A critical comparison of neurosurgical and otolaryngological approaches to acoustic neuromas

Neurosurgeons have traditionally advocated the transmeatal suboccipital craniectomy as the procedure of choice in treating acoustic neuromas of all sizes. With this technique, complete tumor removal was achieved in 91% of our patients. Facial motor activity was fully preserved in 59% and it was only partially deficient in an additional 29%. Conversely, recent otological reports have proposed a more flexible attitute in which the size of the tumor dictates the form of surgical therapy. In that scheme, the universally applicable and clinically proven suboccipital craniectomy is replaced by a series of procedures (translabyrinthine, middle fossa, transsigmoidal), each of which differs in its anatomical and technical requirements. This necessity for several operations seems to stem from the failure of any particular approach either to provide adequate visualization of the entire pathological process, or to afford maximum opportunity for complete tumor removal. By employing these various techniques, total capsular removal has been generally achieved in only 71% of cases. A careful comparison and analysis of these individual procedures reaffirms the superiority of the posterior fossa approach.