Clinical picture of vestibular schwannoma

Management of vestibular schwannoma: focus on vertigo

This article reviews published literature on vertigo and a 'sense of imbalance' affecting patients who are treated with radiosurgery (RS) for vestibular schwannoma. This is a relatively understudied complaint, along with tinnitus, in this patient population, despite its significant impact on quality of life. It is also a symptom that is most inconsistently impacted by either RS or surgery. This article aims to highlight the importance of this symptom in patients managed for vestibular schwannoma primarily with RS to encourage a more systematic study of vertigo as an outcome measure and to help elucidate its potential etiology.

[Assessment of driving in patients with vertigo and dizziness]

The driving performance of patients with dizziness and vertigo has gained only minor attention so far. Patients with permanent vestibular loss or with episodic vestibular symptoms can experience difficulties in driving a motor vehicle. The presence of a chronic or episodic syndrome presenting with dizziness and/or vertigo does not automatically exclude the ability to drive. Assessment of driving performance should consider the degree of the deficits and compensation in chronic dysfunction and the severity and frequency of attacks, prodromes and triggers of symptoms in episodic disorders.

Change in tinnitus after treatment of vestibular schwannoma: microsurgery vs. gamma knife radiosurgery

PURPOSE

Tinnitus is a very common symptom of vestibular schwannoma, present in 45 to 80% of patients. We evaluated changes in tinnitus after translabyrinthine microsurgery (TLM) or gamma knife radiosurgery (GKS).

MATERIALS AND METHODS

Among 78 patients with vestibular schwannoma who underwent TLM or GKS at Severance Hospital from 2009-2012, 46 patients with pre- or postoperative tinnitus who agreed to participate were enrolled. Pure tone audiometry, tinnitus handicap inventory (THI), visual analogue scale (VAS) scores for loudness, awareness, and annoyance were measured before and after treatment. Changes of THI and VAS were analysed and compared according to treatment modality, tumour volume, and preoperative residual hearing.

RESULTS

In the TLM group (n=27), vestibulocochlear nerves were definitely cut. There was a higher rate of tinnitus improvement in TLM group (52%) than GKS group (16%, p=0.016). The GKS group had a significantly higher rate of tinnitus worsening (74%) than TLM group (11%, p<0.001). Mean scores of THI and VAS scores significantly decreased in the TLM group in contrast to significant increases in the GKS group. Tumor volume and preoperative hearing did not affect the changes in THI or VAS.

CONCLUSION

GKS can save vestibulocochlear nerve continuity but may damage the cochlea, cochlear nerve and can cause worsening tinnitus. In cases where hearing preservation is not intended, microsurgery with vestibulocochlear neurectomy during tumor removal can sometimes relieve or prevent tinnitus.

Sex and age associations with vestibular schwannoma size and presenting symptoms

OBJECTIVE

To assess the association of sex and age with presenting symptoms and size of vestibular schwannoma at clinical presentation to our clinics.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic medical center.

PATIENTS

Approximately 1,269 subjects diagnosed with unilateral vestibular schwannoma between 1997 and 2010.

INTERVENTION

Demographic information, tumor characteristics, and treatment strategy were recorded.

MAIN OUTCOME MEASURE

Tumor size, patient-reported presence of hearing loss or dizziness at presentation.

RESULTS

Male subjects had significantly larger tumors than female subjects at presentation (18.23 versus 16.81 mm, p = 0.031); this difference was particularly pronounced in patients younger than 40 years. Patient-reported symptoms at baseline also differed by sex: the prevalence of hearing loss was 95.1% in male subjects versus 90.3% in female subjects (p = 0.001), and the frequency of dizziness was 74.3% in female subjects versus 59.0% in male subjects (p<0.0001). In multivariate analyses, male subjects continued to have a borderline significant positive association with tumor size (p = 0.066) and were 2-fold more likely to have hearing loss (odds ratio [OR], 2.082; 95% confidence interval [CI], 1.300-3.336) but half as likely to have dizziness (OR, 0.501; 95% CI, 0.387-0.649) than female subjects. Additionally, for every 1-mm increase in tumor size, patients were more likely to report hearing loss by 14.7% (OR, 1.147; 95% CI, 1.106-1.191) and dizziness by 2.8% (OR, 1.028; 95% CI, 1.016-1.041).

