gms | German Medical Science

Objective: Surgery is one of the treatment options for vestibular schwannomas (VS), and results have improved enormously during the last decades. But alternative options like observation and radiosurgery have been evolved for VS and a shift towards fewer and later surgery at more advanced stages has occurred. Faced with larger tumors in patients with higher incidences of co-morbidities, surgical sequels and complications need further continuous consideration and were the focus of this study.

Methods: Over the past 11 years 502 tumour resections were performed in 483 patients (14% Neurofibromatosis Type 2, 227 male, 256 female) under continuous neuro-monitoring via a retro-sigmoid approach, 97% in the semi-sitting position by an interdisciplinary oto-neuro-surgical team. Standardized documentation of auditory and facial functions before and after surgery, of intra- and postoperative sequels and complications were analysed.

Results: 182 (36%) patients had small tumours (T1 to T3A; Hannover Classification) and 320 (64%) large tumours (T3B or T4). Some residual hearing (Hannover Classification I to IV), was documented in 367 patients (73%) before and in 116 patients after surgery with more favourable preservation rates in small tumours (39%). Facial palsy was present in 25 patients (HB °3-6) before and in 186 patients after surgery (77 HB°3, 65 HB°4, 44 HB°5-°6). Auditory and facial nerves outcome correlated significantly with tumour size (p<0.001/p<0.05). Intra-operative complications included air embolism in 45 cases (9%) and sinus injury in 3, without further sequels. Post-operative cerebrospinal fluid leakage occurred in 46 (9%), some local haemorrhage in 19 (4%), and surgical revision for either cause was indicated in 22 cases (4%). There were two deaths due to stroke, after total resection of an extensive tumour in patients with complex co-morbidity.

Conclusion: Thorough counselling to the patient leading to individual decision on the adequate treatment option and timing is ideally performed by an interdisciplinary team offering the complete spectrum of consideration. Tumour size and individual co-morbidity remain the most important risk factors in VS surgery. Functional cranial nerve preservation could be achieved at 32% for the auditory and 80% for the facial nerve (HB° 1-3) in this series. So in order to prevent a disadvantage course, surgery at late tumour stages may be avoided by adequate timing of treatment to optimise outcome.