TITLE: Cerebellopontine Angle Tumors with Focus on Vestibular Schwannomas

SOURCE: ran! Roun!s "resentation# Uni$ersit% o& Te'as (e!ical )ranch##

*ept+ o& Otolar%ngolog%
*ATE: September ,-# .-/-
RESI*E0T "12SICIA0: An!rew Coughlin (+*
FACULT2 "12SICIA0: Tomo3o (a3ishima (*# "h*
*ISCUSSA0T: Tomo3o (a3ishima (*# "h*
SERIES E*ITOR: Francis )+ 4uinn# 5r+# (*
ARC1IVIST: (elin!a Stoner 4uinn# (SICS
"This material was prepared by resident physicians in partial fulfillment of educational requirements established for
the Postgraduate Training Program of the UTMB Department of Otolaryngology/ead and !ec" #urgery and was
not intended for clinical use in its present form$ %t was prepared for the purpose of stimulating group discussion in a
conference setting$ !o warranties& either e'press or implied& are made with respect to its accuracy& completeness& or
timeliness$ The material does not necessarily reflect the current or past opinions of members of the UTMB faculty
and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion$"
Introduction
The cerebellopontine angle (CPA) is a dense area of vital neurologic tissue. Tumors growing
in this region can cause significant dysfunction and even death if allowed to grow too large. They
represent 10 of all intracranial tumors and although the differential is !uite e"tensive# $% of
tumors in this region are vestibular schwannomas (1). The second and third most common
tumors in this region are meningiomas and epidermoid tumors respectively. Autopsy studies have
shown an incidence of CPA tumors to be 1.$ to &.$ however a single '() study loo*ing at
10#000 films obtained for non+otologic reasons showed only $ positive cases (&+,). -ecause of
the significant dysfunction these tumors can cause# timely diagnosis and treatment are
paramount.
History of CPA tumors
)n 1%., /ir Charles -alance was the first surgeon to successfully remove a vestibular
schwannoma. 0ue to the significant morbidity of the surgery# however# his first patient died
shortly after the operation from complications. )n 1.0$# -alance# improved upon his previous
outcome and performed a successful surgical e"cision without the patient mortality. 0espite this
outcome the patient still had significant facial nerve paralysis complicating the e"cision (1#2). )n
1.1$ 3arvey Cushing pioneered the subtotal resection through bilateral suboccipital craniectomy
and described the CPA syndrome ($). The CPA syndrome is the constellation and progression of
symptoms as a CPA tumor grows larger. Cushing described it as ipsilateral hearing loss followed
by facial hypesthesia# hydrocephalus# and finally brainstem compression and death.
0espite the high morbidity and mortality rates# surgeons continued to improve upon previous
results# and in 1.&1 4alter 0andy reported a mortality rate of only 10 using a debul*ing and
capsular resection techni!ue (%). 'ost recently in the 1.205s 4illiam house advanced the
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
surgical techni!ue of resecting CPA tumors by introducing the microscope and dental drill# the
translabyrinthine approach# and the middle cranial fossa approach (.+11). 'uch of what 3ouse
accomplished is still considered standard of care today.
Anatomy and Tumor Biology
As stated previously# the CPA is an area densely pac*ed with neurologic tissue and any tumor
growth can cause significant dysfunction. Cranial nerves 6+6))) are affected with more
superiorly based tumors# whereas tumors that e"tend inferiorly can compress cranial nerves )7+
7)). 8"tension to the cerebellum laterally can cause generali9ed ata"ia and even opto*inetic
difficulties with compression on the flocculus. -rainstem compression leading to fourth ventricle
obstruction can lead to hydrocephalus# respiratory depression# and death.
6estibular /chwannomas arise from /chwann cells within the )AC and arise from the
/chwann cell rich 9one of /carpa5s ganglion (1). There is an e!ual fre!uency of vestibular nerve
involvement between the superior and inferior segments# however involvement of the acoustic
portion of the nerve is rare.
6estibular schwannoma formation is thought to be due to a defect in the tumor suppressor
gene :;& found at &&!1&. The :; & gene prevents /chwann cell proliferation. The sporadic
form of unilateral vestibular schwannomas represents .1 of cases (1&). )n this case there are
two hits to the normal :; gene. Patients with :eurofibromatosis &# however# inherit one
defective gene in an autosomal dominant manner# and then develop a genetic defect in the second
normal allele. ;or this reason they are predisposed to developing bilateral vestibular
schwannomas.
