Vestibular Schwannomas—When To Operate?

Indications for microsurgical removal of vestibular schwannomas might be the intention to preserve hearing of the affected ear or to preserve facial nerve function. Microsurgical tumor removal is indicated for relief of brainstem compression by large tumors.

The surgical risk rises with the tumor size; indications for surgery are being determined more often in earlier tumor stages, because hearing preservation and preservation of facial nerve function is more often and more securely achieved.

Radiotherapy is useful only as a stereotactic procedure that controls tumor growth for several years but does not eliminate the tumor. Moreover, if after radiation therapy microsurgical tumor removal becomes necessary, it is technically more demanding and bears a higher risk. Radiation therapy carries the same risks as surgery for facial nerve palsy, trigeminal hypo- or dysesthesia, headache, or vertigo.

Fisch has described—especially in older patients—quite a high proportion of vestibular schwannomas, which do not grow. Therefore simply following the patient might be an alternative to active treatment in selected cases.

In summary, microsurgical removal of vestibular schwannomas is the first line of treatment. Indications for radiotherapy might be given in patients with relevant concomitant medical illesses, patients of older age, tumor recurrences, bilateral tumors with still-preserved hearing, a tumor on the side of only the hearing ear, and when the patient refuses surgery.