Neurotologist, Professor & Director of the UC San Diego Health Acoustic Neuroma Program, Rick Friedman, MD, PhD talks about treating acoustic neuromas.
Interview conducted by Ivanhoe Broadcast News in 2023.
What is acoustic neuroma?
Friedman: An acoustic neuroma is a benign neoplasm of the eighth cranial nerve, which is the hearing and balance nerve. We don’t know why it’s most common on that nerve, but it is. It occurs in about one and 100,000 individuals annually. It’s an abnormal proliferation growth without keeping it in check. Unlike cancer, it doesn’t metastasize but it’s the outer sheath of the neuron. It’s like the covering of the wire that’s just growing out of control, and it damages hearing. It can get big enough to compress the brain stem. Back before modern skull-based surgery and imaging methodology, patients would come in near death from brain herniation because it crushes the brain stem.
What kind of symptoms do they have now?
Friedman: The reason otolaryngology got involved, is the initial symptom is usually hearing loss or tinnitus, ringing in the ear, and sometimes it’s imbalance. Then some pioneers back where I trained and back where Dr. Schwartz and I came from at a place called the House Clinic, pioneered team approaches between neurotologists, which is what I am, and neurosurgeons, which is what Dr. Schwartz is. My job for the most part is to gain exposure of the tumor through the skull base without having to retract the brain, and Marc takes them out.
Do these patients get misdiagnosed for some time?
Friedman: A lot of people are beginning to become aware, but I have a lot of patients who thought it was always age. We don’t lose hearing in one ear because you age, you lose hearing in both. Some of its patient understanding and then sometimes it’s physician understanding that anybody who presents with a single-sided hearing loss, or auditory, or balance symptoms should have an MRI scan.
Are you Julie’s doctor? Can you tell me a little bit about her when you first met her?
Friedman: Yes, she had a small tumor and good hearing.
Where was the tumor?
Friedman: They typically start in what’s called the internal auditory canal, which is a structure straight in from the ear and where these two points bisect, right next to the brain, it’s where the nerves come out and go to the brain from the ear and the face. The delicacy of this is not only saving hearing, but the tumors are always pushing against the nerve that moves the face. Not necessarily a result of the tumor, it’s rare, but the result of treatment can lead to facial weakness. That’s where the tumors are. Hers was confined to the canal, small, which allows us to try to take it out and save hearing. We did, and we were successful for her.
How small was it?
Friedman: I can’t remember hers, but usually it’s under a centimeter and a half. Around 15 millimeters, the size of maybe a big resin.
Is it instant relief? Does everything go back to normal immediately?
Friedman: A lot of them come with some balance impairment that they either may or may not recognize. If it happens slowly over time, the brain compensates. The difficulty for the patients is we take the tumor out and they lose balance in that ear suddenly whatever’s remaining, and the brain does a little bit of a freakout. It makes the patient’s eyes twitch like they were turning their head but they’re not because the brain thinks they are. They have to get over that vertigo, which takes a couple of days, and then imbalance. We just had a patient who we operated on last week who was showing us how he was balancing on rocks here in San Diego during this week. To other people, it can take several months for them to recover.
Does the ringing go away and things like that?
Friedman: About a third of the time it does, but often it doesn’t.
Do they then have tinnitus?
Friedman: They have tinnitus for life a lot of them. If we’re able to save their hearing and they can wear a hearing aid, sometimes the hearing aid helps.
How do you do the surgery?
Friedman: There are three different approaches to these tumors. Which one we choose depends on the size and the patient’s hearing. For very large tumors or patients with bad hearing, we go behind the ear through the mastoid bone in what’s called a trans-lab approach. I have to drill through the inner ear down to the brain stem and the internal auditory canal. Those patients have no hearing after surgery. For tumors that are medium-sized, or what we call bigger inches of small or medium, with good hearing, we do retrosigmoid, which is a little further back. We go into what’s called the posterior cranial fossa and move the cerebellum a little to get to the tumor. Then Dr. Schwartz will take the tumor out at that angle, and I will drill open the canal and take the tumor out of the canal. We try to save hearing in those. Then the real great hearing preservation, because the tumors are smallest is the middle facet. We take a window of bone out and then come from above. In this case, I’m sitting above the patient and looking down at the floor of their cranial cavity and drilling off the bone of the internal auditory canal from above. That’s the procedure that I would say that we do best. We do more of it than any place in the world. Very few places offer that approach, which is unfortunate. There’s been this trend in the care of acoustic neuroma patients to be more conservative and just let their hearing go out. As somebody whose life is hearing, my research is hearing, and my clinical life is hearing outside of the home, of course, because I’m not hurt at all by my six-year-old. But we elect to be a little more proactive than most centers.
It seems like this is a little risky since you’re working with the brains staff.
Friedman: Marc Schwartz and I have been doing this together for 20 years now, we’ve done over one thousand cases in the six years that we’ve been here. We’ve never had mortality, we’ve never had a major complication. I think we’re good at what we do. I would say that the biggest risk is to the facial nerve. Again, I think we have the best facial nerve results in the company. We do so much more than any other center. We better be good at it. Our patients come from around the world because of the facial nerve and hearing preservation.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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