Durability of hearing preservation after microsurgical treatment of vestibular schwannoma using the middle cranial fossa approach

Clinical article

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Object

The middle cranial fossa (MCF) approach is a microsurgical technique described as a primary option in the treatment of small, intracanalicular schwannomas involving the eighth cranial nerve. Excellent rates of complete tumor resection, hearing preservation, preservation of facial nerve function, and low complication rates have been reproduced using this technique. However, the durability of hearing preservation attained using the various treatment options has not been adequately assessed. The purpose of this study was to evaluate the durability of long-term hearing preservation in patients with vestibular schwannoma (VS) treated via the MCF approach. The authors hypothesize that hearing preservation in these patients will prove to be durable years after treatment in a high percentage of cases.

Methods

Retrospective medical chart review was performed in 103 consecutive patients undergoing resection of VS via a modified MCF approach between 1999 and 2008. Patients in whom surgical goals were gross-total resection and hearing preservation were included. Preoperative and postoperative hearing assessment was performed using standard audiometric testing, and classified according to American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) guidelines as a primary outcome measure. Outcomes and neurological complications initially, and at 1, 3, and 5 years following operation were analyzed.

Results

Initial hearing preservation rates were in keeping with the best previously published results. At initial postoperative audiometric follow-up, of the patients presenting with Class A hearing, 67% remained Class A, 17% were Class B, 1% were Class C, and 15% were Class D. Of patients presenting with Class B hearing, 24% were Class A, 53% remained Class B, 6% were Class C, and 18% were Class D. Of patients presenting with Class C hearing, 100% remained Class C.

To assess the durability of hearing preservation in our patients, the authors evaluated hearing function at regular intervals after the initial postoperative audiometric follow-up. Audiometric data were available for 56 patients at 5-year follow-up. Of the 20 patients with Class A hearing at initial postoperative follow-up with 5-year follow-up, 13 (65%) remained Class A, 6 (30%) were Class B, and 1 (5%) was Class C. Of the 12 patients with Class B hearing at initial postoperative follow-up with 5-year follow-up, 4 (33%) were Class A, 4 (33%) remained Class B, and 4 (33%) were Class C. Of the 3 patients with Class C hearing at initial postoperative follow-up with 5-year follow-up, all 3 (100%) remained Class C.

Conclusions

A majority of patients with preserved hearing following the MCF approach for treatment of VS experience durability of their preserved hearing at 5-year follow-up. The initial AAO-HNS classification was preserved in 13 (65%) of the 20 patients who had Class A hearing at 5 years, and in 8 (67%) of the 12 who had Class B hearing at 5 years. Overall, a decline in AAO-HNS classification was noted in 15% of patients with preserved Class A hearing, and in 33% of those with preserved Class B hearing. Facial nerve function was preserved in 91% of cases. Superior hearing preservation as well as good outcomes in facial nerve function and few serious complications can be accomplished using the MCF approach for resection of small VSs.

Abbreviations used in this paper:AAO-HNS = American Academy of Otolaryngology–Head and Neck Surgery; ABR = auditory brainstem response; CPA = cerebellopontine angle; HB = House-Brackmann; IAC = internal auditory canal; MCF = middle cranial fossa; PTA = pure-tone average; RST = retrosigmoid-transmeatal; SRS = stereotactic radiosurgery; VS = vestibular schwannoma; WRS = word recognition score.

Article Information

Address correspondence to: B. Gregory Thompson, M.D., Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Room 3552 Taubman Center, Ann Arbor, Michigan 48109-5338. email: gregthom@umich.edu.

Please include this information when citing this paper: published online February 15, 2013; DOI: 10.3171/2013.1.JNS1297.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    The AAO-HNS criteria grade hearing function based on PTA and WRS. Scatterplots depict audiometry results at (upper left) preoperative, (upper right) 1-year initial postoperative, and (lower) 5-year postoperative assessments. HL = hearing level.

  • View in gallery

    Kaplan-Meier survival curve depicting percentage of patients maintaining WRS > 70% over time. Some debate exists as to whether the utility of hearing preservation should be measured purely by speech discrimination. For this analysis, WRS ≤ 70% at most recent audiometric assessment was considered to represent loss of hearing.

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