Atlas of Acoustic Neurinoma Microsurgery - M. Sanna, et al., (Thieme, 1998) WW

218 Pages·1998·41.43 MB·English

Atlas of
Acoustic Neurinoma

Microsurgery

Mario Sanna
Essam Saleh
Benedict Panizza

Alessandra Russo
Abdel Taibah

with the collaboration of
Refik Caylan.

Fernando Mancini
Giuseppe De Donato
Maurizio Falcioni

Thieme
Atlas of
Acoustic Neurinoma Microsurgery

Mario Sanna, MD
Protexor of Utolaryngatogy
Dept. of Head and Neck Surpery
University ot Chiet

Chieti. aly
Irsututo Seientibco Ospedale San Ratlacle

Rome, Kaly

Gruppo Otologico

Placer, lly

Essam Salch, MD. Benedict Panizza, MBA, FRACS.
Department of Otolaryreetogy ‘Gamott Pesse and Roney Williams Mearoral
ead and Neck Surgery Foundation Clinical Fellow

University of Alexandia, Egypt Gruppo Otelogico, Piacenza. Italy
Alessandra Russo, MD Abdel Taibah, MD

Gruppo Otolegien Gruppe: Oral

Piscerm, (1aly Placenz. Italy

with the eolaboration uf
Refik Caylan, Fernando Mancini, Giuseppe De Donato, Maurizio Falcioni

Foreword by William F, House

452 illustrations, most in color

Thieme
Stuttgart - New York 1998
wv

Libvry of Cores: Caton Pbeton Dat
‘Aids of acastie neucceta ndrosuges Mario Sanne [4
‘a1]: with comirfantons by Reh Cinlan eta] :tovenoa by
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Incl iographicl referees and ee:
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fee Libary 8 Coes

‘Natio Sanna, MD
Prefs ef (nolerynprogy end at Nek Surpary
University of Chie Chie aly

Gruppe Orogion

Pincers. lay

Alesana Rusa MP
‘Abdel Tatab, MD
Giuseppe De Donate MD
‘Mauris Fukioal MD.
Gray Oro
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“Ts ok mas supported by gran fram AINA. (Aan
ere Mallana Newo-Crologes) and ASA. (Aucocsrione
Stati Aglouancento Barano)

‘CwverGesgn by Renu Stosange. Sate

{© 148 Georg Theme Verlag, Rodgestrae 14,
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‘rite in Germany by SudiehDruck. Denauvt

ISBN 7.13 1102810 (GTX, Sungar)

ISBN 0365777268 (PAR New York) lasase

Esam Saleh. MD

Deporsmeet of Otetannoleg, Head and Neck Sorgery
Unneray of lends, Et

ened Punizes. MBBS, MBA. FRACS
ete tgctogt Hood and Neck Speen
Brnfeoe, Aieali

aie Casta aD
ENT Deparment
Unters of Karadenis
Teun Takey

‘portant Note: Medicine san everchangng seen. Re-
serch ae eSnkal aperence are eomincale expan cr
‘owl. npaniculr our inowkage of groper aesrent
she erup traps: nstar a nk Rock meters Se Some
‘aplietion exderemay restassured thet the author.
(eos tral pulses ive made evry effort to esate tha
‘eh relerences eet aondance wih hve midge
tke time uf peodocton of de book

[Nevertieless, thie does sok inal, ily, express ony
sguannee or respon he puri pubes it
Fespec 0 any cusoge irons ae forms ef ppaction
etd te boo Brey wer eu lo exams ee
{hy te manulaclurerseallesaccorrpanying each dup and
te deck, necessary in consi vith api a Spe-
ne, hate the dovage sehen reat erin OF
the-congaindlatons ated by he manfctres fer fer.
Testers nadeinthepresanbock Such exabetns
portico port wah cus ht are eter rarely sed
Or have brea bce iheased ee he market Every dost
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ter rbd expen The utr nd phe ro
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Srimonaces mle

