The effect of age on acoustic neuroma surgery outcomes

Vestibular schwannoma surgery in the ninth decade of life: a case series

BACKGROUND AND PURPOSE

Large symptomatic Vestibular Schwannoma (VS) often requires surgical resection, regardless the patient's age. The aim of this study was to assess the surgical outcomes of patients in their ninth decade of life.

METHODS

This monocenter retrospective observational study included patients aged 80 years or older who underwent VS surgery between 2009 and 2020. We retrospectively analyzed their immediate post-surgical and long-term outcomes and complications.

RESULTS

Thirteen octogenarians who underwent VS surgery were included, with average age of 83.2 ± 1.97 years old (median 83.5, range 80-86 years). One patient had a Koos-Grade II tumor, and 12 patients had a grade IV. All patients had a preoperative ASA score ≤ 3 and underwent surgery in the supine position. Twelve patients underwent a pre-planned partial resection (PR) and one had a gross-total resection (GTR). Good facial function (House-Brackmann grade ≤ 2) was achieved in 10 patients (77%). We reported three Clavien-Dindo grade ≤ 3 treatment-related complications and no life-threatening complication. Two patients experienced tumor recurrence after PR.

CONCLUSION

In this series of patients who underwent VS surgery in their ninth decade of life, surgical outcomes were acceptable. Therefore, age alone should not serve as a contraindication for surgery. Preplanned PR is a reasonable attitude in elderly patients.

Beyond one step: unveiling optimal approach for bilateral knee arthroplasty - a comprehensive meta-analysis

BACKGROUND

Total knee arthroplasty (TKA) is an efficient and common procedure used to treat advanced osteoarthritis of the knee. Geriatric patients make up the majority of TKA patients. For the surgical management of bilateral knee arthritis, there is still debate regarding whether to do a simultaneous or staged TKA. We through this study have gathered data and aimed to assess the safety of simultaneous bilateral TKA in patients.

MATERIALS AND METHODS

We conducted a study according to the PRISMA guidelines by searching through various databases for the following search terms: total knee arthroplasty (TKA), complications following TKA, bilateral TKA, and bilateral vs. unilateral TKA. The search included case series and clinical trials and excluded review articles, yielding 24 articles from the original search. We extracted data upon the outcomes in patients undergoing simultaneous bilateral TKA. We performed additional bias assessments to validate our search algorithm and results.

RESULTS

One hundred and three published articles were identified, and twenty-four that included a total of 2, 18,385 patients were included in the meta-analysis. 93,074 patients underwent simultaneous bilateral TKA and 125,311 patients underwent staged bilateral TKA. Simultaneous bilateral TKA was associated with significantly increased mortality rate (P < 0.00001, Odd's ratio [OR] 1.86, 95% Confidence interval [CI] 1.53-2.26), increased incidence of pulmonary embolism (P < 0.00001, OR 1.58, 95% CI 1.30-1.91), deep venous thrombosis (P < 0.00001, OR 1.31, 95% CI 1.17-1.46), and neurological complications (P < 0.002, OR 1.44, 95% CI 1.14-1.82). There were no significant differences in cardiac complications between both the procedures (P = 0.60, OR 0.93, 95% CI 0.70-1.23).

CONCLUSION

Staged bilateral TKA is associated with less complication rates as compared to simultaneous bilateral TKA. Hence, patients should be counselled and selected based on the risks respective to each strategy.

The effect of symptomatology and mental wellbeing on quality of life in people with acoustic neuroma

INTRODUCTION

Acoustic neuroma (AN) research largely employs a medical framework to understand health outcomes. An alternative is to examine quality of life (QOL) outcomes. This study explored whether mental well-being (i.e., anxiety and depression) were predictive of QOL in those with AN over and above symptomatology.

METHODS

A nationwide online survey was distributed to 24 community organisations. The inclusion criteria were a diagnosis of AN irrespective of the treatment approach. There were 52 respondents. Mental well-being was assessed using the Hospital Anxiety and Depression Scale (HADS), and quality of life was assessed using Penn Acoustic Neuroma QOL scale (PANQOL).

RESULTS

The most frequently reported symptoms reported were poor balance, tinnitus, hearing loss, and headache. Preliminary analyses suggested that headaches, tinnitus and mental well-being were significantly correlated with QOL. Hierarchical regression revealed that these two symptoms and mental well-being accounted for 18.7% and 51.1% of the variance in QOL, respectively. In addition, there was a significant difference in depression scores between management types, with the surgery group having a significantly higher depression score than the radiation group.

CONCLUSION

Symptoms and mood contribute to QOL for those diagnosed with AN. This can be understood through the common-sense model and fear of cancer recurrence. Screening for psychological difficulties should be provided from the point of diagnosis to post-treatment to allow for targeted management plans to mitigate the effects of these on QOL.

Impact of Demographics and Clinical Features on Initial Treatment Pathway for Vestibular Schwannoma

OBJECTIVE

To identify demographic and clinical features impacting initial treatment pathway for vestibular schwannoma.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care academic medical center.

PATIENTS

Patients diagnosed with vestibular schwannoma between 2009 and 2019.

INTERVENTIONS

Observation, stereotactic radiosurgery, or microsurgical resection.

MAIN OUTCOME MEASURES

χ 2 Test, one-way analysis of variance, and multivariate logistic regression were used to correlate demographic and clinical factors with initial treatment pathway for 197 newly diagnosed vestibular schwannoma patients.

