Middle Fossa Approach for Facial Nerve Schwannoma Aiming for Functional Improvement: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (5) ◽  
pp. E167-E168
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Hitoshi Izawa ◽  
Yujiro Tanaka
Keyword(s):  
Facial Nerve ◽  
Facial Palsy ◽  
Tumor Resection ◽  
Nerve Fibers ◽  
Middle Fossa ◽  
Tumor Removal ◽  
Middle Fossa Approach ◽  
Brainstem Response ◽  
Facial Nerve Schwannoma

Abstract The treatment paradigm of skull base surgery has been changed from radical tumor resection to maximal tumor removal while giving priority to functional preservation. Facial nerve schwannoma is one of the representative disorders of this type of paradigm shift.1 This video demonstrates facial nerve schwannoma surgery through the middle fossa approach, aiming for improvement of facial function. A 33-yr-old woman presented with gradually worsening facial palsy (House-Brackmann grade IV), dizziness, and nausea. Neuroimaging revealed a growing tumor involving the geniculate ganglion, and extending to the middle fossa, internal acoustic meatus, and cerebellopontine angle. The nerve-sparing surgery through the left middle fossa approach was performed under detailed neuromonitoring including the evoked facial electromyograms and auditory brainstem response. The facial nerve fibers were involved within the tumor mass and the plane between the tumor and facial nerve could not be identified as seen in most cases of such large facial nerve schwannomas. But sufficient tumor removal with facial nerve preservation was achieved owing to continuous facial monitoring.2 The patient had no new neurological deficits. Her facial palsy has been gradually improving, now at grade III, without any signs of tumor regrowth during the 10 mo of follow up after the operation. Careful follow up is being continued to survey the possible tumor recurrence. The video was reproduced after informed consent of the patient.

Hearing Preservation Using the Middle Fossa Approach for the Treatment of Vestibular Schwannoma

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. 334-341 ◽  
Author(s):  
Joe Walter Kutz ◽  
Tyler Scoresby ◽  
Brandon Isaacson ◽  
Bruce E. Mickey ◽  
Christopher J. Madden ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Academic Medical Center ◽  
Hearing Preservation ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Class A ◽  
Facial Function ◽  
Grade Iii

Abstract BACKGROUND: The incidence of small vestibular schwannomas in patients with serviceable hearing is increasing because of the widespread use of MRI. The middle fossa approach provides the patient with an opportunity for tumor removal with hearing preservation. OBJECTIVE: To determine the rate of hearing preservation and facial nerve outcomes after removal of a vestibular schwannoma with the use of the middle fossa approach. METHODS: A retrospective case review at a tertiary, academic medical center was performed identifying patients from 1998 through 2008 that underwent removal of a vestibular schwannoma by the middle fossa approach. Preoperative and postoperative audiograms were compared to determine hearing preservation rates. In addition, facial nerve outcomes at last follow-up were recorded. RESULTS: Forty-six patients underwent a middle fossa craniotomy for the removal of a vestibular schwannoma. Of the 38 patients that had class A or class B hearing preoperatively, 24 (63.2%) retained class A or B hearing and 29 (76.3%) retained class A, B, or C hearing. When tumors were 10 mm or less in patients with class A or B preoperative hearing, 22 of 30 patients (73.3%) retained class A or B hearing. When the tumor size was greater than 10 mm in patients with class A or B preoperative hearing, 2 of 8 patients (25%) retained class A or B hearing. At most recent follow-up, 76.1% of patients had House-Brackmann grade I facial function, 13.0% had House-Brackmann grade II facial function, and 10.9% had House-Brackmann grade III facial function. CONCLUSION: Hearing preservation rates are excellent using the middle fossa approach, especially for smaller tumors. No patient experienced long-term facial nerve function worse than House-Brackmann grade III.

scholarly journals Surgical treatment of glomus jugulare tumors without rerouting of the facial nerve: an infralabyrinthine approach

2004 ◽  
Vol 17 (2) ◽  
pp. 51-55 ◽  
Author(s):  
Luis A. B. Borba ◽  
Samir Ale-Bark ◽  
Charles London
Keyword(s):  
Facial Nerve ◽  
Surgical Approach ◽  
Facial Palsy ◽  
Jugular Foramen ◽  
Nerve Function ◽  
Tumor Removal ◽  
Glomus Jugulare ◽  
Anterior Transposition ◽  
Radical Removal

