CASE REPORTS AND TECHNICAL NOTES

ACOUSTIC NEUROMAS IN CHILDREN

REPORT OF ~ CASES
WINCHELLMcK. CRAIG,M.D., HENRY W. DODGE,JR., M.D.,
AND PAUL J. Ross, M.D.
Section of Neurologic Surgery, Mayo Clinic, and Mayo Foundation,*
Rochester, Minnesota
(Received for publication March 19, 1954)

T u m o r s affecting the acoustic (eighth cranial) nerve occur most frequently in

the fourth, fifth and sixth decades of life, according to statistics reported in the
majority of published series. 2,4,9 Recently, we operated on ~ children, 11 and 14
years of age, who had typical acoustic neurofibromas (neurilemmomas). The un-
common occurrence of typical tumors of the eighth nerve in the cerebellopontine
angle of children less than 15 years old has prompted us to report these cases.
The available pertinent literature lends emphasis to the fact t h a t these tumors
are rare in children. In his monograph Tumors of the Nervus Acusticus, Cushing ~
in 1917 quoted Henschen as reporting on a patient 19 years old with a tumor of the
eighth nerve. Cushing, s in 19~7, again reported on a patient between the ages of 1O
and 15 years. The exact age was not given. Ziilch TM reviewed 1~1 histologically veri-
fied brain tumors in a series of patients 1 to s years old, in 1938. There was 1 case
of a neurofibroma of the cerebellopontine angle in this series. Of the 100 tumors in
children reported by Bailey and his collaborators t in 1939, 1 case concerned a neuri-
noma (neurofibroma) of the twelfth cranial nerve in a patient 1~ years old. There
was no instance of such a t u m o r affecting the eighth nerve. Of the 130 patients with
acoustic tumors reviewed b y Nielsen 9 in 194~, the youngest was 18 years old. The
youngest patient in the series (154) reviewed by Gonzalez Revilla 5 in 1947 was 19
years old. Keith, Craig and Kernohan ~ reported 4~7 brain tumors in children less
than 15 years old in 1949. There was no instance of a neurofibroma of the acoustic
nerve in this report. Love 7 in 1950 reported on an intrapetrous neurofibroma that
had originated in the eighth cranial nerve in a 16-year-old female. This patient's
s y m p t o m s were of 8 years' duration, and presumably the tumor had been present
when she was 8 years old. Edwards and Paterson 4 listed ~ patients between l0 and
s years of age, but exact ages were not stated. An unusual case in which a unilateral
t u m o r of the eighth nerve afflicted an 889 child was reported by M a r k and
Sweet s in 195~. This lesion was an acoustic neurofibroma. The patient was 6 years
old at the time of onset of symptoms. Among the patients with approximately 410
verified unilateral acoustic neurofibromas operated on at the M a y o Clinic between
January, 1915 and July, 1953, only ~ have been less than 15 years old.
The cardinal signs and s y m p t o m s of tumors of the acoustic nerve in the cere-
bellopontine angle are so well known t h a t it seems unnecessary to repeat them here.
* The Mayo Foundation is a part of the Graduate School of the University of Minnesota.
505
506 W I N C H E L L McK. CRAIG, H E N R Y W. DODGE, JR. A N D P A U L J. ROSS

H o w e v e r , it o c c u r r e d to us t h a t p r e s e n t a t i o n of two cases of these t u m o r s in children

w o u l d be of i n t e r e s t a n d w o u l d show t h e close s i m i l a r i t y b e t w e e n t h e s y m p t o m s as
t h e y a p p e a r in y o u n g c h i l d r e n a n d t h e s y m p t o m s as t h e y a p p e a r in a d u l t persons.

