# A client with acoustic neuroma is scheduled for surgical resection via the translabyrinthine approach. Which nursing intervention should be the priority in the immediate postoperative period?

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## 문제

A client with acoustic neuroma is scheduled for surgical resection via the translabyrinthine approach. Which nursing intervention should be the priority in the immediate postoperative period?

## 보기

1. Monitor for signs of cerebrospinal fluid (CSF) leak and maintain strict bed rest with head of bed elevated. **✔ 정답**
2. Assess bilateral hearing function and document any changes from preoperative baseline
3. Encourage early ambulation to prevent postoperative complications such as pneumonia and thrombosis
4. Administer prescribed antiemetics and monitor for nausea and vomiting related to vestibular dysfunct

**정답: 1**

## 해설

CSF leak is a critical complication after translabyrinthine acoustic neuroma resection, requiring monitoring for clear ear drainage and maintaining bed rest with head elevation to prevent meningitis. Other interventions are important but less urgent.

## 심화 해설

Understanding the Priority: Postoperative Care for Translabyrinthine Acoustic Neuroma Resection

When a client undergoes surgical resection of an acoustic neuroma (vestibular schwannoma) via the translabyrinthine approach, the surgical corridor inherently opens the subarachnoid space of the posterior fossa into the mastoid and middle ear. This creates a direct pathway for cerebrospinal fluid (CSF) to leak. The immediate postoperative period is critical because the surgical site is sealed with a combination of muscle, fascia, and fat grafts, but these require time to heal and form a watertight barrier. The priority nursing intervention is to prevent actions that increase intracranial pressure and disrupt this fragile repair, while vigilantly monitoring for the most common and significant complication: a CSF leak.

A systematic review on skull base repair following vestibular schwannoma surgery highlights that despite advances in reconstruction techniques, CSF leaks remain a common complication [1]. The review synthesizes various repair protocols, emphasizing that the prevention of CSF egress is a central focus of postoperative care. A CSF leak can manifest as clear, colorless otorrhea (from the ear canal) or rhinorrhea (down the eustachian tube and out the nose), and it poses a direct risk for ascending infection, leading to meningitis. Therefore, the nursing actions of monitoring for this specific sign and implementing strict bed rest with the head of bed elevated are directly aimed at mitigating this primary risk. The head elevation promotes venous drainage and reduces cerebral venous pressure, thereby lowering intracranial pressure (ICP) and decreasing the hydrostatic force pushing CSF against the fresh wound closure.

The secondary options, while relevant to the broader postoperative period, do not address the most immediate, life-threatening risk. Assessing bilateral hearing function is important for documenting outcomes, but in the translabyrinthine approach, hearing is intentionally and completely sacrificed on the operative side to access the tumor, making this assessment non-prioritized in the immediate phase. Encouraging early ambulation is contraindicated in the immediate postoperative period following a translabyrinthine approach. Ambulation increases intrathoracic and intra-abdominal pressure, which is transmitted to the intracranial compartment, potentially causing a sudden spike in ICP that could disrupt the dural repair and precipitate a CSF leak. A multidisciplinary perioperative pathway study for vestibular schwannoma patients, which evaluated outcomes including complications, supports a structured approach to mobilization that occurs well after the initial period of bed rest . While administering antiemetics is a crucial comfort and safety measure due to the high likelihood of vestibular dysfunction causing nausea and vomiting, the act of vomiting itself is dangerous because it generates a profound Valsalva maneuver, dramatically increasing ICP. Thus, the foundational intervention to prevent this is the positioning and activity restriction described in the correct option, which makes it the higher priority over simply treating the symptom.References (research sources)

- [1]Skull Base Repair following Resection of Vestibular Schwannoma: A Systematic Review (Part 1: The Retrosigmoid Approach).Meta-analysis/systematic reviewStarup-Hansen J, Williams SC, Valetopoulou A, Khan DZ, Horsfall HL, Moudgil-Joshi J, Burton O, Kanona H, Saeed SR, Muirhead W, Marcus HJ, Grover P. (2024) · DOI: 10.1055/a-2222-0184

## 임상 시나리오

Post-Translabyrinthine CSF Leak PreventionImmediate Postoperative Priorities
The translabyrinthine approach inherently opens the subarachnoid space, creating a direct pathway for a cerebrospinal fluid (CSF) leak. The priority is preventing meningitis by maintaining the integrity of the surgical seal.

Maintain strict bed rest with the head of bed elevated to 30 degrees. This reduces intracranial pressure and promotes venous drainage, decreasing stress on the dural repair.

CautionMonitor for clear, colorless drainage from the ear (otorrhea) or nose (rhinorrhea), which may indicate a CSF leak. A positive halo sign on gauze is a classic bedside test. Report any suspected leak immediately.

Instruct the client to avoid coughing, sneezing, straining, or blowing the nose. Antiemetics are prescribed to prevent vomiting, which can drastically increase intracranial pressure and disrupt the graft site.

## 핵심 개념

- **Translabyrinthine Approach** — A surgical route to the internal auditory canal that involves drilling through the mastoid and labyrinth, sacrificing hearing and creating a direct path for potential CSF leak into the middle ear.
- **CSF Otorrhea** — Leakage of cerebrospinal fluid from the ear, a serious postoperative complication indicating a dural tear that can lead to meningitis.
- **CSF Rhinorrhea** — Leakage of cerebrospinal fluid from the nose, which can occur after skull base surgery when CSF drains through the eustachian tube.
- **Halo Sign** — A classic bedside test for CSF where blood-tinged drainage on gauze forms a central red clot surrounded by a clear or yellowish ring, indicating the presence of CSF.

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