Acta Otorrinolaringol Esp.

2016;67(4):201---211

www.elsevier.es/otorrino

ORIGINAL ARTICLE

Surgical Treatment of Vestibular Schwannoma. Review

of 420 Cases夽
Miguel Ángel Arístegui Ruiz,a Ricardo José González-Orús Álvarez-Morujo,a,∗
Carlos Martín Oviedo,a Fernando Ruiz-Juretschke,b Roberto García Leal,b
Bartolomé Scola Yurritaa

a
Servicio de ORL, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b
Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, Spain

Received 27 April 2015; accepted 1 September 2015

KEYWORDS Abstract
Vestibular Introduction and objectives: Vestibular schwannoma is the most frequent cerebellopontine
schwannoma; angle tumour. The aim of our study is to reflect our experience in the surgical treatment of
Acoustic neuroma; this tumour.
Surgical treatment; Material and methods: Retrospective study of 420 vestibular schwannomas operated in our
Facial nerve; hospital between 1994 and 2014. We include tumour size, preoperative hearing, surgical
Complications approaches, definitive facial and hearing functional results, and complications due to surgery.
Results: A total of 417 patients with 420 tumours were analysed, 209 female (50.1%) and 208
male (49.9%). Mean age at diagnosis was 49.8±13.2 years. The majority of the tumours were
resected through a translabyrinthine approach (80.2%). Total tumour removal was achieved in
411 tumours (98.3%), and anatomic preservation of facial nerve in 404 (96.2%). Definitive facial
nerve outcome was House---Brackmann grade I and II in 69.9%, and was significantly better in
tumours under 20 mm. Surgical complications included cerebrospinal fluid leakage in 3 patients
(0.7%) and retroauricular subcutaneous collection in 16 (3.8%), 5 cases of meningitis (1.2%),
4 patients with intracraneal bleeding (0.9%), and death in 3 patients (0.7%).
Conclusions: Surgery is the treatment of choice for vestibular schwannoma in the majority of
patients. In our experience, the complication rate is very low and tumour size is the main factor
influencing postoperative facial nerve function.
© 2015 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringologı́a y Cirugı́a de
Cabeza y Cuello. All rights reserved.

夽
Please cite this article as: Arístegui Ruiz MÁ, González-Orús Álvarez-Morujo RJ, Martín Oviedo C, Ruiz-Juretschke F, García Leal R, Scola
Yurrita B. Tratamiento quirúrgico del schwannoma vestibular. Revisión de 420 casos. Acta Otorrinolaringol Esp. 2016;67:201---211.
∗ Corresponding author.

E-mail address: ricardomorujo@hotmail.com (R.J. González-Orús Álvarez-Morujo).

2173-5735/© 2015 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. All rights reserved.
202 M.Á. Arístegui Ruiz et al.

PALABRAS CLAVE Tratamiento quirúrgico del schwannoma vestibular. Revisión de 420 casos
Schwannoma
vestibular; Resumen
Neurinoma del Introducción y objetivos: El schwannoma vestibular es el tumour más frecuente en el ángulo
acústico; ponto-cerebeloso. El objetivo de nuestro estudio es reflejar nuestra experiencia en el
Tratamiento tratamiento quirúrgico de este tumour.
quirúrgico; Material y métodos: Estudio retrospectivo de 420 schwannomas vestibulares intervenidos en
Nervio facial; nuestro centro entre 1994-2014. Se incluyen el tamaño tumoral, la audición preoperatoria, los
Complicaciones abordajes quirúrgicos utilizados, el resultado definitivo de la función facial y auditiva y las
complicaciones derivadas de la cirugía.
Resultados: Un total de 417 pacientes con 420 tumores fueron analizados, siendo 209 mujeres
(50,1%) y 208 varones (49,9%). La edad media fue de 49,8±13,2 años. La mayoría de los tumores
se resecaron mediante abordaje translaberíntico (80,2%). La resección tumoral completa tuvo
lugar en 411 tumores (98,3%), y la conservación de la integridad anatómica del nervio facial en
404 (96,2%). El resultado definitivo del facial fue grado i y ii de House-Brackmann en el 69,9%,
siendo significativamente mejor en los tumores de menos de 20 mm. Entre las complicaciones
se incluyen 3 casos de fístula (0,7%) y 16 acúmulos retroauriculares de líquido cefalorraquídeo
(3,8%), 5 de meningitis (1,2%), 4 sangrados intracraneales (0,9%) y exitus en 3 pacientes (0,7%).
Conclusiones: El tratamiento quirúrgico del schwannoma vestibular sigue siendo el de elección
en la mayoría de los casos. En nuestra experiencia, la tasa de complicaciones es baja, siendo
el tamaño tumoral el principal factor influyente en la función facial postoperatoria.
© 2015 Elsevier España, S.L.U. y Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza
y Cuello. Todos los derechos reservados.

