ACOUSTIC NEUROMA/ VESTIBULAR SCHWANNOMA

Taotao, Krisha Anne Tulagan, Precious Vallejo, Maria Theresa BSN041

DEFINITION
Also called: Acoustic neurilemoma, Acoustic neurinoma, Auditory tumor, Vestibular schwannoma Acoustic neuroma is a non-cancerous tumor that develops on the nerve that connects the ear to the brain.

DEFINITION
It is a benign primary intracranial tumor of the myelin-forming cells of the vestibulocochlear nerve (CN VIII). (Neuroma is derived from Greek, meaning "nerve tumor".) The term "acoustic" is a misnomer, as the tumor rarely arises from the acoustic (or cochlear) division of the vestibulocochlear nerve. The correct medical term is vestibular schwannoma, because it involves the vestibular portion of the 8th cranial nerve and it arises from Schwann cells, which are responsible for the myelin sheath in the peripheral nervous system.

WHAT CAUSES VESTIBULAR SCHWANNOMA?

Vestibular Schwannoma is caused by an overproduction of Schwann cells. Schwann cells wrap around nerve fibers to help support and insulate nerves.

PATHOPHYSIOLOGY

The usual tumor in the adult presents as a solitary tumor, originating in the nerve. It usually arises from the vestibular portion of the 8th nerve, just within the internal auditory canal. As the tumor grows, it usually extends into the posterior fossa to occupy the angle between the cerebellum and the pons (cerebellopontine angle). Because of its position, it may also compress the 5th, 7th, and less often, the 9th and 10th cranial nerves. Later, it may compress the pons and lateral medulla, causing obstruction of the cerebrospinal fluid and increased intracranial pressure. Schwannomas can occur in relation to other cranial nerves or spinal nerve roots, resulting in radiculopathy or spinal cord compression. Trigeminal neuromas are the second most common form of schwannomas involving cranial nerves. Schwannomas of other cranial nerves are very rare.

PATHOPHYSIOLOGY

It is a benign Schwann cell tumors affecting CN VIII. These tumors usually unilateral and cause hearing loss by compressing the cochlear nere or interfering with blood supply to the nerve and cochlea. Other neoplasm can affect hearing include meningiomas and metastatic brain tumors. The temporal bone is a common site of metastasis. Breast cancer mat metastasize to the middle ear and invade the cochlea.

PATHOPHYSIOLOGY

Acoustic neuromas may occur sporadically, or in some cases occur as part of von Recklinhausen neurofibromatosis, in which case the neuroma may take on one of two forms.
In Neurofibromatosis type I, a schwannoma may sporadically involve the 8th nerve, usually in adult life, but may involve any other cranial nerve or the spinal root. Bilateral acoustic neuromas are rare in this type. In Neurofibromatosis type II, bilateral acoustic neuromas are the hallmark and typically present before the age of 21. These tumors tend to involve the entire extent of the nerve and show a strong autosomal dominant inheritance. Incidence is about 5 to 10%.

CLINICAL MANIFESTATIONS

Hearing Loss.

ipsilateral sensorineural hearing loss/deafness

Tinnitus

most often a unilateral high-pitched ringing, sometimes a machinery-like roaring or hissing sound, like a steam kettle

Vertigo (spinning)

disturbed sense of balance and altered gait

CLINICAL MANIFESTATIONS

Facial sensory disturbances

Numbness in the face

occurs only in large tumors (about 50 percent of those greater than 2 cm in size). is uncommon.

Facial weakness

Facial twitching

also known as facial synkinesis or hemifacial spasm, occurs in about 10 percent of patients.

Headache

prior to surgery occurs in roughly 40 percent of those with large tumors

Hyperventilation Induced Nystagmus

little known physical sign that may be far more specific for acoustic neuroma.

DIAGNOSTIC STUDIES

Brain Imaging

The major neuroimaging techniques used in drug abuse research are positron emission tomography (PET), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI), along with electro-encephalography (EEG), an earlier technique for monitoring brain activity.

Conventional Audiometry
most useful diagnostic test for acoustic neuroma. most common abnormality is an asymmetrical highfrequency sensorineural hearing loss .

DIAGNOSTIC STUDIES

Hearing test (audiology)

provides an evaluation of the sensitivity of a person's sense of hearing and is most often performed by an audiologist using an audiometer ABR, or Auditory brainstem response, is a test of the hearing, from the ears to the brainstem that can be conducted without the cooperation of the patient. It basically consists of playing sounds to the patient and recording the electrical waves of the brain. It's generally safe and painless.

ABR testing

DIAGNOSTIC STUDIES

Electronystagmography( ENG) Testing

To measure involuntary eye movements, called nystagmus, in order to evaluate the function of the vestibular system and associated brain areas. Test of equilibrium and balance
Test of hearing and brainstem function Test for vertigo

Brainstem auditory evoked response

Caloric stimulation

NURSING INTERVENTIONS
Check

Vital signs Obtain clients assessment of discomfort Establish comfortable and well ventilated environment Provide comfort measures Provide small frequent meal Collaborate in treatment of underlying condition causing discomfort Identify changes in pain characteristics requiring medical follow-ups

NURSING INTERVENTIONS
Review

laboratory results related to causative factors Administer analgesic as needed Be a sources and strengths of information given to the patient Provided from the peer-reviewed medical literature which is the most reliable for patient education

MEDICAL INTERVENTIONS

Gamma Knife procedure

invented by Lars Leksell in 1971 method of irradiating the tumor this procedure avoids surgery with its attendant risks. In the past, this option was usually recommended only for higher risk surgical cases because of the possibilities of late radiation complications, and the need for ongoing MRI monitoring of the results of the procedure.

MEDICAL INTERVENTIONS

Stereotactic Radiotherapy

Radiation other than gamma rays can also be used to treat acoustic neuroma. It is similar to gamma knife No reason to seek out Stereotactic radiotherapy rather than gamma knife. The chance of recurrent tumor using current dose regimens is roughly 5-10%. Tumor growth is rare in patients who remain stable 6-7 years post therapy.

MEDICAL INTERVENTIONS

Surgical Treatment

Translabyrinthine (through the inner ear).

hearing loss is expected and inevitable. not appropriate for very large tumors.

Retrosigmoid or sub occipital (through the skull behind the ear).

retraction of the cerebellum (part of the brain) is necessary. headaches are common after this approach

MEDICAL INTERVENTIONS

Dr. Hain's approach

suggested that prospective operative candidates primarily consider safety and the probability of complications when considering surgery If one has serviceable hearing prior to surgery, and there is no other danger of waiting (such as needing a bigger operation), one might reasonably simply wait until hearing becomes unserviceable before proceeding with surgery or radiation

OUTCOME INTERVENTIONS
Recovery

From Vestibular Schwannoma Surgery: Leaving the Operating Room Recovery From Vestibular Schwannoma Surgery: Leaving the ICU Recovery From Vestibular Schwannoma Surgery: Leaving the Hospital Follow-up Care After Treatment for Vestibular Schwannoma

Vestibular rehabilitation