Acoustic neuroma treatment

The path to deciding on treatment

Nowadays, an acoustic neuroma brain tumour can be successfully treated.
This has become possible through enormous advances in medical technology over the last few decades, and also through the development of specialists in the field of acoustic neuroma treatment.
Successful treatment means the complete and definitive (or at least long-lasting) removal of the tumour, preserving the hearing function and preventing permanent facial paralysis, and therefore preserving the quality of life to a great extent.

Given that this can be achieved in different ways, there is sadly still a certain «cliquish thinking» amongst specialists, and as a consequence also amongst patients. The personal way chosen for certain reasons is often indicated as the main way, or even as the only way, that guarantees success. Unfortunately, the respective situation and constellation of the patient are not always included and evaluated impartially. Often, it is not considered that certain elements and treatments develop. Those with acoustic neuromas are the victims of this situation.

Please use the links at the end of the text and the navigation bar on the right next to the text to surf the pages on acoustic neuroma treatments!
On mobile devices, you will find the navigation bar at the bottom of this page.

Therefore, this website seeks to briefly describe the possible treatments from an unbiased standpoint, to give those seeking advice some initial information to help them to make a decision regarding treatment. Gathering further, extensive information afterwards is still necessary. However, with regards to that the IGAN platform offers possibilities. You can use the forum to discuss with other acoustic neuroma patients and the moderator, you have their wealth of experience on tap. The members of the Medical Advisory Board are available to answer questions, to obtain a second opinion, and also to carry out treatments. Links will take you to other homepages on the topic of acoustic neuroma, and lastly you can contact IGAN's administration.

The chemistry between doctor and patient has to be right
The chemistry between doctor and patient has to be right
(Source: website of GKC Hannover)

For treatment, it is crucial to find a doctor who is competent in the subject of acoustic neuroma and who you trust completely. You must have absolute confidence in this doctor in all matters before, during and after the treatment, so that at no point doubts from external sources or those you might have yourself weaken your psyche and your immune system. IGAN would also like and is able to help particularly with this step, which is of such importance – to find the right doctor in the right clinic – by passing on experiences and linking contacts. However, the last step must be taken by the patient alone: well prepared with his/her medical history and with all the medical documents, to talk to doctors, to ask everything, what inspires him/her and what he/she would like to know, and then decide to put your trust in one doctor. The «chemistry has to be there»!

Provided with a sure diagnosis, an acoustic neuroma patiently fundamentally has a choice between two strategies: treatment or wait. This point of view is not common as waiting is not active, targeted treatment, but here it is deliberately selected as it is regarded as precisely the core of a treatment. Those seeking advice therefore have to choose between two strategies: «to start treatment» or «wait».

Those who choose a treatment strategy, in other words for an immediate or early start of treatment then have the choice between an operation or radiotherapy.

The option of an operation as treatment

An operation to remove an acoustic neuroma aims for the complete (as much as possible) removal of the tumour from the intracranium.
It is performed by using an operating microscope. In the last few years an endoscope has been increasingly used as a support due to its better view of the operating area, but also partly exclusively.
In any case, an essential standard is a permanent monitoring of the auditory nerve function in the operating area, to avoid damaging the nerve during the operation. This so-called intraoperative neuromonitoring is today an essential part of acoustic neuroma treatment and a prerequisite for a successful operation for the purposes outlined at the start.

Operation with an operating microscope
Operation with an operating microscope
(Source: website of University Hospital Erlangen)

Given that an acoustic neuroma presses and damages the auditory nerves and generally begins to grow in the bony ear canal, the operative removal logically falls to the skills of the neurosurgeons and ENT surgeons. The acoustic neuroma operation is both carried out by them alone and also working as a team.
The operation is imperative if the acoustic neuroma has an average diameter larger than 3 cm and if it has already spread to the cranial fossa and is pressing on the cerebullum or/and the Brainstem, as otherwise vitally important functions could be impaired. Even if the tumour is still small, but it has already caused clear symptoms and permanent acute hearing loss or facial paralysis have to be prevented, an operation is the first choice. There is no limit on tumour sizes that support or oppose operating.

