ACOUSTIC NEUROMAACOUSTIC NEUROMATREATMENT OPTIONS 2009TREATMENT OPTIONS 2009

27th Alexandria International Combined ORL Congress

Alexandria Egypt April 10 2009Alexandria, Egypt April 10, 2009

Antonio De la Cruz MD

HOUSE EAR INSTITUTE

Antonio De la Cruz, MDHouse Ear Institute Los Angeles, California

Antonio De la Cruz, MD27th Alexandria International Combined ORL Congress

HOUSE EAR INSTITUTE

g

Alexandria, Egypt April 8, 2009

HOUSE EAR INSTITUTE

HOUSE EAR INSTITUTE

History of ANySandifort E, 1777–First AN in autopsy

Bell 1830Bell, 1830– First to diagnose AN in a living patient–Confirmed cpa tumor at autopsyCruveilhier, 1935,

-First to describe pathology

HOUSE EAR INSTITUTE

History of AN

Sir Charles Ballance, 1894,

• First to operate on acoustic neuroma

• Finger extraction

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History of AN

Cushing H: 1908

Intracapsular debulking • Intracapsular debulking

• 1906, described a death

lMortality

• 40% initially

• 20% after thirty operations

• 7.7% in series of 176 cases

• Others reported 75%

HOUSE EAR INSTITUTE

History of AN

Walter Dandy, 1917

• Moved focus to

surgical curesurgical cure

• 1917-1941 >

perfected the SOC

• Mortality of 2 4% in • Mortality of 2.4% in

last 41 cases

HOUSE EAR INSTITUTE

History of ANOlivecrona, 1950, 1967

304 t• 304 tumors

• GTR in 217

• 40% facial nerve

preservation rate

• 20% recovered facial• 20% recovered facial

nerve function

HOUSE EAR INSTITUTE• 29% mortality

HOUSE EAR INSTITUTEHOUSE EAR CLINIC

fHistory of AN

• William House, 1960

– Temp. bone anatomy– Translabyrinthine y

approach– Middle fossa app.Middle fossa app.– First to remove AN

with the microscopewith the microscope

HOUSE EAR INSTITUTE

Vestibular SchwanomasEarly Diagnosisy g

• History and Physical Exam• History and Physical Exam

• Audiological Evaluation• Audiological Evaluation

• Balance System and ENGBalance System and ENG

• Imaging of Auditory CanalsHOUSE EAR INSTITUTE

Imaging of Auditory Canals

Vestibular SchwanomasVestibular SchwanomasEarly DiagnosisEarly Diagnosis

• Audiological Evaluation

• Balance System and ENG

• Imaging of IAC and CPAHOUSE EAR INSTITUTE

V tib l S hVestibular SchwanomasDefinite DiagnosisDefinite Diagnosis

• CT & MRI must have contrast

• MRI + contrast => early diagnosis

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T2 FAST SPIN ECHOT2 FAST SPIN ECHO

Phelps, 1994p ,

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CISS/FSECISS/FSE

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ACOUSTIC NEUROMA

Treatment OptionsTreatment Options

1- Observation and Re-Scan

2- Radiosurgery- Gamma Knife

3- Total excision, single stage

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ACOUSTIC TUMOR 2009MANAGEMENT OPTIONSMANAGEMENT OPTIONS

N=400N 400

• Observation 20%• Observation 20%

• Surgery 70%• Surgery 70%

• Radiation 10%• Radiation 10%

HOUSE EAR INSTITUTE

ACOUSTIC TUMOR MANAGEMENTACOUSTIC TUMOR MANAGEMENTOBSERVATION + RE-SCANOBSERVATION + RE SCAN

• Older patients

• Small tumors with poor hearing- any age

T t if t th i 2 3 /• Treat- if tumor growth is <2-3 mm/yr

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HOUSE EAR INSTITUTESURGERY

Acoustic Neuroma SurgeryAcoustic Neuroma SurgeryPriorities

• Complete tumor removalp

• Preserve facial nerve function

• Avoid brain injury

• Hearing preservation if possible

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SURGICAL APPROACHESSURGICAL APPROACHES

•Translabyrinthiney

•Middle FossaMiddle Fossa

•Retrosigmoid/ Suboccipital•Retrosigmoid/ Suboccipital

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HEC Vestibular Schwannoma SurgeriesHEC Vestibular Schwannoma SurgeriesProcedure Type by Year

200

res

150

roc

edu

r

MFC100

er

of

Pr

TLCRSC

0

50

Nu

mb

e

0

Year of Surgery90 95 00 05

HOUSE EAR INSTITUTEHOUSE EAR INSTITUTE

HOUSE EAR INSTITUTE

BAHA(Bone Anchored Hearing Amplifier)