Object Glomus jugulare tumors are benign lesions located in the jugular foramen that may or may not extend into the middle ear, petrous apex, and upper neck; these growths sometimes invade intradurally. The surgical management of these tumors is a challenge to neurosurgeons and skull base surgeons. Because of their abundant vascularity, deep location, complex anatomy, and difficult surgical approach, their treatment, has been a controversial issue for many years. Despite advancements in nonsurgical techniques, the only treatment with proven efficacy is radical surgical removal. The authors present a series of patients treated with radical removal, in which the feasibility of removing glomus jugulare tumors with low morbidity and a surgical approach limited to tumor removal are discussed. The extent of surgical exposure is tailored with emphasis placed on the routine anterior transposition of the facial nerve. Methods Between May 1997 and March 2004, 24 patients with glomus jugulare tumors were treated; 17 patients were women and seven were men. Their mean age at the time of diagnosis was 50 years (range 18–71 years). The most common symptom was hearing loss in 77%, followed by dysphagia and dysphonia in 55% of patients. In seven patients the clinical presentation was a facial palsy. Radical tumor removal was achieved in 23 patients. An anterior facial nerve transposition was not needed in any case. No surgery-related death was recorded in this series, although one patient died of a pulmonary embolism 70 days after the procedure. A one-stage procedure was performed in 23 patients and a two-stage procedure was used in the other patient. Cerebrospinal fluid leakage occurred in two patients. The lower cranial nerve function was worse in eight patients; however, only one had a new deficit. The facial nerve was preserved in all patients except one, in whom a large intradural tumor caused a temporary facial palsy. In the patients with pre-operative facial palsy, the tumor only compressed the nerve in three and it invaded the nerve in four. The nerve was decompressed in the cases with no invasion and a graft was placed in the others. The greater auricular nerve was used as a graft in three and the sural nerve was used in one. On follow-up review, the facial nerve function was House–Brackmann Grade 3 in three patients and Grade 2 in three. After 6 months of follow up with no improvement, one patient was referred for a facial muscle transfer. Conclusions The surgical technique must be tailored to each case. The authors believe that the standard surgical approach to jugular foramen tumors with anterior transposition of the facial nerve should be avoided, and that the extent of surgical exposure must be tailored to each case based on the extent of the tumor and the clinical symptoms. Lower morbidity rates and radical removal can be achieved with a good surgical plan.

Hemihypoglossal—facial nerve anastomosis in treating unilateral facial palsy after acoustic neurinoma resection

1995 ◽  
Vol 82 (1) ◽  
pp. 51-54 ◽  
Author(s):  
Hajime Arai ◽  
Kiyoshi Sato ◽  
Akira Yanai
Keyword(s):  
Facial Nerve ◽  
Facial Palsy ◽  
Hypoglossal Nerve ◽  
Tumor Resection ◽  
Postoperative Recovery ◽  
Acoustic Neurinoma ◽  
Content Type ◽  
Facial Reanimation ◽  
Nerve Anastomosis

✓ Eight patients underwent hemihypoglossal—facial nerve anastomosis (anastomosis of a split hypoglossal nerve to the facial nerve) for treatment of unilateral facial palsy. All patients previously had undergone resection of a large acoustic neurinoma and the facial nerve had been resected at that time. The interval between tumor resection and hemihypoglossal—facial nerve anastomosis ranged from 1 to 6 months, with an average of 2.1 months. Postoperative recovery of facial movement was good in all cases during an average follow-up period of 4.2 years. In all eight patients, the degree of hypoglossal nerve atrophy on the operated side was graded mild or moderate, but not severe. It was concluded that hemihypoglossal—facial nerve anastomosis results in good facial reanimation as long as the procedure is performed early after the onset of facial palsy and that this procedure may reduce the degree of hemiglossal atrophy in comparison with classic hypoglossal—facial nerve anastomosis.

