Revision surgery for residual or recurrent vestibular schwannoma

Objective: Assess the requirement for and describe the complication rates of revision surgery for vestibular schwannoma. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Patients undergoing surgery for vestibular schwannoma by the Manchester Neurotology Service between 1978 and 2004. Intervention: Surgery. Main Outcome Measure(s): The presence of recurrent or residual tumor; necessity for further treatment; complications from revision surgery. Results: Primary surgery was undertaken on 1,037 tumors, with 866 total (19 recurred), 128 near-total, and 43 subtotal removals. Further treatment was performed for 4 recurrent, 2 near-total, and I I subtotal excised tumors. Thirty-five revision operations resulted in 14 total (I recurred), 8 near-total, and 13 subtotal removals. Further treatment was required for 3 near-total and 6 subtotal excisions. Poor preoperative facial function (House-Brackmann Grades 4-6) was present in 9 of the 35 patients. A further 10 deteriorated by at least 3 grades by I year postoperatively. Other complications of revision surgery included 3 patients with cerebrospinal fluid leaks, a postoperative hematoma requiring evacuation, 2 cerebrovascular accidents, and 2 patients with new cranial nerve deficits. Conclusion: Most residual tumors after primary surgery are successfully managed with watch and rescan. Tumor fragment size is the greatest determinant of revision treatment. After revision surgery, tumor regrowth is much less predictable. Revision surgery is usually considerably more difficult than primary surgery, with a higher complication rate, particularly with regard to the facial nerve. Changing the approach for revision surgery may confer an advantage to facial nerve function.