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HOUSE EAR INSTITUTE

HOUSE EAR INSTITUTEDr M. Kageyama Mexico, DF

HOUSE EAR INSTITUTEDr M. Kageyama Mexico, DF

HOUSE EAR INSTITUTEDr M. Kageyama Mexico, DF

HOUSE EAR INSTITUTE

HOUSE EAR INSTITUTEM. Sanna, MD Italy

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HOUSE EAR INSTITUTE

ULTRASOUND®SELECTOR®

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HOUSE EAR INSTITUTE

CSF Leak Prevention

• Block ET and Middle Ear with Wax-Surgicel• Block ET and Middle Ear with Wax Surgicel

• Suturing of presigmoid dura g p g

• Strips abdominal fat extending into CPA

• Titanium mesh cranioplasty

• Pressure dressing & Elevate HOB 30o

Titanium Mesh CranioplastyTitanium Mesh Cranioplasty

• Subperiosteal elevation of surrounding tissueg

• Mesh based on 3 sides ( 4 )(use 4 screws)

• Anterior edge placed • Anterior edge placed behind posterior EAC

• Provide lateral support to fat graft

Incision Closure Incision Closure CSF Leaks and Reop Rates

Titanium Classic

CSF Leak 3.3% 10.9%

Re-Op Rate 0.5% 2.5%

Fayad J, Schwartz M et al, COSM 2006Fayad J, Schwartz M et al, COSM 2006

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Post-Op CSF RhinorrheaTreatment Treatment

Early or LateEarly or Late

–Direct obliteration of Eustachian tube, infracochlear and middle ear spacesinfracochlear and middle ear spaces

–Blind Sac Closure of EAC–Lumbar drain

FACIAL NERVE FUNCTIONFACIAL NERVE FUNCTIONPOST ACOUSTIC NEUROMA SURGERY

House Ear ClinicN=500N=500

Facial Grade <1 5cm <3 5cmFacial Grade <1.5cm <3.5cm

I-II 81% 53%I II 81% 53%

III-IV 15% 31%

V-VI 4% 16%

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Delayed Facial ParalysisDelayed Facial Paralysis

• Retrospective 11 year review 1992-2003

• Incidence 25.5%Slattery WH, Hansen M. et al AAO-HNS 2006

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FAMVIR® (famciclovir)All patients undergoing AN SurgeryAll patients undergoing AN Surgery

• Facial Nerve Function Measured DailyF i ® 500 BID P O• Famvir ® 500 mg BID P.O.

– Started 3 days prior to surgery – Continued 5 days post-operatively

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Delayed Facial Paralysis

Controls 25.5%

Famvir Treated 14.5%

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ACOUSTIC NEUROMAS COMPLICATIONSACOUSTIC NEUROMAS COMPLICATIONS

M i itiMeningitis

1 5% ( 1% b t i l)1.5% (.1%> bacterial)

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HEARING PRESERVATIONMiddle Fossa ApproachR i id A hRetrosigmoid Approach

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HEARING PRESERVATIONHEARING PRESERVATIONFavorable IndicatorsFavorable Indicators

Good ABRT t t f d f IAC Tumor not to fundus of IAC RVR on ENGRVR on ENG

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L IAC Mass: 2mm x 4 mm

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Abordaje por FMedia

HOUSE EAR INSTITUTEBNI Phoenix, AZ

ACOUSTIC NEUROMA MANAGEMENT MIDDLE FOSSA APPROACH

•Tumor ↓ 1.5 cm.

•May be to the fundus

•Hearing 30 dB & 70% SDS

•Age ↓ 65

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MIDDLE FOSSA APPROACH

Wid b l• Wide bone removal

• Medial to lateral dissection

• Remove tumor only

• Topical papaverineHOUSE EAR INSTITUTE

p p p

ACOUSTIC NEUROMA MANAGEMENT

RETROSIGMOID APPROACH

Tumor = or < 2 5 cmTumor or < 2.5 cmHearing <30 dB >70% SDSNo history of headachesMedial – not involving distal ½ of IACMedial not involving distal ½ of IAC

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R id l T G hResidual Tumor Growth

Post-op MRI + Gadolineum

+ Fat SuppressionHearing Presevation Attempt => 1 Yr

No Attempt of H. Preservation => 3 Yrs

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HOUSE EAR INSTITUTE

Acoustic NeuromasAcoustic Neuromas

Residual Tumor GrowthResidual Tumor Growth

All A h 0 03 %All Approaches 0.03 %

T l b i thi A 1 1000Translabyrinthine App. 1:1000

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ACOUSTIC TUMOR MANAGEMENT ACOUSTIC TUMOR MANAGEMENT STEREOTACTIC RADIATION THERAPY

(RADIOSURGERY)(RADIOSURGERY)