Any reference ta or meson of manufacturer ov spec
ted names hou px be eepeved as an endorsement of
‘neritenent fo an cnn oF pend

Some athe produc nares, pales veered dens
referred to inthis Book ate ft Fegiterd edema of
ropretay nares even thoughspecl ference to ak
ot sivaye mie inthevext Trfer the appece 08
rare without desiginion as popstar ot 1 be cor
Stic ws raprcnnation by the publ Unt i i Uae
fable deri
Foreword

‘Twenty years ago, Mario Sanna spent several wocks
vith me in Los Angeles as an intreductin to ctologic
suigesy. Forunately be became very interested in
‘scoustic neurinoma surgery ‘this Book is a com
pendium of how Mario has greatly expanded what 1
‘yas uble te show him ine the informarinn in this hock
Tam proud tat he has become one of ny very special
students who has not only vesly extended his know
‘edge, but who bas also taught many otbers what he has
learned and developed in the field of acoustic neuti-
‘ona microsit gery,

‘Present scl future skull base ricresurgecs will
Gnd this book to be a major resourve, Iisa hack ws be

acfuly studied by youn surgeons who ate develop

theie ais this field of surgery. Those who rea
feady sorking wih patents with vondiGons described

this book wil find that re-reading seaments of the
book wll grey benefit their management ot the many
spect of acute neurinoma ad sul ae surgery

1 would be asadstloi leah vould not See his
siden supess his econ plisunents, Iti very raify-
ing for me wo have played a par in Mario's He and his
‘work chat has saved so mang ives and nrade ther hap
Per by avoiding onsecessary NeUrtgi deficits.

William F. House, DDS, ME
Preface

‘This utlas on the microsurgical removal nf acoustic
‘eurinomas was written 10 provide surgeons from the
fields of both neuro-otology and neurosurgery with
access tna detailed, lop-by-slep description of the re-
‘moval of thete lesions, Real ease photographs ware
used lo prevent the misinteepretation aud evofusion
that can arise with stylized drawings. ‘Ibe muraber of
photographs used reflects rhe detail of the deseription
[eevided, the intensinn being nol Us leave annoying ine
eematicn gaps thatthe reader must then sometow El
‘Anatomical and pathological variations requiring an
Alteration of surgical strategy are also included in the
hope that the reader will encounter fewer surprises
when performing this type of surgery.

cis important fo note that great stides have been
‘made in the removal of acoustic neurinomas over the
Jest three to four decades. We all, of course, owe a great
deal u Wim House, who initiated the enormuns el
vances mode inthis field, and to his forward-thinking
colleague, Wiljam Hitselberper. Testing, inthe frm of
electrophysiological astessmient, and computed ton
feraphy and mapnctic resonance imaging have made
the seréening and diagnos ofthese tumors more reia-
tie. Intzoperative monitoring of the facil nerve is
‘now routine, and it has been shown to improve the
Postoperative facial nerve results, More recently,
Cochlear monitoring le been usc! in casts in which
eating preservation is attonipted. ft should be stressed
‘hat heaving preservation is an importa goal in acous-
Tie tumor removal, but that st remains secondary to tbe
preservation of life and facial nerve function and to
lotal tumor removal. Tt is only of use in wery selected
ceases, and shoul not be wel as an argument far
specific approach, when its real benefits to patients (he
‘asl migorly of shim have umlateral famors, with
reat notmal contralateral hearing) have been Title
studied More recently, endeseopes have been used in-
Iraoperaively, and their role in removing acoustic
‘neurinomas.is discussed in Chapter 9.