CONCLUSION

We observed significant sex differences in the presentation and size of unilateral vestibular schwannomas. As management and treatment strategies are predicated on presenting symptoms and patient factors, these observations merit further study to further understand tumor biology, improve risk stratification, and optimize tumor management.

The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation?

OBJECT

Management recommendations for patients with smaller-volume or newly diagnosed vestibular schwannomas (< 4 cm(3)) need to be based on an understanding of the anticipated natural history of the tumor and the side effects it produces. The natural history can then be compared with the risks and benefits of therapeutic intervention using a minimally invasive strategy such as stereotactic radiosurgery (SRS).

METHODS

The authors reviewed the emerging literature stemming from recent recommendations to "wait and scan" (observation) and compared this strategy with published outcomes after early intervention using SRS or results from matched cohort studies of resection and SRS.

RESULTS

Various retrospective studies indicate that vestibular schwannomas grow at a rate of 0-3.9 mm per year and double in volume between 1.65 and 4.4 years. Stereotactic radiosurgery arrests growth in up to 98% of patients when studied at intervals of 10-15 years. Most patients who select "wait and scan" note gradually decreasing hearing function leading to the loss of useful hearing by 5 years. In contrast, current studies indicate that 3-5 years after Gamma Knife surgery, 61%-80% of patients maintain useful hearing (speech discrimination score > 50%, pure tone average < 50).

CONCLUSIONS

Based on published data on both volume and hearing preservation for both strategies, the authors devised a management recommendation for patients with small vestibular schwannomas. When resection is not chosen by the patient, the authors believe that early SRS intervention, in contrast to observation, results in long-term tumor control and improved rates of hearing preservation.

Assessment of antiangiogenic effect of imatinib mesylate on vestibular schwannoma tumors using in vivo corneal angiogenesis assay

Object

Angiogenesis and the platelet-derived growth factor (PDGF) pathway are active in the pathogenesis of vestibular schwannomas (VSs). The purpose of this study was to test whether imatinib mesylate (Gleevec), a PDGF receptor (PDGFR) blocker, reduces angiogenic capacity in sporadic VS and in VS associated with neurofibromatosis Type 2 (NF2) using a corneal angiogenesis assay.

Methods

From 121 VS tissue samples stored in the tumor bank at the Marmara University Institute of Neurological Sciences, 10 samples (6 from sporadic cases, 4 from NF2-associated cases) were selected at random for use in this study. Expression of PDGF-A and PDGF-B and their receptors was evaluated in sporadic and NF2-associated VS as well as in glioblastoma (GBM) and normal brain tissue by means of immunohistochemistry and Western blot analysis. Corneal angiogenesis assay was then used to evaluate the angiogenic capacity of tissue specimens from sporadic and NF2-associated VS with and without imatinib treatment as well as positive and negative controls (GBM and normal brain tissue).

Results

The angiogenic potential of the sporadic and NF2-associated VS tumor tissue differed significantly from that of the positive and negative control tissues (p <0.05). Furthermore, NF2-associated VS showed significantly lower angiogenic potential than sporadic VS (p <0.05). Imatinib treatment significantly reduced the angiogenic potential in both the sporadic VS and the NF2-associated VS groups. The level of PDGF-A and PDGFR-α as well as PDGF-B and PDGFR-β expression in sporadic VS and NF2-associated VS also differed significantly (p <0.05) from the levels in controls. Additionally the level of PDGFR-β was significantly higher in sporadic VS than in NF2-associated VS (p <0.05).

Conclusions

The findings of this study indicate that NF2-associated VS has significantly more angiogenic potential than sporadic VS and normal brain tissue. Additionally, imatinib reduces the angiogenic activity of both sporadic and NF2-associated VS. The authors conclude that imatinib may be a potential treatment for VS, especially for NF2-associated lesions that cannot be cured with resection or radiosurgery.