RESULTS

Among 197 patients, 93 (47%) were initially treated with observation, 60 (30%) with stereotactic radiation (Gamma Knife) and 44 (22%) with surgical resection. Age univariately had no statistically significant impact on initial pathway, but those undergoing surgery trended toward a younger demographic (49.1 yr [surgery] versus 57.2 yr [observation] versus 59.0 yr [Gamma Knife]). Men were more likely to be initially observed than women ( p = 0.04). Patients initially observed were more likely to have a lower Koos classification ( p < 0.001) and have better tumor-ear hearing ( p = 0.03). Only 34.4% of patients living outside the local geographic region were initially observed compared with 53.0% living locally ( p = 0.055). Surgeon correlated with initial treatment ( p = 0.04) but did not maintain significance when adjusting for hearing level or tumor size. A multiple linear regression model found age, maximum tumor diameter, and Koos class to correlate with initial treatment pathway ( p < 0.0001, r2 = 0.42).

CONCLUSION

Initial treatment pathway for newly diagnosed vestibular schwannoma is impacted by demographic factors such as age, sex, and geographic proximity to the medical center. Clinical features including hearing level and tumor size also correlated with initial treatment modality.

A Subset of Intracanalicular Vestibular Schwannomas Demonstrates Minimal Growth Over a 10-Year Period

OBJECTIVE

Vestibular schwannomas (VS) commonly undergo magnetic resonance imaging (MRI) surveillance, but long-term data to support the ideal frequency is limited. Herein, we aim to investigate intracanalicular VS growth predictors and long-term growth rates (GR).

STUDY DESIGN

Retrospective chart review.

SETTING

Two tertiary care centers.

PATIENTS

Sporadic intracanalicular VS with initial conservative management and at least two sequential MRIs.

INTERVENTION

Serial MRI.

MAIN OUTCOME MEASURES

VS were categorized by baseline internal auditory canal tertile sublocalization (fundus, midpoint, porus) and size (≤100, 100-200, >200 mm3). Throughout follow-up, volumetric GR (mm3/yr) were determined (baseline-3 yrs, 3-5 yrs, 5-10 yrs) and treatment rates were assessed.

RESULTS

Ninety-nine intracanalicular VS were identified (mean follow-up of 6.1 ± 4.5 yrs). Mean GR before 5-year follow-up were comparable for baseline tertile involvement and size. After 5-year follow-up, mean GR of VS involving the fundus at baseline were lower than those involving the midpoint and fundus (6.17 ± 21.16 and 119.74 ± 117.57 mm3/yr, respectively; p = 0.034). Mean GR of VS with less than or equal to 100 mm3 at baseline (-7.29 ± 25.44 mm3/yr) were lower than those with 100 to 200 mm3 (86.55 ± 103.99 mm3/yr; p = 0.011) and more than 200 mm3 (45.70 ± 35.71 mm3/yr; p = 0.031). Vestibular schwannomas involving the midpoint and fundus had greater treatment rates compared with VS involving only the fundus (p < 0.001).

CONCLUSIONS

Baseline tertile involvement and size may predict long-term intracanalicular VS growth where fundal tumors or those less than or equal to 100 mm3 exhibit little long-term growth. Extending surveillance after 5-year follow-up may be reasonable for fundal VS.

Postoperative Hearing Preservation in Patients Undergoing Retrosigmoid Craniotomy for Resection of Vestibular Schwannomas: A Systematic Review of 2034 Patients

BACKGROUND

Vestibular schwannomas (VS) are benign tumors derived from Schwann cells ensheathing the vestibulocochlear nerve. The retrosigmoid (RS) surgical approach is useful to resect tumors of multiple sizes while affording the possibility of preserving postoperative hearing.

OBJECTIVE

To conduct a systematic review of published literature investigating hearing preservation rates in patients who underwent the RS approach for VS treatment.

METHODS

The PubMed, Scopus, and Embase databases were surveyed for studies that reported preoperative and postoperative hearing grades on VS patients who underwent RS treatment. Hearing preservation rates were calculated, and additional patient demographic data were extracted. Tumor size data were stratified to compare hearing preservation rates after surgery for intracanalicular, small (0-20 mm), and large (>20 mm) tumors.

RESULTS

Of 383 deduplicated articles, 26 studies (6.8%) met eligibility criteria for a total of 2034 patients with serviceable preoperative hearing, for whom postoperative hearing status was evaluated. Aggregate hearing preservation was 31% and 35% under a fixed and random effects model, respectively. A mixed effects model was used to determine hearing preservation rates depending on tumor size, which were determined to be 57%, 37%, and 12% for intracanalicular, small, and large tumors, respectively. Significant cross-study heterogeneity was found (I2 = 93%, τ2 = .964, P < .01; Q = 287.80, P = < .001), with rates of hearing preservation ranging from 0% to 100%.

CONCLUSION

Tumor size may have an effect on hearing preservation rates, but multiple factors should be considered. Discussion of a patient's expectations for hearing preservation is critical when deciding on VS treatment plans.

The association of age, body mass index, and frailty with vestibular schwannoma surgical morbidity

OBJECTIVE

To evaluate whether increased body mass index (BMI), age, or frailty influence vestibular schwannoma (VS) short-term surgical morbidity.

METHODS

The 2005-2017 National Surgical Quality Improvement Program database was queried for patients with VS undergoing surgical resection. Age was stratified according to age <50, 50-64, and ≥65, while BMI was stratified based on a threshold of 30. Frailty score (0-5) was indicated based on functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension.

RESULTS

A total of 1405 patients were included consisting of 56.7 % females with a mean age of 50.7 ± 13.8 years and mean BMI of 29.4 ± 6.6. Patients <50 (n = 604), 50-64 (n = 578), and ≥65 (n = 223), had different duration of surgery (428 ± 173 vs. 392 ± 149 vs. 387 ± 154 min; p < 0.001) and 30-day mortality rates (0.7 % vs. 0% vs. 1.8 %; p = 0.01). However, post-operative length of stay (LOS) (p = 0.16), readmission (p = 0.08), reoperation (p = 0.54), and complication rates were similar. Post-operative myocardial infarction (p = 0.03) and wound infection (p = 0.02) were more commonly observed in the obese cohort (BMI≥30) but readmission (p = 0.18), reoperation (p = 0.44), and complication rates were similar to those with BMI<30. Severely obese patients (BMI≥35) also had higher rates of deep vein thrombosis (p = 0.004). Frailty score 0 (n=921), 1 (n=375), and 2-4 (n=109) was associated with LOS (4.7±3.5 vs. 5.3 ± 4.1 vs. 6.7 ± 6.6 days, p < 0.001) and prolonged intubation rates (1.0 % vs. 2.4 % vs. 3.7 %; p = 0.03).

