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ACOUSTIC NEUROMAACOUSTIC NEUROMATREATMENT OPTIONS 2009TREATMENT OPTIONS 2009
27th Alexandria International Combined ORL Congress
Alexandria Egypt April 10 2009Alexandria, Egypt April 10, 2009
Antonio De la Cruz MD
HOUSE EAR INSTITUTE
Antonio De la Cruz, MDHouse Ear Institute Los Angeles, California
Antonio De la Cruz, MD27th Alexandria International Combined ORL Congress
HOUSE EAR INSTITUTE
g
Alexandria, Egypt April 8, 2009
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
History of ANySandifort E, 1777–First AN in autopsy
Bell 1830Bell, 1830– First to diagnose AN in a living patient–Confirmed cpa tumor at autopsyCruveilhier, 1935,
-First to describe pathology
HOUSE EAR INSTITUTE
History of AN
Sir Charles Ballance, 1894,
• First to operate on acoustic neuroma
• Finger extraction
HOUSE EAR INSTITUTE
History of AN
Cushing H: 1908
Intracapsular debulking • Intracapsular debulking
• 1906, described a death
lMortality
• 40% initially
• 20% after thirty operations
• 7.7% in series of 176 cases
• Others reported 75%
HOUSE EAR INSTITUTE
History of AN
Walter Dandy, 1917
• Moved focus to
surgical curesurgical cure
• 1917-1941 >
perfected the SOC
• Mortality of 2 4% in • Mortality of 2.4% in
last 41 cases
HOUSE EAR INSTITUTE
History of ANOlivecrona, 1950, 1967
304 t• 304 tumors
• GTR in 217
• 40% facial nerve
preservation rate
• 20% recovered facial• 20% recovered facial
nerve function
HOUSE EAR INSTITUTE• 29% mortality
HOUSE EAR INSTITUTEHOUSE EAR CLINIC
fHistory of AN
• William House, 1960
– Temp. bone anatomy– Translabyrinthine y
approach– Middle fossa app.Middle fossa app.– First to remove AN
with the microscopewith the microscope
HOUSE EAR INSTITUTE
Vestibular SchwanomasEarly Diagnosisy g
• History and Physical Exam• History and Physical Exam
• Audiological Evaluation• Audiological Evaluation
• Balance System and ENGBalance System and ENG
• Imaging of Auditory CanalsHOUSE EAR INSTITUTE
Imaging of Auditory Canals
Vestibular SchwanomasVestibular SchwanomasEarly DiagnosisEarly Diagnosis
• Audiological Evaluation
• Balance System and ENG
• Imaging of IAC and CPAHOUSE EAR INSTITUTE
V tib l S hVestibular SchwanomasDefinite DiagnosisDefinite Diagnosis
• CT & MRI must have contrast
• MRI + contrast => early diagnosis
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMA
Treatment OptionsTreatment Options
1- Observation and Re-Scan
2- Radiosurgery- Gamma Knife
3- Total excision, single stage
HOUSE EAR INSTITUTE
ACOUSTIC TUMOR 2009MANAGEMENT OPTIONSMANAGEMENT OPTIONS
N=400N 400
• Observation 20%• Observation 20%
• Surgery 70%• Surgery 70%
• Radiation 10%• Radiation 10%
HOUSE EAR INSTITUTE
ACOUSTIC TUMOR MANAGEMENTACOUSTIC TUMOR MANAGEMENTOBSERVATION + RE-SCANOBSERVATION + RE SCAN
• Older patients
• Small tumors with poor hearing- any age
T t if t th i 2 3 /• Treat- if tumor growth is <2-3 mm/yr
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTESURGERY
Acoustic Neuroma SurgeryAcoustic Neuroma SurgeryPriorities
• Complete tumor removalp
• Preserve facial nerve function
• Avoid brain injury
• Hearing preservation if possible
HOUSE EAR INSTITUTE
SURGICAL APPROACHESSURGICAL APPROACHES
•Translabyrinthiney
•Middle FossaMiddle Fossa
•Retrosigmoid/ Suboccipital•Retrosigmoid/ Suboccipital
HOUSE EAR INSTITUTE
HEC Vestibular Schwannoma SurgeriesHEC Vestibular Schwannoma SurgeriesProcedure Type by Year
200
res
150
roc
edu
r
MFC100
er
of
Pr
TLCRSC
0
50
Nu
mb
e
0
Year of Surgery90 95 00 05
HOUSE EAR INSTITUTEHOUSE EAR INSTITUTE
CSF Leak Prevention
• Block ET and Middle Ear with Wax-Surgicel• Block ET and Middle Ear with Wax Surgicel
• Suturing of presigmoid dura g p g
• Strips abdominal fat extending into CPA
• Titanium mesh cranioplasty
• Pressure dressing & Elevate HOB 30o
