Neuro4Nurses
Acoustic Neuroma
Definition
Acoustic neuroma is also called vestibular
schwannonma or neurinoma. It is a slow growth benign
tumor arises from the schwan cell of cranial nerve VIII
(acoustic nerve)1.
Epidemiology
Symptomatic acoustic neuromas diagnosed 1 per
100,000. Women are more than men and it is usually
diagnosed at the age between 30 and 60 years 2.
Pathophysiology
Cranial nerve VIII emerge from the brainstem at the
pontomedullary junction. It runs through the
cerebellopontine angle cistern and enters the porus
acusticus (meatus) of the internal auditory canal. CN
VIII divided into two branches, the vestibular branch
(balance) and the cochlear branch (hearing) within the
internal auditory canal. The cochlear branch runs in the
anterior-inferior quadrant of the canal and is beneath
the facial nerve. The vestibular branch is located
posterior to the cochlear branch. The vestibular branch
is further divided into superior and inferior division in
the crista falciformis 3. Acoustic neuroma commonly
arises from the superior vestibular branch as it passes
through the internal auditory canal. It accounts for 75%
to 90% of cerebellopontine (CP) angle tumors1,4. The
tumor growth is very slow, varying between 0.29 and
20mm per year5. As the tumor increases in size, it
extends outside of the internal auditory canal and
compressed on the surrounding structure such as
cerebellar, brain stem, or 4th ventricle. Cranial nerve VII
(facial) passes the internal auditory canal with CN VIII,
when the tumor enlarges, it starts compressing on the
CN VII causes a progressive thinning and stretching of
the nerve6. Compression by the tumor on the cochlear
and ingrowth into the cochlear nerve by the tumor can
cause the hearing impairment7. When the tumor
expense into the CP angle, the trigeminal (CN V) at the
apex of CP and the cranial nerves (IX, X, and XI) at the
base may also affected 8.
Presentation
Jackler and Pitts (1990) have described the
presentations of acoustic neuroma according to the
involvement of the tumor. It divided into 9:
1) The canalicular stage: it is characterized by hearing
loss, tinnitus, and vertigo.
2) The cisternal stage: it includes audiotory and
vestibular function progressively decline and
headache occurs from dura irritation.
3) The brain stem compression stage: it is demarcated
by tumor that displaced the brainstem structures and
obstructed the fourth ventricle. Patient may present
with facial twitch and weakness, worsening
headache, papilledema, and diplopia resulted from
obstructive hydrocephalus may occur.
Other presentations include incoordination, which is
worse in the lower extremities than in the upper
extremities, vertigo, vomiting, fever, visual changes,
headache, and facial nerve palsy 2,8. If the trigeminal
nerve is involved, patient may presented with
hypesthesia or paresthesia of the midfacial region, loss
of corneal reflex, and midfacial tingling and numbness.
Diagnostic Tests
Diagnostic tests for acoustic neuroma include CT
scan, MRI, and auditory brainstem response 1. The
advancement in diagnostic tests such as MRI and
neurophysiology, permit the more precise and early
diagnosis of an acoustic neuroma 10.
Gadolinium-enhanced T1-weighted MRI is the most
commonly used diagnostic test for acoustic neuroma.
MRI has a better resolution on soft tissues compared to
CT scan 2,3.
(A) (B)
MRI of a patient with right acoustic neuroma. (A)
The axial view of the head using MRI-Flair. It
showed the acoustic neuroma compressing the
cerebellum with mild cerebellar edema; (B) The
coronal view using T1-weighted MRI.
Audiologic testing is useful in diagnosis of acoustic
neuroma. Both pure tone audiometry and speech
audiometry are the first line tests 2,7.
Treatment Options
The two most commonly used treatment options for
acoustic neuroma include surgery and radiosurgery.
Recurrent rate in total tumor removal is low; it is
between 0-2% 11.
 There are three different surgical approaches. The
retrosigmid suboccipital approach avoids the cochlea,
vestibule, and semicircular canals; therefore, hearing
may be preserved in some patients. The middle fossa
temporal approach allows complete exposure of the
fundus. This approach is usually used for patients with
small tumors and near normal hearing. The
translabyrinthine approach is used in large tumors and
usually hearing is not able to preserve post-surgery 3,12.
Facial nerve palsy and hearing loss are the most
frequent complications after translabyrinthine
approach1,13. Other surgical complications include CSF
leak, cerebellar hemorrhage, meningitis, seizure,
chronic headache caused by bone dust during the
intradural drilling 11.
Stereotactic radiosurgery is an alternative to surgical
resection of acoustic neuromas especially patients with
tumor less than 3cm or poor surgical risks.
Radiosurgery is able to avoid the potential
complications associated with surgery and patient could
have a quicker recovery 14. The goals of radiosurgery
are prevention of tumor growth, maintenance of
neurological function, and prevention of new neurologic
deficits15. However, radiosurgery is contraindicated in
patients who have symptomatic compression of the
cerebellum or brainstem 1.
Nursing Implications
Hematomas of the cerebellopontine angle may
result in rapid worsening of the patients state of
consciousness. Constant neurological monitoring for
the first 24 to 48 hours is essential 6.
Physical rehabilitation starting on Day 3
postoperatively includes 3 regional fulcra. They include
upper (forehead and eyes), intermediate (nose), and
lower (mimic chewing). It comprises stretching,
maximal resistance, manual contact, and verbal input13.
