approach specific surgeons??

[neuroma_racer]

kinda complicated question . . .
to what degree did your otologist offer a choice of procedures? vs saying that ____ (this, and only THIS) would be the way he would do your AN?
i.e. how often has anyone been given the choice, based on THEIR goals or preferences, to choose between say  . . . middle fossa vs posterior fossa?


also as an aside . . .
is it the neurosurgeon who does the first part of the surgery (i.e. scalp, skull, CSF, moving he temporal lobe (or cerebellum), to expose the skull base.
and then the otologist who excises the tumor from the nerve?
or, is it vice versa?


i have decided on surgery, 100%   
it will most likely be in march, with an off chance of having it in february.

now it just comes down to who, when where, and which approach.

thanks,
jesse

[rupert]

         My otoligist and neurosurgeon both said my AN was to large for mid fossa.  They said they would do retrosig as they have a comfort level with that procedure.  So It depends on size, location  and comfort level of the surgeons for each procedure.   But,   I think if you were insisting on a particular procedure,  ask enough doctors and you will find one that will do it.
             Bryan

[Jim Scott]

Jesse ~

These are individual decisions made by the doctors involved in the surgery. 

I had a (highly skilled) neurosurgeon who was assisted by his very capable young protégé - also a board-certified neurosurgeon - and between them, they did all the cutting and related procedures in my AN surgery.  A technician performed the nerve monitoring.  The technician (brought in from another state), the anesthesiologist and all of the OR nurses were 'hand-picked' by my very experienced neurosurgeon.  No interns or residents were allowed, although I'm sure some observed.  My doctor has a sterling reputation and is the premier AN neurosurgeon in his area (New Haven, Connecticut) but seems to be basically unknown, nationally, which is often the case.  This is why we like to mention that while HEI, the Mayo Clinic, Johns Hopkins and other famed institutions are certainly good places to consider for AN surgery, there are lots of unheralded but very competent surgeons around the country that perform AN resections on a regular basis, usually with good results.  I'm proof of that and there are others (Jan - 'leapyrtwins' - comes to mind) that can say the exact same thing, even though we had different doctors operating in different parts of the country.   

I'm sure you'll do fine at HEI.  They have a lot of experience and a long list of satisfied AN post-op patients.  Congratulations on making your decision.  Let us know when you have a firm date for your surgery.

Jim

[lawmama]

My doctors gave me the option, but my ENT suggested either retrosigmoid or middle fossa since those both gave me a chance to save some hearing.  Of those two procedures, he said he had the most experience with retro, so retro it was for me. 

Per my research:  Most of the time the neurosurgeon will begin the procedure and the ENT (I forget the technical term, otoneurologist?  Otologist?  EAR DOCTOR) will then do the actual resection of the tumor because they are normally more familiar with the structure of the inner ear.  Then the neurologist will close back up.  Of course, this probably varies, so ask you own doctors how they do it.

Lyn

[Lilan]

I will add only that I'm not sure a surgeon would recommend an approach based on his own "goals and preferences," exactly, but as Lyn says, I would expect that many would (sensibly) advocate for the approach they have the most experience with, if it heavily tips in one direction. (Ask for numbers on each approach.)

Now, if they've done 500 translabs, 400 retros and 300 mfs, then it's dealer's choice!

But you may think differently if he's done 100 translabs and 9 middle fossas, for example, and you want/need middle fossa.

Personally, I found that some surgeons, even those with very significant experience overall, had done comparatively few middle fossas.

[Nickittynic]

As for how much the different doctors do, it depends in part n where exactly the tumor is. Mine was large and on the brainstem, so the neurosurgeon did about 80% of the work (all the 'head' stuff) and ENT did about 20% (The "in the ear" stuff). The ENT described my tumor as an "ice cream cone" with the cone part being in the ear and the big scoop being in my head. He said his part was do take out "the cone".

[rupert]

    I haven't had surgery yet so I can't tell you what they did,  only what my neurosurgeon told me.   He would do the craniotomy then locate the facial nerve.  After that he would go in under the AN and remove the part around the brain.   The ( Ear Guy )   would then take care of the inner ear .  I don't believe both surgeons are there the whole time.   Although he mentioned while one was working on your head the other would be obtaining the fat to seal up the incision.   The neurosurgeon then close up.    Bryan

[leapyrtwins]

Jesse -

you should go with the approach that makes the most sense in your case based on the size of the AN, the location of the AN, and the symptoms you are currently experiencing.

For example, mid-fossa isn't always a possibility for everyone based on the 3 factors I just cited.  Translab and retrosigmoid seem to be the more common approaches. 

When I was diagnosed my AN was 1.5 cm (medium), residing on the 7th & 8th cranial nerves, and although I had good word recognition my hearing was already starting "to go".  My neurotologist gave me the choice of radiation (GK) or surgery.  If I chose surgery he told me that the two approaches he does are retrosigmoid and translab and it would be my choice.  I was not a candidate for mid-fossa, but if I would have been and wanted that approach, he would have referred me to his partner. 

