Management of Surgical Complications and Failures in Acoustic Neuroma Surgery

Patient-preferred outcomes in patients with vestibular schwannoma: a qualitative content analysis of symptoms, side effects and their impact on health-related quality of life

PURPOSE

During counseling and management of patients with vestibular schwannoma (VS), the emphasis is shifting from tumour control and nerve preservation towards maintaining or improving health-related quality of life (HRQoL). Understanding the patients' perspective and impact of VS is, therefore, of utmost importance. The current study aimed to identify treatment outcomes preferred by patients and to explore the patient-reported VS symptoms and management-related side effects and their impact on HRQoL.

METHODS

Patients with VS were contacted through the Dutch VS association Stichting Hoormij and questioned using a semi-structured, cross-sectional online survey. Patients were asked to report and rank symptoms and side effects, with their impact on HRQoL and frequency of occurrence. Results were structured through qualitative content analysis. Coded symptoms, side effects, impacts, frequencies, and patient-preferred outcomes were analysed and summarized with descriptive statistics.

RESULTS

Of the 231 respondents, 71% were actively treated. Hearing (symptoms vs. side effects: 78.8% vs. 63.6%), balance (62.3%; 48.8%), and energy issues (33.8%; 32.6%) were the most frequently mentioned symptoms and management-related side effects. Fatigue, deafness, headaches, and hearing loss had the highest impact on HRQoL. The majority of patients identified hearing preservation (61%), balance preservation (38.5%), and reduced tinnitus (34.6%) to be the patient-preferred outcomes.

CONCLUSION

This qualitative study demonstrates that in this population many patients with VS encounter participation difficulties in their daily physical and social activities and value hearing and balance preservation, reduced tinnitus, and restored energy as preferred outcomes as they are hampered by symptoms and side effects related to hearing, balance, and energy. Healthcare professionals should consider these key points and use these and the patient-preferred outcomes in consultation, shared decision making, treatment, and follow-up to optimize patient-centred care.

Investigating Predictors of Increased Length of Stay After Resection of Vestibular Schwannoma Using Machine Learning

OBJECTIVE

To evaluate the predictors of prolonged length of stay (LOS) after vestibular schwannoma resection.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Patients who underwent vestibular schwannoma resection between 2008 and 2019.

INTERVENTIONS

Variables of interest included age, body mass index, comorbidities, symptoms, previous intervention, microsurgical approach, extent of resection, operative time, preoperative tumor volume, and postoperative complications. Predictive modeling was done through multivariable linear regression and random forest models with 80% of patients used for model training and the remaining 20% used for performance testing.

MAIN OUTCOME MEASURES

LOS was evaluated as the number of days from surgery to discharge.

RESULTS

Four hundred one cases from 2008 to 2019 were included with a mean LOS of 3.0 (IQR = 3.0-4.0). Postoperatively, 14 (3.5%) of patients had LOS greater than two standard deviations from the mean (11 days). In a multivariate linear regression model (adjusted R2 = 0.22; p < 0.001), preoperative tumor volume (p < 0.001), coronary artery disease (p = 0.002), hypertension (p = 0.029), and any major complication (p < 0.001) were associated with increased LOS (by 0.12, 3.79, 0.87, and 3.20 days respectively). A machine learning analysis using a random forest identified several potential nonlinear relationships between LOS and preoperative tumor dimensions (length, volume) and operative time that were not captured on regression. The random forest model had lower prediction error compared to the regression model (RMSE 5.67 vs. 44.59).

CONCLUSIONS

Tumor volume, coronary artery disease, hypertension, and major complications impact LOS. Machine learning methods may identify nonlinear relationships worthy of targeted clinical investigation and allow for more accurate patient counseling.

Contralateral sensorineural hearing loss after vestibular schwannoma surgery

INTRODUCTION

Contralateral sensorineural hearing loss (CSNHL) after vestibular schwannoma (VS) is a severe complication, especially in those cases in which hearing preservation in the operated side was not possible. There are several theories that attempt to explain this issue, but there is no established guideline of treatment.

MATERIAL AND METHODS

We report 4 patients treated in our institution who developed a severe CSNHL after surgery.

RESULTS

Of the 185 cases of VS treated with surgery, 4 patients (2.2%) developed a CSNHL after VS surgery. After medical treatment, partial recovery of hearing occurred in one patient the other 3 patients presented a well-established severe SNHL.

CONCLUSIONS

Established treatment guidelines do not exist, but the use of high doses of corticosteroids has been recommended and cochlear implant in cases with no recovery and complete hearing loss may be useful.

Quality of life related to symptomatic outcomes in patients with vestibular schwannomas: A Canadian Centre perspective

Patients with vestibular schwannomas (VS) typically present with hearing loss and tinnitus as well as variable cranial nerve dysfunctions. Surgical resection, stereotactic radiotherapy and/or conservative management employing serial magnetic resonance or computed tomography imaging serve as the main treatment options. Quality of life (QoL) may be impacted by the extent of tumour burden and exacerbated or relieved by treatment. Subjective assessment and quality of life inventories provide valuable information in client centered approaches with important implications for treatment. The intention of QoL measurements affecting VS patients within a clinical setting is to facilitate discussions regarding treatment options and objectively evaluate patient- centered clinical outcomes in a naturalistic setting.