‘The present book represents the philosophy of
acoustic ncurinoma renival used hy the Grlppo
‘Orelogico in Piacenza, Italy, Wis based on the ex
[Perienne af the senior authoe over a period of more
Mian 20 yours Tt doseribes the three prinepal ep
proaches for removing secustic tumors (reansabyrin-
thine, retrosigmond, and mide fossa), and the modifi
cations ofthese approaches that we have used in ordet
tn obtain better results We have attempted to cover all

aspects of patient care, from preoperative assesment
te pestopetstie tolow-up. Each ofthe surge Chap
ters (Chapters 5-8) also includes a section on “hints:
sn pitti” These pies and wring sins are cay
observed through years of experience, and they are
thane here wo a help lhe to id mistakes

‘should ike to scknosiedge ry indebenew in
the rt place to De. A. Mazon who has ellaboesi
vith me over many yon The rainy discesons and
“tcl analytes of our work thal we ve ied out
together, both nformaly daring surgery aa mere for-
inp nthe riny papers we have covsuhored, bas of
course shaped my techniques T would also Tike the
think my co-auhory Essam Saleh and’ Benodet
ania, Essumn culor completed x twngear ele
fefowshipin the Uni, snd eturned io continu is in-
velvemest in wring the books the Unit produced. His
‘ogumental efforts were intrumental in bring the
took to completion. Ben joined he unit >the Garnet
Pio nd Ridecy Willis Memorial Foundation
Ginia Fellow, ding the inital stays the book
Preparation. His fe perspective and clots working,
‘alaionship wih Essa wat ef eourmows bey

wld bt ket thnk Dre Alesends Russo
sal De AbleL Kuler Tab. They fave worked a
par of iy team for many years al are inspec
tn helping me with eugery and in pepesuive and
postoperative patent care

“Thanks ao go wo the who have aborted on
this book~ Dr, ReGk Casta, who nilly started the
project and Dx. Fakioni Br. De Donato and De Mane
SSnivako work wthme inthe clini, Special henks also
20 fo Mis. Daniela Mancini forthe ansrations in
Shika in he book

‘As lays, there are numerous ches 10 whom
Shanks ate de-—all my eine nd research fellows
sho liste helped nie theugh thei esearch projects
lint ther persitem questioning in the pursuit of
Knowledge. Thanks aha go to De. Cliford Bergman,
niedicl editor st Georg Terme Vedap, fo
roperation nd help.

"Fialy Tw He toepres iy thank nd ded
«ae this boc, tal the fanilies fe people centrally
involved i he peodction of te bok and in myn
cal work Iris weir sacrifices tha have made the work
posit,

‘Mario Sanna, MD
wl

a
1

vestigations 1
‘Thromboembolic Propiylasis 1
“The Immediate Preoperative Period. 1
“Operating Room Setp ccaeaer 3
Posleperative Management 10
Dressing, 10
Drains nT)

Exiutation
High Dependency Unit
“Transfer to the Ward

Lestoperative Mediation
Facinl Nerve.
Drestings and Stiiches
Discharge oe...

Fallow Up.

2 Surgery in the Cerebellopontine Angle: General Concepts

Sune! Orctaton in he Casbelpontine
‘Angle o
Taternal Aucitory Canal
Cerchellopontine Angle
‘Surgical Techniques inthe Sarin

iting,

Management of Bleeding
"Mempalir Captain,

3 Radiological Evaluation
Overiew
“Assessment of Tumors
“Tumor Size
Tumor Pesition and Shape «

Bipolar Cosgotation : a
Bleeding from Bony Suriscrs 1"
Gadatin Sponge v
Onidized Cellulose and Oxidized
Regenerated Cellulose ....--- a

iow to Deal with Brsia Tissue and Ouker

‘Neurovascular Strucuzes v

‘Technique of Tumor Dissection wid

Remenal 0

“Tumor Extension and Lavolvement of Adj

‘cent Structures Fa

‘Other Festures a
Differential Diagnosis ny

‘Residuel Tumors.