Ocular vestibular evoked myogenic potentials in patients with acoustic neuroma

To assess the usefulness of vestibular testing in patients with acoustic neuroma, considering two main aspects: to compare diagnostic sensitivity of the current vestibular tests, especially considering ocular vestibular evoked myogenic potentials (OVEMPs) and to identify pre-operative localization of the tumor (inferior vestibular nerve vs. superior vestibular nerve) only with the help of vestibular electrophysiological data. Twenty-six patients with unilateral acoustic neuroma (mainly intracanalicular type) were studied with a full audio-vestibular test battery (pure tone and speech audiometry, caloric bithermal test, vibration-induced nystagmus test (VIN), cervical and OVEMPs). 18 patients (69 %) showed abnormal caloric responses. 12 patients (46.2 %) showed a pattern of VIN test suggestive of vestibular asymmetry. 16 patients (61.5 %) showed abnormal OVEMPs (12 only to AC, 4 both to AC and BC). 10 patients (38.5 %) showed abnormal cervical vestibular evoked myogenic potentials (5 both to AC and BC, 5 only to AC). In one case, results of vestibular evoked potentials and caloric test were confirmed by intra-operative and post-operative findings. Results of electrophysiological tests in AN patients could be helpful for planning the proper surgical approach, considering that sensitivity of every exam is quite low in intracanalicular lesion; clinical data allow a better interpretation of vestibular evoked myogenic potentials.

Factors associated with anxiety and depression in the management of acoustic neuroma patients

The objectives of this study were to describe anxiety and depression levels among acoustic neuroma patients; examine differences in anxiety and depression across the acoustic neuroma management options of microsurgery, radiation and observation; and to investigate management, medical and demographic factors that might predict anxiety and depression in this patient group. A cross-sectional questionnaire was completed by 205 adults diagnosed with, or treated for, a unilateral acoustic neuroma within five years of questionnaire distribution. Median age of participants was 57.0 years, and 120 (58.5%) were female. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). Clinically significant anxiety was reported by 29.8% of participants and 10.2% were depressed. Mean anxiety and depression scores did not differ from general population norms. No significant differences in anxiety and depression were found across management options. Time since management, number of symptoms and comorbid medical conditions predicted anxiety, while depression was predicted by number of symptoms. This appears to be the first study among acoustic neuroma patients in which anxiety and depression were compared across management options. Treating physicians should be aware that as the number of acoustic neuroma symptoms increases, so may the likelihood of clinically significant anxiety and depression.

Preoperative audiovestibular handicap in patients with vestibular schwannoma

OBJECTIVES

To evaluate preoperative hearing, dizziness, and tinnitus handicap in patients with unilateral vestibular schwannoma (VS).

DESIGN

Prospective administration of the Hearing Handicap Inventory (HHI), Dizziness Handicap Inventory (DHI), and Tinnitus Handicap Inventory (THI), prior to surgical intervention.

SETTING

A tertiary referral neuro-otology clinic.

PARTICIPANTS

A total of 145 consecutive patients who were admitted for excision of their vestibular schwannomas between May 1998 and July 2002.

MAIN OUTCOME MEASURES

HHI, THI, and DHI scores.

RESULTS

HHI, THI, and DHI scores were all found to be significantly correlated. There was no significant association between tumor size and any of the questionnaire scores. When data were categorized to give a measure of handicap severity, 68% had mild to significant hearing handicap, 30% had mild to severe tinnitus handicap, and 75% had mild to severe dizziness handicap. Eighty-eight percent of patients had some handicap in at least one domain, and 23% had some handicap in all three domains. Seven percent of patients had severe or significant handicap in all three domains.

CONCLUSIONS

A considerable proportion of patients with unilateral VS have hearing, tinnitus, and dizziness handicap. These patients should optimally be offered appropriate rehabilitation, something that is especially important as conservative management by "watch, wait, and rescan" becomes more common.

Bilateral multicanal benign paroxysmal positional vertigo coexisting with a vestibular schwannoma: case report

We describe a rarely encountered case of coexisting bilateral multicanal benign paroxysmal positional vertigo (BPPV) and vestibular schwannoma in a 56-year-old woman. The patient had presented with a 10-year history of dizziness and imbalance, and her vestibular findings were perplexing. We decided on a working diagnosis of BPPV and began treatment. After several months of canalith repositioning maneuvers had failed to resolve her symptoms, we obtained magnetic resonance imaging, which revealed the presence of the vestibular schwannoma. This case serves as a reminder of the importance of differentiating between central and peripheral vestibular disorders, as well as central and anterior canal BPPV-induced down-beating nystagmus in order to establish the correct diagnosis and initiate appropriate treatment.

