Hearing improvement after middle fossa resection of vestibular schwannoma.

OBJECTIVE: The preoperative, intraoperative, and postoperative variables of patients experiencing hearing improvement after middle fossa resection of vestibular schwannomas were evaluated as potential prognostic indicators.

STUDY DESIGN: Retrospective case review with new objective postoperative data collected on patients with documented hearing improvement.

SETTING: California Ear Institute at Stanford and Stanford University Hospital, a tertiary referral center.

PATIENTS: The patient group consisted of 30 consecutive patients undergoing middle fossa approach to vestibular schwannoma between October 24, 1994, and November 11, 1998.

INTERVENTION: Hearing preservation surgery via the middle cranial fossa approach was performed on all patients.

MAIN OUTCOME MEASURES: Pure-tone averages (PTAs) and speech discrimination scores (SDS) were used to document hearing preoperatively and postoperatively. Preoperative electrophysiologic studies of auditory brainstem response, electronystagmography, electrical neuronography, transient evoked otoacoustic emissions, and distortion product otoacoustic emissions were evaluated. Intraoperative continuous nerve action potential and auditory brainstem response tracings were reviewed. Postoperative auditory brainstem response and transient evoked otoacoustic emissions were obtained when possible on patients whose hearing improved. Statistical analysis was completed using Student's t test and chi-square test.

RESULTS: Seventeen (57%) of 30 patients with tumors ranging from 2 to 31 mm maintained hearing postoperatively. Among patients with hearing preservation, 7 (41% or 23% of the overall group) exhibited hearing improvement (PTA 2 improved by > or =5 dB and/or SDS improved by > or =12%). Three of these 7 patients moved from nonfunctional (AAOHNS class C/D) to functional (AAOHNS class A/B) categories. All patients who enjoyed postoperative hearing improvement had preoperative absence or abnormality of ABRs. No patient with normal preoperative ABR experienced hearing improvement. Hearing improvement patients also had lower preoperative caloric function on electronystagmography compared with the entire group (p < 0.02) and were more likely to have superior vestibular nerve tumors. No differences were noted for electrical neurography and otoacoustic emissions.

CONCLUSIONS: Middle fossa resection of vestibular schwannoma offers patients the possibility of hearing improvement after treatment. The chance of hearing improvement is significantly higher than with other forms of treatment such as radiation therapy or translabyrinthine surgery. Although preoperative ABR abnormality may be an indicator of poor prognosis for hearing preservation, those patients who enjoy hearing improvement come from the group of patients with abnormal preoperative ABRs. Other factors identified as associated with hearing improvement include poor SDS with more normal PTA 2, and significantly decreased electronystagmographic caloric function (as an indicator of superior vestibular nerve tumors). Hearing improvement to the functional range after surgical resection is possible in some patients previously thought to be poor candidates for hearing preservation attempts. Hearing improvement may continue for many months after surgery.