/everal studies have loo*ed at the biochemical effects of different agents on the growth of
vestibular schwannomas. :euregulin is a hormone e"pressed by /chwann cells to control
proliferation and survival of /chwann cells (1). /everal chemo*ines such as ;<;# T<;+-# 68<;#
and P0<; are all chemo*ines that have been evaluated as potential targets to prevent tumor
growth (1=+12). /tudies in the past had previously shown increased growth of vestibular
schwannomas during pregnancy but more recent studies have failed to show an increased growth
rate dependent on se" hormones or their receptors (1$).
Symptoms and Signs
/ymptoms and signs are highly dependent on the epicenter of the tumor. )ntracanalicular
tumors often present with hearing loss# tinnitus# or vertigo. Tumors e"tending into the CPA will
li*ely have dise!uilibrium or ata"ia depending on the amount of e"tension on the brainstem.
4ith -rainstem e"tension midface hypesthesia# hydrocephalus# and other cranial neuropathies
become more prevalent. 6estibular schwannomas most commonly present with sensorineural
hearing loss# followed by tinnitus# dise!uilibrium and facial hypesthesia in decreasing order (1&).
>nilateral hearing loss is present in greater than %1 of patients (1%) but 1 of patients with
vestibular schwannoma will have no associated hearing loss (1.). )n most instances of
retrocochlear losses# despite the sensorineural hearing loss# many patients will have speech
discrimination scores proportionally worse than the observed hearing loss. Patients will therefore
complain of difficulty when tal*ing on the telephone.
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
/udden /:3? will be present in about &0 of patients with a vestibular schwannoma (1&)#
but only 1 of patients with sudden /:3? have a vestibular schwannoma (&0). ;ifty percent of
patients with vestibular schwannoma and sudden /:3? will have spontaneous recovery and
therefore you cannot simply rule out a vestibular schwannoma if they recover.
Tinnitus is the second most common presenting symptom and can present in a variety of
ways. )t can be present without hearing loss# it can be described as a roar# a high pitch ring# or
even hissing# and it can even locali9e to the opposite ear. Therefore any person with a complaint
with unilateral hearing loss should at least be evaluated with an audiogram.
6estibular complaints are present in =2+10 of patients and will describe a vague or transient
lightheadedness. They often will @ust have some dise!uilibrium. Acute vertigo is the presenting
symptom in only about &$ of patients and is associated with smaller tumors (1).
;acial hypesthesia is the presenting symptom in only , of patients# is associated with larger
tumors A&cm and commonly will affect the ma"illary division of cranial nerve 6 first. The
corneal refle" is often the first symptom but involvement of the muscles of mastication can also
occur. ;acial wea*ness is rare with vestibular schwannomas# and if present# should be grounds to
assume there is a different type of tumor.
Bcular complaints are rare and can range from simple loss of corneal refle"# to true ocular
dysfunction. :ystagmus toward the affected side# diplopia from involvement of cranial nerve 6)#
and blurry vision from hydrocephalus leading to paapilledema and optic atrophy.
Physical e"am findings of an acoustic neuroma can include an absent corneal refle"#
wea*ness of the temporalis or masseter muscles# hypesthesia to pinpric* and touch# nystagmus#
and other cranial neuropathies. 3istelberger5s sign is present when the sensory portion of cranial
nerve seven is absent but the motor portion is intact. The actual sign is hypesthesia of the
e"ternal canal (1). ;inally you may identify gait disturbances or difficulties on finger to nose
testing.
Workup
Audiologic testing is paramount when evaluating a patient with a suspected CPA tumor or
vestibular schwannoma. A downsloping high fre!uency hearing loss is the most common finding
on audiogram in about 21 of patients (&1). ;ive percent of all patients will have no hearing loss
(&&). (ollover is a term used to represent retrocochlear hearing loss where patient5s speech
discrimination is worse than e"pected based on pure tone averages that become worse as the
sound is intensified.
There are two classifications used to represent the different stages of hearing loss and can be
seen in Table 1. 'any papers use these classifications to compare preoperative and postoperative
hearing abilities for !ualitative purposes. 'ost papers recogni9e serviceable hearing as AAB+
3:/ class A or - and <ardner+(obinson class 1 or &. 3earing classification is also very
important when determining what surgical procedure a patient is !ualified for based on their
preoperative hearing scores.
