Quality of Life After Acoustic Neuroma Surgery

Quality of life of patients following stages III-IV vestibular schwannoma surgery using the retrosigmoid and translabyrinthine approaches

OBJECTIVE

Surgery is an unquestionable treatment for stages III and IV vestibular schwannomas. The postoperative quality of life (QOL) remains the main issue of concern. In this study, we have evaluated the postoperative QOL of these patients operated by two surgical approaches, the retrosigmoid approach (RSA) and the translabyrinthine approach (TLA).

MATERIALS AND METHODS

This is a retrospective review of 101 stages III and IV vestibular schwannoma cases operated between 2000 and 2006 at our center by the senior author (J.M.). The Short Form SF-36 questionnaire and additional questions were sent to the patients. Comparison was made between the patient group and a control group to evaluate the postoperative QOL.

RESULTS

The response rate was 67.3%. There were 44 males and 57 females. The average follow up was 5.9 years. 59 patients were operated using the TLA and 42 using the RSA. Both patient groups had significantly lower scores on the questionnaire when compared to the normal population, and thus a less satisfactory QOL. Pain was the symptom that correlated most with poorer scores on the SF-36 questionnaire, although it was the least frequent symptom reported by the patients. Unsteadiness and facial weakness were the least bothersome complaints. Facial weakness did not correlate with a poorer QOL.

CONCLUSION

Operated stages III-IV vestibular schwannoma patients suffer from a certain degree of QOL deterioration compared to normal controls. Hearing deficit was the most prevalent symptom. Pain was the least frequent but the most bothersome and with the highest correlation with a poorer QOL. Interestingly, unsteadiness and facial weakness were the least bothersome complaints. Facial weakness did not correlate with a poorer QOL.

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.

Quality of life after gamma knife radiosurgery treatment in patients with a vestibular schwannoma: the patient's perspective

This study evaluates the impact of gamma knife radiosurgery (GKRS) on the quality of life (QOL) of patients with a sporadic vestibular schwannoma (VS). This study pertains to 108 VS patients who had GKRS in the years 2003 through 2007. Two different QOL questionnaires were used: medical outcome study short form 36 (SF36) and Glasgow benefit inventory (GBI). Radiosurgery was performed using a Leksell 4C gamma knife. The results of the QOL questionnaires in relation to prospectively and retrospectively gathered data of the VS patients treated by GKRS. Eventually, 97 patients could be included in the study. Their mean tumor size was 17 mm (range 6–39 mm); the mean maximum dose on the tumor was 19.9 Gy (range 16–25.5 Gy) and the mean marginal dose on the tumor was 11.1 (range 9.3–12.5 Gy). SF36 scores showed results comparable to those for a normal Dutch population. GBI showed a marginal decline in QOL. No correlation was found between QOL and gender, age, tumor size, or radiation dose. Increased audiovestibular symptoms after GKRS were correlated with a decreased GBI score, and decreased symptoms were correlated with a higher QOL post-GKRS. In this study shows that GKRS for VS has little impact on the general QOL of the VS patient. However, there is a wide range in individual QOL results. Individual QOL was influenced by the audiovestibular symptoms. No predictive patient, tumor, or treatment factors for QOL outcome after GKRS could be determined. Comparison with microsurgery is difficult because of intra group variability.

Prospective comparison of quality of life before and after observation, radiation, or surgery for vestibular schwannomas

OBJECT

The best management strategy for small-to medium-sized vestibular schwannomas (VSs) remains controversial between observation, radiation, and microsurgical resection (surgery). The authors undertook a prospective observational cohort study comparing all 3 therapeutic modalities in patients with VSs, focusing on quality of life (QOL) outcomes.

METHODS

All patients in the study completed the 36-Item Short Form Health Survey at regular intervals, with a mean follow-up of 31.8 months. Two hundred five (77.7%) of 264 patients completed questionnaires, including 47 who underwent observation, 48 who received either linear accelerator radiosurgery or fractionated radiotherapy (radiation group), and 134 who underwent surgery (of whom 37 had tumors > 3 cm in diameter). Patients allocated to the observation group had smaller tumors than those in the other groups (mean 1.3 cm; p < 0.001). Patients who received radiation were older than patients in the other groups (mean 60.0 years; p < 0.001).

RESULTS

There were no baseline QOL differences between the observation, radiation, and surgery (tumors <or= 3 cm) groups. Quality of life remained unchanged for the observation and radiation groups throughout the follow-up period. In the surgery group with tumors <or= 3 cm, a significant improvement in total score and composite mental dimension was observed at 24 months. In the surgery group with tumors > 3 cm, there was an early improvement in composite mental dimension at 1.5 months, as well as at 24 months; total score and composite physical dimension were improved at 24 months in this group as well.

CONCLUSIONS

Based on the current management protocol, patients with VSs enjoy similar QOL throughout the follow-up period after undergoing observation, radiation therapy, or surgery.

