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Review
. 2019 Jun;39(SUPPL. 1):S1-S146.
doi: 10.14639/0392-100X-suppl.1-39-2019.

Surgery of the lateral skull base: a 50-year endeavour

E Zanoletti  1 , A Mazzoni  1 , A Martini  1 , R V Abbritti  2 , R Albertini  3 , E Alexandre  1 , V Baro  4 , S Bartolini  5 , D Bernardeschi  6   7 , R Bivona  8 , M Bonali  9 , I Borghesi  10 , D Borsetto  1 , R Bovo  1 , M Breun  11 , F Calbucci  10 , M L Carlson  12   13 , A Caruso  3 , P Cayé-Thomasen  14   15 , D Cazzador  1   16 , P-O Champagne  2 , R Colangeli  1 , G Conte  17 , D D'Avella  4 , G Danesi  8 , L Deantonio  18   19 , L Denaro  4 , F Di Berardino  20   21 , R Draghi  10 , F H Ebner  22 , N Favaretto  1 , G Ferri  9 , A Fioravanti  5 , S Froelich  2 , A Giannuzzi  3 , L Girasoli  1 , B R Grossardt  23 , M Guidi  3 , R Hagen  24 , S Hanakita  2 , D G Hardy  25 , V C Iglesias  8 , S Jefferies  26 , H Jia  27 , M Kalamarides  6   7 , I N Kanaan  28 , M Krengli  18   19 , A Landi  4 , L Lauda  3 , D Lepera  29 , S Lieber  22 , S L K Lloyd  30 , A Lovato  31 , F Maccarrone  9 , R Macfarlane  25 , J Magnan  32 , L Magnoni  20   21 , D Marchioni  33 , J P Marinelli  34 , G Marioni  1 , V Mastronardi  3 , C Matthies  11 , D A Moffat  35 , S Munari  1 , M Nardone  36 , R Pareschi  29 , C Pavone  1 , E Piccirillo  3 , G Piras  3 , L Presutti  9 , G Restivo  8 , M Reznitsky  14 , E Roca  2 , A Russo  3 , M Sanna  3 , L Sartori  4 , M Scheich  24 , W Shehata-Dieler  24 , D Soloperto  33 , F Sorrentino  1 , O Sterkers  6   7 , A Taibah  3 , M Tatagiba  22 , G Tealdo  1 , D Vlad  3 , H Wu  27 , D Zanetti  20   21
Affiliations
Review

Surgery of the lateral skull base: a 50-year endeavour

E Zanoletti et al. Acta Otorhinolaryngol Ital. 2019 Jun.

Abstract

Chirurgia della base del cranio laterale: 50 anni di impegno.

Riassunto: La base del cranio non è anatomicamente divisa in anteriore e laterale, ma è per semplicità che comunemente si intendono i corridoi chirurgici con direzione antero-laterale, laterale pura e postero laterale come “Approcci chirurgici della base del cranio laterale”. Una relazione con titolo “Cinquant’anni di impegno”, di sforzo o di dedizione, vuole essere il riconoscimento a questa chirurgia che nel corso degli anni ha sviluppato interventi sempre più complessi con una morbidità sempre minore. Il principio della chirurgia della base del cranio laterale si fonda sulla possibilità di “fare spazio”, esporre adeguatamente, rimuovere osso per salvaguardare il cervello, insieme alla possibilità di preservare la funzione e adattare l’approccio chirurgico all’istologia della lesione. Il concetto che l’istologia detta l’entità della resezione chirurgica, bilanciando la morbidità intrinseca di ciascun approccio, è oggetto di trattazione nella prima sezione di questa relazione. Nella seconda sezione sono descritti i principali approcci chirurgici, intesi non come descrizione tecnica di ciascun tempo chirurgico, ma dei principi che sono alla base di ciascun approccio. La terza sezione è dedicata alle questioni aperte, quelle ancora irrisolte, inerenti alcuni tumori ed il loro trattamento. L’argomento del neurinoma sporadico dell’ottavo nervo cranico è trattato riportando l'attuale dibattito sulla osservazione, la chirurgia di preservazione dell’udito, la riabilitazione con l’impianto cocleare, la radioterapia e le ricerche recenti su marcatori tumorali predittivi di crescita. Il paraganglioma del forame giugulare è trattato nel contesto della chirurgia radicale, chirurgia parziale, osservazione e radioterapia. La terapia dei meningiomi della base del cranio analizza il punto di vista specifico dell’otochirurgo e del neurochirurgo. Cordomi e condrosarcomi, tumori del sacco endolinfatico, carcinomi dell’orecchio e colesteatoma della rocca sono le altre lesioni affrontate. Infine, nella quarta sezione è proposto un contributo a libera scelta ad autori di riconosciuta esperienza. Lo scopo di questa relazione è stato quello di fornire un aggiornamento della chirurgia della base del cranio laterale dopo 50 anni di duro lavoro e, o forse soprattutto, di permettere alle tante questioni irrisolte, alle domande che ancora non hanno risposta, di trovare espressione, affinchè il dibattito ed il progresso possano continuare con la condivisione di esperienze. Se al termine della lettura vi saranno più domande che risposte, potremo dirci che l’obiettivo di questa relazione è stato raggiunto.

