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Acoustic neuroma — Clinical Guidelines

Overview

Acoustic neuromas, also known as vestibular schwannomas, are benign tumors arising from the Schwann cells of the vestibulocochlear nerve, typically affecting hearing and balance. 5

Diagnosis

Clinical Presentation: Symptoms include unilateral hearing loss, tinnitus, vertigo, and facial weakness. 5

Audiometric Testing: Essential for early detection; protocols emphasizing specific frequency ranges and decibel differences improve sensitivity and specificity. 1

Imaging: MRI is the gold standard for confirming diagnosis, providing detailed visualization of tumor size and location. 5

Grading: Tumor size and extension (e.g., House-Brackmann grading for hearing loss, modified Pittsburgh criteria) guide management decisions. 5

Management

Surgical Approaches:

- Translabyrinthine: Effective for most cases, with low recurrence rates (0.3%). 8 - Retrosigmoid: Used for larger tumors or those extending beyond the internal auditory canal. 6 - Modified Retro-sigmoid: Suitable for tumors not reaching the brainstem or extending laterally. 6

Radiosurgery: Stereotactic radiosurgery (SRS) is an option, particularly for small to medium-sized tumors, with outcomes varying based on surgeon experience. 3

Intraoperative Monitoring: Use of distortion product otoacoustic emissions (DPOAEs) to monitor cochlear function during surgery. 7

Postoperative Pain Management: Addresses headaches and pain through surgical technique refinement and medical management strategies. 4

Special Populations

Pregnancy: Acoustic neuromas may grow rapidly; estrogen receptor presence suggests hormonal influence on growth. 11

Elderly: Considerations for surgical risks and recovery times are crucial, though specific guidelines are not detailed in the abstracts. 5

Key Recommendations

Utilize MRI for definitive diagnosis and grading of acoustic neuromas (Evidence: Strong 5).

Employ audiometric protocols focusing on specific frequency ranges and decibel differences to enhance diagnostic accuracy (Evidence: Moderate 1).

Consider translabyrinthine approach for most cases due to low recurrence rates, unless tumor characteristics necessitate alternative methods (Evidence: Strong 8).

Implement intraoperative monitoring techniques like DPOAEs to safeguard cochlear function during surgery (Evidence: Moderate 7).

Tailor postoperative pain management strategies based on surgical approach and patient-specific factors (Evidence: Expert opinion 4).

References

1 Cheng TC, Wareing MJ. Three-year ear, nose, and throat cross-sectional analysis of audiometric protocols for magnetic resonance imaging screening of acoustic tumors. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2012. link 2 Nguyen-Huynh AT, Jackler RK, Pfister M, Tseng J. The aborted early history of the translabyrinthine approach: a victim of suppression or technical prematurity?. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2007. link 3 Battista RA, Wiet RJ. Stereotactic radiosurgery for acoustic neuromas: a survey of the American Neurotology Society. The American journal of otology 2000. link80047-2) 4 Driscoll CL, Beatty CW. Pain after acoustic neuroma surgery. Otolaryngologic clinics of North America 1997. link 5 Wiegand DA, Ojemann RG, Fickel V. Surgical treatment of acoustic neuroma (vestibular schwannoma) in the United States: report from the Acoustic Neuroma Registry. The Laryngoscope 1996. link 6 Shelton C, Alavi S, Li JC, Hitselberger WE. Modified retrosigmoid approach: use for selected acoustic tumor removal. The American journal of otology 1995. link 7 Telischi FF, Widick MP, Lonsbury-Martin BL, McCoy MJ. Monitoring cochlear function intraoperatively using distortion product otoacoustic emissions. The American journal of otology 1995. link 8 Shelton C. Unilateral acoustic tumors: how often do they recur after translabyrinthine removal?. The Laryngoscope 1995. link 9 Pulec JL. Technique to avoid cerebrospinal fluid otorhinorrhea with translabyrinthine removal of acoustic neuroma. The Laryngoscope 1994. link 10 Mattock C, Crockard A. Does intravascular coagulation contribute to the operative mortality for large acoustic neuromas?. Journal of neurology, neurosurgery, and psychiatry 1986. link 11 Kasantikul V, Brown WJ. Estrogen receptors in acoustic neurilemmomas. Surgical neurology 1981. link90023-9)

Acoustic neuroma