ACOUSTIC NEUROMA I. INTRODUCTION a.

Definition Acoustic neuromas are slow-growing benign tumors of cranial nerve VIII, usually arising from the Schwann cells of the of the vestibular portion of the nerve. Most acoustic tumors arise within the internal auditory canal and extend into the cerebellopontine angle to press on the brain stem , possibly destroying the vestibular nerve . Most acoustic neuromas are unilateral, except in von Recklinghausens disease (neurofibromatosis type 2), in which bilateral tumors occur (Roland, 2003). b. Statistical Data Acoustic neuromas develop in one of every 10,000 people per year. These neuromas account for 5% to 10% of all intracranial tumors and seem to occur with equal frequency in men and women at any age, although most occur during middle age. PATHOPHYSIOLOGY The tumor usually occur in the internal auditory meatus, compressing the auditory nerve where it exists the skull to the inner ear. But the vestibular and cochlear branches are affected; however the tumor arises from the vestibular division of the auditory nerve twice as often. If allowed to grow, the tumor eventually destroys the labyrinth, including the cochlea and vestibular apparatus. As the tumor expands, it erodes the wall of the internal auditory meatus. The tumor may eventually empinge on the inferior cerebellar artery, which provides blood to the lateral pons and medulla, the brainstem, and the cerebellum. An obstructive hydrocephalus can also occur. Cranial nerves VII

II.

(facial) and V (trigeminal) are often affected by the expanding tumor; the tumor frequently wraps around the facial nerve. III. RISK FACTORS Genetic risk of neurofibromatosis 2 The only known risk factor for acoustic neuroma is having a parent with the rare genetic disorder neurofibromatosis 2, but this accounts for only a minority of cases. A hallmark characteristic of neurofibromatosis 2 is the development of benign tumors on the acoustic nerves on both sides of your head, as well as on other nerves. Other possible risk factors: Exposure to loud noise Childhood exposure to low-dose radiation of the head and neck History of parathyroid adenoma, a benign tumor of the parathyroid glands in the neck Heavy use of cellular telephones CLINICAL MANIFESTATIONS

IV. V.

sensorineural hearing loss/deafness, disturbed sense of balance and altered gait vertigo with associated nausea and vomiting, pressure in the ear loss of sensation

DIAGNOSTIC PROCEDURES Contrast-enhanced CT will detect almost all acoustic neuromas that are greater than 2.0 cm in diameter and project further than 1.5 cm into the cerebellopontine angle. Those tumors that are smaller may be detected by MRI with gadolinium enhancement. Audiology and vestibular tests should be concurrently evaluated using air conduction and bone conduction threshold testing to assess for sensorineural versus conduction hearing loss. Diagnosti c Tests CT SCAN (Compute d Tomograp hy Scan) Purpose or Nursing Responsibilities description Client Preparation Intra Post Used to identify Ensure a (if intracerebral signed applicable hemorrhage, consent ) do not tumors, cysts, drink or Check hospital aneurysyms, eat policy on edema,ischemi anything withholding

a, atrophy, and tissue necrosis. May also used to evaluate a shift in intracranial contents and differentiate type of stroke. Involves computer assisted x-rays of several levels across sections of body part being examined; may be done with or without contrast.

food and fluids. Clients are usually on NPO status (except for the medications are ordered as part of the test) for 8 hours before the test if it is done in the morning. If the test is done in the afternoon, the client may have a liquid breakfast. Give medications up to 2 hours before the test. Assess for possible reaction to iodine dye (by asking about allergy to seafood). Document any allergy and inform the physician and radiology department. Remove metal, hairpins, clips, and earings.

before the test except for the ordered medicatio ns. You may be given an intraveno us infusion. When the contrast dye is injected, you may feel warm and have a metallic taste in the mouth. The exam lasts from 30 to 90 minutes. Your head will be positioned in a cradle, and a wide rubber strap will be applied snugly across the forehead during the test ( to keep your head immobiliz ed). The CT scanner is

MRI (Magnetic Resonana ce Imaging)

An MRI is done to identify and monitor conditions of the brain and spinal cord, including stroke , tumors, trauma, seizures, and multiple sclerosis. Use magnetic energy to provide images. Gadolium contrast media may be used to enhance

circular with a round opening. You are strapped to a special table, and the scanner revolves around the body part to be examined. The scanner makes a clicking noise. The test is painless. Someone is always immediat ely available during the test. Assess for metal implants (such as a pacemake r or defribilato r), body piercings, and shrapnel, which would contraindi cated tests.

visualization. A functional MRI is done to evaluate metabolic flow responses of the brain to specific task, such as activity and rest. VI. MEDICAL MANAGEMENT a. Pharmacologic Management There is no medication known to have a substantial effect on the growth of acoustic neuroma tumors.

b. Surgical Management Removal of acoustic neuromas may be performed using several approaches. Each approach has its advantages and disadvantages. Microsurgery for acoustic neuroma is the only technique that removes the tumor. Radiation treatment (discussed in another section) does not remove the tumor, but has the potential to slow or stop its growth. Surgery is the only treatment that will definitively treat balance symptoms associated with tumor growth, as the vestibular nerves are removed at surgery. Radiation therapy Radiation therapy is done in a variety of ways, but mainly by four methods: CyberKnife, gamma knife radiosurgery,fractionated stereotactic radiotherapy, with a linear accelerator (linac), or proton therapy. In the gamma knife approach, 201 beams of gamma radiation are focused on the tumor in a single session. The damage to the tumor at the convergence point may cause it to stop growing but usually does not cause it to shrink in the long term. It may cause short-term shrinkage due to necrosis in the tumor. The damage may be to the tumor cells and/or to the tumor vasculature. A proton therapy machine uses a beam of protons to kill the tumour and a cyclotron is used to generate the beam. This is preferable to the x-rays used by the linac and gamma knife machines as the protons can be stopped before they exit the tumor, thus reducing damage to normal tissue. . VII. NURSING DIAGNOSIS Pain related to edema Sensory perceptual alteration: auditory related to altered sensory reception, transmission or integration

VIII. NURSING MANAGEMENT Observe emotional needs; encourage expression of feelings. Keep background noise at minimum, turn off TV or radio when communicating with client. Stand or sit directly in front of client if possible, make sure adequate light as on nurses face, establish eye contact, and use nonverbal gestures. Speak distinctly in lower voice tones if possible. Provide communication board if needed, or personnel who know sign language. Refer to appropriate resources such as speech therapy, hearing testing, and hearing aid evaluation as needed. Be aware that hearing loss may cause frustration, anger, fear and self-imposed isolation.