Current treatment strategy in the management of vestibular schwannoma

Background: The changing trends in the management of vestibular schwannoma (VS) in our practice over the last two decades as well as the current status are presented here. Materials and Methods: The observations are based on the experience of 559 consecutive cases of VS operated by the first author between 1987 and 2008, 438 of which were operated by microsurgery and 139 by gamma knife radiosurgery (GKR) (18 of which were previously operated by the authors). A detailed analysis of microsurgically managed patients in two different periods (100 consecutive patients each before 1993 and 2008) were compared to see the changing trend and document current results. Results and Discussion: In the initial experience (1990s), the emphasis in microsurgery was preserving life, total excision of tumor and preservation of function in that order. In the 21^st century, the emphasis in microsurgery has been all about functional preservation. In 100 consecutive cases of VS (excluding neurofibromatosis-2) that were treated microsurgically between 2005-08, there were four small tumors (< 2 cm), 14 medium-sized tumors (2-3 cm) and 82 large tumors (≥3 cm). The total excision rate was 83%. The facial nerve anatomical preservation rate was 96% and function was Grade III House-Brackmann (HB) or better in 87%. Both the total excision rate and facial function of Grade II HB or better were 100% in cases with tumor size less than three cm. Functional hearing preservation was achieved in ten cases. There was no operative mortality. Conclusion: Total excision of VS, though aimed at, is no more pursued at the cost of facial function. Moreover, microsurgery, radiosurgery and observation are all valid options in the management of VS and choosing the correct modality helps in achieving optimal outcome.