Case 1 (CS1, CS2)
FIGURE 1. Preoperative MRI scan showing the 2 cm acoustic neuroma in the left internal auditory canal.This 57 year-old woman presented with a several month history of tinnitus (ringing in the ears) in her left ear. Her doctor sent her to an Ear, Nose, and Throat (ENT) specialist who ordered an MRI scan of her brain. A 2 cm mass was detected in the left internal auditory canal. (Figure 1) She was then referred for consultation to one of the House Clinic physicians who ordered an audiogram. Her hearing was intact at a near normal level on the audiogram in the left ear. After consultation it was decided that the best treatment in her case was total surgical removal of the tumor via a middle fossa approach to try and save her hearing.
FIGURE 2. Postoperative MRI scan demonstrating total resection of the acoustic neuroma on the left. The whitish material on the left is a fat graft placed in the area of the surgery to seal off the space containing cerebrospinal fluid.Her tumor was totally removed. (Figure 2) The facial nerve function was perfect after surgery. Hearing was preserved within 10% of her preoperative level on audiogram. She spent 5 days in the hospital (including the day of surgery) and was back to work after a one month recovery period at her home. She has no residual problems after surgery and her tinnitus resolved by 3 months.
Case 2 (CS3, CS4)
FIGURE 3. Preoperative MRI scan showing a 3.5 cm acoustic neuroma exerting pressure on the brain stem and cerebellum.A 72 year-old man with Parkinson’s disease had been followed for several years by his neurologist and treated with medications. He became increasingly unsteady and could no longer walk without the assistance of a walker. This deterioration prompted his neurologist to obtain an MRI scan of the brain. This demonstrated a very large tumor on the right side consistent with an acoustic neuroma. (Figure 3) An audiogram was performed which showed the patient had completely lost hearing in the right ear. The patient’s age and symptoms dictated that a reduction in tumor size to relieve pressure from the brainstem was the goal of treatment. The most effective way to accomplish this is surgical debulking of the tumor.
FIGURE 4. Postoperative MRI demonstrating an approximately 90% reduction in the size of the tumor. The patient had no neurological deficits as a consequence of surgery, made a full recovery and actually improved neurologically with the pressure off the brain stem and cerebellum.The patient underwent a retrosigmoid approach for debulking of the tumor. (Figure 4) The surgery was performed in less than 4 hours and the patient spent one night in intensive care. After surgery facial nerve function was perfect and he had no new problems. He made an uneventful recovery, spending 6 days in the hospital and returned home. His unsteadiness improved and he was able to walk without the walker by 2 months following surgery.
Case 3 (CS5, CS6)
FIGURE 5. Preoperative scans showing the very large acoustic neuroma. This set demonstrates the different views obtained by plain CT, CT with contrast and MRI with contrast.A 26 year-old woman first noticed hearing loss and balance problems 4 years prior to her referral to the House Clinic. She was seen by a neurosurgeon in her city 2 years earlier and was diagnosed with a right-sided 2 centimeter diameter acoustic neuroma. She was told not to worry about this since “these tumors grow slowly”. She continued to gradually lose her hearing and then began having difficulty swallowing. A CT scan of the brain and MRI were then performed showing the tumor had indeed grown significantly over 2 years. It was now 6 centimeters in diameter. (Figure 5)
FIGURE 6. Postoperative CT scan with contrast demonstrating total tumor removal.The patient and her husband researched their options and were directed to the House Clinic in Los Angeles, opting for the most experienced center in the world. She underwent a translabyrinthine approach for a total resection of the tumor. (Figure 6) Her facial nerve was preserved anatomically and had some function after surgery. Facial nerve function has subsequently improved. Her unsteadiness resolved as did her swallowing difficulties in the months following surgery.
Case 4 (CS7, CS8)
A 59 year-old man experienced gradual hearing loss and was diagnosed with a 2 centimeter acoustic neuroma. He underwent surgery via a retrosigmoid approach at another institution. His hearing was lost completely and he had some weakness of his facial nerve. Eighteen months later he had a follow-up MRI which showed that the tumor had returned, again approximately 2 centimeters in size. This time he opted for treatment with the gamma knife. He received a dose of 26 centiGray and had no side effects from radiation.
Two years later he had a routine follow-up MRI scan, which unfortunately detected a tumor that measured 2.5 centimeters in size. (Figure 7) The tumor was growing, despite the gamma knife treatment with a very high dose of radiation. (Figure 8) He then sought the help of physicians at the House Clinic.
FIGURE 7. Post gamma knife MRI scan showing the growing tumor 2 years after stereotatic radio surgery.
FIGURE 8. Histologic section of the acoustic tumor removed by House Clinic surgeons which contains many active tumor cells. These are present despite previous treatment with gamma knife radiosurgery.
A translabyrinthine approach was performed and the tumor was completely removed. Unfortunately, gamma knife treatment had resulted in scar tissue formation around the tumor and the facial nerve. This made it impossible to save his facial nerve and he was left with an immediate total facial paralysis. Several days following his surgery he underwent facial reanimation surgery. His surgeon connected the nerve that moves the tongue to the facial nerve, called a facial-hypoglossal anastomosis. He has since recovered some of his facial function, but still has some weakness.