact at the entrance to the brain stem, but later it got tom at this site. Both examples show that the facial nerve may be injured even after it has been freed. Among patients with large tumours we were able to preserve the facial nerve in 77 7%; within the total series, in 89% (Table 1). A normalfiinction of the facial nerve has so far been achieved in 80% of the patients, and in this respect there is a great difference between the translabyrinthine and the translabyrinthine-suboccipital removal (Table I). Another 5 patients ( 1 1 %) have preserved some function of the facial nerve. Total removal. 46 tumours (98%) were removed in toto, but in 8 (17%) cases this required operation in two stages. The only patient whose tumour has not yet been removed is a 68-year-old man with bronchial asthma and in a poor cardiovascular condition, who Fig. I . EMI-scanning of the biggest acoustic turnour in the had a 5 cm large tumour. We had decided to material, totally removed in two stages. remove this tumour by the translabyrinthine approach and had already removed the greater part when cerebellar oedema restricted the acinternus, but during the suboccipital operation cess to such an extent that it was impossible in could not be followed in its most proximal to get the remainder out. On the next day the course. Indeed, both had postoperative palsy patient’s neurological status was normal and it and are not included in the calculations of seems probable that the oedema was due to facial nerve function which are based upon 45 hypoxia of the cerebellum. Owing to the poor patients. cardiovascular status, suboccipital removal of Among the 38 patients treated exclusively the tumour remnant is hardly indicated, but by translabyrinthine operation, the facial we are following the patient by EM1 scanning. nerve could be preserved in 36 (95%). In 2 Postoperutive liquorrhoea. Six patients cases the nerve was tom by unfortunate ac- (13 96) had postoperative liquorrhoea through cident: in a case of a medium-sized tumour the Eustachian tube lasting for a maximum of the entire facial nerve had been freed, and it 10 days, in one somewhat longer. This patient was intact. Thereafter, part of the nerve, on a had been discharged on the 10th day without level with the porus acusticus, was covered liquorrhoea and was feeling perfectly well. He with surgical putty. After the putty was re- started working in his garden, when the liquormoved, the nerve had been torn. However, rhoea started. After 4 weeks, the liquorrhoea via the translabyrinthine approach it could be fistula in the dura of the posterior cranial fossa sutured with two silk sutures, a procedure was closed by a large graft of fascia lata. The which Drake (1967) considered impossible. In inserted abdominal fat was vital. the case of the other tumour, which was a Cerebellar affection. After the translabyrinlarge one, the nerve was freed in the internal thine operation no patient had cerebellar afmeatus and on a level with the porus. After fection or other cranial nerve palsies, except intracapsular reduction of the tumour the for the eighth. Actci Orolrirvn~olS i r p p l 360
Translabyrinthine surgery of ucoirstic neirrinoma
Downloaded by [McMaster University] at 20:54 05 May 2016
DISCUSSION AND CONCLUSION
By close collaboration with the neurosurgeons, we have succeeded in almost completely centralizing surgery of acoustic neurinoma in Denmark. With a total population of 5.1 million, this is necessary in order to maintain a certain routine. Regardless of the size of the tumour, we commence treatment via the translabyrinthine approach and with increasing experience we are trying in more and more cases to remove even the large tumours by this route. Among the first 13 tumours, four were 3-4 cm in diameter. The remnants were removed by the suboccipital approach, and only one tumour, measuring 2: cm, was removed by the translabyrinthine route. Among the subsequent 26 tumours, we have removed by the translabyrinthine route, in tofo, six tumours measuring 3i-4 cm. Four measuring 41-7 cm (Fig. 1) were removed in two stages. Among the 8 tumours removed most recently, three were 4;-5 cm, and none needed twostage surgery. Thus, our increasing experience has clearly given more courage, so that gradually we are removing tumours up to 5 cm via the translabyrinthine approach. With respect to preserving and obtaining normal facial nerve function, there is a very striking difference between the two operations (Table I). However, it must be admitted that there will still be tumours so large (Fig. 1) that they cannot by any means be removed in toto by the translabyrinthine approach which has its spatial limitations. These results are roughly the same as those published from other clinics (House, 1968, 1978; Clemis, 1971; Glasscock et al., 1978; Morrison, 1978). Among his last 500 tumours operations, House (1978) had a mortality rate of 2.6%, and among 173 large tumours, 7%. The total removal rate was 93.2%, and total facial palsy occurred in 13.5%. Our results should encourage other otosurgeons to start using translabyrinthine surgery in dealing with
47
acoustic neurinomas. Apart from the fact that the results are better than with the suboccipital approach, translabyrinthine surgery in Denmark has afforded a great stimulus to a more active diagnosis, and a considerably larger number of especially medium-sized tumours are being diagnosed today than was the case merely 2 years ago. ZUSAMMENFASSUNG Bei translabyrintharen und translabyrinthar-suboccipitaler Entfernung der 47 Akusticustumoren war die gesamte Letalitat 2.1%, bei 18 grol3en Tumoren 5.6%. Der Fazialis wurde bei 89% der Patienten geschont und 80% hatten normale Funktion. 989%der Tumoren wurden total entfernt, doch wurde bei 17% der Tumorrest durch den suboccipitalen Zugang, eine Woche nach dem translabyrintharen entfernt.
REFERENCES Clemis. J . D. 1971. Microsurgical treatment of acoustic neurinomas (results and complications). Laryngoscope 81. 1191. Drake, C. G. 1967. Surgical treatment of acoustic neuroma with preservation or reconstruction of t h e facial nerve. J Neurosiirg 26, 459. Glasscock, M. E., Hays, J. W . . Miller, G . W., Drake, F. D. & Kanok, M. M. 1978. Preservation of hearing in tumors of the internal auditory canal and cerebellopontine angle. Luryngoscope 88, 43. House, W. F. 1964. Transtemporal bone microsurgical removal of acoustic neuromas. Arch Otolaryngol 80, 599. House, W. F. 1968. Monograph 11. Acoustic neuroma. Arch Otoluryngol88. House, W. F. 1978. Personal communication. Maddox, H. E. 1977. The lateral approach to acoustic tumors. Luryngoscope 87, 1572. Montgomery, W. W. 1973. Surgery for acoustic neuroma. Ann Otol Rhino1 Luryngol82, 428. Morrison, A. W. 1978. Translabyrinthine surgical approach to the internal acoustic meatus. J Roy Soc Med 71. 269. Thomsen, J., Tos, M., Harmsen, A , , Riishede. J. & Thornval, G. 1977. Surgery of acoustic neuromas. Preliminary experience with a translabyrinthine approach. Arta Neiirol Scand 56. 277. M. Tos, M.D. ENT University Clinic Gentofte Hospiiul Copenhagen Denmark