A contemporary review of balance dysfunction following vestibular schwannoma surgery

OBJECTIVES/HYPOTHESIS

This review aims to evaluate the literature pertaining to subjective balance dysfunction following vestibular schwannoma surgery; the effect of postoperative imbalance on disability, handicap and quality of life; and to determine factors that influence vestibular compensation.

METHODS

Ovid MEDLINE, Cochrane databases, and relevant contemporary texts were searched for papers relating to subjective balance dysfunction following vestibular schwannoma surgery. The quality of this clinical evidence was evaluated.

RESULTS

The search yielded 26 studies assessing subjective balance dysfunction following vestibular schwannoma surgery. Analysis revealed that the majority of patients complain of balance dysfunction following surgery; however, a small number report disability or handicap. A few studies have demonstrated a decreased quality of life due to balance dysfunction. Factors have been identified that may contribute to a poor recovery.

CONCLUSIONS

Further study is needed of the factors that influence vestibular compensation following vestibular schwannoma surgery. This will help to counsel patients prior to surgery and develop strategies for rehabilitation.

Asymmetric hearing loss: rule 3,000 for screening vestibular schwannoma

OBJECTIVE

To assess the diagnostic yield of audiograms associated to electronystagmography (ENG) for screening vestibular schwannomas (VSs), to determine what definition of asymmetric sensorineural hearing loss (ASNHL) fits best for the diagnosis of VS, and to determine if cochleovestibular symptoms and atherosclerotic potential risk factors play a role in the VS screening.

STUDY DESIGN

Retrospective chart review in a tertiary care center.

METHODS

One hundred twenty-two patients were included in the study and divided into 2 groups: 1) patients presenting a VS (n = 74) and 2) patients without VS (n = 48). They had received an audiometry assessment, an ENG, and a posterior fossa magnetic resonance imaging (MRI). In addition, a variety of risk factors and clinical data were collected. Mean hearing threshold by frequency, mean asymmetries by frequency, speech discrimination score (SDS), ENG results, and presence or absence of vertigo are studied. Cochleovestibular symptoms and atherosclerotic potential risk factors were collected. Characteristics were studied with analysis of variance, chi2 test, or a paired t test. A receiver operating characteristic curve was obtained. A logistic regression with a step-wise selection based on the likelihood ratio was used to identify the best subgroup of predictors of the VS.

RESULTS

The most revealing data were the mean ASNHL at 3,000 Hz (p < 0.001), the interaural SDS asymmetry (p < 0.001), the vestibular deficit (p < 0.049), and the absence of vertigo (p < 0.001). The ASNHL at 3,000 Hz was the most representative value of all the frequencies and for the SDS asymmetry. Interaural difference of 15 dB or more at 3,000 Hz is sufficient to consider hearing loss as asymmetric. When the cutoff for a positive test was placed at 50% probability, the receiver operating characteristic curve shows a sensitivity of 73%. The grade of the tumor was also related with the degree of ASNHL at 3,000 Hz. Caloric test does not predict the localization or the grade of the VS. Tinnitus and atherosclerotic potential risk factors were not considered significantly linked with VS.

CONCLUSION

To reduce the number of negative MRI performed in the investigation of an ASNHL, we propose the "rule 3,000," ASNHL of 15 dB or more at the 3,000-Hz frequency. In this case, an investigation with MRI is crucial. If this ASNHL is less than 15 dB, we recommend a biannual audiometric follow-up.

Sudden deafness as a presenting symptom of acoustic neuroma: case report

Vestibular schwannoma, also known as acoustic neurinoma, is the most frequent tumor of the cerebellopontine angle, and represents 9% of all intracranial tumors. Case Report: The authors report a case of sudden deafness with unilateral tinnitus. The patients responded to therapy with Prednisone and Pentoxifylline after the diagnosis of acoustic neurinoma by imaging exams. Discussion: Sudden deafness can be described as an intense and abrupt sensorineural loss. Usually it is higher than 30 dB at three or more frequencies and develops in less than three days. Conclusion: Investigation of the etiology of sudden deafness is extremely important to establish the adequate strategy for the case.

