Translab Surgery vs. Others

[Kate B]

Rich,

As long as you are looking at Kaiser in San Diego, you should also consider House Ear Institute in Los Angeles.  Dr. Brackmann et al will review your MRI and consult with you by phone for free.
Your tumor is medium.  Is there indication about whether it is on the superior or inferior nerve?
One has a better chance of hearing preservation.

Honestly, to be given a 10% chance of hearing preservation is probably equivalent to chance. I was given a 70% chance. There is a belief that the more you start with the more you might retain.  What is your current hearing level now?  In my humble opinion, if you can hear well now,  you should consider middle fossa. You are approaching the borderline for Middle fossa  It has higher stats for hearing retention. Have you read the statistics and data relative to hearing preservation?  There is serviceable hearing and usable hearing.

Be persistent....

Kindest regards,
Kate

[kristin]

rich, hi! just wanted to fyi you of my recent surgery for my 8 mm left AN by dr brackmann and dr hitselberger from the House Ear Clinic. i am 29 yrs old and i had middle fossa done on april 14th (just over one week ago). i have no hearing loss and no facial paralysis. i would totally recommend at least talking to these doctors before having anything done.

while i was there i met a girl from Chile who was also there for her AN and there was a girl from isreal, a dad from oklahoma, and a boy w/ NF2 from somewhere...they do many many AN's each week. i heard that brackmann has done over 2000 and hitselberger has done over 5000 AN surgeries. if you go to their website there is a phone number to call and you can send your mri and audiogram and they will call you free of charge.

[Mark]

Rich,

Best of luck with your surgery. The desire to "have it out of your head" is a very valid reason in choosing between surgery and radiosurgery that a lot of folks don't consider. I believe Kate posted to pursue the middle fossa approach for a better chance at preserving hearing. My understanding is that is true, but that is better decided with the surgeon given the size of your AN. In terms of radiation impact not being known 5 plus years out, I think you should talk to someone other than a surgeon who has had a vested interest in doing the procedure. Gamma Knife has been used for over 30 years, so that comment is just flat out wrong. I would suggest that you run that issue past an experienced radiosurgeon if that concern is affecting your decision. I would also agree that House is one of the most experienced groups of doctors and that always improves your odds of success.

[Becky]

I wish I could have the darned thing back in my head, for all the problems I'm left with now!

Besides, just a few days after the surgery they told me they had to leave some behind and gave me a 20% chance of regrowth.  I recall a big let-down hearing that, and thinking, "then why did i just go thru all this??"

If only it were as easy as having the darn thing gone.  Also, pre-op my only symptoms were sudden distorted/muffled hearing and sudden tinnitis on the left.  An MRI was done right away, and I was referred to surgeons for a slow-growing benign acoustic tumor.  (I should have been given steroids, but somehow my hearing was left by the wayside ...) 

Anyway, because of those few symptoms, the surgeons were ON it.  The surgery was offered within 2 wks of my surgery consult.  Now, I have a host of worse symptoms, that no one seems to have cared about for a very long time! 

For me, now that I'm post op, my symptoms haven't mattered very much!  But the original few initiated this entire surgical life-changing event.

Think about it, because you cannot make a raw egg out of one already cooked ...
If only I could have my 1.4 back ...

Becky
P.S.  Not everyone has such a disappointing outcome.

[rich]

    Well I spoke with my doc and he advised against radiation because of my young age (30) and the fact that if the tumor continues to grow it will cause more complications for the neurosurgeon during surgery because of the microscopic scar tissue it leaves. It would then increase all of the risks of side effects post surgery. Also in some cases the tumor becomes molignant (not good).
    He told me the middle fossa approach is similar to the retrosigmoid approach but is usually doctor preferance. He said it does have some advantages to hearing preservation but at a greater risk of permanent facil poralysis and a risk of post op seizures. He does not do that method and said it was in fact abandoned by neurosugeons some time ago but then recently was brought back.
    I did some research and found a study conducted by my doctor in which hearing preservation was attempted during retrosigmoid resection while monitoring the direct eighth nerve response and the auditory brainstem response. The study showed that 35% of the patients hearing was saved when they monitored the direct eighth nerve reponse as opposed to only 10% when the auditory brenstem reponse was monitored in tumors 1.0 cm to 2.5 cm. Interesting I thought. I think now I'll ask if he will be monitoring the direct eighth nerve during my surgery!

[Kate B]

Hi Rich,

There are advantages and disadvantages to all types of surgery.  I know they monitor the nerves during surgery at House.

According to data, tumors under 2 cm have a low rate of permanent facial paralysis.  That is what I found in my reading.

You are asking your doctor thoughtful, analytical questions.
That is exactly the type of perseverance needed. 

