Analysis of causes for late presentation of Indian patients with vestibular schwannoma

Barriers to access to ear and hearing care services in low- and middle- income countries: A scoping review

People living in low- and middle- income countries (LMICs) meet significant challenges in accessing ear and hearing care (EHC) services. We conducted a scoping review to identify and summarise such barriers, to recognise gaps in the literature, and to identify potential solutions. Reviewers independently screened titles, abstracts and full-text articles and charted data. We undertook thematic analysis of supply and demand side dimensions of access, and summarised findings mapped against the Levesque framework. Of 3048 articles screened, 62 met inclusion criteria for review. Across the five access dimensions, supply-side constraints were more frequently described, the most common being a shortage of EHC workforce or appropriate facilities, despite high demand. We identified a thin geographical spread of literature on barriers to accessing EHC services in LMICs, reflecting low availability of such services. LMICs face a diverse range of demand and supply side challenges including workforce, equipment and resource shortages, and challenges for the majority of the population to pay for such services. There is a need for many LMICs to develop health policy and programmes in EHC, including integration into primary care, scaling up the EHC workforce through increased training and education, and improving EHC literacy through public health measures.

Preoperative Visual Impairment in Vestibular Schwannoma Patients: An Overlooked Entity of Developing World

Objective Visual impairment in vestibular schwannomas is an underreported entity. The plethora of literature focuses primarily on facial and hearing preservation. This study aims to describe our experience and find the possible reasons for visual impairment.

Materials and Methods This is a retrospective observational study. We evaluated 114 patients with vestibular schwannoma, operated during 2015 to 2020. Eight parameters were studied—age, gender, maximum tumor size, hydrocephalus, economic status, duration of symptoms, visual loss, and ease of access to the tertiary neurosurgical facility. JASP software (version 0.14.1, Amsterdam) was used for statistical analysis.

Results A total of 42/114 (36.84%) patients had a varying degree of impairment. Patients with impaired vision had significantly larger tumors (4.31 vs. 4.12 cm, p = 0.02), longer duration of symptoms (19.14 vs. 16.45 months, p = 0.02), hydrocephalus (p = 0.03), and were from remote areas (p = 0.009). In stepwise logistic regression analysis, longer duration of symptoms and difficult access to neurosurgical facility stand out as decisive factors for visual impairment. The follow-up data were available for 35/42 (83.33%) cases of visual impairment. Vision improved in 14/35 (40%) of cases. Vision improved in a significantly higher number of patients when a preoperative ventriculoperitoneal shunt was placed (p = 0.03).

Conclusion The visual handicap occurs in a significant number of patients with vestibular schwannoma. Delayed arrival at the neurosurgical facility due to difficult access appears to be the primary factor leading to blindness. Strengthening our healthcare systems in rural areas would go a long way in the timely detection and prevention of blindness in such cases.

Changes in pattern of presentation of patients with unilateral vestibular schwannoma over two decades: Influence of cell phone use in early diagnosis

We aimed to study whether the increased use of cell phone in south Asia over the past two decades has impacted presentation of patients with vestibular schwannoma (VS). In this observational cohort study, data on cell phone use and severity of hearing loss and tumor size was collected using a questionnaire through a patient interview (n = 62) in consecutive patients with VS managed between 2017 and 2020. Association between cell phone use and severity of hearing loss and tumor size were studied and compared with our data published earlier when telephone use was not widely prevalent. 71% of the 62 patients (aged between 15 and 81 years) had large or giant VS. Pure tone audiometry showed moderately severe or profound hearing loss in77.4%. Sixty (96.7%) patients used cell phones. 50% of patients complained of difficulty in using their cell phone because of hearing loss. Compared to the earlier era, a higher proportion consulted an ENT surgeon first for hearing loss (59.7% vs 26%; p = 0.0005) and had small or medium sized tumors (29% vs 8%; p = 0.008) with a smaller mean tumor size (3.3 vs 3.9 cm; p = 0.03). Increased cell phone use has led to earlier diagnosis of VS and smaller tumours in recent years when compared to an earlier era. However, the vast majority of patients continue to present with severe to profound hearing loss and large tumors.

Effect of Gamma Knife Radiosurgery on Vestibular Schwannoma with Serviceable Hearing: A Single-Center Indian Study

OBJECTIVE

Gamma Knife radiosurgery (GKRS) is an established treatment modality for vestibular schwannomas (VSs). The tumor control and hearing preservation rates suggest that GKRS is a good alternative treatment for small- and medium-size VS. Data are lacking from India regarding GKRS for VSs. Our aim was to find the hearing preservation and tumor control rates and the factors contributing to these.

