The choice of approach in surgery for acoustic neuromas (vestibular schwannomas)

The advantages and disadvantages of the different surgical approaches for surgery of vestibular schwannomas are described, as well as the problems in evaluating the outcome of the treatment, regarding especially the evaluation of facial nerve function and hearing capacity. The eclectic Copenhagen treatment algorithm is outlined: 1) All tumors measuring 25 mm or more on MRI are operated via the translabyrinthine approach. 2) All patients with PTA poorer than 30 dB, and SDS poorer than 70% are operated via the translabyrinthine approach. 3) Tumors less than 10mm extrameatally, and PTA better than 30 dB and SDS better than 70% are removed via the middle fossa route. 4) Tumors measuring 10-25 mm and PTA better than 30 dB and SDS better than 70% are operated via the suboccipital route. Finally some consequences of postponing surgical treatment is described, demonstrating that 74% of 127 tumors continued to grow with a mean of 3.4 mm increased tumor diameter per year, and that 75% of patients, who were candidates for hearing preservation surgery lost the candidature in the observation period.