Acoustic Neuroma / Vestibular Schwannoma

Acoustic Neuromas (AN), or as they should be called, vestibular schwannomas are tumours of the vestibulocochlear nerve (CN VIII). They are generally benign space occupying lesions and arise due to proliferation of Schwann cells from around the nerve.
The vast majority of ANs probably go undiagnosed and many are found at autopsy that caused no symptoms in life. The location of the tumour is important as this will dictate the symptoms it produces.
Tumours in the cerebellopontine angle (CPA) have a lot of space to grow in and can become over 4cm in size without causing any problems whereas those in the internal auditory canal will cause symptoms a lot sooner.

Signs and Symptoms

  • Unilateral sensorineural hearing loss!Acoustic neuroma until proven otherwise.
  • Unilateral tinnitus
  • Impaired facial sensation (involvement of CN V)
  • Balance problems
  • Otalgia
  • Ataxia (likely CPA mass)
  • Signs of increased ICP

Investigations

Audiology to test for hearing loss, and MRI (much better than CT in this case)

Management

There are essentially 3 management choices:
  1. Watch and monitor
  2. Surgery
  3. Stereotactic radiosurgery
Although sitting back and watching may sound too conservative, a recent study showed that only 4% of small neuromas actually showed rapid growth over a period of time. If the patient is asymptomatic then avoiding the 1% mortality risks associated with surgery may be the best option. As with most neurosurgery other risks include; meningitis, hearing loss, stroke and epilepsy.

Cancer of the Oral Cavity

Oral cancers are the most common ENT malignancy in the UK. They are more common in men and increase in incidence with age. They are almost always squamous cell carcinomas. Smoking and heavy drinking are by far the most important risk factors.
Tissues from which they can arise include the lips, gums, tongue or surface of the mouth. Very rarely they arise from salivary glands or the tonsils.

Signs and Symptoms

The three main signs are
  • An ulcer that doesn’t heal
  • Red/white plaques on the inside of the mouth
  • A painful lump that does not resolve
Most patients will present with at least one of these complaints. Bleeding, numbness or inexplicable loss of teeth are other, less frequent complaints.

Investigations and Treatment

A biopsy should be taken under GA once the lesion has been localised. MRI and CT are very useful. Staging is by TNM. Cases of oral cancer are often managed in an MDT.
Surgery is usually employed when spread of the cancer is limited. It may involve PDT or excision:
  • Photodynamic therapy (PDT)– Chemicals which react to light are injected into the tumour. The area is then exposed to a strong light and the chemical reacts, releasing free-radicals and causing necrosis of the tumour. This therapy has become more popular in recent times.
  • Excision– The tumour may be in a position from which it can be excised. Cosmetics after surgery must be

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