Now talk to a doctor that does Middle Fossa and find out their side and why they do that over retrosigmoid.  Again, according to data, retrosigmoid may have a higher risk of headaches afterword.  Keep studying your options and asking lots of questions.

I know that I learned something from every doctor visit.  BTW, there is a list of questions at www.anworld.com

Best of luck,
Kindest Regards,
Kate

[Kate B]

    Well I spoke with my doc and he advised against radiation because of my young age (30) and the fact that if the tumor continues to grow it will cause more complications for the neurosurgeon during surgery because of the microscopic scar tissue it leaves. It would then increase all of the risks of side effects post surgery. Also in some cases the tumor becomes molignant (not good).
    He told me the middle fossa approach is similar to the retrosigmoid approach but is usually doctor preferance. He said it does have some advantages to hearing preservation but at a greater risk of permanent facil poralysis and a risk of post op seizures. He does not do that method and said it was in fact abandoned by neurosugeons some time ago but then recently was brought back.
    I did some research and found a study conducted by my doctor in which hearing preservation was attempted during retrosigmoid resection while monitoring the direct eighth nerve response and the auditory brainstem response. The study showed that 35% of the patients hearing was saved when they monitored the direct eighth nerve reponse as opposed to only 10% when the auditory brenstem reponse was monitored in tumors 1.0 cm to 2.5 cm. Interesting I thought. I think now I'll ask if he will be monitoring the direct eighth nerve during my surgery!

Here is some information about the middle fossa surgery vs the retrosigmoid to continue the conversation.  Again, I emphasize to now seek the expert opinion of another surgeon to crystalize all of the data.
# Middle fossa

This approach will be used to attempt hearing preservation. Statistics show that the better the hearing one has ahead of the operation the better the chances of good hearing preservation. The location of the tumor on the superior nerve vs. the inferior nerve is better. The HEI website, www.hei.org, states that "In patients with small tumors who have been operated by the middle fossa approach since 1992., good hearing has been preserved in roughly two thirds of those patients. Any measurable level of hearing was preserved in 80%." It has higher hearing preservation rates for tumors under 2 cm than retrosigmoid. From the HEI website, it states that: "95% of 380 patients undergoing MF maintained excellent facial nerve function. Only five percent suffered minor weakness of facial nerve function."

The incision is made in front of the ear by creating a bone flap. There is an unobstructed view of the entire IAC with this surgical approach. This allows complete tumor removal. The middle fossa approach is performed by lifting of the temporal lobe of the brain. This approach is not recommended for patients above 60. At House Ear Institute, in a review of 500 cases with several years of follow-up, they identified only one case of residual tumor (0.2%).
# Retrosigmoid (suboccipital)

This approach is used to attempt hearing preservation. Success rates vary from 30-65% in CPA tumors smaller than 1.5 cm with good hearing and limited involvement of the IAC. However a tumor extending to the fundus is a contraindication to the RS approach for hearing preservation. The tumor removal is accomplished with mirrors.

Also reported is a "10% incidence of severe postoperative headaches" with this approach (Sliverstien et al, 1991) cited in Brackmann's paper.

[rebecca]

Kaiser San Diego is an EXCELLENT option with very skilled surgeons!!

[amn70]

Rich,

Please be cautious of doctors that negate other treatment options (i.e. radiation). If the doctor was merely presenting the claim that it would be more difficult to operate on a radiated tumor and not inflicting bias in this claim, that is fine. I was diagnosed with an 8mm AN back in June of 2001 (I was 31 years old at the time). I chose to have FSR at Johns Hopkins in October 2001 and unfortunately, my tumor grew to be 1.5 cm. I did have to have the tumor removed (via translab approach in Jan. 2005) and found a surgical team (neurosurgeon and neuro-otologist) that I was confident in to do the surgery. I took issue with my neuro-otologist because during my initial consultation with him, he negated my previous decision to have FSR. Inflicting this type of unecessary bias was out of line and unprofessional. When I met with my neurosurgeon, I was not scolded like a child, but presented with an overview of what complications may or may not arise during my surgery due to previously having FSR. Luckily, NO complications arose during my delicate surgery and the neurosurgeon was able to successfully remove all of my tumor without harm to any of the nerves that were wrapped around it.

Please note that just because a tumor is "extracted", there is no 100% guarantee that it will not grow back (if someone can show me the statistics proving otherwise, please do so). I don't live in fear that it will grow back and I just live my life just as I lived my life after FSR thinking that the radiation stifled the growth of the tumor. Bottom line is that treatment for an AN is a very personal and challenging decision. You need to arm yourself with as much information as possible, choose an option that best suits YOUR needs, and work with professional and skilled medical professionals who will provide sound information and not BIAS. All the best to you during a challenging time.

Regards,
Angela