Introduction obtained and determine the factors associated with poor

Vestibular schwannoma (VS), often called acoustic neuroma,
is the most common cerebellopontineangle (CPA) tumour,
representing up to 75% of skull base tumours.1 There are
several different management approaches to this type of
tumour, including radiotherapy, observation and periodic
control of the tumours, and of course surgery. Since these
tumours are slow growing and of indolent course they may
be periodically monitored with wait and scan nuclear mag-
netic resonance (NMR) imaging and with assessment of
growth. This option may be suitable under certain circum-
stances, such as patients of advanced age, in poor general
health, with small tumours, few symptoms or with relatively
well preserved hearing.2 However, when these tumours are
larger, they may seriously compromise the patient’s life, or
be the cause of major neurological sequelae. Surgical treat-
ment therefore continues to be the treatment of choice
in those tumours where maximum diameter is over 20 mm,
the tumour seriously compresses the brain stem or causes
vestibular symptoms which affect the patient’s well being.
Since VS surgery began at the end of the 19th Century,
when there were countless obstacles and tragic events,
with a mortality rate reaching 80%,3 results have been
increasingly better due to the refinement of surgical tech-
niques, the improvement of anaesthetics, the monitoring
of cranial nerves, and naturally the accumulated experi-
ence of surgeons. The goal of surgery is to successfully
remove the tumour completely, with the possible anatom-
ical preservation of the facial nerve and in several cases,
hearing.
The aim of this study is to reflect our experience in the
surgical treatment of VS, analyse the functional outcome
postoperative facial function and potential complications of
surgery.
Material and Methods
We conducted a retrospective study of VS diagnosed or
referred to our hospital between January 1994 and Septem-
ber 2014. Out of a total of 516 tumours, we decided to
periodically monitor 96 of them (18.6%), whilst the majority,
420 (81.4%), opted for surgical treatment.
Initial NMRI and CT bony labyrinth imaging studies were
performed. Follow-up after surgery was carried out after
one month, 6 months, 12 months and then once a year.
Surgical Approaches
Once the patient had been informed about the different
treatment possibilities and the decision to have surgery had
been taken, the factors analysed for deciding which surgi-
cal approach to take were as follows: tumour size, spread
of the tumour in the internal auditory (IAC), radiological
anatomy, preoperative hearing level in both ears and per-
sonal preference of surgeon. Table 1 shows our therapeutic
formula.
Our preference in the majority of cases was for a wide
translabyrinthine approach (WTLB). This is an extensive
approach which does not require cerebral or cerebellar
compression and offers full control of the CPA with fairly
constant anatomical references, with exposure of the length
of the IAC, and better control of the facial nerve. We always
use this approach when the tumour larger than 1.5 cm EC,
Surgical treatment of vestibular schwannoma 203

Table 1 Therapeutic Formula Used for Decision-making in VS Surgical Treatment (This Is not a Closed Formula and on Occasions
We Have Expanded the Established Limits).

Extracranial size End of IAC Hearing (dB/%) Age (years) Approach

<0.5 cm --- >30/70 <60 EMCF
<1.5 cm Free >30/70 <70 RS/RLBA
>1.5 cm --- --- --- WTLB
--- --- <30/70 --- WTLB
--- --- --- >70 WTLB
IAC: internal auditory canal; EMCF: extended middle cranial fossa; RS: retrosigmoid; RLBA: retrolabyrinthine; WTLB: wide
translabyrinthine approach.

hearing is not functional (<30 dB 70% SDS), or the patient is
over 70. The technical modification which we call modified
translabyrinthine approach (TLBM) includes the closure of
the CAE at a blind end point, the drilling of the back wall,
removal of the middle ear, the sealing of the Eustachian tube
with mucoperiosteum and obliteration with autologous fat
transfer; this approach is indicated in cases where approach
will be narrow, the tumour will be large or a combination of
the two.
In tumours under 1.5 cm EC, which do not penetrate to
the end of the IAC, where hearing is functional and the
patient is under 70, a retrolabyrinthine (RLB), or retrosig-
noid (RS) approach may be used, depending on the anatomy.
In our opinion the RLB approach is a great unknown, and
enables direct access to the CPA, with the result that when
the anatomy is favourable there is a possibility of hearing
preservation, with the added advantage of being a versa-
tile approach which can be transformed into TLB relatively
quickly. With the transmeatal RS approach the possibility of
retaining hearing is present and it provides a panoramic view
of the CPA, although it is an approach which forces the sur-
geon to work at a greater distance and there is no control
of the lateral end of the IAC. It is still a valid approach and
used by many surgeons. Our experience is limited and we
have used it for large tumours which did not fit in with the
decision-making template.
With the middle cranial fossa approach (MFC) tumours
which involve the end of the canal can be reached and hear-
ing can be preserved. We use this approach in patients who
are always under 60, where the dura mater has not deterio-
rated, hearing is functional, and where the extracanalicular
component does not exceed 5 mm. This approach with its
indubitable advantages does however, only offer a very con-
stricted space and demands an exhaustive knowledge of
anatomy.
Finally, on some occasions we have used combined WTLB-
RS approach, which in the opinion of several authors may be
performed sequentially twice to resection giant tumours4 ;
we have used it to improve access to the most posterior and
inferior site areas.
Tumour Size
tumour is purely intracanalicular; Stage I from 1 to 10 mm;
Stage II from 11 to 20 mm; Stage III from 21 to 30 mm; Stage
IV from 31 to 40 mm; and Stage V over 40 mm EC.
Tumour Resection
Resection is divided into total, subtotal and partial. Total
resection is when the whole tumour component is resec-
tioned, with no remaining residual. Subtotal resection is
when a minimal residual remains, because the tumour is
closely attached to the facial nerve or there is no adequate
cleavage plane. It is left so as not to compromise the nerve
function. Finally, partial resection is when surgery leaves a
significant amount of residue due to changes in the patient’s
vital signs, heavy bleeding or compromise of critical struc-
tures.
Facial Function
We used the House---Brackmann (HB) scale to assess the facial
function prior to surgery and postoperatively.6 (Table 2). We
considered that facial function was good at Stages I and II,
acceptable at Stage III, poor at Stage IV and bad at Stages V
and VI.
Hearing Function
To determine useful or potentially useful hearing function
we used the modified Sanna classification, considering useful
hearing to be classes A and B (<30 dB and >70% SDS) (Table 3).
Cerebrospinal Fluid Leakage
It was considered that a patient had cerebrospinal fluid leak-
age (CFL) when there was a leakage of transparent liquid
through the nose (runny nose), ear (ear discharge) or from an
incision (cutaneous). In addition, we also included patients
where CFL collections were subcutaneous.

