The Art of Management Decision Making:

Use of a Novel Clinical Decision-Making Tool in Vestibular Schwannoma Treatment

OBJECTIVE

To determine the usefulness of a personalized tool and its effect on the decision-making process for those with vestibular schwannoma (VS).

STUDY DESIGN

Prospective study.

SETTING

Single institution, academic tertiary care lateral skull base surgery program.

PATIENTS

Patients diagnosed with VS.

INTERVENTIONS

A comprehensive clinical decision support (CDS) tool was constructed from a previously published retrospective patient-reported data obtained from members of the Acoustic Neuroma Association from January to March 2017. Demographic, tumor, and treatment modality data, including associated side effects, were collected for 775 patients and integrated in an interactive and personalized web-based tool.

MAIN OUTCOME MEASURES

Pre- and posttool questionnaires assessing the process of deciding treatment for VS using a decisional conflict scale (DCS) and satisfaction with decision (SWD) scale were compared.

RESULTS

A pilot study of 33 patients evaluated at a single institution tertiary care center with mean ± SD age of 63.9 ± 13.5 years and with average tumor size of 7.11 ± 4.75 mm were surveyed. CDS implementation resulted in a mean ± SD total DCS score decrease from 43.6 ± 15.5 to 37.6 ± 16.4 ( p < 0.01) and total SWD score increase from 82.8 ± 16.1 to 86.2 ± 14.4 ( p = 0.04), indicating a significant decrease in decisional conflict and increase in satisfaction.

CONCLUSIONS

Implementing a decision-making tool after diagnosis of VS reduced decisional conflict and improved satisfaction with decision. Patients considered the tool to be an aid to their medical knowledge, further improving their comfort and understanding of their treatment options. These findings provide a basis for developing predictive tools that will assist patients in making informed medical decisions in the future.

Long-Term Hearing Outcomes Following Stereotactic Radiosurgery in Vestibular Schwannoma Patients-A Retrospective Cohort Study

BACKGROUND

An understanding of the hearing outcomes is needed for treatment counseling for patients with vestibular schwannomas (VS).

OBJECTIVE

To determine long-term hearing results following stereotactic radiosurgery (SRS) for VS and identify any influential variables.

METHODS

Tertiary hospital retrospective cohort.

RESULTS

There were 579 tumors (576 patients) treated with SRS. Eighty-two percent (473) of tumors had ≥1 yr and 59% (344 ≥3 yr follow-up. In the 244 tumor ears, with measurable hearing before SRS who were followed ≥1 yr, 14% (31) had improved hearing, 13% (29) unchanged hearing, and 74% (158) had worsened hearing. In 175 patients with ≥3 yr follow-up and who had measurable hearing pretreatment, 6% (11 ears) improved hearing, 31% (54 ears) unchanged hearing, and 63% (110 ears) had worsened hearing. Patients with tumors with larger target volumes (P = .040) and with neurofibromatosis type 2 (NF2; P = .017) were associated with poorer hearing (P = .040). Patients with word recognition scores (WRS) of 50% or poorer had tumors with a larger volume (P = .0002), larger linear size (P = .032), and NF2 (P = .045). Traditionally reported hearing outcomes using the Gardner Robertson maintenance of PTA ≤50 db or WRS ≥50% were 48% at 3 yr, which overestimates hearing outcomes compared to the above reporting standards.

CONCLUSION

Hearing declines over time in VS treated with SRS in a high proportion of cases. The frequency and magnitude of long-term hearing decline following SRS argues against prophylactic radiation for small tumors in hearing ears with undetermined growth behavior.

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.

Patient Motivation and Long-Term Satisfaction with Treatment Choice in Vestibular Schwannoma

OBJECTIVES

To ascertain primary motivation and long-term satisfaction with treatment selection in patients with vestibular schwannoma.

METHODS

A multicenter, cross-sectional survey was performed. Patients with small- to medium-sized sporadic vestibular schwannoma who underwent stereotactic radiosurgery (SRS; n = 247), microsurgery (n = 144), or observation (n = 148) between 1998 and 2008 were surveyed regarding their motivation behind treatment selection and hindsight satisfaction with their choice of management.