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
AAO-HNS classifcation
Class Pure tone average (0.5, 1, 2, 3
H! "easure# in #$ H%&
S'eec( #iscri"ination score ()&
A 0*30 +0*100
$ 31*50 50*100
C ,50 50*100
- An. /50
0ar#ner-1o2ertson Classifcation
Class Pure 3one4S'eec( 1ece'tion
3(res(ol# (#$ H%&
S'eec( -iscri"ination Score ()&
1 0*30 +0*100
2 31*50 50*56
3 51*60 5*76
7 ,60 1*7
Table 1. /howing different classification schema for hearing loss.
)n addition to audiologic testing# acoustic refle"es can also be used to show a retrocochlear
loss. Acoustic refle" testing has an %1 sensitivity for identifying abnormalities. An abnormal
test will be an increased or absent acoustic refle" threshold compared to cochlear norms. This is
not considered a reliable screening test.
Auditory -rainstem 8vo*ed (esponse testing has a sensitivity of %1 to .0 with a false
positive rate of only about 10. ;alse negative rates were much lower in the past but have
increased to about 1%+=0 due to improvements of imaging techni!ues to find smaller tumors
(&,). 0uring the test five waveforms are produced and a latency of A0.& milliseconds in wave 6
is diagnostic of a retrocochlear loss. )n patients with a low inde" of suspicion for a vestibular
schwannoma# this test can be used for screening purposes.
6estibular testing or electroneurography will show some form of abnormality in $0+.0 of
patients (&1) but 10 of small tumors will produce no abnormalities (&2). Abnormalities in
caloric testing on the ipsilateral side is usually the only abnormal finding# however compression
on the cerebellum and flocculus can lead to opto*inetic abnormalities. )nterestingly this test
pic*s up .% of tumors involving the superior vestibular nerve but only 20 of patients with
tumors involving the inferior vestibular nerve. This is because the superior nerve innervates the
lateral semicircular canal which is tested with calorics where the inferior nerve is supplies the
other two portions of the vestibule (&$). Therefore this cannot be used to screen for vestibular
schwannomas.
)maging is really the gold standard for identifying vestibular schwannomas and other CPA
tumors. Bn CT imaging .0 of tumors will enhance with contrast but the diagnostic accuracy is
only 2= (&%). CT scanning fre!uently misses tumors that are e"tracanalicular and tumors not
e"tending A1mm to the CPA. '() imaging on the other hand is the gold standard for vestibular
schwannomas. Tumors preferentially ta*e up gadolinium for visuali9ation of smaller tumors as
small as =mm in si9e (&.). Contrasted studies will show a hyperintense signal on both T1 and T&
images but non+contrasted studies will show hypointense lesions on T1 and isointense lesions on
T&. /ome institutions have used T& fast spin+echo '()5s as a screening test in those with
contrast allergies# but most patients with abnormalities will re!uire a formal study (=0).
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
-ecause meningiomas are the second most common type of CPA tumor it is important to be
able to differentiate it5s characteristics from that of a vestibular schwannoma on '(). 6estibular
schwannomas will have more of a globular appearance# centered on the internal auditory canal#
and may resemble an ice cream cone. )n contrast# a meningioma will li*ely have more of a
sessile appearance with a Cdural tailD at the periphery and will be hypointense on T1 images but
hypearintense on T& images.
Differential Diagnosis
As stated previously# meningiomas are the second most common CPA tumor and represent
about = of all CPA tumors (1&). They do not metastasi9e but do recur due to bony invasion.
They are formed from cap cells around the arachnoid villi near dural sinus5 and where cranial
nerves enter their foramina. <enerally these tumors are not intracanalicular and therefore must be
much larger to produce hearing loss. /ymptoms and signs again depend on the location of the
tumor. )ntracanalicular tumors usually present similar to vestibular schwannomas. Btherwise
they often present with spontaneous nystagamus# facial hypesthesia and gait ata"ia. )f they
e"tend inferiorly they can produce hoarseness# dysphagia# shoulder wea*ness and even tongue
atrophy (=1). ?i*e vestibular schwannomas# hearing tests will show retrocochlear losses and the
A-( will be normal in &1 of patients (=&). Treatment is surgical but you must remove a rim of
normal tissue due to the bony invasion to prevent recurrence.
