About Prof. Wu Hao
Prof. Wu Hao is a leading otolaryngologist and skull base surgeon at the Eye & ENT Hospital, Fudan University — one of China's foremost centres for otolaryngology, cochlear implantation, skull base surgery, and head and neck oncology. He specialises in cochlear implantation, skull base tumour resection, and complex head and neck surgery, and is recognised as one of China's foremost experts in hearing restoration and complex ENT oncology. His clinical philosophy holds that in skull base surgery, the goal is never simply tumour removal — it is tumour removal with the maximum possible preservation of the neurological structures that define the patient's quality of life. Facial nerve function and residual hearing are not acceptable collateral losses; they are surgical outcomes to be planned for, monitored in real time, and protected with the same rigour as oncological clearance.
Case Overview
Mr. Li (pseudonym), a 45-year-old man, presented with a several-year history of progressive left-sided hearing loss that had recently been accompanied by new-onset headache and left-sided facial numbness. High-resolution MRI confirmed a large left-sided vestibular schwannoma (acoustic neuroma) measuring approximately 3.5 cm at its widest dimension, with significant extension into the cerebellopontine angle, compression of the brainstem, and intimate contact with the facial nerve and cochlear nerve along their course through the internal auditory canal. Audiological assessment confirmed severe sensorineural hearing loss in the left ear with absent auditory brainstem response. Having been advised at multiple institutions that the surgical risk was high and the prognosis uncertain, Mr. Li and his family sought Prof. Wu Hao. Following multidisciplinary review by otolaryngology, neurosurgery, and anaesthesiology, Prof. Wu's team planned a retrosigmoid approach microscopic resection with continuous intraoperative neurophysiological monitoring of the facial nerve and cochlear nerve. The tumour was completely resected. Intraoperative facial nerve monitoring confirmed preserved function throughout. Mr. Li recovered without facial palsy; facial sensation gradually normalised over the following weeks. He reflected: "I had been told the surgery was too dangerous. Prof. Wu's team gave me a clear plan and the confidence to proceed. Waking up without facial palsy — that was the moment I knew everything was going to be all right."
Diagnostic Workup
High-resolution MRI with gadolinium contrast characterised the tumour — confirming its size (approximately 3.5 cm), cerebellopontine angle extension, degree of brainstem compression, and the relationship of the tumour to the facial nerve and cochlear nerve within the internal auditory canal. Thin-slice CT of the temporal bone defined the bony anatomy of the internal auditory canal and posterior fossa, informing the surgical approach and drill trajectory. Pure tone audiometry and speech discrimination testing quantified the degree of sensorineural hearing loss; auditory brainstem response (ABR) testing confirmed absent wave V on the left, establishing the baseline for intraoperative monitoring. Vestibular function testing assessed the degree of vestibular compensation and informed the rehabilitation plan. Multidisciplinary review — otolaryngology, neurosurgery, and anaesthesiology — confirmed the retrosigmoid approach as the optimal surgical strategy for this tumour size and configuration, and established the intraoperative monitoring protocol.
Prof. Wu's pre-operative assessment: The tumour is large and the brainstem compression is significant — this is not a case where we can defer surgery. The facial nerve is the critical structure: at this tumour size, it is displaced and stretched along the tumour capsule, and the dissection will require continuous electromyographic monitoring and meticulous technique at every step. The cochlear nerve is already severely compromised by the tumour — hearing preservation is not a realistic goal in this case, but facial nerve preservation absolutely is. Our objective is complete resection with an anatomically and functionally intact facial nerve.
Treatment Strategy and Course
Diagnosis: Large Left Vestibular Schwannoma (Acoustic Neuroma), Cerebellopontine Angle Extension with Brainstem Compression, Severe Left Sensorineural Hearing Loss, and Left Facial Numbness in a 45-year-old patient.
Treatment principle: retrosigmoid approach microscopic acoustic neuroma resection with continuous intraoperative neurophysiological monitoring — achieving complete tumour removal with anatomical and functional facial nerve preservation.
- Surgical approach and positioning: Retrosigmoid craniotomy approach selected for optimal access to the cerebellopontine angle and internal auditory canal; patient positioned in lateral decubitus; continuous facial nerve electromyography (EMG) and brainstem auditory evoked potential (BAEP) monitoring established before incision
- Tumour exposure and internal decompression: Posterior fossa dura opened; arachnoid dissected to expose the tumour in the cerebellopontine angle; internal decompression of the tumour capsule performed to reduce volume and allow safe dissection of the tumour-nerve interface
- Facial nerve identification and dissection: Facial nerve identified at its root entry zone at the brainstem and traced along the tumour capsule to the internal auditory canal; continuous EMG monitoring confirmed nerve integrity at each step of the dissection; meticulous sharp dissection used to separate tumour from nerve throughout its course
- Complete tumour resection: Tumour resected completely; internal auditory canal drilled to ensure complete removal of intracanalicular component; haemostasis achieved; dura closed watertight; no intraoperative complications; total operative time approximately 6 hours
- Intraoperative monitoring outcome: Facial nerve EMG responses maintained throughout; no significant amplitude reduction at tumour removal; House-Brackmann Grade I facial nerve function confirmed in the immediate postoperative period
- Postoperative recovery: No facial palsy; no cerebrospinal fluid leak; no meningitis; mild postoperative vertigo managed with vestibular rehabilitation; facial numbness gradually resolved over 6–8 weeks; discharged on postoperative day 5
Prof. Wu's clinical reflection: Complete resection with a Grade I facial nerve outcome in a tumour of this size is the result of preparation, monitoring, and discipline at every step of the dissection. The intraoperative EMG is not a safety net — it is a real-time conversation with the nerve, telling you at every moment whether your technique is safe. When the monitoring is continuous and the surgeon listens to it, the nerve tells you where it is and how it is tolerating the dissection. Mr. Li's outcome is what this approach is designed to achieve.
