Prevention of cerebrospinal fluid leakage and delayed loss of preserved hearing after vestibular schwannoma removal: Reconstruction of the internal auditory canal in the suboccipital transmeatal approach

Abstract

The suboccipital transmeatal approach uses packing of a muscle or fat graft into the internal auditory canal (IAC) to prevent postoperative cerebrospinal fluid (CSF) leakage. However, preserved hearing after removal of vestibular schwannomas may decline over time because of the progressive constriction of cochlear vascular supply due to scarring of the IAC. We propose a surgical technique for IAC reconstruction, which separates the preserved cochlear nerve and vasculature from the graft, and regains the CSF space in the IAC. Prior to the drilling of the posterior wall of the IAC, the dura mater of the petrous bone forming the posterior wall of the IAC is harvested for IAC reconstruction. After completion of tumor removal, a 'roof' of the IAC is reconstructed using the dura mater, and a muscle or fat graft soaked with fibrin glue is placed on the 'roof' of the IAC. The IAC was reconstructed using this technique in 26 consecutive patients with vestibular schwannomas who underwent tumor removal via the suboccipital transmeatal approach. Postoperative magnetic resonance imaging confirmed the regained CSF space in the IAC. No delayed hearing loss occurred in four patients with preserved hearing. No CSF leakage occurred after surgery. This new technique of IAC reconstruction may prevent delayed hearing loss as well as postoperative CSF leakage after removal of vestibular schwannomas via the suboccipital transmeatal approach.