CONCLUSIONS

Increased age, BMI, and frailty among VS patients were associated with different post-operative complication rates, operation time, or LOS. Knowledge of these can optimize care for at-risk patients.

Evaluation of VIIth-XIIth cranial nerve anastomosis results by age

OBJECTIVE

To evaluate VIIth-XIIth cranial nerve (hypoglossal-facial nerve) anastomosis results by age.

METHOD

A total of 34 patients who attended a follow-up visit in 2016, aged 20-63 years, were enrolled. The House-Brackmann facial nerve function grading system and the Facial Clinimetric Evaluation scale were applied.

RESULTS

Regarding post-anastomosis facial nerve function, in the group aged 40 years or less, 14 patients (78 per cent) had House-Brackmann grade III and 4 patients (22 per cent) had House-Brackmann grade IV facial nerve function post-anastomosis. In the group aged over 40 years, nine patients (56 per cent) had House-Brackmann grade III and seven patients (44 per cent) had House-Brackmann grade IV facial nerve function post-anastomosis. There was a statistically significant difference between the two groups in mean facial movement domain scores (p = 0.02). Analysis between age and facial movement score in all 34 patients demonstrated a moderate negative correlation (Pearson correlation coefficient: -0.38) and statistical significance (p = 0.02).

CONCLUSION

Facial reanimation yielded better results in younger than in older patients.

Assessment of costs in open surgery and stereotactic radiosurgery for vestibular schwannomas

OBJECTIVE

Microsurgical resection and radiosurgery remain the most widely used interventions in the treatment of vestibular schwannomas. There is a growing demand for cost-effectiveness analyses to evaluate these two treatment modalities and delineate the factors that drive their total costs. Here, the authors evaluated specific cost drivers for microsurgical and radiosurgical management of vestibular schwannoma by using the Value Driven Outcomes system available at the University of Utah.

METHODS

The authors retrospectively reviewed all cases involving microsurgical and radiosurgical treatment of vestibular schwannomas at their institution between November 2011 and September 2017. Patient and tumor characteristics, subcategory costs, and potential cost drivers were analyzed.

RESULTS

The authors identified 163 vestibular schwannoma cases, including 116 managed microsurgically and 47 addressed with stereotactic radiosurgery (SRS). There were significant differences between the two groups in age, tumor size, and preoperative Koos grade (p < 0.05), suggesting that indications for treatment were markedly different. Length of stay (LOS) and length of follow-up were also significantly different. Facility costs were the most significant contributor to both microsurgical and SRS groups (58.3% and 99.4%, respectively); however, physician professional fees were not specifically analyzed. As expected, microsurgical treatment resulted in an average 4-fold greater overall cost of treatment than for SRS cases (p < 0.05), and there was a greater variation in costs for open cases as well. Costs remained stable over time for both open resection and SRS. Multivariable analysis showed that LOS (β = 0.7, p = 0.0001), discharge disposition (β = 0.2, p = 0.004), nonserviceable hearing (β = 0.1, p = 0.02), and complications (β = 0.2, p = 0.005) affected cost for open surgery, whereas no specifically examined factor could be identified as driving costs for SRS.

CONCLUSIONS

This analysis identified the fact that facility utilization constitutes the majority of total costs for both microsurgery and SRS treatment modalities of vestibular schwannomas. LOS, discharge disposition, nonserviceable hearing, and complications contributed significantly to the total costs for the microsurgical group, whereas none of the factors could be identified as driving total costs for the SRS group. This information may be used to establish policies and protocols to reduce facility costs, with the goal of decreasing the total costs without jeopardizing patient care.

Thirty-day morbidity and mortality following otologic/neurotologic surgery: Analysis of the national surgical quality improvement program

OBJECTIVES/HYPOTHESIS

To determine the rate and timing of, as well as risk factors for, postoperative morbidity and mortality following otologic and neurotologic surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

A total of 1,381 patients were identified in the American College of Surgeons National Surgical Quality Improvement Program for the years 2005 to 2010. Simple summary statistics, χ² , and multivariable logistic regression were performed.

RESULTS

Lateral skull base/neurotologic tumor resection (LSB) was done in 35.9%, and middle ear/mastoid procedures (MEM) were performed in 63.5%. The overall adverse event rate was 10.4%, although it was significantly higher for LSB (24.2%) and lower for MEM (2.6%). The overall mortality rate was 1.4%. Complications occurred postdischarge in 40.4% of cases. The outpatient setting (odds ratio [OR]: 0.31, 95% confidence interval [CI]: 0.15-0.65) and undergoing MEM (OR: 0.23, 95% CI: 0.12-0.47) were associated with lower risk of experiencing a complication. Impaired functional status (OR: 10.45, 95% CI: 3.65-29.89) was associated with postoperative mortality. An open wound preoperatively was associated with multiple causes of postoperative morbidity.

CONCLUSIONS

Patients undergoing approaches to the skull base and neurotologic tumor resections had the higher adverse event rate. Open wounds were predictive of several postoperative complications, and poor functional status was associated with mortality. Patients with significant comorbidities should be evaluated early on in their postoperative course to prevent readmission as well as major morbidity and mortality.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:1431-1437, 2018.

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.

The effects of advanced age on primary total knee arthroplasty: a meta-analysis and systematic review

Background

Total knee arthroplasty is an effective treatment when nonsurgical treatments fail, but it is associated with risk of complications which may be increased in advanced age. The purpose of this study was to quantify age-related differences in perioperative morbidity and mortality after total knee arthroplasty through systematic review of existing literature.