Transmastoid Decompression of the Facial Nerve in Temporal Bone Fracture

1982 ◽  
Vol 90 (5) ◽  
pp. 616-621 ◽  
Author(s):  
Naoaki Yanagihara
Keyword(s):  
Facial Nerve ◽  
Temporal Bone ◽  
Bone Fracture ◽  
Facial Palsy ◽  
Bone Fractures ◽  
Closed Head Injury ◽  
Geniculate Ganglion ◽  
Middle Fossa ◽  
Temporal Bone Fracture ◽  
Middle Fossa Approach

Among 41 cases of facial palsy caused by closed head injury, temporal bone fractures were surgically confirmed in 36 cases, of which there were two mixed fractures and 34 longitudinal fractures. The fracture involved the geniculate ganglion area in 20 cases (55%). In 15 cases, decompression of the facial nerve was carried out using the transmastoid supralabyrinthine approach with disarticulation of the incus; in only five cases was the middle fossa approach used. The technique avoids the craniotomy for the middle fossa approach and is a reliable method of treatment in the majority of patients with facial palsy caused by temporal bone fracture involving the geniculate ganglion area.

scholarly journals Management of Facial Nerve Schwannoma: A Multicenter Study of 50 Cases

2018 ◽  
Vol 80 (04) ◽  
pp. 352-356 ◽  
Author(s):  
Adrien A. Eshraghi ◽  
Natalie Oker ◽  
Emre Ocak ◽  
Benjamin Verillaud ◽  
Thomas Babcock ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Tumor Resection ◽  
Retrospective Chart Review ◽  
Treatment Modalities ◽  
Tumor Control ◽  
Management Options ◽  
Multiple Treatment ◽  
Facial Nerve Schwannoma

Objective In the management of facial nerve schwannoma (FNS), surgical tumor resection is now often being replaced with more conservative approaches, such as observation with serial imaging or stereotactic radiosurgery (SRS). Given the scarcity of these lesions, determining the optimal management of FNS remains challenging and subject of debate with multiple treatment approaches supported in the literature. Methods A retrospective chart review was performed in two academic centers for patients diagnosed with FNS between 1996 and 2017. The clinical presentation, treatment modalities employed, tumor control rates, and facial nerve function (FNF) outcomes (House–Brackmann system) were assessed and analyzed. Results The study comprised 50 adult patients. Initial treatment modalities included observation with serial clinicoradiologic review in 27 patients (54%), surgery in 17 patients (34%), and SRS in 6 patients (12%). The FNF were decreased in more than half of the patients who had surgery. Nonetheless, more than 80% of the patients who were initially managed with observation or SRS had stable or improved FNF. Conclusion A prevailing trend toward more conservative treatment modalities for FNS has evolved over time, providing relatively long-term preservation of FNF. As there are multiple management options available, it is of paramount importance that the treating physician be familiar with all treatment modalities and outcomes and counsel patients appropriately. The surgery should be reserved for large tumors and poor FNF at initial presentation or follow-up while watchful observation with imaging is the treatment of choice for rest of the patients.

Middle fossa approach for a pediatric facial nerve meningioma

2020 ◽  
Vol 26 (5) ◽  
pp. 578-582
Author(s):  
Robert C. Rennert ◽  
Danielle M. Levy ◽  
Jillian Plonsker ◽  
Jeffrey A. Steinberg ◽  
Rick A. Friedman ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Cerebellopontine Angle ◽  
Pediatric Patients ◽  
Middle Fossa ◽  
Facial Weakness ◽  
Total Resection ◽  
Who Grade ◽  
Middle Fossa Approach ◽  
Pathological Analysis

Pediatric cerebellopontine angle (CPA) meningiomas are extremely rare and are usually treated with a retrosigmoid surgical approach or radiation. The authors present the use of a middle fossa approach for the treatment of a symptomatic CPA meningioma in a 22-month-old female. The patient initially presented at 17 months with isolated progressive, long-standing right-sided facial weakness. MRI demonstrated a 5.0 × 5.0–mm right CPA lesion just superior to the cisternal segment of cranial nerve (CN) VII, which demonstrated growth on interval imaging. At 22 months of age she underwent a successful middle fossa craniotomy, including wide exposure of the porus acusticus, allowing for a gross-total resection with preservation of CNs VII and VIII. Pathological analysis revealed a WHO grade I meningioma. The patient remained neurologically stable on follow-up. The middle fossa approach can be used to safely access the CPA in properly selected pediatric patients.

scholarly journals Facial Nerve Schwannoma Extending to Jugular Foramen: A Case Report

