Translab vs Retrosigmoid @ House Clinic

[Jeremy/Erica]

My wife Erica is planning surgery to remove a 2 cm tumor and has lost substantial hearing processing capability.  We have contacted the House Clinic and they would recommend the translab approach to maximize probability of retaining facial nerve function.  My question is the following: Have others faced this situation and which procedure was chosen? What are probabilities of favorable outcome for facial nerve function for each procedure for this size tumor? What is probability that current hearling function (although limited) would be preserved?  Does House Clinic frequently choose the Retrosigmoid approach or do they focus upon the translab approach? Any thoughts or help would be appreciated. Thanks.

[Mark]

I did not have surgery , but also had a 2 cm AN. My consults consistently put hearing preservation for that size AN at best between 10-20% with the retro sig approach. In my case, I had , and still have very usable hearing in that ear so I opted for a method that addressed that. On the other hand, if I had opted for surgery and had minimal hearing left, then I would have chosen translab as the approach since it gives better visibility to the facial nerve and enhances preservation. I'm sure the doctors at HEI are operating under the same logic. If there is little hearing to save and odds with retro sig are small anyway, then why jeopardize the facial nerve outcome which most would agree is more important for quality of life later.

Mark

[leapyrtwins]

I had retrosigmoid surgery on 5/31/07 for a 2.5+ cm AN, but not at House.  My facial nerves are fine - slight issue first 2 days post op, but rectified with dose of steroids.  Despite the attempt to save what hearing I had left in my AN ear, I now have SSD.  In my case though, my AN had grown rapidly between the MRI and the surgery (about 6 weeks) and it had wrapped itself around the hearing nerve.  In order to get the entire AN, the surgeons had to "sacrifice" my hearing nerve.  If my AN hadn't grown so much, so unexpectedly, I am confident that my surgeons would have been able to save my hearing nerve and I would have some (diminished) hearing on the AN side.

My recovery from retrosigmoid has been without any major side-effects and although I have SSD, I am completely happy with my decision. Your wife should consider what the docs are House are recommending - they are very qualified and have a very good reputation - but in the end she needs to do what she is most comfortable with.

Good luck to her in her decision-making process, 

Jan

[Judy and Gib]

Hello Jeremy/Erica,

We consulted with Dr. House and he recommended translab to us as well.  He said it was the only approach he recommended in my case, and there is no hope for hearing preservation, even though I still have very useable hearing in my left ear.  The translab approach allows him to get to the facial nerve first.  He feels facial nerve outcome with this approach in my case is very favorable (98%), suggesting it is an important focus.

Good luck with your decision.  We know it is not an easy one.  We have not made a decision yet, but must make one very soon.  We will let you know what we decide and hope you will do the same. 

Judy and Gib

[4cm in Pacific Northwest]

If I had known for sure that I had an acoustic neuroma tumor I would have chosen the translab over the Retrosigmoid. If there was already substantial hearing loss the translab would have been my #1 choice. However my tumor was atypical and we thought it might be a meningioma. I also had fairly good hearing (especially being that the tumor was 4cm)… and 100% word recognition.

My outcome
It was in fact an acoustic neuroma tumor and no hearing was preserved through my Retrosigmoid surgery.

I am at 8 + week post op and still I am dealing with facial palsy on my AN side. The surgery team feels the facial nerve will heal – however only time will tell to what extent.
The single sided deafness is taking me adjustment and rehabilitation


If you have an acoustic neuroma there is minimal chance of hearing preservation but it is not impossible with the Retrosigmoid. With the translab there is no hearing preservation possibility since they go through the hearing nerve.

I deliberated between these two surgeries … and consulted with 9 surgeons. None could say they were 100% certain mine was an acoustic neuroma. If they had said it was an Acoustic Neuroma "for sure"- I would have chosen the translab… At this point I too am wondering if this would have provided better visibility of the facial nerve during tumor dissection...

Dr. Brackmann @ House too recommended I have the translab… when I consulted with him. If we were to take a wager pool of what the pathology of the tumor would be once removed – he would have won. (I.e. Grandpa Brackmann knows is AN stuff- he has seen a zillion of these tumors)

Only time will tell the absolute outcome of my choice and the preservation of my facial nerve.

Best of luck with your choice.