Methods

PubMed, the Cochrane database of systematic reviews, Scopus, and clinicaltrials.gov, were queried for relevant studies that compared primary total knee arthroplasty outcomes of mortality, myocardial infarction (MI), deep vein thrombosis (DVT), pulmonary embolism (PE) and functional status, of geriatric patients (>75 years old) with a younger control group (<65 years old). Pertinent journals and reference lists were hand searched. Eligibility criteria included all articles except case reports, meta-analyses, and systematic reviews. Two authors independently extracted data from each paper. Article quality was assessed using the Newcastle-Ottawa Scale.

Results

Twenty-two studies were included. Geriatric patients had higher rates of mortality, MI, DVT, and length of stay in older compared to younger patients, however the absolute magnitude of these increases were small. The increase in mortality may have reflected decreased life expectancy in the geriatric populations as opposed to mortality specifically due perioperative risk. There were no differences in PE incidence and improvement in pain and functional status was equal in older and younger patients. Existing studies were limited by non-randomized patient selection, as well as variation in definitions and methodology.

Conclusions

Existing data supports offering primary total knee arthroplasty to select geriatric patients, although the risk of complications may be increased. Much of the data was of poor quality. Future prospective studies are needed to better identify risks and benefits of total knee arthroplasty so that patients and surgeons can make informed decisions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0215-4) contains supplementary material, which is available to authorized users.

The Effect of Advancing Age on Total Joint Replacement Outcomes

OBJECTIVE

To describe age-related differences in outcomes among older adults undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).

DESIGN

Retrospective study.

PARTICIPANTS

A total of 1792 patients who underwent primary THA or TKA at the University of Iowa Hospitals and Clinics between 2010 and 2013 were identified in the University HealthSystem Consortium Database and University of Iowa Orthopedics Joint Replacement Registry.

MAIN OUTCOME MEASURES

Hospital length of stay (LOS), 30-day readmission rate, in-hospital mortality, number of days admitted to intensive care unit (ICU discharge disposition), in-hospital complications (pulmonary embolism, deep vein thrombosis, wound infection, hemorrhage, sepsis, or myocardial infarction), quality of life (measured using Short-Form 36 [SF-36]), discharge disposition (home, home with home health, nursing home, inpatient rehabilitation, transfer to another acute care hospital, and dead), and total patient level observed hospital cost (based on hospital charge information from each revenue code and estimated labor costs). Outcomes were compared in patients stratified by age and categorized by decade (ie, ≤50, 51-60, 61-70, 71-80, and ≥81).

RESULTS

A total of 871 THAs and 921 TKAs were performed. The mean age of our cohort was 60.5 years and 56.1% were women. In-hospital complication rates and ICU utilization progressively increased with increasing age. There was also a higher likelihood of skilled nursing facility placement and longer LOS. There was no increase in 30-day readmissions, mortality, or total cost. Improvements in patient reported outcomes (SF-36) scores were similar for all age-groups.

CONCLUSIONS

Compared to younger patients, older THA and TKA recipients were more likely to experience postoperative complications, admission to the ICU, discharge to a skilled care facility, and had longer hospital LOS. Improvements in patient-related outcomes were similar across all age-groups. These findings may be helpful when counseling older patients regarding elective total joint arthroplasty.

Vestibular schwannoma surgery in the elderly: a matched cohort study

Object

The authors' objective was 2-fold: 1) to compare outcomes of microsurgical resection for vestibular schwannoma (VS) between patients aged 70 years or older and patients younger than 70 years and 2) to test the hypothesis that symptomatic tumors in elderly patients represent a more aggressive variant of VS than those in younger adults, resulting in increased morbidity and a higher rate of recurrence after subtotal resection (STR).

Methods

A retrospective matched cohort study was conducted. Patients aged 70 years or older who had undergone microsurgical resection of VS were matched to adult patients younger than 70 years; the matching was performed on the basis of surgical approach, completeness of resection, and tumor size. Associations between clinical, radiographic, and surgical data and postoperative outcome were analyzed using conditional logistic regression.

Results

Twenty patients aged 70 years or older (mean age ± SD 75.9 ± 5.3, range 70–86 years) were identified and matched to a cohort of younger adult patients (mean age ± SD 55.7 ± 13.8, range 25–69 years). The mean tumor size in both groups was approximately 3 cm. Overall, the elderly patients had a poorer preoperative American Society of Anesthesiology physical status score (p = 0.038), were more likely to report imbalance (OR 9.61, p = 0.016), and more commonly exhibited compromised balance and coordination (OR 9.61, p = 0.016) than patients in the younger cohort.

There were no differences between the 2 cohorts in perioperative complications (p = 0.26) or facial nerve function (p > 0.5) at any time. The elderly patients were 13 times more likely to have long-term postoperative imbalance (OR 13.00, p = 0.013) than the younger patients. Overall, 9 tumors recurred among 32 patients undergoing STR; 6 of these patients underwent additional interventions (stereotactic radiosurgery in 5 patients and microsurgery in 1) and showed no evidence of tumor progression at the last follow-up. The median growth rate of the recurrent tumor in the 6 elderly patients was 4.8 mm/year (range 2.1–14.9 mm/year) and, in the 3 control patients, 2.2 mm/year (range 1.9–4.0 mm/year). Overall, the mortality data showed a trend toward statistical significance (p = 0.068) with a higher risk of death in the elderly.

Conclusions

As the number of elderly patients with VS increases, microsurgical resection will remain an important management option for these patients. Despite a poorer preoperative physical status in elderly patients, their morbidity profiles are similar to those in adult patients younger than 70 years. However, elderly patients may require longer convalescence due to prolonged postoperative imbalance. Not surprisingly, overall diminished functional reserve and advanced comorbidities may increase the mortality risk associated with surgical intervention in the elderly patients. Finally, there was a high risk of further tumor growth following STR in the elderly patients (6 [37.5%] of 16), underscoring the need for close postoperative radiological surveillance and consideration of early stereotactic radiosurgery for the tumor remnant following the STR.

