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Hi. My name is Michael Seidman, I am an otorhinolaryngologist head and neck surgeon (also known as an ENT Surgeon). I received my BS degree in nutrition and MD degree both from the University of Michigan, I did a residency training in Otolaryngology and then did a fellowship in hearing, balance, facial nerve, skull base, acoustic neuroma and cochlear implant surgery at the Ear Research Foundation in Florida. I am the only surgeon at HFHS who performs this type of sophisticated tumor surgery, I work closely with several neurosurgeons for this particular problem. A vestibular schwanomma is a tumor of your hearing or balance nerve. It is the most common benign growth that we see. Other possibilities include meningiomas, and malignant tumors which are extremely rare. These are slow growing tumors that typically progress at 2mm per year but can grow up to 10mm a year. More than 50 years ago, people died from these tumors because they often went unrecognized. Today we tend to find these much earlier.

The most common symptom is hearing loss and/or tinnitus (ringing or buzzing) in one ear and rarely some people will have balance problems or facial weakness or paralysis. It is interesting that more people don't have balance problems, since many of the tumors grow on the balance nerve. The primary reason for this is that the tumors grow very slowly so the brain has a chance to equilibrate from this problem. Initial evaluation includes a complete history and physical in relation to the ear, nose, throat and skull base region. A hearing test is imperative and sometimes we will perform an auditory brainstem response test (ABR). This is a fairly accurate screening test, but it is not perfect. The best test and the easiest way to make the diagnosis is with the MRI or CAT scan. As part of the preoperative evaluation, I may request that you have an Electronystagmogram (ENG). This is a special balance test that lets me know how much the balance nerve is involved. Do all thee tumors have to be removed? The easy answer is no. However, in most situations it is in your best interest to have the rumor removed.

It used to be recommended that if you were over 65-70 years of age that the tumor should be watched with repeat/serial MRI every 6-12 months. However, if you have a good history of longevity in your family, these surgeries have been performed even on patients in their 80's. If you are less than 65 years of age and in reasonable health the chances are that this tumor will grow large enough to cause significant problems even potentially kill you. Thus, we usually recommend removal. There are three main ways that these tumors are removed and I will go over these for you.

Translabyrinthine approach. This is the standard way that most of these tumors are removed. The down side of this approach, is that you are guaranteed to have complete loss of hearing in the operated ear, even a hearing aid will not help. The up-side is that it has the least risk to causing facial paralysis.

Retrolabyrinthine approach. This is typically used for tumors that are closer to the brainstem and more in the area called the cerebellar pontine angle. This approach has the positive aspect of being able to possibly save hearing, but hearing preservation with this approach or with the middle cranial approach range form 0-75% and really depends upon the size of the tumor.

Middle cranial fossa approach. This is typically used for tumors primarily in the internal auditory canal and for those growths that are less than 10-15mm in size. This surgery also has the possibility of saving hearing, again with results of 0-75%.

For all of these approaches I work in concert with a neurosurgeon. Typically you come in the day of surgery to the main hospital. The anesthesia team starts, intravenous lines and other lines as necessary. Then we go to the operating room and the anesthesiologist gives you medicines to induce sleep. Once you are asleep, the neurosurgeon usually starts a lumbar drain (a drain to remove cerebrospinal fluid from your back) and we place a facial nerve monitor so we can follow facial nerve function throughout the procedure. If we are trying to save hearing, (this is determined during your visit with me) auditory monitoring will be done as well. The anesthesia / nursing team places a catheter in your bladder, this is done after you are asleep so as not to cause you discomfort, and is removed when you are able to ambulate 1-2 days after surgery). Typically, surgery starts about 1 hour after you are asleep (it takes this long to attach the monitors to you(. The side of your head is shaved and then prepared in a sterile manner. The surgery then begins. With the translabyrinthine approach is usually takes about 3.5-5 hours to get to the tumor. With the other two approaches it usually takes about 1-1.5 hours to get to the tumor. Removing the tumor from the nerve typically takes the longest amount of time. We peel it off the hearing to balance nerve. Sometimes it grows from the inside out of the nerve and unless we remove the nerve itself the tumor will come back. This is why we often have to sacrifice balance and /or hearing on the operated side. It is also usually intimately attached to the facial nerve, and while I have never cut a facial nerve in this region it does happen leaving a complete facial paralysis on the surgical side. Even if the facial nerve is left intact, it is usually weak after surgery. This weakness can last for days or forever even if the nerve is intact.