METHODS

In a retrospective 9-year study period, 87 patients had undergone GKRS for unilateral VS with Gardner-Robertson (GR) class I or II serviceable hearing. All 87 had been evaluated with magnetic resonance imaging and audiometry before GKRS and during follow-up to assess for the factors influencing tumor control and hearing preservation.

RESULTS

Of the 87 patients, 77 with a minimum follow-up of 2 years and magnetic resonance imaging and audiometry evaluations available were included in the present study. The median follow-up period was 30 months. The tumor control rate and hearing preservation rate was 96.1% and 79.2%, respectively. Hearing preservation was not affected by the tumor volume. However, age >40 years, pre-GKRS pure tone average <30 decibels, speech discrimination score >85%, pre-GKRS Gardner-Robertson grade I hearing, mean cochlear dose <4 Gy, and pre-GKRS Ohata class of laterality C, D, E were significant on univariate analysis. The multivariate analysis revealed that age >40 years (P = 0.017), pre-GKRS pure tone average <30 decibels (P = 0.002), and Gardner-Robertson class I (P = 0.001) were significant factors. No patient developed cranial nerve dysfunction, hydrocephalus, or malignant degeneration.

CONCLUSION

For most patients with small VSs, GKRS will be an effective alternative treatment to microsurgery with retained serviceable hearing and good tumor control.

Symptoms in primary care with time to diagnosis of brain tumours

Background

Brain tumours often present with varied, non-specific features with other diagnoses usually being more likely.

Objective

To examine how different symptoms and patient demographics predict variations in time to brain tumour diagnosis.

Methods

We conducted a secondary analysis of brain tumour cases from National Audit of Cancer Diagnosis in Primary Care. We grouped neurological symptoms into six domains (headache, behavioural/cognitive change, focal neurology, 'fits, faints or falls', non-specific neurological, and other/non-specific) and calculated times for patient presentation, GP referral, specialist consultation and total pathway interval. We calculated odds ratios (ORs) for symptom domains comparing the slowest to other quartiles.

Results

Data were available for 226 cases. Median (interquartile range) time for the total pathway interval was 24 days (7-65 days). The most common presentation was focal neurology (33.2%) followed by 'fits, faints or falls' and headache (both 20.8%). Headache only (OR = 4.11, 95% CI = 1.10, 15.5) and memory complaints (OR = 4.82, 95% CI = 1.15, 20.1) were associated with slower total pathway compared to 'fits, faints or falls'. GPs were more likely to consider that there had been avoidable delays in referring patients with headache only (OR = 4.17, 95% CI = 1.14, 15.3).

Conclusion

Patients presenting to primary care with headache only or with memory complaints remain problematic with potentially avoidable delays in referral leading to a longer patient pathway. This may or may not impact on the efficacy and morbidity of therapies. Additional aids are required to help doctors differentiate when to refer headaches and memory complaints urgently for a specialist opinion.

Prospective evaluation of the clinical profile and referral pattern differences of vestibular schwannomas and other cerebellopontine angle tumors

OBJECTIVE

To evaluate the clinical profile, referral pattern, delay in diagnosis, and impact of tumor size of cases involving vestibular schwannomas (VS) versus other cerebellopontine angle (CPA) tumors in an Egyptian population.

STUDY DESIGN

Case series study.

SETTING

Tertiary referral center.

PATIENTS

A prospective study of possible retrocochlear lesions was conducted from 2008 to 2010.

INTERVENTION(S)

Patients were subjected to a full clinical history, complete otorhinolaryngological examination, a basic audiologic evaluation, auditory brainstem response assay, and gadolinium-enhanced magnetic resonance imaging. According to the findings of magnetic resonance imaging, patients with retrocochlear lesions were divided into 2 groups: those with VS (n = 17) and those with other CPA lesions (n = 14).

MAIN OUTCOME MEASURE(S)

Diagnostic delay and criteria of VS and CPA tumors.

RESULTS

Unilateral hearing loss and tinnitus were presented in 52.9% of VS cases with a diagnostic delay of 15.5 months. For cases involving other CPA lesions, a combination of otologic symptoms was observed in 9 (64%) of 14 cases, and a diagnostic delay of 47.5 months was experienced. An absence of auditory brainstem response waves was identified significantly (p < 0.05) for the affected ears of both groups. Only differences in Wave V latency were significant between the 2 groups (p < 0.05).

CONCLUSION

A longer diagnostic delay was associated with cases involving other types of CPA lesions versus cases of VS, and tumor size and volume did not affect the diagnostic delay of the former. Moreover, the only significant difference in clinical presentation for these 2 groups of intracranial tumor involved Wave V latency.