ANA Discussion Forum
Treatment Options => Microsurgical Options => Topic started by: BlueSky on June 02, 2012, 08:32:01 am
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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?
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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
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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
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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
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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
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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.
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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?
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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
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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
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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
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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
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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.
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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,
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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
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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
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I chose retrosigmoid so there would at least be a chance of saving my hearing and I'm sorry I did.
Rich -
sorry to hear of your post op issues, but I'm not sure I'd blame them on your doctors. Docs aren't Gods, they are humans and they can't guarantee any of us "issue-free" outcomes. I'm sure your docs did their best and were honest when they told you about their other patients' experiences. Everyone is different; we all experience different things. I was the first of my doc's AN patients to experience double-vision post op. If I had known enough pre-op to ask him about double-vision, he would have honestly told me that he didn't have any patients who experienced it.
I chose retrosigmoid in the hopes of saving my hearing and I lost that "gamble". While I grieved my hearing loss, I know for a fact that my neurotologist felt just as bad - if not worse about this - as I did. I am fortunate enough not to have headaches associated with my surgery and my life (now with a BAHA) has moved on normally. I know many people who had retrosig and have headaches, but I know just as many people who had translab and have headaches.
While I totally agree that anyone contemplating AN surgery needs to make sure they have experienced, qualified doctors it's important also to keep in mind that experienced, qualified doctors can't guarantee you anything 100%. People on this Forum will argue that the docs @ HEI are THE best, but even they have translab patients who experience horrific headaches.
My point here is, everyone is different. Life can be a crap shoot. Good docs are a must when it comes to AN surgery, but sh*t still happens.
Best,
Jan
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Jan has made some very good points.
Generally different doctors specialize in different procedures. From what I have seen on the forum, there are very few doctors who really specialize in middle fossa (like the HEI doctors, Dr. Gantz etc). This is a very difficult surgery, I wouldn't let a surgeon who does not have a proven track record perform this procedure on me.
As for translab, vs, retro, many times it also depends on the neurosurgeon. My hearing was pretty much gone before surgery so it was not a consideration. 2 out of the 5 doctors I saw recommended translab. 2 recommended a combination of translab and retrosigmoid. The 5th does almost exclusively retrosigmoid and he is very good at it, with an excellent track record. I chose the 5th, not because I preferred retrosigmoid (like I said I had not hearing left), but because I trusted his expertise.
as Jan said, there is no guarantee, the best thing that we can do is to research the credentials of the surgical team, make sure we know what their outcomes are (and I am not talking just "stats', but real patient outcomes) and then hope for the best.
Marianna
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I had 3 different opinions done, two were all for doing trans lab, one for doing Middle Fossa...understanding that I may lose my hearing anyway, I went with Middle Fossa and I had some preservation, although 2.5 years post it has gotten a bit worse...I can hear out of it, but word discrimination is pretty bad. I went to House and Dr. Brackmann/Schwartz did the procedure. I am not suffering from any post surgery issues so all is good! One difference between retro and MF I believe is that MF they do the procedure more in front of the skull, while retro is in behind? Or was that trans lab...either way, MF is definitely more forward. Also, they have to cut a Jaw muscle to get to it, so that was one aspect of my recovery I had to work though, getting my mouth to open wide again! :)
Jay
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Somewhere I saw a diagram that show the various entry locations on the skull. It may have been the ANA literature.