Contact allergy to benzalkonium chloride in patients using a steroid nasal spray: A report of 3 cases

Benzalkonium chloride (BAC) is a bactericidal preservative excipient commonly found in steroid nasal sprays used to treat allergic rhinitis and nasal polyposis. In rare cases, BAC can be responsible for type I and type IV hypersensitivity reactions that can manifest as rhinorrhea, which a clinician might misinterpret as a lack of response to nasal spray therapy rather than a complication of it. We report 3 cases of type IV hypersensitivity reactions in patients who were being treated with mometasone nasal spray. We describe the epidemiology, clinical features, diagnosis, and treatment of these reactions.

Risk of posterior semicircular canal trauma when using a retrosigmoid approach for acoustic neuroma surgery and role of endoscopy: An imaging study

The rate of hearing preservation after vestibular schwannoma surgery is variable and is not as high as expected, possibly due to injuries to the posterior semicircular canal while exposing the tumor. The aim of this study was to estimate the risk of posterior semicircular canal injuries using temporal bone computed tomography (CT) scan findings. Temporal bone CT scans of 30 patients selected between 2013 and 2015 were studied. The median age of the patients was 40 years. Two planes were studied: (1) the axial plane that shows the common crus of the posterior semicircular canal and (2) the coronal plane that shows the two crura of the posterior semicircular canal. Five lines were drawn and four angles and three distances were measured. In this study, we divided the patients into three groups consisting of 10 patients each: (1) patients with no evidence of inflammatory or neoplastic disease, (2) those with chronic ear disease, and (3) those with vestibular schwannomas. The portion of the internal auditory canal that was exposed by drilling while preserving the posterior semicircular canal was 53 to 64% and 61 ± 9% in whole temporal bones in the three groups. The mean angle of vision with an endoscope was less than 105° in 56% of cases, which means even with a 30° endoscope, the fundus could not be visualized. Therefore, according to our data, it seemed impossible to expose the whole length of the internal auditory canal from the porus to the fundus without causing injury to the posterior semicircular canal. However, the use of endoscopes may help to prevent injury.

Perioperative Care of the Patient With Acoustic Neuroma

Acoustic neuromas, also known as vestibular schwannomas, are slow-growing, benign tumors that develop on the eighth cranial nerve. Common signs and symptoms of an acoustic neuroma include hearing loss and balance disturbances. A physical examination, a hearing evaluation, and diagnostic imaging assist in the diagnosis of an acoustic neuroma. Patients with a confirmed tumor have three treatment options: observation, stereotactic radiosurgery, and surgical removal. Complications include cerebrospinal fluid leakage, damage to ancillary brain structures, facial nerve damage, and bleeding or vascular injury. This article focuses on the surgical removal of an acoustic neuroma and the role of the perioperative nurse in the perioperative care of the patient.

[Surgical indications and complications management in vestibular schwannoma]

BACKGROUND

Recent surgical treatment concepts for patients with vestibular schwannoma (VS) require an interdisciplinary approach as well as recognition and mastering of complications.

OBJECTIVE

This paper provides an overview of indications, as well as possible options for function preservation and management of complications in the surgical resection of these tumors.

METHODS

Up-to-date treatment concepts and surgical indications were differentiated according to size and extent of tumors. The frequency of important complications was extracted from the literature. Technical options to avoid and correct complications were compiled from personal experience and review of the literature.

RESULTS

Complications unrelated to cranial nerves are not infrequent, particularly in older patients. Small and medium-sized tumors that do not reach the fundus and cochlear fossa can be completely removed with good chances of hearing preservation. As long as these tumors do not grow, patients benefit from observation. Large tumors are overrepresented in surgical series compared to their prevalence. Postoperative facial nerve function correlates to tumor volume. Hearing preservation in these tumors is rare. Intraoperative electrophysiological techniques are valuable for attempted preservation of cranial nerve function. Persistent facial palsies can be remedied by dynamic and static interventions for facial rehabilitation.

CONCLUSION

Mortality and morbidity associated with surgical treatment of VS are very acceptable. Surgical concepts should be custom-tailored to the individual patient in order to ensure high quality of life.

Subtotal resection of vestibular schwannoma: Evaluation with Ki-67 measurement, magnetic resonance imaging, and long-term observation

Purpose

The aim of this study was to compare the postoperative clinical and radiological data of patients with vestibular schwannomas who were initially managed by near total resection (NTR) or subtotal resection (STR). The Ki-67 analysis results were compared with tumor regrowth to determine the presence of a correlation between this proliferative index and postoperative tumor regrowth.