Keywords: Benign tumors of the skull base; Lateral approaches to the skull base; Lateral skull base surgery; Malignant tumors of the skull base; Skull base surgery.

Plain language summary

Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

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Figures

Fig. 3.3.1.
Fig. 3.3.1.
Schematic drawing showing the outlines of the modified transcochlear approach type A. About 3/4 of the vertical portion of the internal carotid artery (ICA-V) are exposed in contrast to only 1/4 of the horizontal portion of the internal carotid artery (ICA-H) by using this approach.
Fig. 3.3.2.
Fig. 3.3.2.
Schematic drawing showing the limits of the transcochlear approach type B. Note the complete circumferential exposure of the vertical (ICA-V) and horizontal (ICA-H) segments of the internal carotid artery.
Fig. 3.3.3.
Fig. 3.3.3.
Schematic drawing showing the extent of the modified transcochlear type C approach. Note the superior extent of the craniotomy and the cut of the tentorium.
Fig. 3.3.4.
Fig. 3.3.4.
Schematic drawing showing the modified transcochlear approach type D. The red outline shows the additional bone to be removed.
Fig. 3.4.1.
Fig. 3.4.1.
Coronal MRI (T1 sequence with contrast enhancement). Dpt. of Neuroradiology, University Hospital of Würzburg, Germany; Chair: Prof. Dr. M. Pham.
Fig. 3.4.2.
Fig. 3.4.2.
Intraoperative CNAP measurements after tumour removal.
Fig. 3.4.3.
Fig. 3.4.3.
Intraoperative contactless laser resection.
Fig. 3.5.1.
Fig. 3.5.1.
This drawing shows the skin incision with the relevant neurovascular anatomy.
Fig. 3.5.2.
Fig. 3.5.2.
Exposure of the pterional region afforded by inferior retraction of the musculocutaneous flap with the three burr holes, immediately before the realization of the bone flap. 1: the key hole burr hole, 2: the temporobasal burr hole, 3: the burr hole placed at the posterior part of the superior temporal line. A superior cuff of temporalis fascia is preserved over the bone to ease muscular suture during closure.
Fig. 3.5.3.
Fig. 3.5.3.
Cadaveric picture showing the neurovascular anatomy after the opening of the Silvian fissure, anterior exposure.
Fig. 3.5.4.
Fig. 3.5.4.
Intraoperative view showing the neurovascular anatomy after the opening of the Silvian fissure, anterior exposure.
Fig. 3.6.1.
Fig. 3.6.1.
The retroauricolar “C” shape incision. The extension to the neck is interrupted at 2 cm below the mastoid tip.
Fig. 3.6.2.
Fig. 3.6.2.
Closure of the external auditory canal with a pedicled tragal flap.
Fig. 3.6.3.
Fig. 3.6.3.
Surgical field after the rerouting of the facial nerve.
Fig. 3.6.4.
Fig. 3.6.4.
Surgical field after the transection of the posterior fossa dura.
Fig. 3.7.1.
Fig. 3.7.1.
The left infratemporal A approach involves the removal of the external auditory canal, the middle ear, the anterior transposition of the facial nerve from the fallopian canal. The labyrinth may be left in place or removed, if required. This allows a complete visualization of the jugular foramen, the vertical carotid artery and space is left for surgical manoeuvers in the jugular foramen area. The sigmoid sinus is transected ant the presigmoid dura may be opened to enter the posterior fossa. The connection with the petrous cavity and the neck is wide and allows control of the tumor in the soft tissues and in the bone.
Fig. 3.7.2.
Fig. 3.7.2.
The left POTS approach involves the preservation of the external auditory canal, the middle ear, the facial nerve in its Fallopian canal. The labyrinth is left in place. This allows a visualization of the jugular foramen, the vertical carotid artery is hidden and the space left for surgical manoeuvers in the jugular foramen area is reduced, by the presence of the posterior wall of the external ear and the facial nerve in situ. The sigmoid sinus is transected and the presigmoid dura may be opened to enter the posterior fossa. The connection with the petrous cavity and the neck is wide and allows control of the tumor in the soft tissues and in the bone. This more posterior and conservative approach needs the adition, as described in the text, of a retrosigmoid craniotomy to widen the corridor and allow exposure of the posterior fossa.
Fig. 3.7.3.
Fig. 3.7.3.
