Microsurgical posterior fossa vestibular neurectomy: an evolution in technique

Between 1925 and 1945, Walter Dandy and Kenneth McKenzie performed more than 700 posterior fossa eighth nerve sections and vestibular neurectomies, treating the intractable vertigo accompanying Meniere's disease. During the past 10 years, using microsurgical techniques and reaching the posterior fossa through the temporal bone, vestibular neurectomy has enjoyed a resurgence of popularity. When hearing is to be preserved, vestibular neurectomy is the surgical treatment of choice, if the patient fails to undergo a remission of the vertigo of Meniere's disease. This report reviews 115 consecutive vestibular neurectomies performed for the treatment of Meniere's disease from 1978 to 1988.In 1978, the retrolabyrinthine vestibular neurectomy (RVN) was introduced, a procedure in which the posterior fossa is entered anterior to the sigmoid sinus and behind the labyrinth. During the last three years, the approach to the posterior fossa has been a small dural opening behind the sigmoid sinus, the combined retrolabyrinthine-retrosigmoid (R-R) approach. There have been no cases of facial paralysis and no serious complications. A high incidence of headache (75%) resulted when the posterior wall of the internal auditory canal was drilled away for better exposure. Transient cerebrospinal fluid (CSF) leaks occurred in 7% of the patients having the RVN, the incidence was 3% when the combined R-R approach was used. In the RVN series, wound infection occurred in 20% of cases until perioperative antibiotics reduced the rate to 3%. The results in curing or improving vertigo have been excellent (94%), and hearing has been preserved to within 20 dB of the preoperative levels in 76%. Until a cure for Meniere's disease is found, microsurgical posterior fossa vestibular neurectomy remains the best treatment.