Management of the Contracted Mastoid in the Translabyrinthine Removal of Acoustic Neuroma

Several approaches to the internal auditory canal and cerebellopontine angle for acoustic neuroma removal have been described. We prefer the translabyrinthine approach in patients with tumors larger than 2 cm or poor preoperative hearing, since both factors predict poor hearing preservation. Many surgeons perceive this approach as confining and consider it contraindicated in large tumors or contracted mastoids. We have recently described the utility of the translabyrinthine approach for the removal of large (> 4 cm) acoustic neuromas. In more than 5000 tumor excisions performed by the senior author (W.E.H.), no cases required a modification of the approach because of anatomic constraints within the mastoid. We describe our techniques for the management of the low-lying tegmen, the anterior sigmoid sinus, and the high jugular bulb, alone or in combination, during translabyrinthine removal of acoustic neuromas.