REPORT OF CASES
Case 1.--A white boy 11 years old was examined at the Mayo Clinic because of bifrontal
headaches that had begun 8 months earlier. The headaches usually had been present when
the patient awakened in the morning, and by noon had subsided. The headaches had been
constantly present throughout the patient's illness, and were aggravated by coughing, sneez-
ing and straining. Considerable relief was obtained by lying down. Two episodes of nausea
and vomiting had been associated with the headache.
Concurrent with the headaches, the patient became aware of an intermittent buzzing in
his left ear associated with a gradual loss of hearing. Periodic attacks of "dizziness," during
which the patient would stagger and bump into objects, also were experienced.
One month before examination the patient's left arm tired easily and had become in-
creasingly awkward.
Neurologic Examination. Positive findings were sensory impairment on the left side of the
face with decreased corneal reflex, slight weakness of the left facial muscles and minimal
inco-ordination of the upper extremity and the presence of Babinski's reflex on the left.
Movements of eyes disclosed horizontal nystagmus, more marked to the left, with paresis of
conjugate gaze to the left. Subacute edema of the ocular fundi (right ~ D., left 3 D.) was noted.
Caloric stimulation was difficult to evaluate because of the marked spontaneous nystagmus.
A diagnosis of tumor of the left cerebellopontine angle was made.
Operation. Left suboccipital craniectomy was performed. After the dura mater had been
opened, the cerebellum was retracted mesially. An acoustic neurofibroma, 8 by 5 cm., was
found. Total removal was accomplished. After removal of the tumor the seventh cranial nerve
appeared to be intact, and the dura mater was closed. The internal auditory meatus was not
curetted.
Course. The patient's postoperative convalescence was uneventful. A postoperative periph-
eral type of palsy of the seventh cranial nerve developed on the left. The patient was dis-
missed on the 12th postoperative day.
Four months later the patient returned for re-examination. He was found to have made an
excellent recovery, except for the persistent deafness. The facial palsy on the left showed some
abatement to clinical examination and to electromyographic tracings.
Case 2.--A 14-year-old girl was first seen at the clinic in September, 1952. She complained
mainly of loss of hearing in the left ear of 5 years' duration, buzzing in the left ear for the
same period, and twitching of the left eyelid of ~ years' duration. Generalized headaches had
been present for the year previous to her admission, associated with episodes of nausea and
vomiting which had become more frequent in the last 6 months. Three weeks prior to ad-
mission she had become aware of a loss of balance, difficulty in walking and inco-ordination
of the left arm. She also had noticed some degree of double vision.
Neurologic examination revealed horizontal nystagmus, more marked on gazing to the
left, loss of hearing on the left graded --3 (0 normal; - 4 complete deafness) and a decreased
corneal sensation left (graded - 3 ) .
In addition, hyporeflexia on the left, drooping of the left side of the face, marked inco-
ordination of the left upper and lower extremities, ataxia and muscular hypotonicity on the
left side were recorded.
There was also swelling of the optic nerve heads (right 4 D., left 5 D.). The electro-
encephalogram was reported as disclosing no abnormality. Roentgenograms of the skull
showed slight erosion of the tip of the petrous ridge on the left, and decalcification of the floor
of the sella (Fig. 1).
I n view of the clinical and radiologic findings, a diagnosis of tumor of the left cerebello-
pontine angle was made.
 ACOUSTIC N E U R O M A S I N C H I L D R E N 507

FIo. 1. Case 2. (a) Roentgenogram made with the patient ill the Towne position, to illustrate erosion
of the left petrous ridge hy a neurofibroma (neurilemmoma) of the left eighth cranial nerve in the cere-
bcllopontine angle; (b) anteroposterior roentgenogram.
Operation. Left suboccipital craniectomy was performed. A typical acoustic ncurofibroma
was encountered occupying the entire right cerebcllopontinc angle. In view of the patient's
condition and the extent of the tumor a subtotal removal of the tumor was carried out. This
seemed to be in the best interest of the patient under the existing conditions at the time of
operation.
Course. The postoperative recovery was uneventful. Examination at the time of dismissal
revealed marked abatement of neurologic symptoms and the papilledema was subsiding.
COMMENT
I t is a p p a r e n t t h a t a c o u s t i c n e u r o f i b r o m a s a r e u n c o m m o n in c h i l d r e n less t h a n
15 y e a r s of age. T w o cases in which acoustic n e u r o f i b r o m a s afflicted c h i l d r e n 11 a n d
14 y e a r s of age h a v e b e e n p r e s e n t e d . T h e s i m i l a r i t y of t h e clinical course of t h e s e
t u m o r s in c h i l d r e n a n d a d u l t s is e v i d e n t in these cases.
508 C. W. TAYLOR