8pidermoid tumors are histologically the same as cholesteatomas and develop from epithelial
rest cells. They are slow growing and often do not present until the second or third decade. These
tumors will often follow the path of least resistance and therefore will often be irregularly shaped
and !uite large before causing symptoms. ;acial twitching has been described as a common
finding with these tumors and facial wea*ness is more common than with cranial nerve
schwannomas. 4or*up is again consistent with retrocochlear losses and treatment is surgical
e"cision. 8pidermoids can often resemble cysts on '() e"amination as they are hypointense on
T1 images but are bright on T&. )n order to differentiate these lesions from more cystic lesions
li*e an arachnoid cyst# the T1 weighted flair images can be helpful to show the more
heterogeneous characteristics of an epidermoid compared to the homogenous loo* of a cyst.
;acial schwannomas are histologically identical to vestibular schwannomas. They are rarely
restricted to the internal auditory canal# commonly have multiple s*ip lesions# and generally
involve part of the geniculate ganglion. >ni!ue characteristics include aural fullness if distal to
the geniculate ganglion and facial wea*ness is not usually present until these tumors are very
large. 3earing and impedance testing shows a retrocochlear loss but in addition the stapedial
refle" can be lost in these tumors. Treatment is observation until there is significant growth or
grade ))) facial nerve dysfunction and nerve graft repair is commonly performed at the time of
resection (1).
<lomus tumors can present with @ugular foramen syndrome and involvement of cranial
nerves )7+7). Treatment is surgery. 3emangiomas are usually centered on the geniculate and
lead to a progressive facial wea*ness. Treatment is surgery with primary nerve graft repair.
Arachnoid cysts can often be drained without large operations. Cholesterol granulomas are bright
on both T1 and T& in contrast to cholesteatomas and can often be drained. 8mbryonic tumors and
primary C:/ tumors are resected as appropriate.
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
Management: !ser"ation
Bnce a CPA tumor is found counseling is of the utmost importance. Bften times resection or
treatment of these tumors# especially slow growing vestibular schwannomas can leave the patient
with more dysfunction than they had prior to treatment. )t is with this idea in mind that the
options of observation# radiation therapy# and surgery can be offered depending on the
circumstances and patient preferences.
)f patients opt for observation it is important to let them *now what to e"pect. Average
growth rates for vestibular schwannomas are &mm per year with a range of 0 to &cm per year
(==). A review of multiple studies have shown that about ,0 to %0 of tumors will show some
growth by = years after diagnosis (&=) and 1, to &, of patients who are observed will go on to
have some form of treatment (11). ?ongstanding hearing loss may represent a slow growing
tumor and therefore may help guide treatment options (=,). Age should not be the only
determining factor for which patients receive different treatment options. Eounger patients may
be able to tolerate a large operation better than the elderly# older patients may outlive any
symptoms of their surgery# but all patients regardless of age with life threatening symptoms
should be offered some form of treatment. )f observation is chosen# '() should be repeated at
least every 2 months if not every = months during the first year and then yearly after that to
obtain proper growth surveillance.
(anagement: Ra!iation6Stereotactic Ra!iosurger%
<amma Fnife (<F) was first introduced by ?es*ell in 1.2. using a cobalt 20 source. )t
utili9es &01 ioni9ing beams of radiation to attac* tumors from multiple directions. The ?):AC
system uses a linear accelerator as its source of electrons# but has much fewer beams of radiation
compared to the gamma *nife. -oth of these modalities re!uire only a single session for
treatment. 'ore recently fractionated radiotherapy has been used to catch cells in different stages
of the cell cycle for ma"imal effect. The drawbac* to fractionated therapy is that it re!uires
multiple sessions for full treatment.
>ltimately the goal of radiosurgery is to arrest tumor growth rather than to shrin* it or
remove it. ?ocal control is defined as patients treated with radiation# not re!uiring salvage
therapy. 4hen combining all three previously mentioned modalities %$ to 100 local control
rates have been published. 0espite these numbers appro"imately &= of patients will develop a
transient increase in tumor si9e for 2 months up to 1 years due to central necrosis of the tumor
(&=). Therefore it is important to differentiate true tumor growth from transient swelling post
therapy to prevent unnecessary salvage therapy.