RESULTS

"Physician recommendation" was the most commonly stated reason for modality selection in all 3 groups. The second and third most common reasons for selecting SRS included "less invasive option than surgery" in 80 patients (32%) and "less recovery time than surgery" in 16 patients (6%). The second and third most common reasons for selecting observation included "to avoid side-effects of treatment" in 25 patients (17%) and "symptoms not severe enough to warrant intervention" in 22 patients (15%). The second and third most common reasons for selecting microsurgery included "do not want tumor in head" in 35 patients (24%) and "most definitive treatment" in 15 patients (10%). Overall, 232 patients (96%) treated with SRS, 141 observed patients (97%), and 121 patients (85%) who underwent microsurgical treatment were satisfied with their original decision (P < 0.001).

CONCLUSIONS

Motivation behind treatment selection varies between individuals. Those who select observation and SRS commonly reference less invasiveness and lower risk, whereas those who select microsurgery are commonly motivated by having their tumor physically removed and the more definitive nature of treatment. Posttreatment satisfaction is highest in patients who undergo SRS and observation, although all 3 groups report high levels of satisfaction.

[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.

Diagnostics and therapy of vestibular schwannomas - an interdisciplinary challenge

Vestibular schwannomas (VS) expand slowly in the internal auditory canal, in the cerebellopontine angle, inside the cochlear and the labyrinth. Larger tumors can displace and compress the brainstem. With an annual incidence of 1:100,000 vestibular schwannoma represent 6-7% of all intracranial tumors. In the cerebellopontine angle they are by far the most neoplasm with 90% of all lesions located in this region. Magnetic resonance imaging (MRI), audiometry, and vestibular diagnostics are the mainstays of the clinical workup for patients harboring tumors. The first part of this paper delivers an overview of tumor stages, the most common grading scales for facial nerve function and hearing as well as a short introduction to the examination of vestibular function. Upholding or improving quality of life is the central concern in counseling and treating a patient with vestibular schwannoma. Preservation of neuronal function is essential and the management options - watchful waiting, microsurgery and stereotactic radiation - should be custom-tailored to the individual situation of the patient. Continuing interdisciplinary exchange is important to monitor treatment quality and to improve treatment results. Recently, several articles and reviews have been published on the topic of vestibular schwannoma. On the occasion of the 88^th annual meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck surgery a special volume of the journal "HNO" will be printed. Hence this presentation has been designed to deviate from the traditional standard which commonly consists of a pure literature review. The current paper was conceptually woven around a series of interdisciplinary cases that outline examples for every stage of the disease that show characteristic results for management options to date. Systematic clinical decision pathways have been deduced from our experience and from results reported in the literature. These pathways are graphically outlined after the case presentations. Important criteria for decision making are size and growth rate of the tumor, hearing of the patient and the probability of total tumor resection with preservation of hearing and facial nerve function, age and comorbidity of the patient, best possible control of vertigo and tinnitus and last but not least the patient's preference and choice. In addition to this, the experience and the results of a given center with each treatment modality will figure in the decision making process. We will discuss findings that are reported in the literature regarding facial nerve function, hearing, vertigo, tinnitus, and headache and reflect on recent studies on their influence on the patient's quality of life. Vertigo plays an essential role in this framework since it is an independent predictor of quality of life and a patient's dependence on social welfare. Pathognomonic bilateral vestibular schwannomas that occur in patients suffering from neurofibromatosis typ-2 (NF2) differ from spontaneous unilateral tumors in their biologic behavior. Treatment of neurofibromatosis type-2 patients requires a multidisciplinary team, especially because of the multitude of separate intracranial and spinal lesions. Off-label chemotherapy with Bevacizumab can stabilize tumor size of vestibular schwannomas and even improve hearing over longer periods of time. Hearing rehabilitation in NF2 patients can be achieved with cochlear and auditory brainstem implants.

[Quality of life in patients with vestibular schwannoma]

BACKGROUND

Vestibular schwannoma (VS) is a disease which might affect health-related quality of life (HR-QOL) in a negative manner. For many years, only generic quality of life instruments such as SF-36 were available to measure HR-QOL. However, some years ago, the Penn Acoustic Neuroma Quality Of Life (PANQOL) tool, a disease-specific instrument, was developed and validated. It is expected that the application of this instrument will be able to better assess relevant aspects of the HR-QOL of VS patients in the future. A validated German version of the instrument does not exist yet. The disease-specific symptoms most frequently named by patients are headache and dizziness.