2021 ◽  
pp. 014556132110002
Author(s):  
Jiangyu Yan ◽  
Fangfang Pan ◽  
Mengmeng Zhen ◽  
Yuan Ren ◽  
Wenjuan Hao ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Medical History ◽  
Facial Palsy ◽  
Infratemporal Fossa ◽  
Tumor Resection ◽  
Type A ◽  
Jugular Foramen ◽  
Lateral Muscle ◽  
The Right ◽  
Facial Nerve Schwannoma

Facial nerve schwannoma (FNS) is a benign, slow-growing schwannoma that originates from Schwann cells. Facial nerve schwannoma is the most common tumor of the facial nerve but rare and only accounts for 0.15% to 0.8% of intracranial neurinomas. It may be manifested as asymmetric hearing loss, facial palsy, and hemifacial spasm. A 56-year-old woman was transferred to our department, because of pain behind the right ear and spasm of the right lateral muscle for more than 2 years and pulsatile tinnitus for half a year. Based on the preoperative medical history, physical signs, and auxiliary examination, it was diagnosed with jugular foramen (JF) space-occupying lesion. We removed the tumor through the infratemporal fossa type A approach and found that the tumor originated from the facial nerve. After the tumor resection, sural nerve transplantation was performed. The patient demonstrated postoperative facial palsy (House-Brackman grade VI) and was smoothly discharged after good recovery. Facial nerve schwannoma rarely invades the JF, and the most common tumor in the JF is the glomus jugular tumor, followed by the posterior cranial schwannoma. They have common symptoms, making it difficult to obtain a correct diagnosis. Clinical data, medical history, and auxiliary examinations should be carefully analyzed to avoid misdiagnosis or mistreatment. Infratemporal fossa type A approach is an effective method for treating FNS of JF.

Middle Fossa Approach For Acoustic Tumor Removal

1992 ◽  
Vol 25 (2) ◽  
pp. 347-359 ◽  
Author(s):  
William F. House ◽  
Clough Shelton
Keyword(s):  
Middle Fossa ◽  
Tumor Removal ◽  
Middle Fossa Approach ◽  
Acoustic Tumor

Endoscopic Endonasal Interdural Middle Fossa Approach to the Maxillary Nerve: Anatomic Considerations and Surgical Relevance

2017 ◽  
Vol 13 (4) ◽  
pp. 522-528 ◽  
Author(s):  
Kumar Abhinav ◽  
David Panczykowski ◽  
Wei-Hsin Wang ◽  
Carl H. Synderman ◽  
Paul A. Gardner ◽  
...  
Keyword(s):  
Average Length ◽  
Tumor Resection ◽  
Human Head ◽  
Proximal Part ◽  
Gasserian Ganglion ◽  
Middle Fossa ◽  
Perineural Spread ◽  
Endoscopic Endonasal ◽  
Middle Fossa Approach ◽  
Maxillary Nerve

Abstract BACKGROUND: The maxillary nerve (V2) can be approached via the open middle fossa approach. OBJECTIVE: To delineate the anatomy of V2 and its specific segments with respect to the endonasal landmarks. We present the endoscopic endonasal interdural middle fossa approach to V2 and its potential application for the treatment of perineural spread in sinonasal/skull base tumors. METHODS: Five human head silicon-injected specimens underwent bilateral endoscopic endonasal transpterygoid approaches. V2 prominence and the maxillary strut were identified in the lateral recess along with paraclival carotid protruberance. The regions superior and inferior to V2 corresponding to the anteromedial and anterolateral triangles of the middle fossa were exposed. RESULTS: V2 can be classified into 3 segments: interdural (from the Gasserian ganglion to the proximal part of the maxillary strut), intracanalicular (corresponding to the anteroposterior length of the maxillary strut), and pterygopalatine (distal to the maxillary strut and the site of its divisions). Endonasally, the average length of the interdural and the intracanalicular segments were approximately 9 and 4.4 mm, respectively. V2, following its division distal to the maxillary strut, was successfully dissected off the middle fossa dura and transected just distal to the Gasserian ganglion. CONCLUSION: Endonasally, the interdural segment can be safely mobilized between the periosteal and meningeal dural layers while ensuring the integrity of the middle fossa dura. This allows transection of infiltrated V2 to facilitate tumor resection without entering the intradural/arachnoidal space. Posteriorly, this is limited by the Gasserian ganglion and superomedially by the dural envelope surrounding the cavernous sinus and the paraclival carotid artery.

Sign in / Sign up

Export Citation Format

Share Document