Information for patients. Acoustic Neuroma. Neurosurgery: Neurosciences. Supported by

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1 Information for patients Acoustic Neuroma Neurosurgery: Neurosciences Supported by

2 What is an Acoustic Neuroma You have been diagnosed as having an acoustic neuroma. An acoustic neuroma also known as a vestibular schwannoma, is a benign noncancerous tumour and is in most cases slow growing with symptoms often developing gradually over a number of years. These tumours arise from the balance nerve as it runs from the bone of your ear into your brain. Your hearing may be affected because the tumour stretches the nearby hearing nerve. For most patients with an acoustic neuroma, the cause is unknown. Very rarely, these tumours occur as part of an inherited genetic condition such as Neurofibromatosis Type 2 (NF2). What are the Symptoms of an Acoustic Neuroma? Loss of hearing in the affected ear Tinnitus (ringing or buzzing noise in the ear) Vertigo (dizziness) Numbness, tingling or pain on one side of the face Other Less Common Symptoms Weakness of the face Visual problems Headaches Swallowing difficulties How is an Acoustic Neuroma Diagnosed? Tests to check your hearing (audiometry) CT scan (computerised tomography) is a combination of x-ray and computer technology. The scan is a type of x-ray examination but different from ordinary x-rays because it shows the body in slices and builds up a 3-D picture. The scan takes cross sectional images of the head to create a full picture of your brain to show up the acoustic neuroma more clearly, you will be given an iodine based dye (contrast) through a small fine tube (cannula) into a vein, usually in your arm or on the back of your hand. MRI Scan (magnetic resonance Imaging) uses radio waves and a magnetic field to create cross sectional images of the structures within your brain. MRI scans also require an injection of contrast to provide a detailed picture of the brain and of the neuroma. 2

3 What Are My Treatment Options? Your treatment will depend on the size of the tumour, the growth rate and how the symptoms are affecting you and your general health. If the tumour is small and your symptoms are mild you may not require immediate treatment but instead your surgeon may simply suggest continued monitoring with regular scans and follow-up. There is a team of specialists involved in planning your treatment: Neurosurgeon, ENT (ear, nose and throat) Surgeon, Oncologist and Clinical Nurse Specialist. We differentiate between small and large acoustic neuromas: Small Acoustic Neuroma 3

4 Large Acoustic Neuroma With small tumours, you have 3 choices in relation to treatment 1. Watch, Wait and Rescan 2. An Operation 3. Stereotactic radiosurgery / radiotherapy With larger tumours (3cm or more in diameter), we tend to recommend surgery in the first instance. However, if you have significant general health problems that might make an anaesthetic particularly risky we may advise treatment with stereotactic radiosurgery or radiotherapy. Your Neurosurgeon will discuss the relative benefits of these treatments with you in more detail. Some patients may require an operation before the tumour is removed or if stereotactic radiotherapy is planned to manage a condition called hydrocephalus. This is caused by a build-up of fluid in the brain as a result of the tumour. Such an initial operation could involve the insertion of a shunt which is a small tube implanted in the brain to drain fluid away to another part of the body, usually to the tummy (abdominal cavity). 4

5 1) Watch, Wait and Rescan You will undergo an MRI scan at regular intervals (6 months - 2 years) to see if your tumour increases in size. This helps us to know whether and when to recommend treatment. If an increase in size is found, you would be offered either stereotactic radiosurgery or an operation. It is important that you inform us of any new symptoms or worsening symptoms in between clinic visits. About half of small acoustic neuromas do not increase in size when followed up over many years. Most of the remainder will grow at a rate of 1-2mm per year. Most patients with intact hearing undergoing interval imaging rather than an operation or stereotactic radiosurgery will lose their hearing within 7-10 years of diagnosis, irrespective of whether their tumour grows or not. 2) An Operation Surgery is very intricate which means that an operation can take 6 hours or more to complete. The surgical approach will depend on the size and shape of the tumour and your degree of hearing loss. With a small tumour the aim of open surgery is complete tumour removal. With larger tumours the aim is often to remove enough of the tumour to create more space for the nerve and brain structures. Depending on the size of the tumour left behind on your post-operative scan or if your tumour is noted to be growing on subsequent scans, you may be offered further treatment with stereotactic radiosurgery. Your Neurosurgeon will discuss the best surgical option for you as each approach has its own benefits and risks: Trans-labyrinthine approach through the bone of the ear Retromastoid approach through a small trap door behind the bone of the ear A significant risk of surgery is damage to the facial nerve which is directly related to the size of the tumour. Some patients will have a temporary weakness following surgery whilst the nerve recovers and these patients will have normal or near normal facial movement some months after surgery. The facial nerve controls your eyelid, and hence your ability to close your eye, blink and make facial expressions. It also contributes to your speech and chewing. 5