To determine tumour size we used the classification agreed Statistical Analysis

upon some years ago,5 which divides the tumours into
6 groups according to the maximum extracanalicular (EC) Statistical analysis was made using the Chi-square test, with
diameter measured in the axial section of the NMR: Stage 0 values of P<.5 as a statistically significant level.
204 M.Á. Arístegui Ruiz et al.

Table 2 House---Brackmann Classification.

I Normal facial nerve
II Mild dysfunction Notable superficial weakness at close inspection
Normal tone and symmetry when resting
Forehead movement with good to moderate function
Complete closer of the eye with minimum effort
Minimal asymmetry of mouth with movement
III Mild to moderate Obvious paralysis but not disfiguring, asymmetry at rest and with activity
dysfunction Existence of synkinesis and/or increase in facial muscle tone
Movement of forehead moderate to slight
Complete closure of eye with effort
Slight weakness of mouth with maximum effort
IV Moderate to severe Obvious weakness and/or disfiguring symmetry
dysfunction Asymmetry at rest
No movement of forehead
Incomplete eye closure
Asymmetry of mouth with effort
V Severe dysfunction Hardly perceptible movement
Asymmetry at rest
Incomplete eye closure
Only slight mouth movement
VI Total paralysis No movement

Results Tumour Size

A total of 417 patients were assessed. Of these 209 (50.1%) Table 4 show the distribution of the tumours in accordance
were women and 208 men (49.9%). The mean age at diagno- to the extracanalicular size in 6 Stages.
sis was 49.8±13.2 years, with a range of between 12 and 80.
Ten patients presented with type II neurofibromatosis (NF2) Surgical Approaches Used
(2.38%). The total number of resectioned tumours was 420
(in 3 patients with NF2 we decided on a sequential surgi-
The most frequently used surgical approach was the wide
cal treatment of both tumours), with 217 patients left side
translabyrinthine (WTLB) in 61.9% of cases, followed by the
(51.6%) and 203 right side (48.3%).
modified translabyrinthine (MTLB), in 18.3%.
Preliminary clinical symptoms were: hypoacusia (79.8%),
The surgical approaches used are shown in Table 5.
tinnitus (54%), instability (33.5%), vertigo (13%), sudden
deafness (10.1%) and changes in the trigeminal nerve (4.8%).
Preoperative facial function was Stage I HB in 96.4% of Tumour Control
patients; Stage II HB in 1.4%; Stage III in 0.7%; Stage IV in
0.2%; Stage V in 0.2%; and Stage VI in 0.4%. Preoperative hear- Total tumour resection was performed in 411 patients
ing was normal in 15% of patients; between 20 and 40 dB in (98.3%). A subtotal resection was performed in 3 patients
12.6%, between 40 and 60 dB in 26.2%, between 60 and 80 dB (0.7%) and a partial resection in 4 (0.9%).
in 24.8%, 80 and 100 dB in 11.8% and 9.9% of patients were
deaf. 27.6% of patients had potentially functional hearing. Postoperative Facial Function
However, a surgical approach with the possibility of preser-
ving hearing was not used in all of them due to advanced
Full anatomical preservation of the facial nerve was
age, large sized tumours or the presence of both factors.
achieved in 404 patients (96.2%). In 16 patients the nerve

Table 4 Distribution of Tumours According to Extracanalic-

Table 3 Modified Sanna Classification. ular Size (EC).