CSF leak is the most frequent complication after
surgery10. It can be presented as rhinorrhea, or
cutaneous leak. Surgical intervention can resolve it
spontaneously. Alternate treatment is insertion of the
lumbar drain.
Temporary cranial nerve 9th and 10th deficit may
cause swallowing dysfunction and aspiration
pneumonia 6. Careful monitoring patients speech and
swallowing may avoid these.
Patients with acoustic neuroma may have corneal
compromise. It is related to decrease corneal
sensation, facial palsy and poor eye lids closure, and
decreased vasomotor tone to the lacrimal gland due to
seventh nerve palsy 16. Application of artificial tears or
eye lubricants regularly, taping the affected eye lids
together, and put on protective glasses may decrease
irritation and corneal injury.
Hearing preservation is unlikely in patients with large
tumor 6. Patient may develop single-sided deafness
after surgery, which means patient is unable to
perceive the directionality of sound and decreased the
ability to hear speech in background noise. Bone
anchored hearing aid (BAHA) system uses bone
conduction to transmit the sound from the nonhearing
side to the functional cochlea has been used17.
Reduced postural control after surgery may results
in accidental slips and falls. Vestibular compensation
(visual and proprioceptive input) takes place during the
first month after surgery even without rehabilitation.
This compensation may not be perfect particularly in
darkness, when patient is fatigue, sudden change of
body position, or walking on uneven surface. Postural
control may be enhanced through vestibular
rehabilitation 5.
Reference
1) Spoelhof, G.D. (1995). When to suspect an acoustic neuroma.
American Family Physician, 52, 1768-1774.
2) Kim, L.J., Klopfenstein, J.D., Porter, R.W., & Syms, M.J. (2004).
Acoustic neuromas: Symptoms and diagnosis. Barrow Quarterly,
20(4), 7-13.
3) ORourke, B.D., & Wallace, R.C. (2004). Imaging of acoustic
neuroma. Barrow Quarterly, 20(4), 14-21.
4) Wright, A., & Bradford, R. (1995). Fortnightly review: management of
acoustic neuroma. British Medical Journal, 311, 1141-1144.
5) Levo, H., Blomstedt, G., & Pyykko, I. (2004). Postural stability after
vestibular schwannoma surgery. Ann Otol Rhinol Laryngol, 113, 994-
999.
6) Sanna, M., Russo, A., Taibah, A., Falcioni, M., & Agarwal, M. (2004).
Enlarged translabyrinthine approach for the management of large
and giant acoustic neuromas: a report of 175 consecutive cases. Ann
Otol Rhinol Laryngol, 113, 319-328.
7) Forton, G.E.J., Cremers, W.R.J., & Offeciers, F.E. (2004). Acoustic
neuroma ingrowth in the coclear nerve: Does it influence the clinical
presentation? Ann Otol Rhinol Laryngol, 113, 582-586.
8) Wright, A., & Bradford, R. (1995). Fortnightly review: management of
acoustic neuroma. British Medical Journal, 311, 1141-1144.
9) Jackler, P.K., & Pitts, L.H. (1990). Acoustic neuroma. Neurosurgery
Clinics of North America, 1, 199-223.
10) Tonn, J-C., Schlake, H-P., Goldbrunner, R., Milewski, C., Helms, J.,
& Roosen, K. (2000). Acoustic neuroma surgery as an
interdisciplinary approach: a neurosurgical series of 508 patients.
Journal of Neurology Neurosurgery and Psychiatry, 69, 161-166.
11) Yamakami, I., Uchino, Y., Kobayashi, E., Yamaura, A., & Oka, N.
(2004). Removal of large acoustic neurinomas (vestibular
schwannomas) by the retrosigmoid approach with no mortality and
minimal mobodity. Journal of Neurology and Neurosurgery, 75, 453-
458.
12) Jain, Y. Falcioni, M., Dlorcs, DLO, M.A., Taibah, A., & Sanna, M.
(2004). Total facial paralysis after vestibular schwannoma surgery:
probability of regaining normal function. Ann Otol Rhinol Pharngol,
113, 706-710.
13) Barbara, M., Monini, S., Buffoni, A., Cordier, A., Ronchetti, F.,
Harguindey, A., Di Stadio, A., Cerruto, R., & Filipo, R. (2003). Early
rehabilitation of facial nerve deficit after acoustic neuroma surgery.
Acta Otolaryngology, 123, 932-935.
14) Porter, R.W., Daspit, C.P., Kresl, J.J., Biggs, C.A., Brachman, D.G.,
& Syms, M.J. (2004). Stereotactic radiosurgery in the management
of acoustic neuroms. Barrow Quarterly, 20(4), 33-39.
15) Kondziolka, D., Lungsford, L.D., McLaughlin, M.R., & Flickinger, J.
(1998). Long term outcomes after radiosurgery for acoustic neuroms.
The New England Journal of Medicine, 339,1426-1433.
16) Rogers, N.K., & Brand, C.S. (1995). Acoustic neuroma may impair
vision. British Medical Journal, 312, 511.
17) Syms, M.J. (2004). Bone-anchored hearing aid (BAHA). Barrow
Quarterly, 20(4), 48-50.
2013
Disclaimer: The author of this article neither represents nor guarantees that the
practices described herein, if followed, ensure safe and effective patient care. The
author further assumes no responsibility or liability in connection with any
information or recommendations contained in this article. The recommendations and
instructions in this article are based on the knowledge and practice in neuroscience
as of the date of publication. These recommendation and instructions are subject to
change based on the availability of new scientific information.