Jugular foramen paraganglioma, C2 . The CT bone scan shows erosion of the vertical tract of the carotid artery: this should orient the surgeon to consider infratemporal A approach to allow an adequate resection of tumor with the least risk of microscopic residual disease. A POTS approach is feasible, when a planned deliberate incomplete removal is considered or the risk of microscopic disease is accepted.
Fig. 3.8.1.
Fig. 3.8.1.
A), B): modified park bench position adopted by the author.
Fig. 3.8.2.
Fig. 3.8.2.
Pre and post-operative MRI (T1 + Gadolinium) showing petroclival meningioma with superior extension and subtotal resectiom leaving small residual severely adherent to 3 and 6 cranial nerves. The surgical approach selected was the modified “Hakuba” presigmoid retrolabyrinthine combined approach.
Fig. 3.8.3.
Fig. 3.8.3.
A), B): intraoperative photograph of left CPA epidermoid; C), D): endoscopic view depicting residual deposits followed by complete removal.
Fig. 3.9.1.
Fig. 3.9.1.
Axial bone window CT scan, the surgical corridor from craniotomy to Fallopius in retrosigmoid RLM, left.
Fig. 3.9.2.
Fig. 3.9.2.
Operative picture showing transverse crista (*), facial nerve running up to Fallopius on the righr of crista, cochlear nerve on left up to cochlear quadrant.
Fig. 3.10.1.
Fig. 3.10.1.
See text.
Fig. 3.10.2.
Fig. 3.10.2.
See text.
Fig. 3.10.3.
Fig. 3.10.3.
A), B), C), D), E), F), G), H) from left to right.
Fig. 3.10.4.
Fig. 3.10.4.
See text.
Fig. 3.11.1.
Fig. 3.11.1.
Skin incision marked 6 cm below the mastoid tip, along the anterior border of the SCM, and curving superiorly toward the superior nucal line.
Fig. 3.11.2.
Fig. 3.11.2.
VA transposition from its groove after unroofing and removal of the transverse process.
Fig. 3.11.3.
Fig. 3.11.3.
Tumor exposure through the ELA approach: after completing the mastoidectomy, the sigmoid sinus (SS) is unroofed and exposed to allow the drilling of the occipital condyle.
Fig. 3.12.1.
Fig. 3.12.1.
The vertical carotid canal represents the axis of the en bloc subtotal temporal bone resection, as it carries both the start and the end of the bone cuts. Right temporal bone, lateral side. Temporal and retrosigmoid craniotomies allow to free the bone block from dura of the temporal and petrous sides, to close the sigmoid-jugular complex and to free the vertical carotid artery by drilling off its bone canal up to the neck.
Fig. 3.12.2.
Fig. 3.12.2.
First cut from vertical carotid canal to glenoid fossa (broken line) as seen from the temporal craniotomy. First part of the second cut (see at Fig. 3.12.3).
Fig. 3.12.3.
Fig. 3.12.3.
Posterior side of petrous bone as seen from the retrosigmoid craniotomy. Second cut from carotid canal all across the anterosuperior (Fig. 3.12.2) and posterior side of the petrous bone, and cutting through the internal auditory canal. The cut from the petrous ridge (arrow) down to the jugular fossa (JF).
Fig. 3.12.4.
Fig. 3.12.4.
Low side of the temporal bone. Final cut from the jugular fossa to vertical carotid canal.
Fig. 3.13.1.
Fig. 3.13.1.
Left side: schematic drawing showing anatomical details of the transcanal endoscopic transpromontorial approach of the left ear. The orange area indicates the bony area which may be removed to reach the internal auditory canal (IAC) passing through the cochlea and the vestibule. Right side: computed tomography scan (coronal view), showing the working area and the bony removal (yellow area), to reach the fundus of the IAC.
Fig. 3.13.2.
Fig. 3.13.2.
Left side: schematic drawing showing anatomical details of the transcanal endoscopic infracochlear approach of the left ear. The orange area indicates the bony area which may be removed to reach the petrous apex under the cochlea. Main landmarks of this area are the cochlea superiorly, the carotid artery anteriorly, and the jugular bulb inferiorly. Right side: computed tomography scan (coronal view), showing the working area and the bony removal (yellow area) needed to reach the petrous apex cells.
Fig. 3.13.3.
Fig. 3.13.3.
Left side: schematic drawing showing anatomical details of the transcanal endoscopic suprageniculate approach of the left ear. The orange area indicates the bony area, which may be removed to reach the petrous apex in the suprageniculate region. Main landmarks of this area are the middle cranial fossa superiorly, the facial nerve and geniculate ganglion inferiorly and the labyrinthine block posteriorly. Right side: computed tomography scan (coronal view), showing the working area and the bony removal (yellow area) needed to reach the suprageniculate area.