Expert Commentary — Prof. Wu Hao
1. Vestibular Schwannoma: Natural History, Surgical Indications, and the Case for Early Intervention in Large Tumours
Vestibular schwannomas are benign tumours arising from the Schwann cells of the vestibular division of the eighth cranial nerve. Their natural history is variable — small tumours may remain stable for years, and observation with serial MRI is an appropriate strategy for selected patients. However, large tumours with brainstem compression, as in Mr. Li's case, carry a different risk profile: progressive neurological deterioration, hydrocephalus, and — in the most severe cases — life-threatening brainstem compromise. For tumours of this size, surgery is the treatment of choice. The surgical objective is complete resection with preservation of the facial nerve — the cranial nerve most at risk during tumour dissection and the one whose dysfunction (facial palsy) has the most immediate and visible impact on the patient's quality of life. Hearing preservation is an additional goal in smaller tumours with serviceable hearing, but in large tumours where hearing is already severely compromised, facial nerve preservation becomes the primary functional objective.
2. Intraoperative Neurophysiological Monitoring: The Technical Basis for Facial Nerve Preservation in Skull Base Surgery
Continuous intraoperative neurophysiological monitoring of the facial nerve — using electromyography (EMG) to detect spontaneous and evoked muscle activity in the facial musculature — is the standard of care for acoustic neuroma surgery and has transformed outcomes in this field. The facial nerve, displaced and stretched along the tumour capsule in large schwannomas, cannot be reliably identified by visual inspection alone; its course is distorted by the tumour, and its appearance may be indistinguishable from tumour capsule or arachnoid. EMG monitoring provides real-time feedback on nerve integrity: spontaneous activity signals mechanical irritation; evoked responses to direct stimulation confirm nerve identity and function; and the maintenance of response amplitude throughout the dissection is the intraoperative correlate of postoperative facial nerve function. The combination of continuous monitoring and meticulous microsurgical technique — sharp dissection, minimal traction, and bipolar coagulation used sparingly and at a distance from the nerve — is the technical basis for the facial nerve preservation rates achievable in experienced skull base centres.
3. Multidisciplinary Skull Base Surgery: The Otolaryngologist-Neurosurgeon Partnership
Acoustic neuroma surgery at the cerebellopontine angle sits at the intersection of otolaryngology and neurosurgery — a surgical territory that requires the anatomical expertise of both specialties and the organisational framework of a dedicated skull base programme. The otolaryngologist brings expertise in the anatomy of the temporal bone, the internal auditory canal, and the cranial nerves of the posterior fossa; the neurosurgeon brings expertise in posterior fossa craniotomy, cerebellar retraction, and brainstem-adjacent dissection. In experienced skull base centres, these roles are integrated rather than sequential: the two surgeons operate together, each contributing their specialist expertise at the relevant phase of the procedure. The anaesthesiologist's role — maintaining haemodynamic stability, optimising brain relaxation, and managing the physiological demands of a prolonged posterior fossa procedure — is equally critical. The outcome in Mr. Li's case — complete resection, Grade I facial nerve function, no cerebrospinal fluid leak, and discharge on day five — reflects the integrated performance of this multidisciplinary team.
How CMCS Shanghai Coordinated This Case
CMCS Shanghai supported Mr. Li and his family throughout the diagnostic, surgical, and rehabilitation pathway at the Eye & ENT Hospital, Fudan University, including: priority consultation coordination with Prof. Wu Hao's skull base surgery team; bilingual interpretation across all otolaryngology and neurosurgery consultations, surgical planning discussions, and follow-up appointments; bilingual explanation of the acoustic neuroma diagnosis, the surgical approach, the intraoperative monitoring strategy, and the facial nerve preservation plan; coordination of MRI, CT temporal bone, audiological assessment, and vestibular function testing with bilingual results communication; bilingual surgical consent; intraoperative family liaison and postoperative ward coordination including neurological status updates and discharge planning; and rehabilitation coordination including vestibular rehabilitation scheduling and long-term surveillance MRI planning.
For international patients and expatriates in China facing skull base tumours, acoustic neuromas, or complex ENT oncology, Prof. Wu Hao's team at the Eye & ENT Hospital, Fudan University offers access to one of Shanghai's most experienced skull base surgery programmes. CMCS ensures that expertise is accessible — in the patient's language, with every step coordinated and communicated clearly.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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