A 55-year-old female presented with decreased hearing in her right ear for 10 years. An MRI revealed a vestibular schwannoma (VS), the most common type of cerebellopontine angle tumor. VS are usually slow-growing and unilateral benign tumors arising from Schwann cells covering vestibular nerves. Treatment options include conservative surveillance for small tumors, microsurgery for larger tumors, or stereotactic radiosurgery which provides high tumor control with good facial nerve and hearing preservation.

1. Farhad Hussain

2.  55 years old female, married with 3 kids,
resident of Quetta, came to OPD with complain
of:
 Decreased Hearing in Right ear for 10 years

3.  According to patient she was alright 1year ago,
then she noticed hearing from right ear, it has
insidious onset and slowly progressing, she
had no headache, vertigo, vomitings, or
difficulty in walk, swallowing , aspiration or
hoarseness.

4.  HTN for 10years on tab norvasc, 5mg.
 Had Lap Cholecystectomy 15 years ago.
Family HX:
 Mother Had DM, and she died of Breast Ca.
Socioeconomic status:
 Middle class family.

5.  Personal Hx:
 Normal sleep, bowel habits are normal, decreased
appetite.

6. 55 years old female with anxious look, sitting on
bed comfortably, well oriented to time, place
and person.
Vitally – stable
Systemic examination – unremarkable

7.  HMF – Intact
 Upper and lower examination:
 Motor – intact
 Sensory – intact
 Cranial Nerve Exam :
 Normal except for 8th , Air conduction was more
than Bone conduction in both ears, Weber’s test
lateralized to left ear.

8.  Base Line workup – Normal
 MRI Brain with contrast

10. 1- Vestibular schwannoma (VS) (most common
92%).
2- CPA meningiomas (second most common 3–
7%).
3- Epidermoid cyst (2–6%).
4- Trigeminal schwannoma.
5- Facial schwannoma.

11. Clinical Presentation:
 Unilateral sensory neural hearing loss with
high frequency and speech discrimination
being the most affected.
 Tinnitus and dizziness are common but true
vertigo is rare.
 If facial weakness then think of facial
schwannoma.

12.  VS may result into compression of the lower
cranial nerves leading to difficulty in
swallowing, aspiration or hoarseness.
 In very large VS the fourth ventricle can be
obstructed leading to hydrocephalus,
papilloedema and reduced level of
consciousness.

13.  Represent about 6% of all intracranial tumours.
 They are benign, slow growing tumours, which
arise from Schwann-cells in the nerve sheath
that surrounds the vestibular nerves.
 The incidence of VS is around 13 cases/
million/year.
Moffat DA, Hardy DO, Baguley DM. Strategy and benefits of acoustic neuroma searching. J Laryngol
Otol 1999; 103: 51–59
 The median age at diagnosis is approximately
50 years.
Propp JM, McCarthy BJ, Davis FG et al. Descriptive epidemiology of vestibular schwannomas. Neuro-
oncol 2006; 8: 1–11.

14.  The tumours are unilateral in more than
90%,affecting the right and left sides with equal
frequency.
Edwards CG, Schwartzbaum JA, Lonn S et al. Exposure to loud noise and risk of acoustic neuroma. Am J Epidemiol 2006;
163: 327–333

15.  The vast majority of VS are sporadic and
unilateral in more than 90%.
 Bilateral vestibular schwannomas are primarily
limited to patients with autosomal dominant
neurofibromatosis (NFII).

16.  Slow growing tumours
 These tumours are slow growing and may
shrink in size spontaneously.
 Some authors recommended an initial one year
radiological surveillance in all small VS and if
they grew in the first year they were treated.
O’Reilly B, Murray CD, Hadley DM. The conservative management of acoustic neuroma: a review of forty-four
patients with magnetic resonance imaging. Clin Otolaryngol 1999; 25: 82–86
 Others recommended that surveillance should
be abandoned in favour of intervention if the
tumour grew by 2 mm in the first year.
Smouha EE, Yoo M, Mohr K et al. Conservative management of acousticneuroma: a meta analysis and proposed
treatment algorithm. Laryngoscope 2005; 115(3): 450–454

18.  Conservative:
 Radiological survillence if small as VS are slow
growing tumors.
 Surveillance should be abondoned by tumor grow
by 2mm in first year.
 Some suggest intervention if tumor size is 15mm or
bigger.

19.  Microsurgery:
 Recommended for tumors more than 3cm in size and
in the presence of brain stem compression and
hydrocephalus.
 Surgical approaches vary as per tumor pathological
involvement.
 While complete excision is planned for most cases,
the intimate involvement of surrounding structures
may impose unwarranted morbidity if complete
excision is attempted.

20.  Translabyrinthine
 Suboccipital (retrosigmoid = RS)
 Middle fossa (MCF) craniotomies
The choice of approach is based on specific
location and hearing status

21.  If one of the goals of surgery was to preserve hearing
then the retrosigmoid (RS) or middle cranial fossa
(MCF) approaches would be preferred.
 If the VS was mainly in the CPA, the RS approach
would be preferable and for intracanalicular VS the
MCF approach would be preferred.
 The RS approach is the only one that enables hearing
preservation regardless of tumour size.

22.  SRS had become a universally accepted
treatment option for small VS (< 3 cm in
diameter).
 94% tumour control rate, 77% normal facial
preservation rate and 51% hearing preservation
rate was reported with SRS
 Kondziolka D, Lunsford LD, McLaughlin MR et al. Long-term outcomes after radiosurgery for acoustic
neuromas. N Engl J Med 1998; 339: 1426–1433.