4 Decision-Making in Acoustic Neurinoma Surgery

Surgical Versus Nonsurgical Treatment
‘Smell Neurons 3
‘Avoustie Neurinoma in the Only Tearing

3s
cs

8

36

5 The Enlarged Translabyrinthine Approach
Rutionale ...
Suigical Anatomy |.
Inications
Contraindictious
‘Suigical‘eehnigue
Tumor Removal.
Removal of » Modium-Sired Right
Acoustie Neutinomia
Removal of = Large Right Acoustic
Neurinorsa

‘Selecting the Surgical Approuch ca
‘otal Versus Subtotal Removal. 38
‘Specie! Situations 8
“Tumors in Patients with Preqperstive
“Hyrooephalus - %
‘Type 2 Neurofibromaenie Paticnts 35
Removal of ¢ Small Right Acoustic
Neunsoma . ”
[Removal of « Small Right Acoustic
‘Nouriner 6
‘Special Considutulions in the Tranwlanyrinehine |
‘Approach al
‘Problems Lacouatcred during the Approach
(Fore Phase) a
Munuyement of Anatomical Variaata <0. 81
Mexigement of Surgical Mishaps. ”
Special Cosaratons Dung Tumor

Rationale .
Surgical Anatomy — aoe
Indications 0-00-0002 TIT aaa
(Conmraindicaticns

Summary

Surgical Techmique «. 14
“Tamer Removal... oc
Removal of Medlal Tumors -

Hint and Pafalls.
Summary ee. 00.

7 The Enlarged Middle Cranial Fossa Approach

Rationile ......ecseeseeseeseeee 144
Surgical AAutamy 21s
Tndivatinns « hae
(Contraindicatioas car
Special Pestcning hier
8 Other Approaches
The Transotic Approach 187
Rationale .. 1167
Indications 167
Contrainte 168
Songical Technique 2168
Turner Removal Due
Hints and Pitfalls lim
Summary « fi

Surgical Technique
Tumur Remowt
Removal of a Tumor Dispacing the Facial
Nerve Posteriorly

‘ints and Pitfalls

Summary

‘The Modified Transcochlear Approach
Rationale ......+
Indications
Contraindications 20.00.0000)
Surgical Technique.”
Hints and Pitas. 2
Summary.

9 The Role of Endoscopy in Acoustic Neurinoma Surgery

Introduction .
Endoscopic Surgical Anutony _
From the Posterioc Aspect of the Temponal
Bone: Retrosigmoid Approzct -
‘Through the Superior Surface of the
“emporl Rone: Enarped Mile Fos
Approach

= 183
at)

Postoperative Complications Specific bo Cetebel.
lopontine Angle Surgery... 2. eeeeeeeeeeeee
Memorhage ---.e.cesssscescese
Infarction

Cerebrospinal Fil Lenk.

g 8 BRRRBEE g

Applications
“Trarstabyrinikine Approush

Risks of Cerebellopantine Angle Endoscopy

Residual Tumor .
Attia .. u
Oter TINE

General Complications..." :
‘Alelecass and Preunonia
Deep Vencus Thrombosis and inonary
Embolim
‘Wound Infection and Hematoma
‘Transfusion ..

i sii
Index 211

contsinications 180
Wine 182
Indleations 180
ae 2

glad technique 180

N
Nene(9)
stbekcent 104
rata) 203
eis 23
facia)
Position retetne to tamor 9
oserior displacement 155
poseperative statis 12
loser erst 108
eigen 1
trachea 108
‘Neurofiremataca type 38
‘Neurmascular etrucures
‘eoustc neurnoma 13

o

Opecating roe eetop2
onyeelT

invasion by aoastie neurinoma L1¢
“Thrombosis
‘Seep tenott 204
‘Tims 258
“Traalabyrevhine approach
‘eakncopy 189
alan?
toma vite 81

itwotvement of aacen stucres 24
postion 2.