The impact of comorbidities, regional trends, and hospital factors on discharge dispositions and hospital costs after acoustic neuroma microsurgery: a United States nationwide inpatient data sample study (2005-2009)

OBJECT

Hospitalization cost and patient outcome after acoustic neuroma surgery depend on several factors. There is a paucity of data regarding the relationship between demographic features such as age, sex, race, insurance status, and patient outcome. Apart from demographic factors, there are several hospital-related factors and regional issues that can affect outcomes and hospital costs. To the authors' knowledge, no study has investigated the issue of regional disparity across the country in terms of cost of hospitalization and discharge disposition.

METHODS

The authors analyzed the Nationwide Inpatient Sample (NIS) database over the years 2005-2009. Several variables were analyzed from the database, including patient demographics, comorbidities, and surgical complications. Hospital variables, such as bedsize, rural/urban location, teaching status, federal or private ownership, and the region, were also examined. Patient outcome and increased hospitalization costs were the dependent variables studied.

RESULTS

A total of 2589 admissions from 242 hospitals were analyzed from the NIS data over the years 2005-2009. The mean age was 48.99 ± 13.861 years (± SD), and 304 (11.7%) of the patients were older than 65 years. The cumulative cost incurred by the hospitals from 2005 to 2009 was $948.77 million. The mean expenditure per admission was $76,365.09 ± $58,039.93. The mean total charges per admission rose from $59,633.00 in 2005 to $97,370.00 in 2009. The factors that predicted most significantly with other than routine (OTR) disposition outcome were age older than 65 years (OR 2.22, 95% CI 1.411-3.518; p < 0.001), aspiration pneumonia (OR 16.085, 95% CI 4.974-52.016; p < 0.001), and meningitis (OR 11.299, 95% CI 3.126-40.840; p < 0.001). When compared with patients with Medicare and Medicaid, patients with private insurance had a protective effect against OTR disposition outcome. Higher comorbidities predicted independently for OTR disposition outcome (OR 1.409, 95% CI 1.072-1.852; p = 0.014). The West region predicted negatively for OTR disposition outcome. Large hospitals were independently associated with higher hospital charges (OR 4.269, 95% CI 3.106-5.867; p < 0.001). The West region had significantly higher (p < 0.001) mean hospital charges than the other regions. Patient factors such as meningitis and aspiration pneumonia were strong independent predictors of increased hospital charges (p < 0.001). Higher comorbidities (OR 1.297, 95% CI 1.036-1.624; p = 0.023) and presence of neurofibromatosis Type 2 (OR 2.341, 95% CI 1.479-3.707; p < 0.001) were associated with higher hospital charges.

CONCLUSIONS

The authors' study shows that several factors can affect patient outcome and hospital charges for patients who have undergone acoustic neuroma surgery. Factors such as younger age, higher ZIP code income, less comorbidity, private insurance, elective surgery, and the West region predicted for better disposition outcome. However, the West region, higher comorbidities, and weekend admissions were associated with higher hospitalization costs.

Hearing preservation: microsurgery

PURPOSE OF REVIEW

To evaluate the recent and significant contributions to the literature that examine hearing preservation outcomes and prognostic factors in vestibular schwannoma microsurgery.

RECENT FINDINGS

Hearing preservation rates overall range considerably between 2 and 93% in recent studies. There are a number of factors that have been reported to be significant in the prediction of hearing preservation. Characteristics such as approach, results of preoperative neurophysiological testing, tumor size and nerve of origin have long been reported. A more recent contribution to the literature has included the association between MRI T2 signal in the fundus of the internal auditory canal and hearing preservation. This review provides a summary of some of the landmark studies in conjunction with more recent work detailing the prognostic factors for hearing preservation in the surgical management of vestibular schwannoma.

SUMMARY

Hearing preservation in vestibular schwannoma surgery has undergone tremendous evolution over the past 50 years. In this review, we outline the prognostic factors that predict hearing preservation and describe recent contributions.

Impact of fundal extension on hearing after surgery for vestibular schwannomas

OBJECTIVE

To compare hearing preservation after surgery for intracanalicular vestibular schwannomas with or without fundal extension.

STUDY DESIGN

Retrospective chart review.

PATIENTS

Patients with intracanalicular tumors (≤ 10-m maximal dimension) undergoing retrosigmoid craniotomy between 2001 and 2010.

INTERVENTION

Preoperative and postoperative audiograms, preoperative magnetic resonance imaging, and operative reports were reviewed.

MAIN OUTCOME MEASURES

Preoperative and postoperative hearing (American Academy of Otolaryngology-Head and Neck Surgery classification).

RESULTS

Complete data for 53 patients (27 female and 24 male subjects, sex was not recorded for 2 patients) meeting selection criteria was available. Fundal involvement was identified in 39 (73.6%) of the 53 patients. The remaining 14 patients did not have tumor with fundal extension (26.4%). Average tumor size for patients with fundal extension (+FE) was 6.9 ± 2.2 mm and without fundal extension (-FE) was 8.2 ± 1.9 mm (p = 0.05, Student's t test). Average preoperative speech discrimination score for the entire study was 90.5 ± 11.8 (n = 53). After retrosigmoid approach for tumor resection, 79% of patients (42/53) had preserved hearing defined as American Academy of Otolaryngology-Head and Neck Surgery class A, B, or C. Average postoperative speech discrimination score for these patients was 89.3 ± 12.1, and average postoperative pure-tone average was 35.9 ± 9.1%. Eighty-five percent (33/39) of +FE patients had preserved hearing (class A, B, or C). In contrast, 64% (9/14) of -FE patients had hearing preserved (class A, B, or C; Fisher's exact test, p = 0.034).

