Transtemporal Supralabyrinthine (Middle Cranial Fossa) Vestibular Neurectomy: A Review of the Last 100 Cases

Abstract

The outcome of 100 consecutive transtemporal supralabyrinthine vestibular neurectomies performed between 1982 and 1992 was analyzed retrospectively and compared with that of the first 100 operations (1969 to 1975) in order to analyze the effects of the learning curve on immediate postoperative complications. A total sensorineural hearing loss, which occurred in 2% of the cases initially, could be totally avoided by (1) opening the tegmen tympani for better identification of the superior ampulla and (2) preserving the saccular branch of the inferior division of the vestibular nerve when the identification of the cochlear nerve was difficult because of a narrow anatomic space. As in the first series of patients, no immediate or delayed total loss of facial function was observed. However, a slightly higher number of delayed, temporary facial weaknesses (7% vs 3%) were recorded. The impairment of facial function was limited mostly to an asymmetric eyelid closure, unnoticed by the majority of the patients, which disappeared within 10 days. The number of postoperative temporary CSF leaks (through the wound or nose) resolving spontaneously remained the same (12%). There was no instance of postoperative meningitis. Due to the minimal dural elevation involved in transtemporal, supralabyrinthine vestibular neurectomy, no temporal lobe complications (particularly seizures) have been observed. In patients over 65 years of age, the operation lasted, on average, 10 minutes longer and the hospitalization was 3 days longer. There was no difference in the duration of the acute subjective vertigo (3 days) in patients younger than 65 versus older patients. Transtemporal, supralabyrinthine vestibular neurectomy offers an effective cure for disabling vertigo while preserving hearing in Menière's disease. The complications are acceptable even in patients over 65 years of age if the operation is carried out with limited elevation of the middle cranial fossa dura by a sufficiently trained and experienced skull base surgeon.