Class PTA, dB SDS % Stage No. %

A 0---20 100---80 Stage 0 (intracanalicular) 49 11.6
B 21---30 79---70 Stage I (1---10 mm EC) 69 16.4
C 31---40 69---60 Stage II (11---20 mm EC) 122 29
D 41---60 59---50 Stage III (21---30 mm EC) 121 28.8
E 61---80 49---40 Stage IV (31---40 mm EC) 39 9.3
F >81 39---0 Stage V (>40 mm EC, giant) 20 4.7
Surgical treatment of vestibular schwannoma 205

Table 5 Surgical Approaches Used in the Treatment of Ves- Table 7 Factors Relating to Poor Definitive Facial Prognosis
ticular Schwannoma. (Stages V and VI HB).
Approach No. % Factor No. % P (2 )
Wide translabyrinthine approach (WTLB) 260 61.9 Gender
Modified translabyrinthine 77 18.3 Male (n=200) 23 11.5 P=.722
Retrolabyrinthine 30 7.1 Female (n=202) 21 10.4
Middle cranial fossa 30 7.1
Side
Transmeatal Retrosigmoid (RS) 17 4
Left (n=209) 28 13.4 P=.101
Transotic 3 0.7
Right (n=193) 16 8.3
Combined WTLB-RS 2 0.5
Transcochlear 1 0.2 Age
<65 (n=339) 36 10.6 P=.627
>65 (n=63) 8 12.7
was sectioned during surgery (3.81%). When the nerve could Size
not be preserved all the tumours were larger than 20 mm <2 cm EC (n=233) 3 1.28 P=.0001
EC or had undergone radiosurgery previously. These patients >2 cm EC (n=169) 41 24.3
were given a nerve graft to restore integrity in 9 cases, 6
with the great auricular nerve and 3 with the sural nerve. NF 2
In another 6 cases reinnervation after deferred xii-vii anas- NF 2 (n=12) 2 16.6 P=.519
tomosis was performed; one of these patients died after No NF 2 (n=390) 42 10.8
surgery. Previous surgery
Table 6 shows the postoperative facial function in the Operated (n=7) 2 28.6% P=.531
402 tumours which were operated on, with the definitive Not operated (n=395) 42 10.6%
outcome. Table 7 shows the different variables associated
with a poor result (Stages V and VI) of the postoperative Previous radiosurgery
facial function. No differences were found regarding gen- Radiotherapy (n=4) 2 50% P=.011
der, side or age. In tumours under 20 mm EC only 1.28% had No radiotherapy (n=398) 42 10.5%
a poor outcome of postoperative facial function (Stages V
and VI), whilst in those larger than 20 mm EC this rose to
24.2% (P=.0001). Table 8 shows the outcome of the defini- were 28.3%, with the best approach being MCF with regard
tive facial function in accordance with tumour size. Stage to RLB and RS. Transmeatal RS was used in 17 cases and hear-
V and VI results were more frequent in tumours over 30 mm ing was not preserved in any case, although in several the
(24.3%), and especially in those above 40 mm EC, which were tumour was large and this approach was not used with the
considered giant (66.6%). Table 9 shows the definitive out- primary goal of hearing preservation.
come of facial function in tumours under 20 mm depending
on the different surgical approaches. Cerebrospinal Fluid Leakage and Meningitis

Hearing Preservation
Table 10 shows the outcome obtained using MCF and
RLB surgical approaches which potentially enable hearing
preservation. Overall results of useful hearing preserved
Three patients presented with CFL (0.7%), 2 with nose dis-
charge (0.47%) and the other with incisional leakage (0.23%).
2 of these patients received secondary surgery (0.47%). In
addition there were 16 cases of retroauricular subcutaneous
collection of CFL (3.8%). This was mainly resolved using

Table 6 Definitive Outcome of the Facial Function (n=402).

House---Brackmann staging No.=402 %

I Normal 235 58.4 Good
n=281
69.9%
II Slight dysfunction 46 11.4
III Slight to moderate dysfunction 69 17.2 Acceptable
17.2%
IV Moderate to severe dysfunction 8 1.9 Poor
1.9%
V Severe dysfunction 5 1.2 Bad
n=44
10.9%
VI Total paralysis 39 9.7
206 M.Á. Arístegui Ruiz et al.

Table 8 Results of the Postoperative Facial Function According to Tumour Size (n=402).

No.=402 IC No.=49 <1 cm EC No.=68 1---2 cm EC No.=116 2---3 cm EC No.=114 3---4 cm EC No.=37 >4 cm EC No.=18
I 35 (71.4%) 56 (82.35%) 77 (66.37%) 54 (47.36) 11 (29.72%) 4 (22.22%)
II 6 (12.24%) 6 (8.82%) 12 (10.34%) 16 (14.03%) 4 (10.81%) 1 (5.55%)
III 7 (14.28%) 3 (4.41%) 24 (20.68%) 22 (19.29%) 11 (29.72%) 1 (5.55%)
IV 1 (2.04%) 1 (1.47%) 1 (0.86%) 2 (1.75%) 2 (5.41%) 0
V 0 0 0 3 (2.63%) 0 2 (11.11%)
VI 0 2 (2.94%) 2 (1.72%) 17 (14.91%) 9 (24.32%) 10 (55.55%)

