[THE MULTIDISCIPLINARY TREATMENT OF VESTIBULAR SCHWANNOMA (ACOUSTIC NEUROMA)].

UNLABELLED: GENERAL: Treatment of vestibular schwannoma (VS) via microsurgery, radiosurgery (SRS), or fractionated radiotherapy (FRT), is advocated for symptomatic patients or those with rapid tumor growth, despite older age and comorbidities. VS growth rate >2.5 mm/year is associated with lower hearing preservation rates. Regardless of growth rate, conservative management is associated with a progressive hearing loss, ranging 2.77-5.39 dB/year. MICROSURGERY: The retrosigmoid approach is associated with higher hearing preservation and facial nerve function rates for VS >1.5 cm in largest diameter, while the middle fossa approach seems to offer better outcomes for patients with VS <1.5 cm. The retrosigmoid approach harbors higher rates of CSF leak and post-operative headaches compared to other surgical approaches. The translabyrinthine approach is reserved for patients in whom hearing is severely compromised. SRS: SRS offers excellent tumor control and facial nerve function preservation rates with modest rates of hearing preservation. Current level 2 studies suggest that SRS is associated with higher facial nerve function and hearing preservation rates and better functional outcomes with similar rates of tumor control compared to microsurgical approaches.

SUMMARY: SRS is the treatment of choice for VS <3 cm in largest diameter. For VS >3 cm, microsurgery remains the treatment of choice. For functional preservation, larger VS can be safety and maximally debulked with the residual tumor treated with SRS. In patients with large VS who either refuse or are unable to undergo surgical resection, fractionated SRS or FRT may prove to be effective in treating large tumors >3 cm.