Titanium Mesh CranioplastyTitanium Mesh Cranioplasty
• Subperiosteal elevation of surrounding tissueg
• Mesh based on 3 sides ( 4 )(use 4 screws)
• Anterior edge placed • Anterior edge placed behind posterior EAC
• Provide lateral support to fat graft
Incision Closure Incision Closure CSF Leaks and Reop Rates
Titanium Classic
CSF Leak 3.3% 10.9%
Re-Op Rate 0.5% 2.5%
Fayad J, Schwartz M et al, COSM 2006Fayad J, Schwartz M et al, COSM 2006
HOUSE EAR INSTITUTE
Post-Op CSF RhinorrheaTreatment Treatment
Early or LateEarly or Late
–Direct obliteration of Eustachian tube, infracochlear and middle ear spacesinfracochlear and middle ear spaces
–Blind Sac Closure of EAC–Lumbar drain
FACIAL NERVE FUNCTIONFACIAL NERVE FUNCTIONPOST ACOUSTIC NEUROMA SURGERY
House Ear ClinicN=500N=500
Facial Grade <1 5cm <3 5cmFacial Grade <1.5cm <3.5cm
I-II 81% 53%I II 81% 53%
III-IV 15% 31%
V-VI 4% 16%
HOUSE EAR INSTITUTE
Delayed Facial ParalysisDelayed Facial Paralysis
• Retrospective 11 year review 1992-2003
• Incidence 25.5%Slattery WH, Hansen M. et al AAO-HNS 2006
HOUSE EAR INSTITUTE
FAMVIR® (famciclovir)All patients undergoing AN SurgeryAll patients undergoing AN Surgery
• Facial Nerve Function Measured DailyF i ® 500 BID P O• Famvir ® 500 mg BID P.O.
– Started 3 days prior to surgery – Continued 5 days post-operatively
HOUSE EAR INSTITUTE
Delayed Facial Paralysis
Controls 25.5%
Famvir Treated 14.5%
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMAS COMPLICATIONSACOUSTIC NEUROMAS COMPLICATIONS
M i itiMeningitis
1 5% ( 1% b t i l)1.5% (.1%> bacterial)
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
HEARING PRESERVATIONMiddle Fossa ApproachR i id A hRetrosigmoid Approach
HOUSE EAR INSTITUTE
HEARING PRESERVATIONHEARING PRESERVATIONFavorable IndicatorsFavorable Indicators
Good ABRT t t f d f IAC Tumor not to fundus of IAC RVR on ENGRVR on ENG
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMA MANAGEMENT MIDDLE FOSSA APPROACH
•Tumor ↓ 1.5 cm.
•May be to the fundus
•Hearing 30 dB & 70% SDS
•Age ↓ 65
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
MIDDLE FOSSA APPROACH
Wid b l• Wide bone removal
• Medial to lateral dissection
• Remove tumor only
• Topical papaverineHOUSE EAR INSTITUTE
p p p
ACOUSTIC NEUROMA MANAGEMENT
RETROSIGMOID APPROACH
Tumor = or < 2 5 cmTumor or < 2.5 cmHearing <30 dB >70% SDSNo history of headachesMedial – not involving distal ½ of IACMedial not involving distal ½ of IAC
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
R id l T G hResidual Tumor Growth
Post-op MRI + Gadolineum
+ Fat SuppressionHearing Presevation Attempt => 1 Yr
No Attempt of H. Preservation => 3 Yrs
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
Acoustic NeuromasAcoustic Neuromas
Residual Tumor GrowthResidual Tumor Growth
All A h 0 03 %All Approaches 0.03 %
T l b i thi A 1 1000Translabyrinthine App. 1:1000
HOUSE EAR INSTITUTE
ACOUSTIC TUMOR MANAGEMENT ACOUSTIC TUMOR MANAGEMENT STEREOTACTIC RADIATION THERAPY
(RADIOSURGERY)(RADIOSURGERY)
• Gamma KnifeGamma Knife
• CyberknifeCyberknife
• Linacac
• Proton BeamHOUSE EAR INSTITUTE
ACOUSTIC TUMOR MANAGEMENT ACOUSTIC TUMOR MANAGEMENT IRRADIATIONIRRADIATION
HOUSE EAR INSTITUTE
Radio-Surgery FailuresRadio Surgery FailuresSalvage Surgery N=89g g y
• Poor hearing salvageoo ea g sa age
• Facial nerve outcomes 50% poorerp
• Increased perioperative complications p p p
(CSF leak, ataxia, hydrocephalus)
• Poor ABI performance
HOUSE EAR INSTITUTE• Gamma knife
ACOUSTIC NEUROMA MANAGEMENT
STEREOTACTIC RADIATIONSTEREOTACTIC RADIATIONINDICATIONS
• Growing tumor• Tumor ↓ 3 cm with little doubt of
diagnosis on imagingdiagnosis on imaging• Younger patients who refuse surgery
HOUSE EAR INSTITUTE
Stereotactic RadiosurgeryC t i di tiContraindications
• Tumors 3 cm
• NF 2 ( p53)
• Uncertain diagnosis
Di ti t ?• Dizzy patients?
