Pros and cons of surgical approaches?

[BlueSky]

Is there a list of pros and cons for the surgical approaches? I know some can save or not save hearing, but I have also heard of different complications such as headaches or how invasive the approach is - any thoughts?

[TJ]

BlueSky

I know that the booklets that you can get from the AN Association describes each of the types of surgery and they also explain some of the side effects.

TJ

[leapyrtwins]

Definitely check the ANA brochures.

Translab is said to give the docs the best view of the tumor, but it typically means automatic hearing loss.  Retrosigmoid gives a better chance of saving the hearing than translab, but the odds aren't spectular; in fact they are less than 50/50 I believe.  Mid-fossa definitely gives the best chance of saving the hearing, but not everyone is "eligible" for it (depends on size and location of the tumor) and not all docs do it.

Theoretically retrosigmoid has a higher incidence of facial paralysis - but in practice that isn't always what happens (for example, I had retrosig and have no facial paralysis).  And on the flip side I know people who had translab and have facial paralysis.  Retrosigmoid also supposedly means a bigger chance of post op headaches, but there are many (like me) who had retrosig and don't have headaches.

Jan

[Jim Scott]

Blue Sky ~

As I understand it, most surgeons chose their surgical approach to the AN based on it's size and, most importantly, it's exact location.  I believe it's a fairly subjective decision based on the individual doctor's experience.  So, the choice of what surgical procedure a doctor uses is not necessarily based on it's possible post-op complications but on it's viability, as determined by the operating physician. 

As Jan noted, the Retrosigmoid approach is very common.  My large (4.5 cm) AN was 'debulked' using that procedure and, like Jan, I never suffered from headaches or experienced any facial paralysis or other deficits.  Unfortunately, no doctor can guarantee the outcome of any specific surgical approach or whether it will produce post-op problems.  My neurosurgeon had decades of AN removal experience and said he would do everything he could to avoid post-op problems.  I'm delighted to report that he was as good as his word.  I hope you and every AN surgical patient have a similar surgical experience. 

Jim 

[leapyrtwins]

I agree with Jim on why a doc may or may not choose a surgical approach, but in my case my neurotologist gave me the choice of translab or retrosigmoid.  He does both and said it was up to me; I'm certain he based this on the size and location of my AN.

Jan

[BlueSky]

Thank you for your responses. I understand that a doc will pick one approach or another based on the size/location but at this time my tumor is pretty small, at 6mm, so I think I am going to have all the options available to me. I have good hearing so I think it will come down to Mid-fossa (first doc already suggested this) and Retrosigmoid so I wanted to know the differences if I was given a choice.

[LizAN]

Thank you for your responses. I understand that a doc will pick one approach or another based on the size/location but at this time my tumor is pretty small, at 6mm, so I think I am going to have all the options available to me. I have good hearing so I think it will come down to Mid-fossa (first doc already suggested this) and Retrosigmoid so I wanted to know the differences if I was given a choice.

What are the relative risks to the brain, with mid-fossa vs. retro?

[Syl]

BlueSky:

I had the retrosig procedure, hoping to save my 60% word recognition. Post-surgery my hearing was at 20%. I don't have facial paralysis or weakness, but I do get chronic headaches. I don't know that any of the other procedures would have spared me the headaches.

Syl

[Jim Scott]

LizAN ~

To the best of my knowledge, both the Retrosigmoid and Middle Fossa surgical approaches require a minute retraction of the brain.  Although it sounds scary, this is rarely an issue.  My neurosurgeon informed me that during my surgery he had to retract my brain "just a tiny bit" but that he didn't believe it would affect my recovery.  It didn't.  Had he not told me I would have been totally unaware of the retraction. 

Because both procedures involve some minor brain retraction, that should preclude it from becoming a deciding point for any AN surgical patient in the process of choosing a surgical preference.