6 Neither surgery nor radiosurgery can bring back any hearing that is already lost. Most patients diagnosed with an acoustic neuroma already have significant hearing loss and therefore the preservation of hearing is not an issue. Occasionally patients with small tumours do have intact useful hearing on the side of the tumour. A trans-labyrinthine approach always results in complete loss of hearing on the side of the tumour. The retromastoid approach also commonly results in hearing loss. If directional hearing is important for your job i.e. knowing exactly where a sound is coming from, a bone anchored hearing aid (BAHA) may be of benefit. After your surgery, you are likely to spend a day or two in the critical care unit before being transferred to the neurosurgical ward where there are highly experienced neurosurgical nurses familiar with the complex needs of patients who have had removal of an acoustic neuroma. You can expect to stay in hospital for approximately one week although a small number of patients may require a slightly longer stay. Other health professionals who may be involved in your recovery include speech and language therapists, physiotherapists, dieticians, ophthalmologists and audiologists. We would expect you to be independent and self-caring at the time of your discharge from hospital, but it would be advisable to have someone at home as you will be tired and possibly dizzy for a few weeks after surgery. 3) Stereotactic Radiosurgery/Radiotherapy Patients having stereotactic radiosurgery will be treated at either The Christie Radiotherapy Satellite Centre at Salford Royal NHS Foundation Trust or at the National Centre for Stereotactic Radiosurgery in Sheffield. Stereotactic radiosurgery, despite the name, does not involve surgery. The tumour is treated using highly focused beams of radiation usually in a single treatment. Before radiosurgery can take place, you will have a lightweight head frame fitted to your skull under local anaesthetic and this will stay in place whilst you have a further MRI scan followed by treatment. Radiosurgery aims to stop the growth of a small acoustic neuroma or any tumour cells that are left behind after surgery. It achieves this aim in about 90-95% of cases and does occasionally result in some tumour shrinkage. It does not get rid of the tumour and does not generally result in improvement in symptoms caused by the tumour. 6

7 Radiotherapy may be given to patients who have a large acoustic neuroma or are not fit for an operation to remove the tumour. If a larger area needs to be treated then more than one session of radiotherapy may be required. Radiotherapy has a reduced effectiveness in treating large tumours as compared to smaller tumours. Radiotherapy treatment for acoustic neuromas has a lower risk of permanent side-effects than surgery. However, some people may still experience hearing loss and occasionally some damage to the nerves that affect the face. These effects are usually temporary with a very small percentage being permanent. The risks of radiotherapy will be discussed in more detail at the treating hospital. Flying We would recommend that you do not undertake any air travel for a period of up to 8 weeks following acoustic neuroma surgery. Driving Patient s treated with surgery or stereotactic radiosurgery for an acoustic neuroma must not drive for a period of time and you must notify the DVLA for further clarification. The DVLA can be contacted by phone on or at gov.uk. If you have contacted the DVLA previously and they have permitted you to drive, you will need to contact them again if your condition changes. It is your legal responsibility to do so. 7

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12 Sources of further information British Acoustic Neuroma Association Tel: Brain Tumour UK Tel: British Tinnitus Association Tel: Facial Palsy UK Tel: Questions about cancer? We re here to help, the Macmillan Cancer Information & Support Service at Lancashire Teaching Hospitals is open to anyone affected by cancer and is situated at both Chorley Hospital & Royal Preston Hospital. Contact us on or Lancashire Teaching Hospitals NHS Foundation Trust is not responsible for the content of external internet sites. Please ask if you would like help in understanding this information. This information can be made available in large print and in other languages. Lancashire Teaching Hospitals is a smoke-free site On 31 May 2017 Lancashire Teaching Hospitals became a smoke-free organisation. From that date smoking is not permitted anywhere on any of our premises, either inside or outside the buildings. Our staff will ask you about your smoking status when you come to hospital and will offer you support and advice about stopping smoking including Nicotine Replacement Therapy to help manage your symptoms of withdrawal. If you want to stop smoking you can also contact the Quit Squad Freephone Department: Neurosciences Division: Neurosurgery Production date: March 2018 Review date: March 2020