Tumors are rated on their size:
Small < ,1.0-1.5 cmMedium 1.5-3.0 cmLarge>3.0 cm
For tumors that are less than 1.0 cm in size I am able to keep facial function intact in about 85-90%. For tumors that are 1.5 cm facial function is kept intact in about 60-75% of cases. For tumors that are larger than 3.0 cm the likelihood of keeping the facial nerve intact are about 50%.

If you should have facial paralysis, which is the most common side effect of surgery behind hearing loss, there is a chance for re-animation procedures, but typically we wait for at least one year to see how much function returns. When people have good hearing with a tumor of less than 2.0cm in size, I typically recommend the retrolabyrinthine approach or the middle cranial fossa approach and I will try to save hearing. When tumors are less than 1.0cm in size I have save hearing in approximately 65-75% of patients. However, sometimes the hearing will slowly go out after surgery anyways. Most people do not try to save hearing in tumors that are larger than 1.0cm, but on rare occasion, I have saved hearing in tumors that are 2.0cm in size, but the likelihood is low. The surgery takes anywhere from 5-24 hours depending upon the size of the tumor and most take around 6-10 hours. You will be in the intensive care unit for 24-48 hours depending upon your needs. The sooner we can get you up and walking the more rapidly your balance will improve. Typically you are in the hospital for three – seven days. You will need to be off work for 2-8 weeks depending upon how rapidly your recover. Usually after surgery people will complain of some headaches, but these rapidly improve. The most common problems deal with facial weakness or paralysis, eye closure, burning of the eye (because it is not tearing normally), balance problems and generalized tires feeling. These are all normal feelings after surgery and will improve with time.

The primary risks with surgery are: Bleeding (<2-5%); infection (<2-5%); Infection (<2-5%); cerebrospinal fluid leak (brain fluid) (10-20%); if brain leak occurs meningitis can occur (<2-5%); brain abcess (very unlikely); regrowth of tumor (<5%). However, sometimes we will intentionally leave a small amount of tumor on the facial nerve in the hopes of reducing the risk of facial paralysis, rarely this may regrow. Hearing loss, 100% is translabyrinthine with the other two approaches it truly depends upon the size of the tumor. The smaller the tumor the less likelihood of complete hearing loss. Facial paralysis: this depends upon the size of the tumor. Smaller tumors have a better chance of keeping the face intact, which is one reason that we like to catch these when they are smaller than 1-1.5 cm in size. Change or loss of sense of taste on the tongue of the operated side.

What are other options?
If the tumor is small (i.e. less than 6-7 mm = .6-.7 cm) we can consider watching the tumor. This essentially means repeating the MRI in 6-12 months. If there has been no growth then we can continue the "wait and see" protocol. You must realize that there is risk of rapid growth, but this is not very likely.

Stereotactic radiation therapy. This is widely advocated in Canada. This is a one time treatment of high dose directed radiation (directed to the tumor). Some other institutions routinely recommend this approach, but most of us do not. Typically, I recommend this for tumors in the very elderly population or the extremely ill patient that is a great risk for surgery. Often times the radiologist will tell you that it is much less risky than surgery, but we have seen major strokes, hearing loss, facial paralysis and continued growth with SRT. The tumor at best may shrink a bit, but usually it just stops growing. The tumor is not removed and remains in your head. I have had several patients, after understanding all their options, elect to proceed with this form of treatment, but we usually do not recommend it as we are seeing similar risks and some of these patients still end up needing surgery and it is significantly more difficult to operate in the radiated field.

Because this is a relatively common problem and one that causes some problems for people, there are support groups even here in town. There is also a society, called the Acoustic Neuroma Society that can provide additional information. I will be in to answer any questions that you may have.

In summary, I would like to say that it is normal to be scared or nervous about any type of surgery. These particular types of surgeries are ones that I have performed many times, I teach residents, medical students and other doctors to do this type of surgery and I lecture around the world and publish articles related to these subjects. So all in all, you are in good hands, I know you will do well and I will take the best possible care of you. Our anesthesia and nursing personnel are some of the best and I have a great deal of faith and trust in all of them. They will also take wonderful care of you. Please tell me of any concerns or questions so I can address them

Support Staff Telephone Numbers:
Secretary: (248) 661-7211
Nursing station: (248) 661-7214
Appt. Scheduling: (248) 661-6472

Copyrighted to Michael Seidman,MD., FACS
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