I chose retrosigmoid because my hearing was going, but not gone.  It was my thought I'd like to give my docs the chance to save my hearing rather than just automatically take it away due to the translab approach.  Kind of like nothing ventured, nothing gained.  Long story short, I ended up SSD but I knew I was gambling and the situation could have gone either way.  My neurotologist was really bothered by the fact that he and the neurosurgeon couldn't save my hearing, but like I told him - they did their best and I was totally comfortable with that (I still am).

My neurosurgeon does AN surgeries with my neurotologist and my neurotologist's partner, so he obviously does all the different approaches. 

I don't recall who did what in my surgery, I'd have to read my surgical report, but I know my docs (and most docs) alternate duties.  As I'm sure you know, AN removal (actually the tumor is peeled off in layers) is very tedious, "close" work done through a small hole in the skull and involves a microscope; generally the surgery lasts for many hours.  When the doctors work as a team, they can "spell" each other and give their eyes a break.

Jim's post makes it sound like you've already decided to go to House for your surgery.  I'm not sure if that's true or not, but I want to echo Jim - and very loudly here - there are lots of excellent doctors that aren't at "big name" places.  My docs were local and I had an excellent outcome.  Nothing at all against the big names, but it's just not practical - or financially feasible - for all AN patients to travel great distances for treatment.  If you want to, and can, by all means do so.  If you don't want to - or can't afford to - you can and will find qualified docs right in your own backyard or just a few hours away.

Jan

[Pooter]

Okay, now you all have me wondering who did what in my surgery.  I was always under the impression that the otologist opened and would "get to" the tumor and the the neurologist would resect then the otologist would close up.  But, I'll have to get my surgical report to know for sure..  I was comfortable with both, so it didn't occur to me at the time to see what was doing what..

As far as choice in approach goes..  I left that decision up to my surgeons.  At first, they told me they'd probably use the translab approach, but then after consulting with each other they decided on retro because it gave them a better overall view of MY tumor and ajoining structures.  I don't know how true that is, but I do know they switched approaches after my visit with the otologist.  I didn't find out until my otologist filled out my FMLA paperwork.  *shrug*  Bottom line is that I didn't have much say so in approach at all, but then my tumor was on the large side and so it just needed to come out.

If you've decided on HEI, I'll echo Jim and Jan in saying you'll be in good hands there.  They have a stellar reputation in the AN world.

Regards,
Brian

[leapyrtwins]

Pooter -

although Jesse will be in good hands if he goes to House, that's not what I said in my post.  I stressed that there are good hands out there in many places and the places don't all have "big names".

Jan

[neuroma_racer]

haven't yet decided on anyone, or anywhere,
just that surgery IS the course for me

A) I am to see a Dr Scott Thompson, in Columbia, S.C. monday 1/18.
not sure where he trained.
and i have no heads-up, on his proclivities for one approach vs another.

B) I see a Dr John McElveen, from Raleigh, NC (DUKE) wednesday 1/20.
he comes here, and other cities as well, to SEE patients,
but DOES all his ANs, THERE, at Duke, (4 hours away)
Dr McElveen, is a graduate of House, having done his fellowship there.

interestingly, there will be another surgeon FROM House, coming in March to collaborate with him.
it sounds like they do this perhaps 2 to 4 times a year.

from speaking with Dr McElveens nurse,:
it sounds like he USUALLY does posterior/retrosigmoid approaches, most of the time, as that's the approach with which his usual neurosurgeon is more familiar.
it sounds like he primarily does his middle fossa approaches, ONLY when the other guy FROM HEI comes out.

so this is all a long way of saying :
i wonder about how well versed he is in doing the middle fossa approach.

i am sure i am putting the cart too far in front of the horse, as we havent even met, face to face, yet

that being said,
i think, from my viewpoint, like middle fossa would be better for my case than retrosigmoid
(translab is obviously out)
additionally, the local neurosurgeon frined, who i saw, ALSO thinks that middle fossa, moreso than retrosigmoid, would be the better choice.

obviously, i need to wait to see what the two otologists, with whom i am scheduled,  have to say . . .

i just find myself wanting this to be done with.
i have already taken the entire month of march off,
and, if someone were to be able to do it in the latter 2/3 of feb, i'd trade out of my five shifts towards the end of feb, giving my 47 days off, right there.

(do ya' think patience is my strong point ?)

C) i was strongly considering Dr Shahinian, at the skull base institute,
we had a very nice 25" conversation on the phone a few days ago.
everyone i have spoken to has had glowing remarks.
i am confident in his abilities.

chiefly, my decision to go the more traditional surgical route, is for fear of the potential "buyer's remorse" if i lost my hearing, after taknig the minimally invasive route.
meaning, if i go SSD after a middle or posterior approach, then "oh well", thats where the chips fell, move on, those have been the standard of care for 50+ years.
whereas, if i became SSD, after SBI, I can easily see myself always wondering what if . . .

all for now,

jesse

[leapyrtwins]

Jesse -

I think mid fossa is a good idea for you too based on what you've told us about your AN and your symptoms.

I saw your other thread about Dr. Thompson in S.C. and can find no posts on the Forum about him.

IMO Duke would be a good possibility for you if the doctor there does mid fossa.  We have forumites who have gone to Duke for treatment.

Jan