Study Design

Seventeen adult patients (7 male, 10 female) were retrospectively reviewed. Nine (52.9%) and eight (47.1%) patients underwent NTR and STR, respectively. Postoperative clinical and radiological data associated with vestibular schwannoma growth were compared with the Ki-67 immunohistochemical analysis results.

Results

Evidence of clinically significant regrowth was observed in four (23.5%) patients. Patients who underwent NTR had a lower rate/incidence of tumor regrowth than did patients who underwent STR. Patients with a higher Ki-67 index had the highest tumor regrowth rates.

Conclusions

Our study indicates that assessment of the Ki-67 index may be useful for determining the probability of regrowth of vestibular schwannomas when only partial removal is accomplished.

Long-term quality of life in patients with vestibular schwannoma: an international multicenter cross-sectional study comparing microsurgery, stereotactic radiosurgery, observation, and nontumor controls

OBJECT

The optimal treatment for sporadic vestibular schwannoma (VS) is highly controversial. To date, the majority of studies comparing treatment modalities have focused on a narrow scope of technical outcomes including facial function, hearing status, and tumor control. Very few publications have investigated health-related quality of life (HRQOL) differences between individual treatment groups, and none have used a disease-specific HRQOL instrument.

METHODS

All patients with sporadic small- to medium-sized VSs who underwent primary microsurgery, stereotactic radiosurgery (SRS), or observation between 1998 and 2008 were identified. Subjects were surveyed via postal questionnaire using the 36-Item Short Form Health Survey (SF-36), the 10-item Patient-Reported Outcomes Measurement Information System short form (PROMIS-10), the Glasgow Benefit Inventory (GBI), and the Penn Acoustic Neuroma Quality-of-Life (PANQOL) scale. Additionally, a pool of general population adults was surveyed, providing a nontumor control group for comparison.

RESULTS

A total of 642 respondents were analyzed. The overall response rate for patients with VS was 79%, and the mean time interval between treatment and survey was 7.7 years. Using multivariate regression, there were no statistically significant differences between management groups with respect to the PROMIS-10 physical or mental health dimensions, the SF-36 Physical or Mental Component Summary scores, or the PANQOL general, anxiety, hearing, or energy subdomains. Patients who underwent SRS or observation reported a better total PANQOL score and higher PANQOL facial, balance, and pain subdomain scores than the microsurgical cohort (p < 0.02). The differences in scores between the nontumor control group and patients with VS were greater than differences observed between individual treatment groups for the majority of measures.

CONCLUSIONS

The differences in HRQOL outcomes following SRS, observation, and microsurgery for VS are small. Notably, the diagnosis of VS rather than treatment strategy most significantly impacts quality of life. Understanding that a large number of VSs do not grow following discovery, and that intervention does not confer a long-term HRQOL advantage, small- and medium-sized VS should be initially observed, while intervention should be reserved for patients with unequivocal tumor growth or intractable symptoms that are amenable to treatment. Future studies assessing HRQOL in VS patients should prioritize use of validated disease-specific measures, such as the PANQOL, given the significant limitations of generic instruments in distinguishing between treatment groups and tumor versus nontumor subjects.

Complications of Surgery for Sporadic Vestibular Schwannoma

Objectives

We sought to investigate the postoperative complications of vestibular schwannoma excision and determine their significant clinical predictors.

Study Design

Cross-sectional.

Setting

California Hospital Inpatient Discharge Datasets 1997-2011.

Subjects and Methods

Data for vestibular schwannoma excisions performed in California were extracted using the ICD-9-CM code “04.01 excision of acoustic neuroma.” Demographics, principal payer, state of residence, comorbidities, as well as hospital case volume were examined as possible predictors. Postoperative complications and patient disposition were examined as outcome variables. Comorbidities and complications were identified using ICD-9-CM diagnoses and procedures codes.

Results

Overall, 6553 cases were examined. Comorbidities were present in 2539 (38.7%) patients. Postoperative complications occurred in 1846 (28.2%) patients; 1714 (26.2%) neurological and 337 (5.1%) medical complications. Patients’ admission ended with death or further care (ie, skilled nursing facilities) in 260 (4.0%) cases. Mortality rate was 0.2%. No significant changes were observed over time. Multivariate analysis revealed that the odds of neurological complications were greater in the 2007-2011 period (OR = 1.51; 95% CI, 1.12-2.04), in patients with comorbidities (OR = 1.48; 95% CI, 1.16-1.88), and in hospitals with low case volume (OR = 1.69; 95% CI. 1.31-2.18). The odds of medical complications were also greater in the 2007-2011 period (OR = 1.69; 95%, CI 1.02-2.80). Female gender, non-Caucasian ethnicity, presence of comorbidities, and low hospital case volume were associated with greater odds of patients requiring further care.

Conclusion

Comorbidities and low hospital case volume were major risk factors for complications. No significant changes in rates of complications from vestibular schwannoma surgery were observed over the 15-year period.