Jim

[LizAN]

LizAN ~

To the best of my knowledge, both the Retrosigmoid and Middle Fossa surgical approaches require a minute retraction of the brain.  Although it sounds scary, this is rarely an issue.  My neurosurgeon informed me that during my surgery he had to retract my brain "just a tiny bit" but that he didn't believe it would affect my recovery.  It didn't.  Had he not told me I would have been totally unaware of the retraction. 

Because both procedures involve some minor brain retraction, that should preclude it from becoming a deciding point for any AN surgical patient in the process of choosing a surgical preference.

Jim

What about a reason for choosing translab over either Middle Fossa OR retrosigmoid?  Is preservation of facial nerve enough reason to do that?

I'm slated to have translab, and part of me is still wondering whether I ought to go with Mid Fossa to see if any of my hearing would come back.

Liz

[leapyrtwins]

Translab may or may not preserve the facial nerve.  Supposedly retrosigmoid is notorious for facial nerve paralysis, yet lots of us who had retrosig don't have facial paralysis - and on the flip side, I know several people who had translab and had/have paralysis.  That said, most docs monitor the facial nerve during surgery and there are less cases of permanent facial nerve damage from AN surgery today than in the past.  Facial nerves are delicate and are easily damaged, but they stretch and - unlike hearing nerves - they have the ability to regenerate.

Not all docs do all approaches - for example, I know my doc doesn't do mid-fossa (he does retrosig and translab), but his partner does.  As far as I know it's just one of those "doc preference things".

My doc gave me the choice of translab or retrosig and I chose retrosig because it was important to me to at least have him and the neurosurgeon try to save my hearing.  My reasoning was that if I went with translab, I'd never know if my hearing could be saved or not - and personally I would always wonder.
 
My hearing was diminished, but I had decent word recognition.  My doc was very upfront about the odds of saving my hearing (not very good) but I wanted to say that we at least tried. 

Jan

[RichB57]

I chose retrosigmoid so there would at least be a chance of saving my hearing and I'm sorry I did.  I've had headaches since about 5 weeks post op (just over a year ago) and I feel like my life is on hold.  My headache is pretty much constant, and without constant medication I can't function at all.  Luckily I have a desk job, because any physical activity causes my headache to increase to the point that I have to lie down and put an ice pack on my head.  If my job involved any physical activity, I'd be on disability.  I used to be very active.  I practiced karate, and yoga, did lots of home improvement projects, auto maintenance and yard work.  That's all over.  My headache frequently gets to an 8 out of 10, and before the pain management docs figured out the right med combination, I had a few that were 9.5 out of 10.  My neurosurgeon said, "Oh, the headaches are not that bad.  Most patients can control them with Tylenol".  He didn't mention the people that end up like me.  I feel I was lied to.

Why take the chance of ending up like me.  I've seen other posts on this forum saying the incidence of severe headaches is extremely low with translab.  I don't know what the percentages are, but my advice is keep doing research and press your doctors for complete answers.  I was afraid I would insult the doctors, and the fact that I went to Mass General, I figured I should be able to trust them.  DON"T!  It's your head they'll be messing with, and they just feel they've done their job if they get the tumor out.  After that, they feel they are done with you.

[pjb]

I chose retrosigmoid so there would at least be a chance of saving my hearing and I'm sorry I did.  I've had headaches since about 5 weeks post op (just over a year ago) and I feel like my life is on hold.  My headache is pretty much constant, and without constant medication I can't function at all.  Luckily I have a desk job, because any physical activity causes my headache to increase to the point that I have to lie down and put an ice pack on my head.  If my job involved any physical activity, I'd be on disability.  I used to be very active.  I practiced karate, and yoga, did lots of home improvement projects, auto maintenance and yard work.  That's all over.  My headache frequently gets to an 8 out of 10, and before the pain management docs figured out the right med combination, I had a few that were 9.5 out of 10.  My neurosurgeon said, "Oh, the headaches are not that bad.  Most patients can control them with Tylenol".  He didn't mention the people that end up like me.  I feel I was lied to.

