Cerebellopontine Angle Tumour

Physical Examination

Decreased facial sensation or absence of corneal reflex, linked to the involvement of the trigeminal nerve (V). (Don’t forget to mention that you would like to examine corneal reflex)

• The presence of nystagmus, which could indicate cerebellar or vestibular dysfunction.

• Abducens nerve (VI) palsy may manifest as diplopia or lateral gaze palsy.

• Lower motor neuron facial nerve (VII) palsy can result in facial asymmetry, inability to close the eye, smile, or puff out the cheeks on the affected side.

• Vestibulocochlear nerve (VIII) involvement usually presents as sensorineural deafness. There may also be tinnitus or vertigo.

• Cerebellar signs may be present, including tremor, ataxia, dysdiadochokinesis, dysmetria, or scanning speech.

• Examine for scars behind the ear over the petrous bone, indicating previous surgeries.

Investigations

Audiometry: Essential for determining the degree of sensorineural hearing loss, comparing both sides and identifying the pattern of hearing loss.

• Vestibular function tests: To assess balance and coordination-related issues, as these can be affected in cerebellopontine angle tumors.

• MRI brain with gadolinium contrast: Gold standard for diagnosing cerebellopontine angle tumours, providing detailed images of soft tissues including the brain, cranial nerves, and tumour.

• Laboratory Tests: Basic tests, including CBC, renal and liver function tests, electrolytes, and coagulation profile, are important prior to any possible surgical intervention.

• Speech and swallowing assessment: To assess lower cranial nerve function if there is any indication of speech or swallowing impairment.

Management

General Management:

• Patient education and counselling: Explain the diagnosis, treatment options and potential complications of cerebellopontine angle tumour to the patient and their family.

• Monitor for changes: Regular assessment of the patient's neurological status, including cranial nerve function and any changes in hearing or balance.

• Multidisciplinary care: Coordinate care among neurologists, neurosurgeons, radiologists, and physiotherapists.

Medical Management:

• Symptom control: Medication for symptom management including analgesics for headache, antiemetics for nausea, and vestibular suppressants for vertigo.

• Steroids: Short-term use of corticosteroids to reduce peritumoral edema, which can help alleviate symptoms, particularly prior to surgery.

• Follow-up: Regular follow-up with serial imaging for small, asymptomatic tumours, in elderly patients, or in patients where surgery is not feasible due to other comorbid conditions.

Surgical Management:

• Tumor resection: Surgical removal of the tumor is the mainstay of treatment for symptomatic cerebellopontine angle tumors. The goal is maximal safe resection to preserve neurological function.

• Different surgical approaches: Translabyrinthine, retrosigmoid, and middle fossa approach. The choice depends on the size of the tumour, the degree of hearing loss, and the surgeon's preference.

• Stereotactic radiosurgery: For patients not suitable for conventional surgery, or for residual or recurrent tumours after surgery. Radiosurgery such as Gamma Knife can be used to deliver targeted radiation to the tumour.

Other Management:

• Rehabilitation: Post-surgical rehabilitation involving physiotherapy, occupational therapy and speech and language therapy can help improve patients' quality of life.

• Supportive care: Psychological support and counselling to help patients cope with hearing loss or facial palsy.

• Follow-up: Long-term follow-up with serial imaging to monitor for any recurrence or growth of residual tumour.

Palliative Care:

• Consider palliative care involvement for symptom management and support, particularly in cases where curative treatment is not possible or appropriate.