Table 9 Results of Postoperative Facial Function in Extracanicular Tumours Under 20 mm, Depending on Surgical Approach
Used.
Stage WTLB No.=162 RLB No.=28 MCF No.=29 RS No.=12
I 115 (70.98%) 24 (85.71%) 19 (65.51%) 8 (66.66%)
II 17 (10.49%) 2 (7.14%) 4 (13.79%) 1 (8.33%)
III 25 (15.43%) 2 (7.14%) 4 (13.79%) 3 (25%)
IV 1 (0.61%) 0 2 (6.89%) 0
V 0 0 0 0
VI 4 (2.47%) 0 0 0
MCF: middle cranial fossa; RLB: retrolabyrinthine; RS: retrosigmoid; WTLB: wide translabyrinthine.

Table 10 Results of Hearing Preservation With Approaches Where This Was Possible (n=60).

Functional classa MCF No.=30 RLB No.=30 Overall No.=60

Complete (A, B) 13 (43.3%) 4 (13.3%) 17 (28.3%)
Partial (C, D) 7 (23.3%) 7 (23.3%) 14 (23.3%)
No preservation (E, F) 10 (33.3%) 19 (63.3%) 29 (48.3%)
MCF: middle cranial fossa; RLB: retrolabyrinthine.
a Modified Sanna classification.

conservative methods (rest, compression bandage) and on
occasion lumbar draining.
Five cases of meningitis (1.2%) were reported. In 2 of
them there was CFL (one cumulus and one fistula).
Postoperative Complications
Table 11 outlines the postoperative complications in the
420 tumours operated on. The most frequent cause of surgi-
cal review was haematoma or abdominal bleeding from the
site where the autologous fat was taken to sealing purposes.
This occurred in 4 patients.
In our series we recorded 4 cases of intracranial bleeding
(0.9%). Of these, 2 patients had massive haemorrhages in the
CPA (0.4%) and died immediately after the operation. The
other 2 patients presented haematomas (one subdural and
the other extradural) which required immediately surgical
draining. Both evolved favourably and there were no neu-
rological sequelae. 2 patients (0.4%) developed immediate
postoperative pneumoencephalus tension with neurologi-
cal repercussions and trepanation had to be performed.
One patient who presented with cerebellous haematoma
postoperatively caught pneumonia in the ICU and required
temporary tracheotomy.
Other complications such as ataxia, dysarthria, or tran-
sitory ischaemic events occurred in a low percentage of
cases, under 0.5%. The cases of postoperative aphasia (0.4%)
were transitory, and only one patient had a dysarthria which
required complementary speech therapy. 6 patients pre-
sented with postoperative cranial nerve VI paralysis which
was apparent through diplopia (1.43%), all of whom com-
pletely recovered in time. 5 patients had affected lower
cranial nerves (1.1%), related to the large size tumour resec-
tions.
Finally, 3 patients died (0.71%): 2 due to massive haem-
orrhaging in the CPA and the other from massive haematoma
of the cerebellum and cerebral peduncles.
Discussion
Since the beginnings of VS surgery during the last century,
there have been major advances in diagnostic and microsur-
gical techniques over the last few decades, to the extent
that this surgical intervention may currently be performed
with minimum morbidity and mortality. Nowadays, thanks
to the early detection of VS from systematic request for an
NMR for hearing and/or tinnitus asymmetry, the number of
tumours detected each year has increased, simultaneously
with the mean tumour size steadily decreasing. Surgical
Surgical treatment of vestibular schwannoma 207

Table 11 Postoperative Complications (n=420).

Complication No.=420 % Comments

Subcutaneous accumulation 16 3.8 Conservative management
CFL 3 0.7 Nose discharge: 2; ear
discharge: 0; incisional: 1;
re-intervention: 2
Abdominal haematoma 8 1.90 Surgical review: 4
Wound infection 8 1.90 Fistulae: 2; surgical review: 1
Meningitis 5 1.19 CFL: 2
Pneumoencephalic tension 2 0.48 Emergency trephination: 2
CPA haemorrhage 3 0.71 Death: 2 (ventricular
haemorrhaging)
Cerebellar haematoma 2 0.48
Subdural haematoma 1 0.24 Surgical draining
Extradural haematoma 1 0.24 Surgical draining
Cerebellum infarction 1 0.24 Tracheotomy by prolonged OTI
due to pneumonia
Temporary aphasia 2 0.48
Ataxia 2 0.48
Dysarthria 1 0.24 Required speech therapy
Ischaemic attack 1 0.24
Cranial VI nerve 6 1.43 All cases were temporary
deficit
Low cranial nerve pathways 5 1.19
Neuralgia of the v nerve 2 0.48
Salt loss syndrome 2 0.48
Death 3 0.71
CPA: cerebellopontine angle ll; OTI: orotracheal intubation; CSF: cerebrospinal fluid.