Long-term follow-up of vestibular neuritis

The long-term outcome of vestibular neuritis was evaluated in 35 patients using 4 bedside tests (head impulse, head heave, head shake, vibration), the caloric test and two surveys that explored the degree of disability (Dizziness Handicap Inventory [DHI]) and the anxiety and depression levels (Hospital Anxiety and Depression Scale [HADS]). Sixty-six percent of patients showed a positive bedside clinical test or calorics abnormalities. DHI scores were significantly higher in the patients group, while HADS scores were comparable between patients and controls. Disability from vestibular neuritis is primarily due to the vestibular disturbance itself, rather than purely psychological factors.

Diagnosis and therapy of vestibular schwannoma

MRI studies are of paramount importance for diagnosis and follow-up measurements during conservative and postinterventional management of vestibular schwannomas (VS). MRI findings that convey important information for hearing-preservation VS surgery are: length of tumor-cochlear nerve contact, involvement of the internal auditory canal, incomplete filling of internal auditory canal, tumor size less than 15 mm and the intralabyrinthine signal intensity on 3DFT-CISS gradient-echo images. Functional neuro-otologic studies of facial nerve function, hearing and vestibular/balance function provide a valuable means of assessment of the actual impairment of the functional status of the VS patient. Intraoperative monitoring of facial nerve function and hearing has been refined, resulting in improved final postoperative facial nerve and hearing outcomes in VS patients treated with microsurgery. Long-term results reported by teams practicing stereotactic radiosurgery or fractionated stereotactic radiotherapy have been very encouraging. On the other hand, conservative management appears to be a viable option for a select group of VS patients. The refinement of surgical technique has rendered surgery safer and less invasive, resulting in better functional outcomes. Steroid use is currently used postinterventionally to improve final hearing outcome, although with questionable effectiveness. Physical rehabilitation programs are applied to accelerate vestibular functional recovery postoperatively and there is weak evidence that early physical rehabilitation may improve the final facial nerve outcome. Quality-of-life measures have emerged as important determinants of final therapeutic decision-making. More studies with high levels of evidence are needed to support clinical decisions.

Suggested response criteria for phase II antitumor drug studies for neurofibromatosis type 2 related vestibular schwannoma

Neurofibromatosis type 2 (NF2) is a tumor suppressor gene syndrome characterized by multiple schwannomas, especially vestibular schwannomas (VS), and meningiomas. Anticancer drug trials are now being explored, but there are no standardized endpoints in NF2. We review the challenges of NF2 clinical trials and suggest possible response criteria for use in initial phase II studies. We suggest two main response criteria in such trials. Objective radiographic response is defined as a durable 20% or greater reduction in VS volume based on post-contrast T1-weighted MRI images collected with 3 mm or finer cuts through the internal auditory canal. Hearing response is defined as a statistically significant improvement in word recognition scores using 50-word recorded lists in audiology. A possible composite endpoint incorporating both radiographic response and hearing response is outlined. We emphasize pitfalls in response assessment and suggest guidelines to minimize misinterpretations of response. We also identify research goals in NF2 to facilitate future trial conduct, such as identifying the expectations for time to tumor progression and time to measurable hearing loss in untreated NF2-related VS, and the relation of both endpoints to patient prognostic factors (such as age, baseline tumor volume, and measures of disease severity). These data would facilitate future use of endpoints based on stability of tumor size and hearing, which might be more appropriate for testing certain drugs. We encourage adoption of standardized endpoints early in the development of phase II trials for this population to facilitate comparison of results across trials of different agents.

Gamma Knife surgery of vestibular schwannomas: longitudinal changes in vestibular function and measurement of the Dizziness Handicap Inventory

Object

Gamma Knife surgery (GKS) is one of the methods available to treat vestibular schwannomas (VSs), in addition to microsurgical resection; however, clear information regarding balance function outcomes and the impact of treatment on patients' quality of life over time remains an important clinical need. The purpose of this study was to assess the longitudinal balance outcomes and Dizziness Handicap Inventory (DHI) following GKS for VSs.

Methods

This was a prospective clinical study of balance outcomes in all patients with VSs treated in the Acoustic Neuroma and Skull Base Surgery Program at a tertiary referral center by the senior author and the Gamma Knife team between June 2000 and May 2008. The main outcome measures included preoperative vestibular testing and postoperative caloric testing performed at 6-month intervals to determine vestibular function. The DHI questionnaires were administered retrospectively to assess the impact of GKS on self-perceived disability.

Results

Between June 2000 and May 2008, 55 sporadic VSs were treated. There was a ≥ 60-month follow-up available in 27 of these patients, ≥ 48 months in 32, ≥ 36 months in 38, ≥ 24 months in 43, ≥ 12 months in 51, and ≥ 6 months in 54 (1 patient was excluded from the analysis because the follow-up was < 6 months). Various patterns of changes in vestibular function were observed in either positive or negative directions. A significant difference in total DHI score was seen only in the elderly (> 65 years old) patients pre-GKS compared with post-GKS (t = 1.34, p = 0.05).

Conclusions

Longitudinal changes in vestibular function occur over time, with the largest changes seen in the first 6 months after treatment. Potential for clinical intervention, such as vestibular rehabilitation therapy, exists during this interval; however, larger cohorts must be studied to determine the timing and efficacy of this intervention. The statistically significant improvement in the DHI score in the patient cohort > 65 years old treated with GKS suggests that this group may benefit from this option when considering the symptom of dizziness.