4





   

[4cm in Pacific Northwest]

Here are my old threads (same topic- 2 different categories)
http://anausa.org/forum/index.php?topic=4053.msg43435#msg43435

&
http://anausa.org/forum/index.php?topic=4054.msg43436#msg43436

RE “The ( “TLâ€?) Translab vs the “RSâ€?) Retrosigmoid (sub-occipital)  approach?â€? debate

You will also find that there appears to be a little (ok understatement) controversial debate on this very question amidst the neurotologists and the neurosurgeons.

I chose to contact Dr. Robert Jackler as he is experienced in ALL procedures and was able to give me a good “objectiveâ€? opinion. I liked him so much I finally asked him if he personally would consider being my surgeon. He and his neurosurgeon partner also have very impressive CV’s and “recordsâ€? (you bet I paid out to view these through  http://www.healthgrades.com/  )

I think if you want a true objective opinion that pertains to your particular case (and every AN patent is SO different) Dr. Jackler is an excellent AN counselor to consult with. (Even if you do not choose him as the final surgeon) He is President of the American Neurotology Society and The Stanford University Department of Otolaryngology-Head and Neck Surgery (ENT) Chair.

This is his webpage
http://med.stanford.edu/ohns/faculty/jackler.html

House (HEI) is a world renowned clinic for AN. Dr. House himself developed the translab surgery many years ago.  Dr Brackmann (now in his 70’s) there is the Dr. Brackmann who developed the House-Brackmann Facial Nerve Grading Scale you will see in the ANA booklets. Dr. House and Dr. Brackmann were THE pioneers in the treatment of Acoustic Neuroma. (I consulted with Dr. Brackmann and feel much honored to have met him in person – a delightful man!)

There are surgeons that trained under them and have since moved on - to develop reputable institutions of their own. In. fact Dr. Jackler did his fellow year with Dr. Brackmann at House. They wrote this medical textbook together
http://www.amazon.com/exec/obidos/ASIN/0323018300

And now Dr. Jackler is training MD’s in both the TL and the RS approach… and they will in-turn develop their own reputable institutions. House is THE most well known center for AN treatment- but please know that not they are not the ONLY.

I recommend you get multiple "professional" opinions (if your insurance permits) and not just pick a reputable surgeon but also one that YOU are very comfortable working with. Although my surgeon could not be there to hold my hand through ALL of this AN journey- he made sure he delegated to people who could. He also gives his patients an 'Acoustic Neuroma  package' that points them to this ANA. (Some but not all surgeons will do this or respect our patient forum and feedback. I know this as I consulted with 9 different surgeons.)


Here is the AN list of surgeons by the ANA
http://www.anausa.org/physician_list.html

Remember that typically AN tumors are slow growing. Do not make any panic decisions. Take the time to read, research and carefully reflect your choice. Do not let any surgeon pressure you into a decision. (I had 2 who were SO incredibly manipulative with me - I could see right through)

Although I am currently having facial and eyelid issues (which may or not be temporary) and I am permanently deaf on one side I have not been effected “cognitively� even though I had a 11 + hour brain surgery and a blood transfusion (my own blood) while they dissected a very vascular and sticky tumor. Sadly however some patients have been. To me having my mind (and brain) in tact was THE most important. I can use that to have the rest of me adapt. This is why I was SO particular as to what surgery I was to choose and to which team (the “who�) was going to do it.

If you want to speak with someone at HEI who is from the ‘newer school’ and also is skilled at the Retrosigmoid approach I suggest you ask Dr. Marc Schwartz to look at your records there at HEI.
http://www.earinstitute.org/news/bios/schwartz.htm
He is young and quickly gaining recognition in the AN world here in the USA. I spoke with him, too, about my case. He was most professional.

I realize this is a lengthy reply. I have become rather passionate about the TL vs the RS debate being that I was a ‘patient in the middle’ of it -this last summer.

I hope some of my anecdotal ‘thesis length’ reply here is helpful to you (and others who end up in the middle of this debate: patients, surgeons, medical professors or otherwise…)

Keep moving forward!

“4�

[hhb]

My husband has just completed RS surgery for a 2cm AN in Seattle. This approach was chosen to try to retain the hearing. The configuration of the tumor did not allow for the nerve to remain intact. The surgeons feel the tumor was completely excised. His hearing in the one ear is gone. He has a very slight facial palsy(mouth droop) which should resove itself. His balance problems are very minor. Having said that it is speculated that the vestibular fucntion was already compirmised and his other vestibular nerve had already begun to compensate.  He wanted to be discharged from the hospital  48 hours post -op but instead will come home about 2.5 days after his operation.

The surgical team that my husband used had both a neurosurgeon and a neurotologist. They would have been fine with any of the three approaches.