treatment continues to be the treatment of choice for large
tumours. However, there is major controversy regarding
tumour management for medium and small sized tumours.
The options for small tumours include microsurgery, radio-
therapy and observation. There is an increasing tendency
for periodical monitoring to be used for small sized tumours,
particularly in patients of advanced age or in poor general
health, or when the tumour does not present many symp-
toms or hearing is normal. When these circumstances are
present we prefer to observe the tumours, which is what we
have been doing in 18.6% of our patients. This strategy is
being increasingly adopted in the majority of hospitals. In
a recent review of 8330 patients diagnosed with VS in USA
between 2004 and 2011 it was observed that 48% of tumours
were operated on, 29% were periodically reviewed and 24%
received radiotherapy.7
Tables 12 and 13 show the surgical outcome of the large
series published in the literature.
Tumour Control
Total resection of the tumour was performed in the great
majority of patients, and only incompletely in 7 patients
(1.7%), showing similar results to those of other series.
In Table 12 we may observe how in similar studies total
resection ranges between 91% and 99%. The main limiting
factors which explain why a total resection is not performed
are the absence of a clear cleavage plane and attachment
of the tumour to critical neurovascular structures.8,9 In
several cases, due to the unfavourable conditions, it was
not possible to perform a complete resection in a single
operation and we therefore programmed a second opera-
tion to complete resection. In general, we prefer to perform
total resection on younger patients to prevent the possibil-
ity of residual tumour regrowth. In older patients with a
shorter life expectancy, and therefore lower risk of recur-
rence, if we foresee that total resection may cause sequelae
and reduce the patient’s quality of life, we may decide on
partial resection.
Facial Function
Postoperative facial function is one of the main priorities of
VS surgery. Damage to the facial nerve may lead to per-
manent cosmetic defects which deteriorate the patient’s
quality of life and additional procedures may often be
required to improve the aesthetic damage.
Intraoperative facial monitoring together with the per-
fecting of microsurgical techniques, enables the nerve to
be preserved in the majority of patients.10 In our series
anatomic preservation took place in over 95% of cases,
a similar result to that recorded in other similar stud-
ies (Table 12). Experienced surgeons usually achieve facial
nerve preservation in 90% of cases. Despite this, nearly 11%
of our patients presented with a poor outcome of definitive
facial function (Stages V and VI HB). This means that, in some
cases, despite preserving the facial nerve, the patient may
 208
Table 12 Results of Postoperative Facial Function in the Large VS Surgery Series.
Author Total cases TLB cases Total resection Anatomic HB I HB II HB III HB IV HB V HB VI
preservation
Glassock et al. (1986) 616 (568 SV) 436 610 (99.02%) 373 (85.55%) --- --- --- --- --- ---
Thomsen et al. (1991) 504 504 495 (98.2%) 488 (96.82%) 284 (57.48%) 60 (12.14%) 40 (8.09%) 26 (5.26%) 27 (5.47%) 57 (11.53%)
Samii y Matthies (1997) 1000 Only RS 979 (97.9%) 929 (93.93%) 470 (50.59%) 120 (12.91%) 140 (15.06%) 60 (6.45%) 100 (10.76%) 39 (4.19%)
Wiet et al. (2001) 500 370 --- --- 162 (62.79%) 40 (8.86%) 47 (10.42%) 15 (3.32%) 10 (2.21%) 33 (7.31%)
Darrouzet et al. (2004) 400 229 390 (97.5%) 384 (96%) 283 (70.75%) 97 (24.25%) 20 (5%)
Brackman et al. (2007) 512 512 484 (94.53%) 500 (97.65%) 265 (67.6%) 52 (13.26%) 32 (8.16%) 28 (7.14%) 3 (0.76%) 12 (3.06%)
Sanna et al. (2012) 1865 1865 1722 (92.33%) 1661 (95.35%) 852 (48.90%) 191 (10.56%) 508 (29.16%) 75 (4.30%) 24 (1.37%) 92 (5.28%)
Present study 420 324 411 (98.3%) 404 (96.19%) 235a (58.4%) 46a (11.4%) 69a (17.2%) 8a (1.9%) 5a (1.2%) 44a (10.9%)
a The results of patients are included for whom we have a definitive outcome of facial function.

Table 13 Complications of the Large VS Surgery Series.

Author Total cases CFL (%) Meningitis (%) Intracranial Other cranial Ischaemic Ataxia (%) Death
bleeding (%) nerve pathways stroke (%)
(%)
Glassock et al. (1986) 616 (568 VS) 49 (11.23) 33 (5.35) 4 (0.64) 20 (3.24) 2 (0.32) --- 4 (0.64)
Thomsen et al. (1991) 504 45 (8.92) 15 (2.97) 7 (1.38) 9 (1.78) --- 20 (3.96) 9 (1.78)
Samii and Matthies (1997) 1000 92 (9.2) 30 (3) 22 (2.2) 55 (5.5) 7 (0.70) 350 (35) 11 (1.1)
Slattery et al. (2001) 1687 159 (9.42) 25 (2.04) 15 (1.22) --- 4 (0.32) --- 2 (0.16)

M.Á. Arístegui Ruiz et al.