Treatment of vestibular schwannomas. Why, when and how?

Sporadic vestibular schwannoma (VS) causes unilateral hearing loss, tinnitus, vertigo and unsteadiness. In many cases, the tumour size may remain unchanged for many years following diagnosis, which is typically made by MRI. In the majority of cases the tumour is small, leaving the clinician and patient with the options of either serial scanning or active treatment by gamma knife radiosurgery (GKR) or microneurosurgery. Despite the vast number of published treatment reports, comparative studies are few, and evidence is no better than class III (May, 2006). The predominant clinical endpoints of VS treatment include tumour control, facial nerve function and hearing preservation. Less focus has been put on symptom relief and health-related quality of life (QOL). It is uncertain if treating a small tumour leaves the patient with a better chance of obtaining relief from future hearing loss, vertigo or tinnitus than by observing it without treatment. Recent data indicate that QOL is reduced in untreated VS patients, and may differ between patients who have been operated and patients treated with GKR. In the present paper we review the natural course and complaints of untreated VS patients, and the treatment alternatives and results. Furthermore, we review the literature concerning quality of life in patients with VS. Finally, we present our experience with a management strategy applied to more than 300 cases since 2001.

Translabyrinthine surgery for disabling vertigo in vestibular schwannoma patients

OBJECTIVE

To determine the impact of translabyrinthine surgery on the quality of life in vestibular schwannoma patients with rotatory vertigo.

STUDY DESIGN

Prospective study in 18 vestibular schwannoma patients.

SETTING

The study was conducted in a multispecialty tertiary care clinic.

PARTICIPANTS

All 18 patients had a unilateral intracanalicular vestibular schwannoma, without serviceable hearing in the affected ear and severely handicapped by attacks of rotatory vertigo and constant dizziness. Despite an initial conservative treatment, extensive vestibular rehabilitation exercises, translabyrinthine surgery was performed because of the disabling character of the vertigo, which considerably continued to affect the patients' quality of life.

MAIN OUTCOME MEASURES

Preoperative and postoperative quality of life using the Short Form 36 Health Survey (Short Form-36) scores and Dizziness Handicap Inventory (DHI) scores.

RESULTS

A total of 17 patients (94%) completed the questionnaire preoperatively and 3 and 12 months postoperatively. All Short Form-36 scales of the studied patients scored significantly lower when compared with the healthy Dutch control sample (P < 0.05). There was a significant improvement of DHI total scores and Short Form-36 scales on physical and social functioning, role-physical functioning, role-emotional functioning, mental health and general health at 12 months after surgery when compared with preoperative scores (P < 0.05).

CONCLUSIONS

Vestibular schwannoma patients with disabling vertigo, experience significant reduced quality of life when compared with a healthy Dutch population. Translabyrinthine tumour removal significantly improved the patients' quality of life. Surgical treatment should be considered in patients with small- or medium-sized tumours and persisting disabling vertigo resulting in a poor quality of life.

Sensorimotor postural rearrangement after unilateral vestibular deafferentation in patients with acoustic neuroma

Unilateral vestibular lesion, as acoustic neuroma and its surgical removal, leads to impaired balance control. After initial vertigo and postural instability corresponding to unilateral vestibular deafferentation, improvement in symptoms and global balance functions occurs by a process called vestibular compensation. In this respect, this prospective study aimed to assess the differential contribution of sensory inputs to the regulation of posture during the recovery process after acoustic neuroma removal. Twenty-seven patients with acoustic neuroma underwent vestibular and posturographic testings, shortly before and 8 days, 1 month and 3 months after surgical removal of the tumour. Immediately after vestibular deafferentation, vestibular function was asymmetrical, postural performances were altered, especially in eyes closed conditions and in sensory challenged situations. One month, and more particularly 3 months after surgery, restoration and even improvement of vestibular and balance performances occurred, associated with a lower number of falls, development of more appropriate sensorimotor strategies and better resolution of sensorial conflicts. Postural perturbations are related to erroneous vestibular afferences, leading to incoherence in information about head position and interference with somatosensory and visual pathways. The time-course implementation of central adaptive mechanisms, characterized by substitution by other sensory afferences and new behavioural strategies, leads to an improvement of balance performance.