[leapyrtwins]

hhb -

glad your hubby is done with surgery and doing fine.  His surgery sounds a lot like mine - neurosurgeon/neurotologist, slight facial palsy (didn't last more than a few days), retrosigmoid to try to save hearing nerve but tumor wrapped around it, entire tumor removed, SSD now.

Hope his recovery continues to be uneventful,

Jan

[jlamborn]

I was facing the same choice last December; my hearing in the AN ear was almost totally gone and I was having pretty bad balance issues that were just about to the point of not being able to drive or stay at work.  I chose the trans-lab exactly because it gave them the best access to the tumor.  They drilled completely through the outer bone and I believe took out most of the inner ear structures (none of that gets put back and they fill it with abdomen fat) and got the best exposure of the facial nerve and the tumor.  The hearing and balance nerves were cut and I knew I was going to be completely deaf in that ear, but I wanted the least risk of facial paralysis.  When I woke up, I had full facial function; the next day (probably due to normal swelling) I had some weakness on that side:  the eye would blink at a slower rate and I couldn't completely close it, and had drooping of the side of the mouth.  They had seen this before and believed that how you come out of surgery is basically how you are going to be.  Sure enough, my facial weaknesses are totally gone, just took time to completely heal.  I do not regret my decision.  My balance has greatly improved as the left side has learned to compensate for the lack of signal from the right side.  In fact, I had an easier time after the surgery because of the pre-surgery balance issues; they believe that the left side was already learning to compensate because of what was happening in the AN ear.

I just had my first follow-up MRI and so far so good.  They believe they got it all and so far there is no sign of regrowth.  Will have another one in a year.

[mindyandy]

MARK
You have CK in 2001?? How are you today. I'm gonna have CK soon and would like some feedback.
Thanks
mindy

I did not have surgery , but also had a 2 cm AN. My consults consistently put hearing preservation for that size AN at best between 10-20% with the retro sig approach. In my case, I had , and still have very usable hearing in that ear so I opted for a method that addressed that. On the other hand, if I had opted for surgery and had minimal hearing left, then I would have chosen translab as the approach since it gives better visibility to the facial nerve and enhances preservation. I'm sure the doctors at HEI are operating under the same logic. If there is little hearing to save and odds with retro sig are small anyway, then why jeopardize the facial nerve outcome which most would agree is more important for quality of life later.

Mark

[Mark]

Mindy,

I glow in the dark a little, but otherwise ......

Just kidding.

Right now I'm doing fine but ask me at the end of the month when I have my 6 yr MRI and check up with Dr.Chang. I have the audiogram on Friday. At this point, I have no reason to feel that the hearing or AN status (approx 25% smaller at last check post treatment) have changed. I always start to get nervous by nature as these time lines approach but I'm hoping for and assuming a passing grade and check back in 2 years report card.

Mark

[neal r. lyons]

Hello Jeremy and Erica.  I have just recently begun activity again on the forum.  I had my surgery(translab) on June 22, 2007 at House.  I returned to work in Alaska in early September.  Since my tumor was 2.8 cm I decided to go with the translab.  My hearing was very poor on the affected side.  Dr. Schwartz  told me he would make the same choice were he in my shoes.
     The good news is that the tumor was likely removed entirely.  The surgery report which is available to you post surgery (not sure exactly how soon)  indicated there could be some very very small pieces of the tumor remaining.  I don't believe that that is unusual.  At any rate I'm able to do what I was doing before(physically). 
      The not the best news is that I do have to apply eyedrops every few hours daily and my speech has been altered due the loss of facial nerve function post surgery.  My lips don't come together like they used to making some sounds more difficult.  Both Dr. Brackmann and Dr. Schwartz expect facial nerve recovery but cannot forecast the extent of the recovery.  If I have significant facial nerve recovery I will be satisfied with my decision.  Facial nerve preservation means that the nerve remained intact post surgery, and that is certainly a good thing.  However, it is important to realise that the function of the facial nerve is often extensively affected inspite of the fact that it remained intact. 
      I don't know if you have made a decision yet or not. 
      I'm naturally happy that the surgery is behind me.  It does allow me the luxury of looking back.  Had my tumor been smaller I think I would have seriously explored radiation as an alternative, and first option.  I would have had to be convinced that it was a better option than microsurgery, however.   I was comfortable with the Dr's and treatment in general at the House Clinic and St. Vincent's hospital.   Wishing you well, Neal