:REFERENCES
1. BAILEY, P., BUCHANAN,D. N., and Bvcr, P . C . Intracranial tumors of infancy and childhood.
Chicago: University of Chicago Press, 1939, xiii, 598 pp.
3. CUSHING, H. Tumors of the nervus acusticus and the syndrome of the cerebellopontile angle.
Philadelphia: W. B. Saunders Co., 1917, viii, 396 pp.
3. CUSHING,H. The intracranial tumors of preadolescence. Amer. J. Dis. Child., 1937, 33: 551-584.
4. EDWARDS,C. H., and PATERSON,J . H . A review of the symptoms and signs of acoustic neuro-
fibromata. Brain, 1951, 75: 144-190.
5. GONZALEZREVILLA,A. Neurinomas of the cerebellopontilc recess. A clinical study of one hundred
and sixty cases including operative mortality and end results. Johns Hopk. Hosp. Bull., 1947, 80:
354-~96.
6. KEITH, H. M., CRAIO,W. McK., and KEI~NOHAN,J.W. Brain tumors in children. Pediatrics, 1949,
3: 839-844.
7. LOVE, J. G. Unilateral deafness and progressive facial palsy due to intrapetrous neurofibroma:
surgical treatment. Proc. Mayo Clin., 1950, 25: ~38-33~.
8. MARK, V. H., and SWEET, W.H. An unusual case of unilateral eighth nerve tumor. J. Neurosurg.,
195~, 9: 395-397.
9. NIEI~EN, A. Acoustic tumors with special reference to end-results and sparing of the facial nerve.
Ann. Surg., 1943, 115: 849-863.
10. Z/2LCH,K . J . Die Hirngeschwiilste des Jugendalters. Z. ges. Neurol. Psychiat., 1938, 161: 183-188.

SPINOTHALAMIC TRACTOTOMY FOR INTRACTABLE ITCHING

C. W. TAYLOR, M . D . *
Division of Neurosurgery, Calgary General Hospital, Calgary, Alberta, Canada
(Received for publication April 26, 1954)

Will high section of the pain tract abolish intractable itching? In the light of our
experience with one case we would say that the answer is "no."
Faced with this problem, I talked it over with Dr. K. G. McKenzie, who sug-
gested consideration of a high pain tract section. 1 I t was decided to try the operation
on one side. If it proved helpful the second side could be done at a later date. I t was
argued that pain tract section abolished tickle sensation as well as the sensations of
heat and cold and so might give a better result than a lobotomy. The result in our
patient here has been a complete failure. Postoperatively the tickle element of light
touch was indeed gone, but the patient continued to itch and excoriation continued
relentlessly. The case is briefly recorded as it may be helpful to others faced with a
similar but unusual neurosurgical problem.

CASE REPORT
Mr. A.M., aged 71, had suffered from a chronic erythematous skin eruption for m a n y
years. Itching had become intractable so t h a t incessant scratching excoriated the skin over
both arms and legs. Subacutc infection was frequently supcraddcd so t h a t repeated hospital-
izations had been necessary. As soon as he was discharged from hospital excoriation would
again occur. He denied any other somatic complaints. There was no suggestion t h a t he was
psychotic. Because the situation was desperate, a ncurosurgical opinion was sought.
Operation. While awaiting a bed in the Calgary General Hospital he had a severe attack
of herpes zoster involving the ~nd, 3rd and 4th sacral dermatomcs on the left side, and he
complained of severe pain in his left loin. F o r this reason we decided to cut the right spino-
thalamic tract. This was done 5 mm. below the obex by means of an incision 4 mm. deep,
placed between the rootlets of origin of the spinal accessory and hypoglossal nerves.
* 410 Greyhound Bldg., Calgary, Alberta.