Acoustic Neuroma Treatment- Ear Nose And Throat (ENT), Neurology, Neurosurgery

Acoustic Neuroma

An acoustic neuroma is a slow-growing benign tumor that is found on the vestibular nerve and, sometimes, the auditory nerve. The vestibular nerve is attached to the inner ear and is involved in sending information about movement and position, while the auditory nerve is important for hearing.

The tumor is sometimes referred to as a vestibular schwannoma since it develops from Schwann cells on the vestibular nerve. The neuroma can grow large and cause problems with balance, hearing, headaches, and even pain if it affects the facial nerve.

Who treats acoustic neuroma?

An otolaryngologist, neurotologist, neurosurgeon, and sometimes also a radiation oncologist are involved in treating the condition.

Diagnosis for treatment

An audiogram is used to evaluate hearing loss. Loss of hearing on only one side may indicate an acoustic neuroma. Electronystagmography is done to assess eye movement and balance.

The diagnosis can be confirmed with an MRI test using a specific contrast dye known as gadolinium. The MRI can show the presence of the neuroma and also indicate the size of the tumor. MRI imaging can help doctors determine what treatment approach to take in a particular situation.

Treatment options for an acoustic neuroma

Observation

Since a neuroma is slow-growing, doctors may prefer to leave it alone if it is small. This is a conservative approach, but the tumor needs to be monitored because it can eventually cause problems.

Sometimes a neuroma is discovered accidentally but does not yet cause hearing loss or other issues for the patient. If the neuroma continues to grow, leading to hearing loss and balance problems, additional methods may be used.

Stereotactic radiosurgery and radiotherapy

The stereotactic radiosurgery (SRS) method is also called gamma knife surgery. It uses radiation to stop the tumor from growing further. Stereotactic radiotherapy (SRT) involves the same procedure but uses much less radiation per session and so requires several treatments instead of one.

For the procedure, the patient has to wear a type of head frame so that the radiation can be precisely aimed at the tumor. For adults, light sedation is given, while children are put under anesthesia.

Over time the neuroma may decrease in size with these methods. A benefit of SRS and SRT is that they reduce the odds of damage to any cranial nerves, which is a risk of conventional surgery. This method is sometimes preferred for older patients, where microsurgery is significantly risky.

Post-surgery and post-therapy care

• The head frame will be taken off after the procedure
• You will be given medicine if you feel nauseated or have a headache
• You may be released the same day or stay overnight. However, you will not be able to drive back home because of the sedation administered.

Complications

Complications from radiosurgery are rare, but patients may experience the following:

• Tiredness
• Swelling
• Irritation of the hair and scalp
• Minimal risk of damage to hearing and balance

Microsurgery

Surgery is the only method that can potentially remove the tumor completely. The procedure is completed under general anesthesia. Incisions may be made through the skull, behind the ear, or through the inner ear to access the tumor. The aim of microsurgery is to carefully, using fine instruments, remove as much of the neuroma as possible while not damaging the facial nerve.

If the tumor is too close to the facial nerve, it may not be possible to remove all of the tissue. The three approaches surgeons take to access the tumor are as follows:

• Translabyrinthine: a cut is made behind the ear, and the inner bones of the ear are removed. This method works for any size of tumor and is only used when hearing is already irretrievably lost.
• Retrosigmoid: a cut is made behind the ear followed by removing a part of the skull. The tumor is then located and removed.
• This method is used for medium-sized to large tumors that put pressure on the brain.
• Middle fossa: a cut is made on the side of the head to get to the inner ear. This is used for taking out small tumors that lie inside the ear canal.

Post-surgery care

• You will stay in the hospital for 3 to 5 days after the surgery
• Your pain will be managed, and you will be encouraged to walk
• You will need to see the neurosurgeon a week later for an evaluation
• Rehabilitation may be needed to help improve your balance
• Imaging scans such as an MRI can help show how much of the tumor was removed
• Full recovery can take a couple of months, but your neurosurgeon can give you a better idea based on your particular situation

Complications

Complication rates of microsurgery for acoustic neuroma are low, but the risk does increase depending on the size of the tumor. Removing a tumor larger than 3.5 cm, for instance, is more likely to result in complications than removing one that is 1 cm.

Complications include:

• Damage to the facial nerve
• Weakness of the facial nerve
• Damage to the cochlear nerve
• Hearing loss
• Tinnitus: ringing in the ears
• Dizziness
• Headaches
• Cerebrospinal fluid leaks
• Infection
• Vision and taste problems

References:

• Barker-Collo, S., Miles, A., & Garrett, J. (2022). Quality of life outcomes in acoustic neuroma: systematic review (2000–2021). The Egyptian Journal of Otolaryngology, 38(1), 1-26.
• Karpinos, M., Teh, B. S., Zeck, O., Carpenter, L. S., Phan, C., Mai, W. Y., ... & Woo, S. Y. (2002). Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery. International Journal of Radiation Oncology* Biology* Physics, 54(5), 1410-1421.
• Robson, A. K., Leighton, S. E. J., Anslow, P., & Milford, C. A. (1993). MRI as a single screening procedure for acoustic neuroma: a cost effective protocol. Journal of the Royal Society of Medicine, 86(8), 455-457.
• Smouha, E. E., Yoo, M., Mohr, K., & Davis, R. P. (2005). Conservative management of acoustic neuroma: a meta‐analysis and proposed treatment algorithm. The Laryngoscope, 115(3), 450-454.
• Zanoletti, E., Faccioli, C., & Martini, A. (2016). Surgical treatment of acoustic neuroma: Outcomes and indications. Reports of Practical Oncology and Radiotherapy, 21(4), 395-398.

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