Preoperative postural control of patients with vestibular schwannoma assessed by visual feedback posturography

BACKGROUND

The need for an objective method to describe the functional postural control of patients with vestibular schwannoma in agreement with their subjective sensation of balance.

OBJECTIVES

The objective was to compare the postural control of 49 patients with unilateral vestibular schwannoma (VS) with that of healthy subjects by using visual feedback posturography (VFP). We aimed to find out if preoperative postural control of the patients correlates with their subjective sensation of balance.

METHODS

In the VFP, while standing on the platform, patients were instructed to move their center of gravity (COG) marker to the targets as fast and accurately as possible. Hit delay (HD) to the targets, hold percentage (HP) within the targets, COG marker velocity (CMV) to the targets, and balance index (BI) were calculated. We rated intensity of balance disturbance using a 5-point qualitative scale.

RESULTS

Twenty-two (45%) patients had at least one abnormal VFP parameter, and 49% of patients were simultaneously symptomatic. Mean hit delay (HD), hold percentage (HP), and balance index (BI) were significantly worsened in patients with VS (p < 0.05). Increased HD and BI correlated significantly with subjective sensation of imbalance (p = 0.02).

CONCLUSIONS

The overall deficit in preoperative postural control of the VS patients was not severe, and this finding agreed well with their subjective sensations.

Postural control after vestibular schwannoma resection measured with visual feedback posturography

BACKGROUND

Vestibular symptoms after surgery diminish rapidly, but the simultaneous progress in active postural control has not been fully addressed.

OBJECTIVES

The aim was to evaluate the progress in postural control in operated vestibular schwannoma (VS) patients with visual feedback posturography (VFP).

METHODS

36 consecutive patients with unilateral VS were studied with the VFP pre-operatively, 1 month and 3 months after the surgery. The accuracy and velocity of active postural control movements to distant targets in VFP was measured and compared to that of healthy controls.

RESULTS

The hold percentage within the targets was significantly reduced in the VS patients compared to the controls (pre-operatively p = 0.005; postoperatively at 1 month p = 0.002 and at 3 months p = 0.017). The sway velocity (SV) within the targets among patients with VS was significantly increased pre-operatively (p = 0.009), at the 1-month (p = 0.004) and at the 3-month follow-up visits (p = 0.016). All the postural control parameters except SV tended to improve slightly postoperatively. The consecutive VFP measurements in individual VS patients correlated statistically significantly (p < 0.001 for all parameters). The abnormality in the pre-operative VFP results correlated statistically significantly with that of postoperative VFP (p = 0.001).

CONCLUSIONS

The VFP is an objective and repeatable method, which can be used to assess and follow up the active postural control in individual patients with VS. Persisting abnormality in the VFP seems to be an indication for more aggressive vestibular rehabilitation to normalize the disturbed postural control.

[Disorders of the cerebellopontine angle]

Disorders of the cerebellopontine angle may present by symptoms like vertigo, hearing problems, affection of the trigeminal or facial nerve. Ipsilateral ataxia and contralateral hemiparesis develop in case of a rather large tumor in this region and display an involvement of the cerebellum and/or brainstem. However, some of these typical symptoms are not recognized by the patient. Thus, in case of a suspicion of a disorder of the cerebellopontine angle the relevant functions have to be tested clinically. In addition, electrophysiology can confirm dysfunction of these cranial nerves. Mainstay of the therapy should be the treatment of the underlying cause. Nevertheless, not seldom it is necessary to treat symptoms like vertigo or facial pain.

[Audiologic diagnostics of vestibular schwannoma]

INTRODUCTION

Vestibular schwannoma (acoustic neuroma) is a rare, but important cause of sensorineural hearing loss. Patients with asymmetric hearing loss, or unilateral tinnitus should be evaluated expeditiously, to prevent further neurological damage.