Option of radiation treatment

Radiotherapy of an acoustic neuroma aims to genetically change the tumour tissue with the expectation that the tumour will not continue to grow. A «melting away» of the acoustic neuroma cannot be the treatment aim due to the proximity of many important cranial nerves. However, for certain situations and certain patients radiotherapy in an alternative treatment.

Radiotherapy is possible both using natural radioactive rays and artificially generated rays. For natural rays sources from cobalt 60 are used. The strength of rays are defined in Grays (Gy).

The artificial radioactive rays are generated directly during the radiation process through a so-called accelerator. During the so-called single or one-time radiotherapy, the whole dose necessary is radiated onto the tumour. For better protection of the healthy tissue and better tolerance of radiotherapy, the method of radiating very low Gray doses (radiation amount) very often was developed, the so-called fractionated radiotherapy.

Fractionated radiotherapy
Fractionated radiotherapy
(Source: Wikipedia website)
Radiotherapy with the cyberknife
Radiotherapy with the cyberknife
(Source: CKZ Munich)

Despite the most precise, three-dimensional pre-determination of the tumour volume and the most accurate radiation focussing on this irregularly formed tumour mass (it is called stereotactic guided radiation therapy) the area surrounding the tumour receives either a somewhat lower dosage than the tumour core or – if the dosage to the surrounding area is not reduced – there is a risk of damaging radiation to the adjacent, healthy tissue. Undeniably this is objectively the physical and medical problem of radiotherapy. However, not only the structures located around the acoustic neuroma would possibly be unnecessarily radiated, but inevitably the tissue between the radiation sources and the target tumour as well. The bigger the target volume, the bigger the integral (summary) dosage for the normal brain tissue and so the risk of side effects increases, particularly the risk of necrosis (death of the tissue).

The target volume must also remain confined. For this reason, acoustic neuroma with an average diameter bigger than 2.5 up to max. 3.0 cm are not suitable for radiation.

The strategy of «wait under observation»

After the diagnosis of an «acoustic neuroma» not acting, in other words choosing and starting no treatment, only waiting, without a concept, would be foolish. What are you waiting for? For the acoustic neuroma to actually shrink by itself, for the symptoms to subside or even to disappear, belongs to the still inexplicable events, whose frequency or rather rarity cannot even be expressed in numbers. As described on other pages of this website, an acoustic neuroma grows slowly, not steadily and uniformly, but it grows. The tendency is pre-existing that the complaints due to the AN will increase and at one point can become critical. Moreover, with time you lower the chance that the tumour can be removed without lasting damage to the cranial nerves.

To hold off one of the treatments to combat the tumour can only make sense under certain circumstances and for a specific group of patients. Sometimes the acoustic neuroma is detected by accident through another diagnosis. The acoustic neuroma patient does not feel any symptoms whatsoever. Or individual symptoms appear only faintly and sporadically and do not present any impairments for the patient. Or the patient's health, family or professional situation means that an AN operation can in no way be arranged (in the latter case, the complaints from the AN should still be very slight.).

Verständlicher sind aber Gründe, die außerhalb des Tumors liegen: Beispiele: Die gesundheitliche, die familiäre oder die berufliche Situation des Betroffenen ist gerade so, dass eine AN-Operation auf keinen Fall mit eingeordnet werden kann (In letzterem Fall sollten die Beschwerden durch das AN aber noch gering sein.).

In these cases action must not be taken immediately. However, at the same time two things are essential: first of all, a risk assessment by the doctor giving specific reasons for delaying the start of treatment. This assessment is discussed with the patient.
Secondly, there must be constant monitoring of the tumour's behaviour.

This monitoring must be carried out by the doctor and the patient together. The doctor must create a close network of MRT images, and the patient must record everything very sensitively, which could possibly lead back to the existence and growth of the acoustic neuroma (e.g. increasing hearing loss, vertigo, ear noise, numbness in the face, frequent headaches). Only then is it guaranteed that it is not useless, or even damaging waiting, but rather that the start of treatment should only be delayed without any date being missed.
Currently, this strategy is labelled differently: watch and wait, wait and see.

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