CONCLUSION

Hearing preservation rate after retrosigmoid craniotomy for intracanalicular vestibular schwannomas may be superior for tumors with fundal extension compared with tumors that do not extend to the fundus.

Analysis of hearing preservation and facial nerve function for patients undergoing vestibular schwannoma surgery: the middle cranial fossa approach versus the retrosigmoid approach--personal experience and literature review

OBJECTIVE

To compare hearing preservation and facial nerve function outcomes in patients undergoing vestibular schwannoma surgery performed using either the middle cranial fossa approach (MCFA) or the retrosigmoid approach (RSA).

MATERIALS AND METHODS

A review of the medical records of patients diagnosed with vestibular schwannoma who underwent surgical tumor removal in a single reference center via the MCFA or the RSA between January 1988 and December 2008 was conducted.

RESULTS

During this period, 90 patients underwent surgery via the MCFA while 86 patients received surgical treatment via the RSA. Of the patients subjected to the MCFA, 80.7% were characterized by a House-Brackmann (HB) grade I or II outcome, whereas 96.5% of patients undergoing the RSA were characterized by a HB grade I or II outcome (p = 0.001). This difference appeared only for extrameatal tumors when we compared size-matched tumors (58.3% MCFA vs. 98% RSA; p = 0.0006). There was no statistically significant difference in the hearing outcomes upon consideration of hearing preservation as characterized by the modified Sanna classification system involving classes A and B (18.9% MCFA vs. 10.6% RSA; p = 0.122).

CONCLUSION

No statistically significant difference in hearing preservation was identified when comparing tumors operated upon via the MCFA versus the RSA. However, our results indicate that a higher risk of facial nerve function impairment exists if the surgery is performed via the MCFA under circumstances where the tumor extends to the cerebellopontine angle.

Utilization of preoperative cerebrospinal fluid drain in skull base surgery

OBJECTIVE

Retrospectively assess the efficacy of lumbar cerebrospinal fluid (CSF) drainage placed preoperatively in skull base operations in decreasing the incidence of postoperative CSF fistula.

METHODS

A retrospective review of 150 patients undergoing a posterior fossa craniotomy from 1989 to 2000 was conducted. Patients were divided into those receiving preoperative lumbar drains and those that did not. The rates of postoperative CSF leakage were compared between the two groups. Patient data were analyzed to determine if there were other comorbidities affecting the postoperative incidence of CSF leakage such as smoking, diabetes, or hypertension.

RESULTS

Between 1989 and 1994, 25/72 (35%) patients with no preoperative lumbar drain had a postoperative CSF leak. From 1995 to 2000, 9/78 (12%) patients with a preoperative lumbar drain had a CSF leak. This was a 23% decreased incidence of postoperative CSF leakage and a significant decrease in the probability (p < 0.001) of CSF leakage in patients treated with a preoperative lumbar drain. The comorbidities of diabetes, smoking, or hypertension did not increase the probability of a CSF leak (p = 0.43).

CONCLUSIONS

A preoperatively placed lumbar drain can significantly lower the rate of postoperative CSF leakage after skull base surgery. The drain is a well-tolerated adjunct to dural closure and helps increase surgical exposure of the posterior fossa. The comorbidities of diabetes, smoking, or hypertension do not contribute to an increased rate of CSF leakage.dagger Lyal Leibrock M.D., F.A.C.S. is Deceased.

Surgical management of vestibular schwannoma in elderly patients

This study aimed to evaluate surgical results of vestibular schwannoma in elderly patients using a retrospective study in a Quaternary Neurotology and Skull Base Referral Center setting. The data of 232 elderly patients (above 65 years) operated on for vestibular schwannoma in the period between April 1987 and July 2009 were reviewed. Most patients were operated on via translabyrinthine approach (TLA) using transapical extension for large tumors. Other approaches used were retrosigmoid, middle cranial fossa, and transcochlear. Total tumor removal was achieved in the majority of cases, while planned subtotal removal was used in specific occasions. Postoperative complications included facial nerve palsy, other cranial nerves injury, persistent instability, intracranial hemorrhage, CSF leak, meningitis, and death. Patients were followed after surgery for tumor regrowth or occurrence of complications. The results showed low rate of morbidity and mortality. Despite that complete removal is the main target of the surgery; adoption of subtotal removal in selected cases can improve postoperative facial nerve results and reduce the duration of surgery.

Beyond audiofacial morbidity after vestibular schwannoma surgery

Object

Outcomes following vestibular schwannoma (VS) surgery have been extensively described; however, complication rates reported in the literature vary markedly. In addition, the majority of reports have focused on outcomes related to cranial nerves (CNs) VII and VIII. The objective of this study was to analyze reported morbidity unrelated to CNs VII and VIII following the resection of VS.

Methods

The authors performed a comprehensive search of the English language literature, identifying and aggregating morbidity and death data from patients who had undergone microsurgical removal of VSs. A subgroup analysis based on surgical approach and tumor size was performed to compare rates of CSF leakage, vascular injury, neurological deficit, and postoperative infection.

Results

One hundred articles met the inclusion criteria, providing data for 32,870 patients. The overall mortality rate was 0.2% (95% CI 0.1–0.3%). Twenty-two percent of patients (95% CI 21–23%) experienced at least 1 surgically attributable complication unrelated to CNs VII or VIII. Cerebrospinal fluid leakage occurred in 8.5% of patients (95% CI 6.9–10.0%). This rate was markedly increased with the translabyrinthine approach but was not affected by tumor size. Vascular complications, such as ischemic injury or hemorrhage, occurred in 1% of patients (95% CI 0.75–1.2%). Neurological complications occurred in 8.6% of cases (95% CI 7.9–9.3%) and were less likely with the resection of smaller tumors (p < 0.0001) and the use of the translabyrinthine approach (p < 0.0001). Infections occurred in 3.8% of cases (95% CI 3.4–4.3%), and 78% of these infections were meningitis.