renova technique 18

sida 34,278.
1 Introduction

Diagnosis

Acoustic neurinomas ean present with a variety of
symplons. The elacsicl presentation is one of asyt
‘metical sensorineural hearing loss associated with tin-
‘Me investigate any
semsorinetrel hear
ing loss, sudden deafness, unilateral timitus, unstead
Ines, oF cranial uerve syniptoms. which mity preset in
combination oF separately. The investigation alway
includes » pure lone suchograva and speech dscrinins=
lion. Whether to procaed to auditory bean stem

sespomes (ABR). computed tomography (CT), or
srggetieresouznceimaping (MRI) isa complex dec
sion thats changuig with tine and technological
Sevelopments Necless to sa, the Felaive cos of
‘how invetigalions (which vary belween eotmtrics)
ad the Ieyel of suspicion for pethulogy will dite
‘which ivestigtive path o take.

Preoperative Workup and Preparation

lm Investigations

Along withthe radiological evaluation (see Chapter 3),
itis routine to perforay audiolugical testing if this bas
not steady been done as described abewve, A ist ofthe
fests carned out to help assess the patients fitness for
surgery is shown in Table 1. In adeition, of the euro
is larger than 2 em, provisions ate made for an autolo-
0s blond transfusion,

To avoid interference with their normal coagule-
ign pathways. patients arc advised net to take any new
Lugs in the 30 days preesding surgery: Specie mon-
tion is made of saiesetes and nonstervel untinflam-
matory drugs.

‘@ Thromboembolic Prophylaxis

Hepstin is aot used, amd no prublems have eawurred
ath respect to clisically wppurent deep venous throm
bonis or pulmonary embolism. Compressive stockings
ate apphed prenperatively. and the patients are aetive
Fy encuurayyd to mobilize ezy.

@ The Immediate Preoperative Period

Routinely, a nasogasric tube and indwelling catheter
fate inserteal while the patient ix om the ward. Hl 01
hour before induction, 2g pipertilin (Avocin) is pie-
enintravenously.

‘le 11 Ravine pera patent escation
Ful ocd ount

serum este

Prothwonb te 7, acieted poral Beorboplastn dire
earn,

Bed group deci Rh

Ure ore dchoies

epee Band human imrunedefiieeey uns QV) secerig
(elle pants de 30°)

Gucse

Urns

Let enzymes (ST, AST, ALT LDH

Poniny

Bestcrdogror ond carduloy evslucbon

Chestradegiach
21 Irtvotuction
Operating Room Setup

“The operating room sotup is shown in Figure 1-1. eis
important that the number of personnel s limited lo
thuse absolutely necessury,

‘The operative site is prepared by shaving the
patient houd fo unpeimimately 4 cm short ofthe mic
Tipe. Bouh a Myoalsiin (Ouolab) (Fig 1.2) and a Nerve
Integrity Monitor-2 (Komed-tirvace) (Fg. 1.2) re use
for facial werve monitoring. As the NIM-2 docs 101 func
‘ion during bipolar disthermy. dhe Myealani is also
used te increase the reliability of monitoring of the
facial nerve. Pais of needle eletiodes are placed in the
lorbicularis ecali and erhiculesis oris museles to allow

electromyographic monitoring of the Fecal
M2). A pressure transducer inthe form of a
balloon is neat inserted into the upper ipsilateral gine
sivobuecal sulcus, near the canine fossa, to alow divect
Iasucetamt of facial mupele contraction (Mynarm)
{fan attempt is being nade w preserve hearing, eniysk
Iaderat ear stimulator is applied, and electrodes are
inserted for auditory vain stem esponse (ABR) and
direct eighth-nerve action potential nioniworing
(Fig. L3)-The operative site is then prepared with ether
10 ppam. followed by Citosl (Glaxo, Tay.

Fig. 11a Operating ‘oom seni fr the enlarge
\Wordobynrthine ari retest argroaches. b Operating
oom se up for Ue erage ee rama os approach.

Enqupmeet and persorol:
1 Auch sand
2 Operating micescepe

5 Sen me
6 teriteing datherry and setion ane
7 each te

8 Imgation att cp tarde

© poesteist

10 Anesthetic mache