A Comprehensive Approach Towards Post-Operative Complications of Schwannoma Resection: A Case Report

Case Diagnosis: Vestibular schwannoma

Case Description or Program Description: 70 year-old male with 10-year history of vestibular schwannoma with brainstem compression causing hearing loss presents for a right retrosigmoid craniectomy with schwannoma resection. Surgery was complicated by intra-operative bleeding, requiring irrigation and cauterization. In the NSICU, the patient developed dysarthria, facial nerve dysfunction, dysphonia, and cranial nerves VI, VII, IX, X and XII palsies on the right, dysphagia, and right sided hearing loss.

Setting: Acute rehabilitation hospital

Assessment/Results: Post-operative CT demonstrated pneumocephalus in the posterior fossa and parenchymal hemorrhage with edema. Nasolaryngoscopy demonstrated right vocal fold immobility, palatal weakness, and velopharyngeal insufficiency (VPI). Patient treated with hyaluronic acid (HA) injection and palatopharyngoplasty during acute hospitalization. Eventually underwent right eyelid weight placement, canthoplasty, and G-tube for dysphagia. Patient was discharged to acute rehab at a level of MaxA with IADLs, despite being independent prior to hospitalization. In rehabilitation, he received multidisciplinary care with PT, OT and SLP to address mobility, gait imbalance, dysphagia, and speech intelligibility. He was discharged at a supervision level without an oral diet due to severe pharyngeal weakness. Outpatient reassessment showed less VPI after HA injection and he continued SLP.

Discussion (relevance): Cranial nerve palsies are common after vestibular schwannoma resection, and risk is increased in patients with postoperative complications. While intraoperative nerve monitoring can reduce damage, nerve dysfunction still requires early rehabilitative intervention. Management of cranial nerve deficits such as dysphagia includes VPI HA injection and palatopharyngoplasty, and consideration of G-tube placement for persistent aspiration risk. For facial nerve palsy, eyelid weighting and canthoplasty are crucial for corneal protection.

Conclusions: This case highlights the importance of early and comprehensive rehabilitation following vestibular schwannoma resection, particularly when cranial nerve palsies occur. A multidisciplinary approach, incorporating speech therapy, dysphagia management, and timely consultations of specialists, with prompt intervention of postoperative complications, is essential for optimizing recovery and preventing long-term disability.