• Gamma KnifeGamma Knife

• CyberknifeCyberknife

• Linacac

• Proton BeamHOUSE EAR INSTITUTE

ACOUSTIC TUMOR MANAGEMENT ACOUSTIC TUMOR MANAGEMENT IRRADIATIONIRRADIATION

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Radio-Surgery FailuresRadio Surgery FailuresSalvage Surgery N=89g g y

• Poor hearing salvageoo ea g sa age

• Facial nerve outcomes 50% poorerp

• Increased perioperative complications p p p

(CSF leak, ataxia, hydrocephalus)

• Poor ABI performance

HOUSE EAR INSTITUTE• Gamma knife

ACOUSTIC NEUROMA MANAGEMENT

STEREOTACTIC RADIATIONSTEREOTACTIC RADIATIONINDICATIONS

• Growing tumor• Tumor ↓ 3 cm with little doubt of

diagnosis on imagingdiagnosis on imaging• Younger patients who refuse surgery

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Stereotactic RadiosurgeryC t i di tiContraindications

• Tumors 3 cm

• NF 2 ( p53)

• Uncertain diagnosis

Di ti t ?• Dizzy patients?

• Facial nerve symptomsHOUSE EAR INSTITUTE

• Facial nerve symptoms

Radio-Surgery Failuresg y

Salvage Surgeryg g y

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ACOUSTIC NEUROMA MANAGEMENT

STEROTACTIC RADIATIONFAILURES

• To date 95 patients surgically treated after irradiation failureafter irradiation failure

• Size at time of irradiation average g1.7; range 1.1 – 2.6 cm

• Size at time of salvage surgery • Size at time of salvage surgery average 2.9; range 1.5 – 3.8 cm

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N i di t d TNon-irradiated Tumor

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Irradiated TumorIrradiated Tumor

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St t ti R diStereotactic RadiosurgeryMalignant TransformationMalignant Transformation

• 20 cases in the literature20 cases in the literature

• 4-5 year latency• 4-5 year latency

All Fatal• All Fatal

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ACOUSTIC NEUROMASACOUSTIC NEUROMAS

Surgical MortalitySurgical Mortality• Schisano et al 1956 - 41% mortality Schisano et al., 1956 41% mortality

• Arseni et al., 1970 - 25% mortality, y

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HOUSE EAR INSTITUTE

ACOUSTIC NEUROMAS

House Clinic

Mortality (1989-1998)y ( )(N = 1687)

• 2 patients (0.12%)

W. Slattery, MDHOUSE EAR INSTITUTE

W. Slattery, MD

CONCLUSIONSCONCLUSIONS

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Vestibular SchwanomasEarly Diagnosisy g

• History and Physical Exam• History and Physical Exam

• Audiological Evaluation• Audiological Evaluation

• Balance System and ENGBalance System and ENG

• Imaging of Auditory CanalsHOUSE EAR INSTITUTE

Imaging of Auditory Canals

ACOUSTIC TUMOR MANAGEMENT

3 OPTIONS3 OPTIONS- Observation + re-scan- Surgery

Middle FossaMiddle FossaRetrosigmoidTranslabyrinthine

- RadiationRadiationGamma KnifeFocused Stereotactic Radiation (FSR)

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Focused Stereotactic Radiation (FSR)

H i P tiHearing PreservationOutcome PredictorsOutcome Predictors

P h i l l• Preop hearing levels

T mo lo tion• Tumor location

• Tumor size• Tumor size

• ABR • ABR

• ENG (calorics)HOUSE EAR INSTITUTE

• ENG (calorics)

ACOUSTIC TUMOR MANAGEMENT OPTIONSMANAGEMENT OPTIONS

N=400N 400

• Observation 20%• Observation 20%

• Surgery 70%• Surgery 70%

• Radiation 10%• Radiation 10%

HOUSE EAR INSTITUTE

ACOUSTIC NEUROMA MANAGEMENT HECACOUSTIC NEUROMA MANAGEMENT HEC

CONCLUSIONS 2009

Microsurgery remains our treatment of choice• Microsurgery remains our treatment of choice

• Radiotherapy does not achieve a curepy

• 5-10% failure: excludes the chance of surgical

hearing preservation, 50 % worse facial nerve results

F ll d i l t d ti t• Follow-up and re-scan in selected patients

HOUSE EAR INSTITUTE

ACOUSTIC NEUROMAACOUSTIC NEUROMATREATMENT OPTIONS 2009TREATMENT OPTIONS 2009

27th Alexandria International Combined ORL Congress

Alexandria Egypt April 10 2009Alexandria, Egypt April 10, 2009

Antonio De la Cruz MD

HOUSE EAR INSTITUTE

Antonio De la Cruz, MDHouse Ear Institute Los Angeles, California