Fig. 3.13.4.
Fig. 3.13.4.
Left ear: A) microscopic view during ExpTTA approach, showing drilling of the cochlear turns; B) endoscopic view after tumor removal, with final check of the anatomical structures.
Fig. 4.1.2.1.
Fig. 4.1.2.1.
Axial T1-weighted post contrast MRI demonstrate a post contrast enhancing small acoustic neuroma in the left cerebellopontine angle.
Fig. 4.1.2.2.
Fig. 4.1.2.2.
Coronal T1-weighted post contrast MRI demonstrate a post contrast enhancing small acoustic neuroma in the left cerebellopontine angle.
Fig. 4.1.2.3.
Fig. 4.1.2.3.
Radiosurgery treatment plan with volumetric-modulated arc therapy (VMAT). The red colour wash volume is encompassed by the isodose of 95% (dose prescription to 13 Gy).
Fig. 4.1.6.1.
Fig. 4.1.6.1.
Spectral energy of speech and noise.
Fig. 4.1.7.1.
Fig. 4.1.7.1.
Tumor removal though a modified translabyrinthine approach with middle ear obliteration.
Fig. 4.1.7.2.
Fig. 4.1.7.2.
Array insertion though the round window.
Fig. 4.1.7.3.
Fig. 4.1.7.3.
Post-operative CT scan confirms the correct position of the array. The surgical cavity is filled with abdominal fat.
Fig. 4.2.3.1.
Fig. 4.2.3.1.
T1-weighted magnetic resonance imaging showing the typical salt-and-pepper pattern of the malignant paraganglioma.
Fig. 4.2.4.1.
Fig. 4.2.4.1.
Algorithm of treatment of tympano-jugular paraganglioma.
Fig. 4.2.4.2.
Fig. 4.2.4.2.
Comparison between the two groups of patients with residual tumor after partial surgery.
Fig. 4.2.4.3.
Fig. 4.2.4.3.
A) A case of C2; B) Post-op. after partial surgery.
Fig. 4.2.4.4.
Fig. 4.2.4.4.
A) A case of C2 D2e; B) Stable at 4 years of follow-up; C) Stable at 7 years of follow-up.
Fig. 4.2.5.1.
Fig. 4.2.5.1.
Stenting of the ICA, as shown by the angiogram (left picture).
Fig. 4.3.3.1.
Fig. 4.3.3.1.
Rate of GTR, NTR, partial resection.
Fig. 4.3.4.1.
Fig. 4.3.4.1.
Meningioma arising on both sides of the petrous bone (middle and posterior fossae).
Fig. 4.3.4.2.
Fig. 4.3.4.2.
The dural origin of the different groups of petrous bone meningiomas: A group, green; b1 subgroup, light blue; b2 subgroup, blue; C group, orange; D group, area included in the red line.
Fig. 4.3.6.1.
Fig. 4.3.6.1.
Schematic drawing of Sanna’s classification of PBC (see text for detailed description).
Fig. 4.3.6.2.
Fig. 4.3.6.2.
A 38 years-old male with recent vertigo and recurrent otorrhea. Flat-panel CT scans (a: axial; b: coronal) showed a soft-tissue mass occupying the left petrous apex (arrow), determining a large erosion of the anterior, superior and posterior surface of the petrous pyramid, suggesting the presence of an invasive cholesteatoma.
Fig. 4.3.6.3.
Fig. 4.3.6.3.
MRI in the axial plane showed a soft-tissue mass in the left petrous apex (arrows) with low signal on T1-weighted sequence A), high signal on T2-weighted sequence B), high signal on DWI C) with corresponding low ADC (Apparent Diffusion Coefficient) D). MRI findings unequivocally confirm the suspicion of PBC.
Fig. 4.3.6.4.
Fig. 4.3.6.4.
Schematic drawing of transotic approach to right the petrous apex with representation of the use of an endoscope to access blind spots (MCF: middle cranial fossa dura; PCF: posterior cranial fossa dura; IAC: internal auditory canal; JB: Jugular bulb; VII: Fallopian canal; ICA: internal carotid artery; SS: sigmoid sinus).
Fig. 5.1.1.
Fig. 5.1.1.
The petrous apex is divided into an anterior triangular and a posterior quadrangular (Q) compartment.
Fig. 5.1.2.
Fig. 5.1.2.
The course of the right petrous internal carotid artery (ICA) and the anterior foramen lacerum (AFL) can be identified in this dissected specimen. Other visible structures are the abducens nerve (VI) in the Dorello’s canal (DC) and the anterior inferior cerebellar artery (AICA).
Fig. 5.2.1.
Fig. 5.2.1.
Axial T1 Weighted image enhanced with Gadolinium DTPA revealing a 3mm vestibular schwannoma at the fundus of the left IAC (white arrow).
Fig. 5.2.2.
Fig. 5.2.2.
Histogram of tumour size in the surgical series (n = 1,044).
Fig. 5.2.3.
Fig. 5.2.3.
Facial nerve outcome of the last 200 surgical cases. The facial nerve outcome for tumours less than 1.5 cm in maximal diameter was 94% with a normal face or House Brackmann I or II result and 100% had a HBI to III or satisfactory outcome. For tumours of 1.5 to 2.4 cm, 80% had a normal face and 99% a satisfactory result and in tumours of 2.5 to 3.4 cm, 67% were normal and 94% satisfactory. In tumours of 3.5 to 4.4 cm, 54% were normal and 83% satisfactory and tumours larger than 4.5 cm it was 33% normal and 54% satisfactory.
