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t Back in Combined Techniques Treat a Giant Acoustic Neuroma he Game By Nicholas Bambakidis, MD football practice, the patient's brother had also noticed that the patient had balance difficulties while running. A hearing test revealed complete loss of hearing in the right ear; a follow-up MRI ordered by the patient's ear, nose and throat specialist showed a large (4 to 4.5 cm) acoustic neuroma (also known as vestibular schwannoma). A Evaluation and Treatment Acoustic neuromas are tumors that, although not malignant, can be fatal because they cause the brain to be compressed; the patient can then develop hydrocephalus and brain herniation. For older patients, removing part of the tumor to relieve pressure on the brain may be an option. But in young patients these tumors can grow rapidly. Based on the age of this patient, we chose to remove the entire tumor. Because the tumor was so large, a modifi cation of a standard technique, the translabyrinthine approach, was used. Adding a retrosigmoid subtemporal craniotomy offered the best exposure while avoiding injury to healthy brain tissue and to the nerve that controls facial motion. 1 7 - Y E A R - O L D M A L E PRESENTED with severe headaches, hearing loss and dizziness. During summer The 7½-hour procedure began with the retrosigmoid subtemporal crani- otomy – removing bone from the skull and putting it aside, to be replaced later from the temporal and occipital regions. Surgeons then drilled through the mastoid and labyrinth (inner ear) structures to gain access to the posterior fossa. This approach freed the sigmoid sinus, minimizing brain retraction. The next step was removal of the lateral part of the tumor, exposing and freeing the facial nerve, and then removal of the bulk of the tumor against the brain stem. Outcome Upon awakening from the surgery, the patient immediately asked for his family. He went home three days after surgery, his symptoms resolved (except for the hearing loss, which is permanent). One week after the procedure, he walked onto the football fi eld at the head of his team. A six-month MRI scan looked fi ne. The patient doesn't appear to be at risk for recurrence, but if his annual MRI this fall is negative, annual scans will be repeated for fi ve years. Discussion Although acoustic neuroma in chil- dren is unusual, four or fi ve new adult cases – mostly patients in their 30s and older – are seen each week. Logically, not every patient is treated surgically. Some are put under observation, and for smaller tumors, stereotactic radiosurgery can prevent the tumor from growing further. Nicholas Bambakidis, MD, is a surgeon with the UH Neurological Institute and serves as Director of the UH Cerebrovascular and Skull Base Surgery program. He also serves as an Associate Professor for the Case Western Reserve University School of Medicine Department of Neurological Surgery. n