AUDIOLOGIC DIAGNOSTICS

Audiologic diagnostics represents the basic diagnosis for early detection of vestibular schwannoma. Patients with vestibular schwannomas may present with a variety of clinical features, including retrocochlear pattern of sensorineural hearing loss. Supraliminary audiometry, tympanometry, stapedius reflex and otoacoustic emissions as well as vestibular response to caloric testing are methods for selection of patients with suspicion of this tumor.

CONCLUSION

The golden standard for audiologic diagnostics of vestibular schwannoma is BAEP (Brainstem Auditory Evoked Potentials). Patients with pathological findings of BAEP should undergo MRI of the posterior fossa. Gadolinium-enhanced magnetic resonance imaging is the best and final tool for making a diagnosis of vestibular schwannoma.

Change in dizziness handicap after vestibular schwannoma excision

OBJECTIVE

To evaluate the change in dizziness handicap after translabyrinthine vestibular schwannoma excision.

STUDY DESIGN

Prospective administration of the Dizziness Handicap Inventory preoperatively and at 3 and 12 months postoperatively; retrospective review of case notes.

SETTING

A tertiary referral neuro-otology clinic.

PATIENTS

A total of 100 consecutive patients who had vestibular schwannomas excised between June 1998 and November 2001 and who had completed Dizziness Handicap Inventories preoperatively and at 3 and 12 months postoperatively.

INTERVENTIONS

Translabyrinthine excision of a unilateral sporadic vestibular schwannoma; preoperative and postoperative generic vestibular rehabilitation exercises.

MAIN OUTCOME MEASURES

Dizziness Handicap Inventory scores.

RESULTS

For most patients, dizziness handicap does not worsen postoperatively. However, for those in whom it does, dizziness handicap becomes significantly worse between preoperative and 3-month postoperative time points but then does not continue to decline. Tumor size, sex, and magnitude of preoperative canal paresis significantly affect the degree of change in handicap. Age, the presence of central vestibular system abnormalities, and the nature of the patient's principal presenting symptom have no effect on this handicap change.

CONCLUSIONS

These findings help the clinician in counseling the patient preoperatively about dizziness handicap to be expected postoperatively. In particular, the clinician is now able to take an informed and positive stance in the event of a severe canal paresis preoperatively.

El papel de la videonistagmografía en el diagnóstico del neurinoma del acústico

AIM

Schwannoma of the vestibular nerve represents 75% of all expansive processes affecting the pontocerebellosum angle. Hearing loss is the most frequent symptom at diagnosis (86%) with or without tinnitus, in the intracanalicular tumors. Vestibular symptoms are described in 60% of patients.

MATERIAL AND METHOD

We study twenty cases of acoustic neuromas diagnosed between years 2000 and 2002 in both Otolaryngology and Neurosurgery Departments in our hospital. Videonystagmography (VNG) was performed in all of them. Videonystagmographic findings were analyzed statistically together with the tumoral size and hypoacusia level.

DISCUSSION AND CONCLUSION

According to the medical literature reviewed for this paper, we conclude that caloric tests are the most frequently altered ones (77%), showing vestibular hyporreflexia or arreflexia.

Pulsatile and nonpulsatile tinnitus: a systemic approach

Tinnitus is an annoying symptom that affects approximately 10% of the population. Unfortunately, in more than 60% of patients, even an extensive workup may not lead to diagnosis, partly because of the diverse causes of the symptom. The imaging protocol study should therefore be adapted to the history of the patient, and each imaging study should underline which etiologies it may exclude. Imaging studies should only be performed after a careful clinical examination and otoscopy. Some characteristic clinical findings are suggestive of such etiologies as pulsed synchronous tinnitus or positional tinnitus, varying with the venous pressure. History of associated neurological deficits, nerve palsies, trauma, ischemic attacks, and visual disturbance (in overweight women) may modify the imaging protocol. Study of the brain and the cervical vessels should always be included to rule out a benign intracranial hypertension. Path and size of the internal carotid artery should be systematically described with regard to the size of the jugular vein and presence of emissary veins. Objective pulsatile tinnitus and tinnitus in children always need a careful imaging study.