• Facial nerve symptomsHOUSE EAR INSTITUTE
• Facial nerve symptoms
Radio-Surgery Failuresg y
Salvage Surgeryg g y
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMA MANAGEMENT
STEROTACTIC RADIATIONFAILURES
• To date 95 patients surgically treated after irradiation failureafter irradiation failure
• Size at time of irradiation average g1.7; range 1.1 – 2.6 cm
• Size at time of salvage surgery • Size at time of salvage surgery average 2.9; range 1.5 – 3.8 cm
HOUSE EAR INSTITUTE
N i di t d TNon-irradiated Tumor
HOUSE EAR INSTITUTE
Irradiated TumorIrradiated Tumor
HOUSE EAR INSTITUTE
St t ti R diStereotactic RadiosurgeryMalignant TransformationMalignant Transformation
• 20 cases in the literature20 cases in the literature
• 4-5 year latency• 4-5 year latency
All Fatal• All Fatal
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMASACOUSTIC NEUROMAS
Surgical MortalitySurgical Mortality• Schisano et al 1956 - 41% mortality Schisano et al., 1956 41% mortality
• Arseni et al., 1970 - 25% mortality, y
HOUSE EAR INSTITUTE
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMAS
House Clinic
Mortality (1989-1998)y ( )(N = 1687)
• 2 patients (0.12%)
W. Slattery, MDHOUSE EAR INSTITUTE
W. Slattery, MD
CONCLUSIONSCONCLUSIONS
HOUSE EAR INSTITUTE
Vestibular SchwanomasEarly Diagnosisy g
• History and Physical Exam• History and Physical Exam
• Audiological Evaluation• Audiological Evaluation
• Balance System and ENGBalance System and ENG
• Imaging of Auditory CanalsHOUSE EAR INSTITUTE
Imaging of Auditory Canals
ACOUSTIC TUMOR MANAGEMENT
3 OPTIONS3 OPTIONS- Observation + re-scan- Surgery
Middle FossaMiddle FossaRetrosigmoidTranslabyrinthine
- RadiationRadiationGamma KnifeFocused Stereotactic Radiation (FSR)
HOUSE EAR INSTITUTE
Focused Stereotactic Radiation (FSR)
H i P tiHearing PreservationOutcome PredictorsOutcome Predictors
P h i l l• Preop hearing levels
T mo lo tion• Tumor location
• Tumor size• Tumor size
• ABR • ABR
• ENG (calorics)HOUSE EAR INSTITUTE
• ENG (calorics)
ACOUSTIC TUMOR MANAGEMENT OPTIONSMANAGEMENT OPTIONS
N=400N 400
• Observation 20%• Observation 20%
• Surgery 70%• Surgery 70%
• Radiation 10%• Radiation 10%
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMA MANAGEMENT HECACOUSTIC NEUROMA MANAGEMENT HEC
CONCLUSIONS 2009
Microsurgery remains our treatment of choice• Microsurgery remains our treatment of choice
• Radiotherapy does not achieve a curepy
• 5-10% failure: excludes the chance of surgical
hearing preservation, 50 % worse facial nerve results
F ll d i l t d ti t• Follow-up and re-scan in selected patients
HOUSE EAR INSTITUTE
ACOUSTIC NEUROMAACOUSTIC NEUROMATREATMENT OPTIONS 2009TREATMENT OPTIONS 2009
27th Alexandria International Combined ORL Congress
Alexandria Egypt April 10 2009Alexandria, Egypt April 10, 2009
Antonio De la Cruz MD
HOUSE EAR INSTITUTE
Antonio De la Cruz, MDHouse Ear Institute Los Angeles, California
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