Transcochlear Approach to Cerebellopontine Angle and Clivus Lesions: Indications, Results, and Complications

Objectives: Evaluate transcochlear (TC)/transotic (TO) approaches surgery for midline intradural lesions arising from the clivus and cerebellopontine angle masses arising anterior to the internal auditory canal. Study Design: Retrospective chart review. Setting: Tertiary referral neurotologic practice. Patients/Intervention: Forty patients who underwent TC/TO approach surgery. Patients were grouped by whether the facial nerve was mobilized (TC, n = 15) or not (TO, n = 25). Main Outcome Measures: Indications, postoperative outcomes, and complications including tumor removal and facial nerve status (House-Brackmann grade). Results: Forty percent of all TC patients were meningiomas, whereas 36% of all TO patients were cochlear neuromas. The remainder included tumors associated with NF2, acoustic tumors, malignancies, and other lesions. Complete removal was achieved in 92.5% of tumors. Of all patients, 42% and 55% had normal facial nerve function at the time of hospital discharge and follow up, respectively. Moreover, 22% underwent a facial nerve reanastomosis procedure. Early and late complications occurred in 11 and 14%, respectively. There was one surgery-related death. Complications included cerebrospinal fluid leak (9%) and unsteadiness (9%). Conclusion: The TC and TO approaches provide access to midline intradural lesions, intradural petroclival tumors, and cerebellopontine angle tumors and cholesteatomas arising anterior to the internal auditory canal, without using brain retractors. Total tumor removal, including its base and blood supply, is possible. Facial weakness is frequent when the facial nerve is rerouted, but excellent facial nerve results are accomplished with the TO approach. With these approaches, recurrence is rare when all tumor has been removed. Their safety and efficacy encourage their use in extensive lesions.