Why take the chance of ending up like me.  I've seen other posts on this forum saying the incidence of severe headaches is extremely low with translab.  I don't know what the percentages are, but my advice is keep doing research and press your doctors for complete answers.  I was afraid I would insult the doctors, and the fact that I went to Mass General, I figured I should be able to trust them.  DON"T!  It's your head they'll be messing with, and they just feel they've done their job if they get the tumor out.  After that, they feel they are done with you.

Sounds like my situation as well but with me I had a desk job but could not function not only with the headaches but with my words and writings was not good at all after surgery and the surgeons dismissed all of my problems and after 3 months developed tinnitus which I still cannot cope with...I did not do my research or asked any questions I thought I was at a top notch hospital and put all my faith in them. So if I can help anyone and tell them to research thoroughly and to choose a Great team of doctors is the main key to a near or somewhat normal life after an AN.

Best Wishes,

[Syl]

What about a reason for choosing translab over either Middle Fossa OR retrosigmoid?  Is preservation of facial nerve enough reason to do that?

I'm slated to have translab, and part of me is still wondering whether I ought to go with Mid Fossa to see if any of my hearing would come back.

Liz

One of the reasons I didn't choose Middle Fossa is because my drs told me that the brain is retracted more than with retrosig, increasing the chance of stroke.

I vaguely remember one person in the forum who's hearing actually improved after surgery. If treated with steroid injections early on, it can return. Unfortunately, our hearing nerve is not as resilient as the facial nerve & what hearing has already been lost, most often, is gone for good. Many times we are lucky if the surgery doesn't damage the nerves involved in ANs even more.

Syl

[Jim Scott]

What about a reason for choosing translab over either Middle Fossa OR retrosigmoid?  Is preservation of facial nerve enough reason to do that?

I'm slated to have translab, and part of me is still wondering whether I ought to go with Mid Fossa to see if any of my hearing would come back.

Liz

Liz ~

The Translab (Translabyrinthine) surgical approach is purported to pose less risk to damaging the facial nerve than either Retrosigmoid or Middle Fossa approaches but of the three, Middle Fossa apparently offers the best chances of preserving hearing (on small tumors).

As other posters have indicated, none of the three surgical approaches can guarantee anything, be it hearing preservation or the lack of post-op facial paralysis.  Because one or ten AN surgical patients that underwent a specific procedure with no problems - or a host of problems - doesn't prove that another AN surgical patient will have the identical experience with that particular surgical procedure.  We are unique and there are many factors involved, including the exact size and location of the tumor as well as the surgeon's skill, which does vary.

The harsh reality is that hearing preservation with AN removal surgery is problematic and the odds of preserving hearing in the affected ear is usually rather small.  That being the case, I would be cautious about choosing a surgical procedure based solely on the hope of preserving your bilateral hearing.   However, for many AN surgical patients, preserving complete facial function takes precedence over preserving hearing and so, many chose the Translab approach.  It is popular with surgeons due to it's ability to avoid facial nerves and offers the doctor a good look at and ability to work on the AN.  Ultimately, it's your decision, of course and, again, outcomes cannot be guaranteed.  That is what make this decision so difficult for many AN surgical patients. 

I was fortunate, in a way.  Upon diagnosis, my AN was huge (4.5 cm) and due to the location of the tumor the neurosurgeon opted for the Retro approach.  He had decades of AN removal experience and I trusted his judgement but I also made it clear that preserving facial function was paramount.  He completely agreed.  My AN was 'debulked' and later radiated (via FSR).  All went well.  No headaches or facial issues.  Unfortunately, my bilateral hearing was already gone by the time of my AN diagnosis so preserving hearing was never an issue for me, which, obviously, made my decision much easier.  I trust that your surgery decision will be rewarded with a good, issue-free outcome.

Jim