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Acoustic Neuroma Acoustic Neuroma & Hearing Loss
Acoustic Neuroma Acoustic Neuroma & Hearing Loss
Acoustic
Neuroma &
Hearing Loss
K. Kevin Ho, M.D.
Vicente A. Resto, M.D., Ph.D.
Department of Otolaryngology
University of Texas Medical Branch
Historical Perspectives
(contd)
Meticulous dissection
Hemostasis: silver clips, bone wax,
electrocautery
Mortality: 20 % (1917) 4% (1931)
Complete removal of AN
Mortality: 10%
Cerebellopontine Angle:
Anatomy
Epidemiology
Pathogenesis
Tumor Size
Intracanalicular
I (small)
Tumor confined to
IAC
< 10 mm
II (medium)
11-25 mm
III (Large)
25-40 mm
IV (Giant)
> 40 mm
Intracanalicular:
Cisternal:
Compressive:
Hydrocephalic:
Compressive
Cisternal
Hydrocephal
Hearing Loss
Most frequent initial symptom
Most common symptom ~ 95% AN
patients
Asymmetric SNHL
Down-sloping / High Frequency
Decreased Speech Discrimination
Serviceable Hearing
SDS (%)
100
70
50
A
P
T
T
(dB)
30
B
50
Distribution of Hearing
in AN
Pathophysiology of Hearing
Loss
in Acoustic Neuroma
Normal or Symmetrical
Hearing in Acoustic
Neuroma
Selesni Shaan
Lustig Magdzi
Selesni Shaan
ck 1993 1993
AN
patient
s
Norma
l
hearin
g
Lustig
1998
Magdzi
arz
2000
126
100
546
369
5
(4%)
6
(6%)
29
(5%)
10
(3%)
% Small
(< 1cm)
% Medium
Normal
All ANs
Hearing
(126 Patients)
(29 Patients)
24
45
42
59
12
16
(1-3 cm)
% Large
(> 3 cm)
> 20 mm
Beders
on
Selesni
ck
Charab
i
Raut
Walsh
70
55
8
12
6
72
72
FollowNo
+
up
Growt Growt Growt
h (%) h (%) h (%)
26 mo
40
7
53
3 yr
54
3.8 yr
12
82
80 mo
3.2 yr
42
50
19
14
39
37
A
A
B
D
PTA
SDS
Initial
Volume
Gender
Age
Estimating Tumor
Growth
Tumor Growth:
Biomarkers
Delayed Diagnosis
Duration of Symptoms Prior to
Diagnosis
Symptoms
Hearing Loss
Vertigo
Tinnitus
Headache
Dysequilibrium
Trigeminal
Facial
Years
3.9
3.6
3.4
2.2
1.7
0.9
0.6
Hearing Loss
Vertigo
Dysequilibrium
Tinnitus
Headache
Nystagmus
Cranial neuropathy
CN V, VII
Lower cranial nerves (IX-XII)
Frequency of Symptoms
Hearing Loss
(85-97% ; 94% )
Vertigo
(5-70 % ; 39% )
Dysequilibrium (46-70% ; 56 %)
Tinnitus
(56-70% ; 64 %)
Facial nerve
(10-77% ; 38 %)
Trigeminal nerve
(16-63% ; 26 %)
Headache
(12-38% ; 25% )
Visual symptoms
(1- 15 % ; 7% )
Lower cranial nerves: Dysphagia, Hoarseness,
Aspiration, Shoulder weakness (Jugular foramen
syndrome)
Symptoms in AN patients
with Normal Hearing
Sudden Sensorineural
Hearing loss
Idiopathic
Diagnosis
Audiogram
ABR
OAE
MRI
CT
Gold Standard
ABR: Retrocochlear
Pathology
ABR patterns in AN
40-60 % with
wave V latency
delay
10-15 % have
normal findings
ABR: Diagnostic
Efficiency
Stacked ABR
Attempt to improve
detection rate in
small < 1 cm ANs
Stacking of
derived band
response
Out of 25 ANs, 5
tumors less than 1
cm missed in
Standard ABR were
picked up by Stacked
ABR.
OAE
Reflect cochlear/ OHC / sensory hearing
Not primarily used as screening tool
Presence of OAE in SNHL
Retrocochlear
However, 50 % AN demonstrate both
cochlear and retrocochlear hearing loss
RiskTEOAE
stratification for hearing
Preoperative
preservation surgery
T1 pre-Gad
T1:
to CSF
T2:
to CSF
T2
T1 post-Gad
Treatment options
Observation
Surgery
Translabyrinth
ine
Retrosigmoid
Middle fossa
Radiotherapy
Conventional
Stereotactic
Conservative
Management
+ : 39 %
0: 42%
- : 19%
Conclusions
Thank You