)n &001# 3asagawa et al. loo*ed at =1$ patients treated with <F therapy and $.% years of
median follow up. 10 year local control rates were A.& and significantly better in patients with
tumors G11cm=# with no brainstem compression# and no ,
th
ventricle compression (=1). 'ost
tumors that progressed did so within the first = years post+therapy. ;reidman et al. in &002 loo*ed
at =.0 patients treated with ?):AC and a median dose of 1&.1<y. 'edian follow up was ,0
months. 1 and 10 year local control rates were .0 and only 1 of patients re!uired salvage
therapy. 4ith fractionated therapy being so new# there is a wide variety of study treatments
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
ranging from 11 to 1$.2<y in = to =& fractions. 'edian follow up over multiple studies has been
,% months and the 1 year local control rate is A.0 (&=).
4hen comparing tumor control# tumor growth# and hearing preservation between
fractionated therapy and radiosurgery (<F or ?):AC)# fractionated therapy has shown better
ranges loo*ing at multiple studies. Tumor shrin*age however is similar between the two
modalities (=$).
)nitially patients were being treated with 12<y doses with hearing preservation of only ,2.
?ower doses were instituted at 1&+1=<y# which led to hearing preservation of 2% to $% without
change in local control rates (&=). A study loo*ing at 11= patients followed for a median of ,.&
years showed that useful hearing was preserved in 1% of patients but that tumors G1cm= had
significantly more patients with preserved hearing compared to those with tumors A1cm= of $1
vs 1$ respectively. 4hen comparing radiosurgery to fractionated therapy# one study in &001
was able to show serviceable hearing preservation at = years follow up of %1 versus ==# <F
versus fractionated therapy respectively (=.). ;acial and trigeminal neuropathy showed similar
results compared to hearing preservation. As radiation dose was decreased from 12<y to 1&+
1=<y complications decreased (=2# ,0)# and fractionated therapy showed better results than
radiosurgery for both complications (=$).
Bther complications observed with radiation therapy included hydrocephalus (0+11)#
tinnitus (0.&+1)# ata"ia (1.,+=.2)# vertigo (1.,+1.$)# malignant transformation (0+0.=)# and
dise!uilibrium (==)(,1).
(anagement: Surger%
4hen it comes to surgery there are three different options including the translabyrinthine
approach (T?)# the middle cranial fossa approach ('C;)# and the retrosigmoidHsuboccipital
approach (/). All surgical options re!uire discussion and collaboration with neurosurgery.
The T? approach has several advantages. )t provides an option for resecting a tumor of any
si9e# it has e"cellent e"posure of the posterior fossa# it utili9es the least cerebellar retraction and
the facial nerve is easily identified throughout the case. The ma@or disadvantage is the fact that
any residual hearing is sacrificed through this approach (,&). Control rates with total resection
range from ...1+...$ (,=+,,). :ear total resection has been described as G&1mm& or &mm
thic* tumor left in the operative field. ;ifty percent of lesions can be visuali9ed on '() with
near total resection and = of patients will have a recurrence (,1+,2).
The 'C; approach is one of the approaches that allow hearing preservation. Additionally it
provides good e"posure of the lateral internal acoustic meatus# CPA and clivus# and drilling is
e"tradural thereby decreasing morbidity. 0isadvantages include si9e limits of tumors G&cm in
greatest dimension# e"tensive temporal lobe retraction# limited e"posure of the posterior fossa#
and re!uired facial nerve dissection to access tumors (,&). Control rates for this techni!ue are
.% (,$).
The (/ approach is another hearing preservation procedure and li*e the T? approach# a
tumor of any si9e can be reached as long as there is less than &cm of e"tension into the )AC.
Additionally there is wide e"posure of the brainstem and lower cranial nerves with consistent
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
identification of the facial nerve throughout the procedure. 0isadvantages include increased ris*
of in@ury to the endolymphatic sac and vestibular labyrinth with lateral tumors# cerebellar
retraction leading to occulomotor and dise!uilibrium difficulties# and increased ris* of air
embolism with older positioning techni!ues (,&). Control rates using total resection techni!ues
are .1 with this approach (,%).
/erviceable hearing can be preserved in appro"imately 11 and =1 'C; vs (/
approaches respectively (&=). 'eyer et al in &002 loo*ed at 12& consecutive patients treated with
'C; approach and showed ,1 AAB+3:/ class AH- hearing and that 10 of patients with
word recognition scores greater than $0 preoperatively maintained that level (,.). They also
showed that as tumor si9e increased serviceable hearing decreased in an e"pected manner.
