The Unrecognized Rotation of the Vestibular and Cochlear Nerves from the Labyrinth to the Brain Stem: Its Implications to Surgery of the Eighth Cranial Nerve

Abstract

The cochlear and vestibular nerves rotate 90 degrees from the inner ear to the brain stem. Most of the rotation occurs within the internal auditory canal (IAC); only minimal rotation occurs in the cerebellopontine (CP) angle. At the labyrinthine end of the IAC, the cochlear nerve—which at first lies anterior to the inferior vestibular nerve (saccular nerve)—rapidly fuses with the inferior vestibular nerve. It then rotates to become inferior as the nerves leave the porus acousticus. The cochleovestibular (C-V) cleavage plane lies in a superior-inferior direction in the lateral IAC and rotates to become anterior-posterior in the CP angle. In 25% of patients in whom no C-V cleavage plane can be seen, it is not possible to completely transect all vestibular fibers. The surgical implications are that (1) the most complete vestibular neurectomy can be done only in the lateral IAC, (2) the cochlear and inferior vestibular nerves, because of their intimate association, should not be separated in the mid-IAC, in order to prevent damage to the cochlear nerve, and (3) to create a complete denervation of the vestibular labyrinth, only the posterior ampullary nerve along with the superior vestibular nerve should be transected.