RESULTS AND DISCUSSION

The available literature shows that the therapeutic approaches affect HR-QOL differently. In particular, radiation therapy of small and medium-sized tumors has no pronounced negative effects on HR-QOL. However, restrictions after surgery become similar to those after radiotherapy over the course of several years. For large VS with a diameter >3 cm, no guiding data on this aspect are currently available. To clarify the outstanding issues, future prospective studies with long-term follow-up of 10 years and more are desirable.

Multifactor Influences of Shared Decision-Making in Acoustic Neuroma Treatment

OBJECTIVE

To identify factors associated with treatment modality selection in acoustic neuromas.

STUDY DESIGN

Prospective observational study.

SETTING

Tertiary care neurotology clinic.

PATIENTS

Data were prospectively collected from patients initially presenting to a tertiary care neurotology clinic between 2013 and 2016. Patients who did not have magnetic resonance imaging (MRI), demographic, psychometric, or audiometric data were excluded from analysis.

INTERVENTION

Demographic information, clinical symptoms, tumor characteristics, and psychometric data were collected to determine factors associated with undergoing acoustic neuroma surgical resection using univariate and multiple logistic regression analysis.

MAIN OUTCOME MEASURE

The decision to pursue acoustic neuroma surgical resection versus active surveillance.

RESULTS

A total of 216 patients with acoustic neuroma (mean age 55 years, 58% women) were included. Ninety eight patients (45.4%) pursued surgical resection, 118 patients (54.6%) pursued active surveillance. Surgical treatment was significantly associated with patient age less than 65, higher grade tumors, growing tumors, larger volume tumors, lower word discrimination scores, Class D hearing, headache, and vertigo as presenting symptoms, higher number of total symptoms, and higher headache severity scores (p < 0.05). There was no significant association between surgical intervention and preoperative quality of life, depression, and self-esteem scores. On multiple logistic regression analysis, the likelihood of undergoing surgical resection significantly decreased for patients older than age 65 (odds ratio [OR] 0.19; 0.05-0.69) and increased in patients with medium (OR 4.34; 1.36-13.81), moderately large (OR 33.47; 5.72-195.83), large grade tumors (OR 56.63; 4.02-518.93), tumor growth present (OR 4.51; 1.66-12.28), Class D hearing (OR 3.96; 1.29-12.16), and higher headache severity scores (OR 1.03; 95% confidence interval [CI] 1.01-1.05). The likelihood of undergoing surgical resection was completely predictive for giant grade tumors and not significant for small grade tumors and Class B or C hearing.

CONCLUSIONS

Non-elderly acoustic neuroma patients with larger tumors, growing tumors, significant hearing loss, and worse headaches are more likely to pursue surgical resection rather than active surveillance. Psychological factors such as quality of life, depression, and self-esteem do not seem to influence decision-making in this patient population.

Sulforaphane, a natural component of broccoli, inhibits vestibular schwannoma growth in vitro and in vivo

Vestibular schwannoma (VS) is an intracranial tumor that causes significant morbidity, including hearing loss, tinnitus, dizziness, and possibly even death from brainstem compression. However, FDA-approved pharmacologic treatments for VS do not exist. Sulforaphane (SFN) is a naturally occurring isothiocyanate found in cruciferous vegetables, such as broccoli, with potent chemoprotective effects in several cell types. Our objective was to determine whether SFN is effective against VS in vitro and in vivo. Human primary VS cells, HEI-193 schwannoma cells, and SC4 Nf2^−/− Schwann cells were used to investigate the inhibitory effects of SFN in vitro. Cell proliferation was assessed by bromodeoxyuridine (BrdU) incorporation, and cell viability and metabolic activity was calculated by MTT assay. Apoptosis was measured by flow cytometry, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining, and Western blot for cleaved caspases. A mouse model with a murine schwannoma allograft was also used to examine the antitumor activity of SFN. SFN exhibited significant antiproliferative activity in schwannoma cells in vitro, via the inhibition of HDAC activity and the activation of ERK. SFN treatment induced apoptosis and cell cycle arrest at the G2/M phase. SFN also significantly inhibited schwannoma growth in vivo. Our preclinical studies motivate a future prospective clinical study of SFN for the treatment of VS.

[Vestibular schwannoma - management and microsurgical results]

BACKGROUND

The experience of the medical team, interdisciplinarity, quality of the physician-patient relationship, sensible use of modern technology, and a sound knowledge about the long-term results of observation and interventions all influence treatment quality in patients with vestibular schwannomas.