Conclusions

This study provides statistically powerful data for practitioners to advise patients about the published risks of surgery for VS unrelated to compromised CNs VII and VIII.

Duraplasty using autologous fascia lata reenforced by on-site pedicled muscle flap: technical note

OBJECTIVE

Postoperative cerebrospinal fluid (CSF) leak is a common complication in the practice of neurosurgery, and various surgical techniques were described to overcome and manage this problem. Besides not applying watertight closure of the duraplasty, the inviability and the poor vascularization of the graft and/or the dura (eg, reoperations, multiple operations, or cranial radiotherapy) may lead to delayed healing of the suture site and resultant persistent CSF leaks. We present a simple technique that uses on-site muscle flap with pedicle to supply and vascularize the autologous fascia lata, preserving the viability of the graft and reenforcing its healing ability.

METHODS

We applied this technique in 6 patients with postoperative CSF leaks. After harvesting a fascia lata graft with appropriate size from the patients, the graft was sutured to dural defect in watertight fashion. The suboccipital, temporal, and temporal muscles in 4 patients who had posterior fossa duraplasty, in 1 patient who had pterional craniotomy, and in 1 patient who had subtemporal craniotomy, respectively, were dissected, stretched, and sutured to the fascia graft covering the dura graft suture site and then reinforced by Tisseel fibrin glue (Baxter Healthcare Corporation, Deerfield, IL). Postoperatively, CSF lumbar drain was kept open for 72 hours with pressure wound dressing. The technical nuances are illustrated.

RESULTS

Cerebrospinal fluid leaks were controlled successfully in 5 patients without recurrence. One patient with posterior fossa duraplasty had recurrence of CSF leak that required reexploration 21 days after the first surgery and a second dural repair in a site distant from the fascia lata attachment. During reexploration intraoperatively, the fascia lata graft was inspected and studied, which has shown the healing of the dura graft site and the graft neovascularization.

CONCLUSIONS

Duraplasty using autologous fascia lata reenforced by on-site pedicled muscle flap is an effective technique to control CSF leak, especially when dura is poorly vascularized and less viable. The unfortunate recurrence of CSF leak and reexploration in the seventh patient helped us to observe the effectively healed dural defect with profound early postoperative vascularization of the graft, supporting our idea about the effectiveness of this technique.

Do facial nerve displacement pattern and tumor adhesion influence the facial nerve outcome in vestibular schwannoma surgery?

OBJECTIVE

To assess the nerve facial displacement by a vestibular schwannoma and nerve adhesion to tumor as predictive factors of facial function outcome.

STUDY DESIGN

A prospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

Ninety-six patients undergoing a solitary vestibular schwannoma surgery during 2005 were included. Data concerning tumor size (Stage 1, intracanalicular; Stage 2, < or =15 mm in the cerebellopontine angle [CPA]; Stage 3, 15-30 mm in the CPA; and Stage 4, >30 mm in the CPA), intraoperative facial nerve displacement (Type 1, anterior to the tumor; Type 2, anterior and superior to the tumor and separated from the cochlear nerve; Type 3, superior to the tumor; and Type 4, posterior to the tumor), degree of tumor adhesion (weak, intermediate, and strong) and postoperative facial function according to the House and Brackmann classification at days 10, 30, 90 and 180 were collected.

RESULTS

A good facial function (Grade 1 or 2) was reported in 73% at postoperative Day 180. Univariate analysis showed that facial outcome was better in small tumors, in displacement Types 1 and 2 (Type 1, 46%; Type 2, 34%; and Type 3, 20%), and in tumors with weak and intermediate adhesion (weak, 10%; intermediate, 38%; and strong, 52%). Facial nerve displacement and adhesion were related to tumor stage. The combination of tumor stage, adhesion, and nerve displacement in a logistic regression model was highly predictive of postoperative facial function.

CONCLUSION

Facial nerve displacement and nerve adhesion to tumor are significant predictive factors of facial function outcome after vestibular schwannoma surgery in addition to tumor size.

Management of acoustic neuromas in patients 65 years or older

OBJECTIVE

To analyze an optimal management protocol for patients 65 years or older at the time of acoustic neuroma diagnosis.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care hospital.

PATIENTS

Two hundred sixteen patients with acoustic neuroma 65 years or older at time of diagnosis.

INTERVENTION

Patients with smaller tumors (<2.5 cm) were followed with serial magnetic resonance imaging. If significant growth occurred, they were treated with surgery. Surgery was performed at initial diagnosis on patients with larger tumors or in selected patients for hearing preservation. Stereotactic radiotherapy was performed for poor surgical candidates and for patient choice.

OUTCOME MEASURES

Measurement of acoustic neuroma growth and tabulation of complications.

RESULTS

One hundred fourteen patients were initially managed by observation, 80 with surgery, and 3 with radiation therapy, with an average follow-up of 35.4 months. For patients in the observation group, average tumor growth was 1.2 mm/yr. Thirty-two patients required crossover to surgery or radiotherapy due to tumor growth (average growth, 4.1 versus 0.3 mm/yr for those remaining in the observation group). One of the patients in the observation group had a complication (0.9%).

CONCLUSION

Management of acoustic neuromas in elderly patients can be based on size and "biological age" criteria. Surgical treatment can safely be reserved for the few patients who have significant tumor growth.

Surgical approaches and complications in the removal of vestibular schwannomas

Vestibular schwannomas are benign tumors that usually originate from the balance portion of cranial nerve VIII. The treatment options currently available for vestibular schwannomas include observation with serial imaging, stereotactic radiation, and microsurgical removal. Although the ultimate goal in treatment of vestibular schwannomas is preservation of life, the best option for each patient depends on symptoms, tumor size, tumor location, and the patient's general health and age. Surgical exposure of the cerebellopontine angle for removal of vestibular schwannomas can be performed safely via a translabyrinthine, retrosigmoid, and middle fossa approach. Each approach has its advantages and disadvantages. The goal of surgery is complete eradication of tumor with preservation of hearing and facial nerve function when possible.