Darrouzet et al. (2004) 400 52 (13) 18 (7.86) 2 (0.87) 15 (3.75) 4 (1.74) 2 (0.50)
Brackman et al. (2007) 512 28 (5.5) 3 (0.6) 7 (1.36) --- 5 (0.97) --- 0
Sanna et al. (2012) 1865 16 (0.85) 2 (0.10) 15 (0.80) 18 (0.96) 1 (0.05) 13 (0.69) 2 (0.10)
Present study 420 3 (0.7) 5 (1.19) 4 (0.95) 9 (2.1) 1 (0.23) 1 (0.23) 3 (0.71)
Surgical treatment of vestibular schwannoma
present over time with severe facial dysfunction or total
paralysis.
As may be expected, the results were worse for large
tumours compared with those which were smaller, similarly
to reports by other authors.6,8,11---13 In general, tumours under
20 mm EC with Stage V and VI HB outcome were present in
a low percentage of patients, whilst this increased notably
when the tumour was above this size. Despite the fact that
in tumours over 30 mm EC the facial nerve was fully pre-
served in 90.1% of cases, definitive facial function was highly
affected. In these large schwannomas the attachment of the
tumour to the facial nerve means that during surgery there is
greater manipulation. Dissection of the facial nerve tumour
capsule produces a contusive effect and may disrupt micro-
circulation of the nerve, which would explain the loss of
postoperative function. For this reason, the main factor in
function preservation of the nerve is tumour attachment,
large sized tumours and cystic neurinomas.14,15 Further-
more, we observed that in tumours under 20 mm EC poor
facial nerve outcome was low, regardless of the surgical
approach used, whether it was WTLB or any of the other
approaches indicated in each case (Table 9).
In patients with NF 2 tumours were usually closely
attached to the facial nerve and outcomes were conse-
quently slightly poorer. However, in tumours which had
been operated on previously with incomplete resection,
and above all those previously referred for radiosurgery,
definitive outcome was drastically poorer (Table 7). The
difficulties a surgeon may have in operating on a tumour
which has previously been treated with radiotherapy and
with no growth control must therefore be considered, as this
generally negatively affects the outcome relating to facial
function.16,17
Hearing Preservation
With regards to hearing preservation with those surgical
approaches where this is possible, discussion in the litera-
ture is highly controversial. Hearing preservation rates may
range between 13% and 82%, and there is disagreement with
regards to what constitutes useful hearing. Table 14 includes
the outcome from useful hearing published by different
authors. Samii et al.18 published a retrospective analysis of
200 patients with preservation of anatomic integrity of the
cochlear nerve at 75.8% of cases, with preservation of useful
hearing of 60% in small tumours, and 43% in tumours which
compress the brain stem. For Sanna et al.19 the potential
hearing range differed significantly according to the clas-
sification used. In one retrospective study of 90 patients
who underwent MCF surgery and 86 RS, where the Sanna
modified classification was used to quantify the outcomes.
Rabelo de Freitas et al.20 published useful hearing rates of
18.9% and 10.6%, in the MCF and RS approaches, respec-
tively. Hearing preservation rates in the literature are not
infrequently expressed according to different classifications
and so too does the criteria of useful or functional hearing
vary according to different authors. Among the prognostic
factors quoted are usually tumour size, penetration to the
end of the IAC or surgical approach used. In this sense, it is
very infrequent to preserve hearing in tumours over 15 mm
EC and those which have spread to the end of the IAC.
209
Moreover, preservation of the cochlear nerve does not con-
stitute hearing preservation since the tumour of the internal
auditory artery may lead to deafness.21
We consider useful hearing to be classes A and B of
the Sanna modified classification (Table 3). We had global
results of preserved useful hearing of 28.3%, the best being
the MCF approach compared with RLB and RS (the latter
approach was also used in tumours over 20 mm EC with-
out hearing preservation being the goal in all of them.
Although it is possible to preserve hearing in VS surgery
with different techniques, it should be noted that in our
experience this occurs in a low percentage of cases and
should never constitute additional risk in the definitive facial
outcome.
The cases where we believe that hearing preservation
is much more important is in patients with NF 2 and those
who have VS in a single ear. In these patients, where there
is risk of bilateral cofosis, anticipatory strategies are vital.
Translabyrinthine resection with preservation of the audi-
tory nerve can even be indicated for large tumours and a
simultaneous cochlear implant in the same surgical proce-
dure may be inserted, with good long term outcome.22,23 In
our experience, with the cochlear implant the outcome is
usually better than with ABI.
Cerebrospinal Fluid Leakage and Meningitis
Despite technical advances, cerebrospinal fluid leakage
continue to be one of the most common and feared
complications of VS surgery.24 In our series only 3 patients
presented with CFL In addition to this we had several cases
of retroauricular subcutaneous collection of CFL all of which
were resolved using compression bandages and on occasion
lumbar draining.
We attribute the success of this low percentage of cere-
brospinal fluid leakage to a systematic technique, envisaging
closure the moment the incision has begun, with a meticu-
lous conservation of musculoperiostic flaps, sealing of the
cavity with abdominal fat, obliteration of the space with
muscle-periosteum, and a highly carefully placed compres-
sion bandage, following the guidelines of other authors who
have achieved similar outcomes.25 Despite having suggested
there is a relationship between tumour size and the inci-
dence of cerebrospinal fluid leakage,6,26 we have not seen,
similarly to other authors,27,28 a clear correlation between
tumour size and presence of fluid, which has occurred with
tumours of different sizes, regardless of dimension. Equally,
we have not seen a clear relationship between the inci-
dence of cerebrospinal fluid or retroauricular subcutaneous
collection of CFL with the surgical approach used.
Meningitis is an uncommon complication which presented
in a low percentage of patients operated on for VS. In the
majority of the series this is under 5% (Table 13). We only
recorded 5 cases of meningitis (1.1%), of which 2 presented a
CFL collection or fistula. The strong correlation between the
CFL fistula and the incidence of meningitis was documented
by Slattery et al.,26 who founds that in the presence of a
fistula, meningitis presented in 9.7%, whilst in its absence
this was much lower, only 1%. Similarly we found that in
those patients who either had cerebrospinal fluid leakage
or retroauricular subcutaneous collection of CFL, meningitis
210 M.Á. Arístegui Ruiz et al.

