Staged removal of acoustic tumors: techniques and lessons learned from a series of 83 patients

The removal of large acoustic tumors is associated with increased mortality and cranial nerve injury. One method for treating these difficult lesions is staged resection. Between 1972 and 1992, more than 600 acoustic tumors were resected at our institution. Of these, 83 were removed in stages. This represents the largest series of staged acoustic tumor resections reported to date. A review of available films and patient records was performed for all acoustic tumors resected in stages between 1972 and early 1993 to analyze demographic information, tumor size, operative technique, outcome, and complications. The information was collected on standardized data sheets and entered into a computer database. Virtually all tumors were large, with the average size being 4 cm in greatest diameter. The average patient age was 41 years, and there was a slight preponderance of female patients. Ten patients had neurofibromatosis Type 2. The suboccipital approach was used in most patients. Anatomic preservation of the VIIth cranial nerve was achieved in > 72% of patients, with an average House-Brackmann score of Grade 3 at the longest follow-up (mean, 43 mo). Facial reanimation was performed in 19 of 23 patients with transected VIIth cranial nerves. Complications included cerebrospinal fluid fistulas in 11 patients, with 8 of 11 fistulas resolving after lumbar drainage. Six patients had meningitis (bacterial in three and aseptic in three). Two patients developed wound infections, and 10 patients developed exposure keratitis. There were two documented recurrences. There were no operative deaths. In most series, the incidence of cranial nerve deficits as well as morbidity and mortality is directly related to tumor size. Our operative strategy involved debulking the lateral aspect of large tumors during Stage I. Second stage removal is performed after the remaining tumor is shown to decompress out of the pons on computed tomographic or magnetic resonance images. During the second procedure, the residual tumor is less vascular and no longer densely adherent to the brain stem. Although staged removal is not without risk, there seems to be no apparent increase in morbidity when these results are compared with the results of series from the literature. Although there remain no absolute indications for staged resection of acoustic tumors, we think that it may represent the safest option for these difficult lesions.