[Predictive factors of facial palsy of the acoustic neurinoma after retrosigmoid surgery: 230 cases]

OBJECTIVES

To determine predictive factors influencing postoperative facial palsy during retro sigmoid approach in vestibular schwannoma surgery.

MATERIAL AND METHODS

Retrospective study over 230 patients with vestibular schwannoma, mostly stade I and II, operated by retro sigmoid approach, by the same oto neuro chirurgical team between 1993 and 2004. Pre and post operative parameters taken into consideration: quantitative: age and sex, audiometric parameters, duration of clinical symptoms; qualitative: tumor anatomic factors and facial nerve function according to House Brackmann classification.

RESULTS

8 days after surgery, 92% of patients have a normal or subnormal facial nerve function, 5% a facial paresis and 3% a paralysis. After one year, only 4% of patients still have a grade III to VI paralysis. Latency of vertigo with facial nerve paralysis is 4.33 vs. 1.97 year in absence of paralysis. Hearing conservation is 85% without facial nerve paralysis vs. 58% with facial nerve paralysis; Wave III latency (PEAP) with facial nerve paralysis is 4.54 vs. 4.28 ms if not.

CONCLUSION

Significant predictive factors of facial nerve palsy outcome are: age, post surgery hearing conservation, wave III latency, difficulty in tumor dissection, vertigo latency.

Facial Nerve Rerouting in Skull Base Surgery

Facial nerve rerouting techniques were developed to facilitate re-section of extensive tumors occupying the skull base. Facial nerve rerouting has its own limitations and risks, requiring microsurgical expertise, additional surgical time, and often some degree of facial nerve paresis. This article presents different degrees of anterior and posterior facial nerve rerouting, techniques of facial nerve rerouting, and a comprehensive review of outcomes. It then reviews anatomic and functional preservation of the facial nerve in acoustic neuroma resection, technical aspects of facial nerve dissection, intracranial facial nerve repair options, and outcomes for successful acoustic neuroma surgery.

Facial Paralysis and Surgical Rehabilitation: A Quality Of Life Analysis in a Cohort of 1,595 Patients after Acoustic Neuroma Surgery

OBJECTIVES

On the basis of survey results of the Acoustic Neuroma Association, we report patient ratings of facial dysfunction and outcomes for various facial rehabilitative therapies after surgical treatment of acoustic neuroma (AN). We assessed patients' perceived quality of life (QOL) and reviewed the literature regarding facial dysfunction and its management associated with AN.

STUDY DESIGN

The Acoustic Neuroma Association mailed a detailed questionnaire to 2,372 members to identify preoperative and postoperative symptoms, complications, and long-term effects on physical and psychosocial function. A cohort of 1,595 (82.2%) respondents who underwent surgical treatment of ANs reported their experiences with facial dysfunction.

PATIENTS

Of all 1,940 survey respondents, 1,682 of 1,875 that had ANs underwent surgical treatment. The study included 1,595 patients with ANs (82.2% of all respondents) who underwent surgical treatment by way of the translabyrinthine, suboccipital, or middle fossa approaches and excluded 87 respondents who did not report the type of surgical approach.

METHODS

Respondents answered questions intended to qualify and quantify the degree that facial dysfunction impacted QOL parameters. Responses were analyzed for tumor size, surgical approach, patient age, and sex. Statistical analysis was performed using SPSS software.

RESULTS

In our analysis, 11% of all respondents experienced some degree of preoperative facial weakness or eye problems. Of all respondents, 45.5% (725 patients) experienced worsened facial weakness caused by surgery, and of these, 72% reported that it was permanent. The most commonly used successful therapy for facial reanimation for 271 (19.6%) patients was placement of a gold weight. The factor most often associated with poor outcome was a large tumor. Of all respondents, 28% felt significantly affected by facial weakness, 63% felt their smile was symmetric, and 70% were content "quite a bit" or "very much" with their QOL.

CONCLUSIONS

In this large cohort study of AN patients, facial dysfunction was a significant morbidity. Physicians should be aware of the risk factors identified, specifically large tumor size and the impact facial dysfunction has on QOL, when counseling patients regarding optimal management of AN.

Chronic Pachymeningitis Presenting as Asymmetric Sensorineural Hearing Loss

OBJECTIVE

The objective of this study was to characterize the auditory dysfunction associated with chronic pachymeningitis (inflammation of the dura mater).

STUDY DESIGN AND SETTING

We conducted a university-based retrospective review.

RESULTS

Three patients were identified who were diagnosed with chronic pachymeningitis after being referred for asymmetric sensorineural hearing loss. All patients were found to have other neurologic symptoms and signs during careful neurotologic evaluation. Two varieties of chronic pachymeningitis exist: a hypertrophic mass lesion and a linear dural thickening. Although the hypertrophic variety could be easily detectable by noncontrast magnetic resonance imaging (MRI), the linear form is only visible with the use of gadolinium enhancement.

CONCLUSION

Chronic pachymeningitis is a rare form of sensorineural hearing loss that could portend an underlying disease of greater concern. Extensive evaluation is needed to exclude identifiable causes of chronic pachymeningitis, including infectious, neoplastic, and autoimmune diseases.

SIGNIFICANCE

The clinician should be aware that the evaluation of a patient with asymmetric sensorineural hearing loss involves more than simply ruling out an acoustic neuroma. Fast-spin echo MRI techniques without the use of gadolinium contrast could miss a number of potentially treatable diseases such as chronic pachymeningitis. Patients with asymmetric sensorineural hearing loss should be carefully evaluated for other neurologic findings, and imaging with enhanced MRI is recommended.