Purely Endoscopic Management of Vestibular Schwannomas

Introduction: Endoscopic resection of CPA tumors remains a scarcely reported entity. Several authors have described excellent results in utilizing endoscopy for MVD in cranial nerve compression syndromes, however, only a handful of reports currently exist describing CPA tumor resection in a purely endoscopic manner. This despite numerous articles indicating that endoscopy can improve visualization of neuro-vascular structures in the CPA. Among CPA tumors, vestibular schwannomas remain one of the most challenging tumors to resect and has rarely been described in a purely endoscopic technique. We report our results of resecting vestibular schwannomas in a purely endoscopic manner.

Methods: Retrospective review was conducted on 12 patients that underwent purely endoscopic resection of vestibular schwannoma at our institution from 2007 to 2013. The operative microscope was not used at any point and surgery was conducted in a multi-disciplinary fashion involving both neurosurgery and neuro-otology. A small 1-inch linear incision and 14 mm retrosigmoid craniectomy allowed for adequate access to the CPA and full tumor resection. Patient demographics, including age, gender, side and size of tumor were recorded. We also report post-operative facial nerve preservation, hearing preservation, length of hospital stay, mean operative time, estimated blood loss, extent of tumor resection and all neurologic complications.

Results: Among the 12 patients, mean age at time of surgery was 46.7 with 8 male patients and 4 female. All tumors were unilateral, with 7 located on the left and 5 on the right. Mean tumor diameter was 1.4 cm with a range of 1.0–2.0 cm. 11 of 12 patients (91.7%) had gross total resection while 1 of the 12 patients (8.3%) had a sub-total resection. All 12 patients had full facial nerve function pre-operatively (House-Brackman 1) and 11 of the 12 patients (91.7%) had complete facial nerve preservation post-operatively (HB 1), while 1 patient (8.3%) had a HB 3. Mean length of hospital stay was 3.58 days with a range of 2–7 days. Mean operative time was 261.6 minutes with a range of 180–512 minutes and mean estimated blood loss of 80 cc. We also report details of successful hearing preservation. No patients had any post-operative complications.

Conclusion: Purely endoscopic resection of vestibular schwannomas is not only possible but can yield excellent results in well-selected patients. The procedure is done with a minimal craniectomy and without the need for the operative microscope at any time. We do, however, emphasize that surgeons gain the appropriate familiarity and experience with the endoscope prior to performing this procedure.