Fig. 5.2.4.
Fig. 5.2.4.
Histogram illustrating illustrating the increasing number of patients undergoing observation of their unilateral sporadic vestibular schwannomas compared with those undergoing microsurgical removal.
Fig. 5.2.5.
Fig. 5.2.5.
The current management algorithm for patients with a unilateral sporadic vestibular schwannoma.
Fig. 5.4.1.
Fig. 5.4.1.
Case 1: A) After retrosigmoid exposure of this T3b tumor; B) electrophysiological mapping and tumor enucleation are performed; C) during CUSA enucleation, continuous irrigation is applied; D) the IAC is opened and the lateral portion of the tumor is mobilized and loosened; E) at exposure of the VIII nerve, a direct nearfield electrode is placed; and F) it is kept in place with some moist cottons during further dissection at the tumor nerve plane; G) until final complete intra-extra-meatal resection with anatomical and functional preservation of acoustic and facial nerves is reached.
Fig. 5.4.2.
Fig. 5.4.2.
Tumor extension by Hannover classification in NF2 series.
Fig. 5.4.3.
Fig. 5.4.3.
Preserved natural and rehabilitated bionic hearing function in 52/57 patients.
Fig. 5.4.4.
Fig. 5.4.4.
Case #2: A) despite Bevacizumab trial with temporary response, worsening of the clinical status necessitates surgery of the large R VS and ABI implantation in view of repeated hearing drops in the L; B), C) under further bevacizumab trial the L VS has been stable over the last 2 years.
Fig. 5.4.5.
Fig. 5.4.5.
Case #3: A) this cystic VS with severe brainstem compression is treated by partial decompression and IAC opening in 2006, with improvement of gait and hearing; B), C) despite growth of solid tumor, thanks to open IAC, hearing remains useful until 2008; D) in 2009, due to further progress of the disease, deterioration of gait and auditory function led to surgery and ABI implantation; E) at control in 2011, the brainstem is well decompressed and clinical function has remained stable until now.
Fig. 5.5.1.
Fig. 5.5.1.
Left minimally invasive retrosigmoid approach; the craniotomy is centered on the mastoid emissary vein.
Fig. 5.5.2.
Fig. 5.5.2.
Left minimally retrosigmoid approach; the “protected” surgical corridor to access the cerebellopontine angle.
Fig. 5.5.3.
Fig. 5.5.3.
Endoscopy of the left CPA. A) V (trigeminal nerve), SCA (superior cerebellar artery),VIII (auditory nerve), AICA (anterior-inferior cerebellar artery), VII (facial nerve), VA (vertebral artery), PICA (posterior-inferior cerebellar artery); B) offending vessels (AICA and VA) at the Root Exit Zone of the facial nerve (VII); C) decompression of the facial nerve (VII) with Teflon pad (T).
Fig. 5.5.4.
Fig. 5.5.4.
Right trigeminal neuralgia. A) operating microscope view, V (trigeminal), VIII (auditory); B) endoscope view of the decompression of the SCA (superior cerebellar artery) from the trigeminal nerve (V); C) Teflon pads(T) insulating trigeminal nerve (V) from SCA and AICA.
Fig. 5.5.5.
Fig. 5.5.5.
Left hemifacial spasm with embedded PICA loop at the REZ of facial nerve.
Fig. 5.5.6.
Fig. 5.5.6.
Left hemifacial spasm. A) decompression of the REZ of the facial nerve (VII) from an offenfing PICA loop rising from VA (vertebral artery); B) Teflon (T) between the facial nerve and the offending vascular loop.
Fig. 5.5.7.
Fig. 5.5.7.
Left incapacitating tinnitus. A) intracanalicular AICA loop VII (facial) VIIII (auditory); B) drilling of the internal auditory canal to expose the cross-compression
Fig. 5.5.8.
Fig. 5.5.8.
Subarcuate artery (As) “hugging the auditory nerve” (VIII).
Fig. 5.6.1.
Fig. 5.6.1.
Contrasting disease incidence to disease prevalence within the confines of epidemiologic research.
Fig. 5.6.2.
Fig. 5.6.2.
68-year-old man with minimal asymmetrical sensorineural hearing loss and a 4 mm right-sided intracanalicular vestibular schwannoma that has not grown over the course of 18 months of observation. C, D) 58-year-old woman with an incidentally diagnosed 2 mm right-sided distal intracanalicular lesion most consistent with a tiny vestibular schwannoma.
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3.7. The petro-occipital transigmoid approach (POTS)