;acial nerve function for microsurgical treatment is best reported at 2 months or 1& months
as the gold standard. Patients treated with the (/ approach had the best facial nerve function
(grade )H))) followed by the 'C; and T? approach respectively (.1 vs %% vs $$) (&=).
0elayed paralysis has been described where patients have normal postoperative facial nerve
function and develop paralysis A$& hours after surgery. The incidence is appro"imately 1 and
$. of patients will regain normal function by 1 year follow up (10).
C/; lea* is more common with patients treated with (/ (11) approach compared to 'C;
(2) and T? (%) approaches and the overall rate is considered to be about % (11).
Postoperative headache of over = months occurs in appro"imately 10 of patients with (/
(&1) approach having the highest incidence compared to 'C; (%) and T? (=) approaches
(11). The most li*ely reason is due to intradural drilling where bone dust contacts the meninges
and C/; leading to aseptic meningitis.
Bther microsurgical complications include a mortality of 1 usually due to neurovascular
in@ury. 'eningitis occurs in 1+% of patients with aseptic meningitis being the most common.
This can be simply treated with steroids. -acterial meningitis re!uires antibiotics and is most
commonly caused by #$ aureus. Tinnitus occurs in about 10 of patients but 10 of patients
with preoperative tinnitus will have resolution postoperatively (1&). /ei9ure# hydrocephalus# and
stro*e represent G& of cases and are rarely encountered (&=).
Microsurgery "ersus #adiosurgery
/everal studies have compared radiosurgery to microsurgery for treatment of vestibular
schwannomas. )n a retrospective review by 'yrseth et al in &001 with median follow up of 1..
years# local control rates between microsurgery and gamma *nife were not statistically different
(%..& versus .,.&) (1&). ;acial nerve function and !uality of life were both significantly
worse in the surgery group versus the gamma *nife group. <amma *nife boasted a facial nerve
preservation rate of .,.& while surgery only showed $..% 3- grade )H)).
To give further clout to 'yrseth5s study# Polloc* et al. in &002 performed a prospective
cohort of %& patients treated with surgery versus gamma *nife in %& patients with tumors G=cm
in si9e. 'edian follow up was ,& months and local control rates were not significantly different
between the groups (.2 versus 100). 0espite these findings# facial nerve functionHhearing
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
preservation were both significantly worse in those treated with surgery versus those treated with
gamma *nife ($1H1 versus .2H2=) (1=).
Conclusions
Any patient with unilateral sensorineural hearing loss or tinnitus must be evaluated for
possible CPA tumor. Although the differential diagnosis for CPA tumors is !uite large# the vast
ma@ority are vestibular schwannomas. 6estibular schwannomas less than =cm in si9e can be
treated with either <F or ?):AC radiosurgery# however fractionated radiation is gaining promise
and may become the standard of care. )f a surgical approach is re!uired and the patient has no
serviceable hearing the T? approach is the best option but after that either the (/ or 'C;
approach can be utili9ed for hearing preservation depending on surgeon preferences. The most
important thing to remember when counseling a patient regarding therapy is that treatment of
these lesions can often lead to an increase in symptoms or side effects compared to their baseline
function. Therefore a candid informed consent is re!uired prior to any therapy of these lesions.
DISC$SSA%T: Tomoko Makis&ima' MD' P&D on
Cere!ellopontine Angle Tumors (it& )ocus on *esti!ular Sc&(annomas
This was a nicely prepared review of CP angle tumors. There was
emphasis on management options, especially regarding newer
radiotherapy technology.
ost cases will undergo conservative management and
observation. !owever, for those cases that do undergo surgery, "
would li#e to further emphasi$e the importance of pre%operative
evaluation and consent with the patients. "t is very important to
e&plain and ma#e sure the patient understands e&actly what to
e&pect after surgery. any patients have the e&pectation that their
symptoms will get better after surgery, or don't e&pect it to get
worse. (specially, the postoperative outcome regarding di$$iness is
often unpredictable. "t is important to #eep in mind that the tumor
itself is non%life threatening, and that by performing surgery, you
may be causing the patient to end up with more symptoms than
before surgery.
And, regarding infections such as cholesterol granulomas,
cholesteatomas, and dermoid cysts ) the gold standard of treatment
is to remove the infection, or obtain a *drainage* pathway. !owever,
given the di+culty reaching the disease, sometimes this will not be
feasible, and will result in multiple surgeries.
Cerebellopontine Angle Tumors with Focus on Vestibular
Schwannomas
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