Table 14 Preservation of Useful Hearing in Diverse Studies.

Author Year Patients (n) Approach Useful hearing (%)
Friedman et al. 2003 119 MCF 61
Meyer et al. 2006 162 MCF 61
Brackman et al. 2000 333 MCF 59
Hillman et al. 2010 88 MCF 59.3
Hutz et al. 2012 46 MCF 63.2
Samii et al. 1997 732 RS 47
Lassaletta et al. 2003 29 RS 17
Mohr et al. 2005 128 RS 24.2
Tringali et al. 2010 213 RS 47.3
Rachinger et al. 2011 90 RS 42
Nguyen et al. 2012 53 RS 85
MCF: middle cranial fossa; RS: retrosigmoid.

rose to 10.5%, whilst in those who had no fluid leakage the
rate was only 0.74% (P=.0001).
Complications
One of the most feared complications of VS surgery is postop-
erative intracranial bleeding. Although this is not common,
it is a potentially serious complication which may require
immediate action. In the majority of the series it was
observed that the rate of intracranial bleeding was low.
In our series there was 0.9% of bleeding, similar to other
series, where it did not usually rise above 2% (Table 13).
Cases of postoperative pneumoencephalus tension may also
present which require emergency evacuation. We are thus
highlighting the need for strict patient control in the imme-
diate postoperative phase because although infrequently,
it is during this critical period when potentially serious
complications usually occur. This is the reasons why we usu-
ally keep the patient in the ICU for the first 12 h after an
operation, to detect any complications in time and estab-
lish the necessary treatment early. Furthermore, a CAT scan
is performed on all patients within 24 h following surgical
intervention. The low incidence of intracranial bleeding is,
among other motives, due to a bloodless surgical proce-
dure with meticulous haemostasis and preservation of the
arachnoidal cleavage plane which enables the safe sepa-
ration of the tumour capsule from the other structures.
The veins which cross over the tumour may be coagulated
when there is bleeding, or condition the rumour resection,
but without sequelae. On the contrary, coagulation of veins
which flow from the brain stem must be avoided at all
costs, because this may lead to a haemorrhagic stroke. Strict
haemostasis at the end of the procedure leads to a low
percentage of postoperative bleeding. With respect to neu-
rological complications, this occurred in a low percentage of
cases, similarly to that reported in other studies (Table 13).
The involvement of other nerve pathways resulting from VS
surgery is usually low, below 5%, and generally corresponds
to large tumour resections. In the case of large sized schwan-
nomas where lower cranial nerves may be involved, it may
be necessary for speech therapy or complementary surgery
to take place.
Conclusion
Surgery continues to be the treatment of choice in young
patients with large VS, deteriorated hearing, symptomatic
tumours and also in previously observed cases where sig-
nificant growth has taken place. It is also offered to
those patients who present reasonable possibility of hear-
ing preservation. The final aim of surgery is to undertake a
complete resection, with a clearly established order of pri-
orities among which, firstly, is surgery without any danger
to the patient’s life and without any neurological sequelae.
Secondly, preservation of the facial nerve and its function,
and finally, hearing preservation only when conditions allow.
The outcome of the facial function is mainly conditioned
by the size of the tumour, but also by other factors such as
prior intervention with a subtotal resection, radio surgery
or the cystic nature of the tumour.
Hearing preservation probability with those different sur-
gical approaches which allow for it are low, and this should
never condition the definitive result of the facial function.
In experienced hands the rate of complications is low. In
our opinion, this type of surgery requires relatively frequent
repetitive practice and the inclusion of an interdisciplinary
team of surgeons, anaesthetists, radiologists, nursing team
and physiotherapists for a satisfactory outcome.
Conflict of Interests
The authors have no conflict of interests to declare.
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