Surgery for Vestibular Schwannomas (Acoustic Neuromas)
Microsurgical excision of vestibular schwannomas remains the ideal treatment option for medium to large vestibular schwannomas. It is also an option for selected cases of smaller tumours when hearing preservation can be realistically achieved. Many tumours can be safely observed if small and not growing, with radiotherapy considered for the smaller growing tumours in older patients, or in those patients where surgery is high risk.
There are three surgical approaches used to access these tumours each of which have advantages and disadvantages. The general principle of all these ‘skull base’ approaches is to minimise brain retraction by removing bone to gain a wide exposure of the tumour and surrounding neural structures.
The most common approach used by the St Vincent’s Otology and Skull Base unit is the translabyrinthine approach as it affords the best exposure and preservation of the facial nerve, with the lowest rates of post-opeartive CSF leak and headache. The middle cranial fossa approach is reserved for those smaller tumours where hearing preservation is an option and the retrosigmoid approach used when there is a medium sized predominantly central vestibular schwannoma, or in rare cases where there is significant inferior or medial extension.