Acoustic Neuroma- how to manage?
A 59-year-old woman was presented with acute pain around the lower lip, jaw, and right temporomandibular joint (TMJ), which impaired mouth opening. The main complaint was the difficulty to open the mouth due to shooting pain attacks on the right side of the face. Pain happened along the trigeminal nerve path, yet not reaching beyond the median line. Pain attacks were typically sudden, acute, short and episodic. The patient's previous history revealed the clinical signs characteristic of depression and anxiety. Pain prior to a car accident was also reported. The patient also described persistent and localized episodes of bilateral pain in the left and right masseter as well as in the temporalis muscles which increased with function, and the presence of painful hypertrophic bands. When palpating the right masseter, pain was felt in the insertion region and in the muscle itself and was graded as 3 by the patient on a four-point scale (0 = no pain, 1 = report of discomfort, 2 = report of pain, 3 = report of pain with withdrawal reflex). On the left side, pain happened in the masseter itself, and was graded as 1. As for right and left temporal muscles, the patient reported grade 1 pain in all muscle sheaths. Pterygoid muscles were also reported to be affected by the pain on both sides, graded as 3. How to manage this case of acoustic neuroma?
@cherry There are three main courses of treatment for acoustic neuroma:
Observation is also called watchful waiting. Because acoustic neuromas are not cancerous and grow slowly, immediate treatment may not be necessary. Often doctors monitor the tumor with periodic MRI scans and will suggest other treatment if the tumor grows a lot or causes serious symptoms.
Surgery for acoustic neuromas may involve removing all or part of the tumor.
There are three main surgical approaches for removing an acoustic neuroma:
Translabyrinthine, which involves making an incision behind the ear and removing the bone behind the ear and some of the middle ear. This procedure is used for tumors larger than 3 centimeters. The upside of this approach is that it allows the surgeon to see an important cranial nerve (the facial nerve) clearly before removing the tumor. The downside of this technique is that it results in permanent hearing loss.
Retrosigmoid/sub-occipital, which involves exposing the back of the tumor by opening the skull near the back of the head. This approach can be used for removing tumors of any size and offers the possibility of preserving hearing.
Middle fossa, which involves removing a small piece of bone above the ear canal to access and remove small tumors confined to the internal auditory canal, the narrow passageway from the brain to the middle and inner ear. Using this approach may enable surgeons to preserve a patient's hearing.
Radiation therapy is recommended in some cases for acoustic neuromas. State-of-the-art delivery techniques make it possible to send high doses of radiation to the tumor while limiting expose and damage to surrounding tissue.