At present, there are three main surgical routes for resection of an acoustic neuroma. These approaches are chosen based upon educational bias, surgical experience, and the specific goals of the operation.
- The
suboccipital retrosigmoid approach is the oldest and remains
widely used, particularly when hearing preservation is attempted.
- The
translabyrinthine approach destroys hearing but provides direct
exposure of the tumor without cerebellar retraction. Even large tumors
can be removed through this route.
- The "middle fossa" approach is performed by a temporal craniotomy but requires elevation of the temporal lobe and drilling of the temporal bone to expose the auditory canal from above. Using this route, hearing preservation can be attempted. It is usually chosen for patients with intracanalicular tumors.
The goals and acceptable clinical outcomes have evolved over time. Many years ago, the goal was simple debulking of the tumor (which was often large) and relief of regional brainstem compression and hydrocephalus. The goal was life saving. Neurologic deficits such as hearing loss, facial weakness, or balance disorders were tolerated as simply part of the expected result.
In the 1970's, the introduction of the operating microscope facilitated meticulous dissection of the tumor so that attempts at cranial nerve preservation could be made. Over the next 20 years, preservation of facial nerve continuity became more common than not.
During the 1990's, hearing preservation became an achievable goal in selected cases. At the same time, improvements in anesthetic technique and wound closure reduced the risk of cerebellar infarction, meningitis, and cerebral spinal fluid leakage. Nevertheless these problems still continue to exist and cerebral spinal fluid leakage remains a significant problem after resection (2).
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