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3.9. Occipital approaches, retrosigmoid approach

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3.10. The suprameatal approach and the transpetrous-transapex approach

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3.11. The extreme lateral approach: highlights on the key steps of surgical technique

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3.12. En bloc resections of the temporal bone

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4.1.1. Observation in vestibular schwannomas - a systematic review

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4.1.2. Radiotherapy in acoustic neuroma

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4.1.3. Vestibular schwannoma: surgery after radiotherapy

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4.1.4. Complications in acoustic neuroma surgery

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4.1.5. Hearing Preservation Surgery (HPS) with the retrosigmoid approach

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4.1.6. Assessing hearing to orient the choice of treatment for acoustic neuroma

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4.1.7. Vestibular schwannomas and cochlear implant

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4.1.8. The hearing-focused therapy in acoustic neuroma: hearing preservation surgery, hearing rehabilitation with CI, observation

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4.1.9. Current molecular knowledge on sporadic VIII cranial nerve schwannoma

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4.2.1. Treatment options for sporadic tympano-jugular paraganglioma (TJPGL)

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4.2.4. Partial surgery in paraganglioma: indications and results

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4.3.4. Lateral skull base meningiomas: the neurosurgeon’s perspective

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4.3.6. Petrous bone cholesteatoma

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5.1. Petrous apex and surrounding areas lesions: clinical and surgical management

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5.2. The evolving evidence based algorithm in vestibular schwannoma management

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5.3. Management of NF2: from vestibular schwannoma microsurgery to hearing restoration

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5.4. When preservation of auditory function is a must: technique and outcome in a series of neurofibromatosis type II

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5.5. Endoscope-assisted microsurgery of trigeminal, facial and auditory nerves

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5.6. Modern shifts in the clinical epidemiology of sporadic vestibular schwannoma and its implications

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5.7. Preventing surgical morbidity in jugular paraganglioma

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