OBJECTIVES

Compilation of findings regarding the results of observation and microsurgical treatment of patients with these tumors. Deduction of strategies for the medical management from these data.

MATERIALS AND METHODS

Review of the pertinent literature concerning the course of the disease with observational management and microsurgical treatment with respect to tumor growth and symptoms.

RESULTS

Reported annual growth rates of vestibular schwannoma vary between 0.3 and 4.8 mm. Vertigo is the symptom that is most influential on quality of life regardless of the medical management strategy. Up to 75 % of patients are treated within 5 years of the primary diagnosis. Independent of the approach, reported resection rates are higher than 95 %, even with preservation of function as the primary goal. Recurrence rates after subtotal removal are three times higher than after complete removal. Facial nerve preservation is accomplished in more than 90 % of cases. With functional hearing before surgery and small tumors, the chance of hearing preservation exceeds 50 %.

CONCLUSIONS

Quality of life is primarily defined by symptoms caused by the tumor itself and only secondarily by the medical interventions. Treatment should be directed towards the preservation of the patient's quality of life from the beginning. Results of medical treatment should be superior to the natural course of the disease.

Development and validation of a convenient formula evaluating the value and applicability of medical literature in clinical practice

OBJECTIVE

Evidence-based medicine offers explicit methods to evaluate the evidence grades of literature. However, evidence grades do not meet all the practical needs of physicians. This study is aimed to develop a convenient method for evaluating the clinical value of medical literature from the perspective of the clinician.

METHODS

A literature applicability equation was formulated through the Delphi method and the analytic hierarchy process. A consistency check was used to ascertain the efficacy of the formula. Three senior clinicians assessed 30 articles based on their clinical experiences and subjective opinions, while one independent researcher performed independent assessments of the applicability of 30 articles using the evaluation formula.

RESULTS

The literature applicability equation was Y = 3.93X1 + 11.78X2 + 14.83X3 + 44.53X4 + 24.93X5, where Y = literature applicability, X1 = years since publication, X2 = target question covered or not, X3 = sample size, X4 = study type, and X5 = journal quality. Consistency index (CI) values for the first-level indicator ("literature applicability") and the second-level indicators ("pertinence and timeliness" and "quality of results") were 0.0325, 0.0012, and 0.0001, respectively. The weights used to calculate the matrix indicators had satisfactory accordance (random coincidence coefficient = 0.056). A consistency check for the efficacy of the formula revealed kappa = 0.749 and P < .001. Conclusion : The developed and validated literature applicability evaluation formula may be a useful and convenient tool for identifying clinically valuable medical literature.

Diagnostic Approach, Treatment, and Outcomes of Cervical Sympathetic Chain Schwannomas

Objective

This review examined the diagnostic approach, surgical treatment, and outcomes of cervical sympathetic chain schwannomas (CSCS) to guide clinical decision making.

Data Sources

Medline, EMBASE, and Cochrane databases.

Review Methods

A literature review from 1998 to 2013 identified 156 articles of which 51 representing 89 CSCS cases were evaluated in detail. Demographic, clinical, and outcomes data were extracted by 2 independent reviewers with high interrater reliability (κ = .79). Cases were mostly international (82%), predominantly from Asia (50%) and Europe (27%).

Conclusions

On average, patients were 42.6 years old (SD = 13.3) and had a neck mass ranging between 2 to 4 cm (52.7%) or >4 cm (43.2%). Nearly 70% of cases were asymptomatic at presentation. Presurgical diagnosis relied on CT (63.4%), MRI (59.8%), or both (19.5%), supplemented by cytology (33.7%), which was nearly always inconclusive (96.7%). US-treated cases were significantly more likely to receive presurgical MRI than internationally treated cases but less likely to have cytology ( P < .05). Presurgical diagnosis was challenging, with only 11% confirmatory accuracy postsurgically. Irrespective of mass size, extracapsular resection (ie, complete resection with nerve sacrifice) was the most frequently (87.6%) performed surgical procedure. Common postsurgical adverse events included Horner’s syndrome (91.1%), first bite syndrome (21.1%), or both (15.7%), with higher prevalence when mass size was >4 cm. Adverse events persisted in 82.3% of cases at an average 30.0 months (SD = 30.1) follow-up time.

Implications for Practice

Given the typical CSCS patient is young and asymptomatic and the likelihood of persistent morbidity is high with standard surgical approaches, less invasive treatment options warrant consideration.