Facial nerve neuromas are usually indistinguishable from acoustic lesions until the tumor is encountered at surgery . Surgery is therefore performed either by the translabyrinthine or retrosigmoid approach according to the patient's pre-operative hearing. Neuromas of the trigeminal nerve often present with a dumbbell mass present in both the posterior and middle cranial fossae. We usually remove such lesions via a pre-sigmoid combined posterior fossa/middle fossa approach. The otic capsule is left intact during drilling of the temporal bone. The petrous face dura is opened to gain access to the posterior fossa. If the tumor is large, the dura in the retrosigmoid region should be exposed and opened. If necessary, the sigmoid sinus is divided to improve access. If this is contemplated, pre-operative venous angiography is advised. A low, middle fossa craniotomy is performed to enable the middle fossa component of the tumor to be adequately exposed. The tentorium cerebelli is divided to greatly enhance simultaneous access into the middle and posterior fossae. The line of division should be parallel to the petrous apex, but just posterior to where the trochlear nerve pierces the dura at the medial edge of the tentorium.
Neuromas of the vagus, glossopharyngeal and spinal accessory nerve are exceedingly rare. Total resection was achieved in all five patients reported in the Cambridge series. All patients had at least one cranial nerve palsy, but only one required phonosurgery (teflon injection to vocal cord), and all swallow satisfactorily.
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