Change in Hearing Handicap after Translabyrinthine Vestibular Schwannoma Excision

Surgery of the lateral skull base: a 50-year endeavour

Disregarding the widely used division of skull base into anterior and lateral, since the skull base should be conceived as a single anatomic structure, it was to our convenience to group all those approaches that run from the antero-lateral, pure lateral and postero-lateral side of the skull base as “Surgery of the lateral skull base”. “50 years of endeavour” points to the great effort which has been made over the last decades, when more and more difficult surgeries were performed by reducing morbidity. The principle of lateral skull base surgery, “remove skull base bone to approach the base itself and the adjacent sites of the endo-esocranium”, was then combined with function preservation and with tailoring surgery to the pathology. The concept that histology dictates the extent of resection, balancing the intrinsic morbidity of each approach was the object of the first section of the present report. The main surgical approaches were described in the second section and were conceived not as a step-by-step description of technique, but as the highlighthening of the surgical principles. The third section was centered on open issues related to the tumor and its treatment. The topic of vestibular schwannoma was investigated with the current debate on observation, hearing preservation surgery, hearing rehabilitation, radiotherapy and the recent efforts to detect biological markers able to predict tumor growth. Jugular foramen paragangliomas were treated in the frame of radical or partial surgery, radiotherapy, partial “tailored” surgery and observation. Surgery on meningioma was debated from the point of view of the neurosurgeon and of the otologist. Endolymphatic sac tumors and malignant tumors of the external auditory canal were also treated, as well as chordomas, chondrosarcomas and petrous bone cholesteatomas. Finally, the fourth section focused on free-choice topics which were assigned to aknowledged experts. The aim of this work was attempting to report the state of the art of the lateral skull base surgery after 50 years of hard work and, above all, to raise questions on those issues which still need an answer, as to allow progress in knowledge through sharing of various experiences. At the end of the reading, if more doubts remain rather than certainties, the aim of this work will probably be achieved.

Dizziness is more prevalent than autophony among patients who have undergone repair of superior canal dehiscence

OBJECTIVE

Studies have reported high early success rates in rectifying dizziness and autophony after primary repair of superior canal dehiscence (SCD). We sought to identify the prevalence of dizziness and autophony at later time points in patients who had undergone SCD repair. We also assessed any problems with hearing in this population, along with prevalence of headaches and decreases in overall quality of life.

STUDY QUALITY DESIGN

Identification of patients via retrospective chart review, followed by administration of multiple validated surveys.

SETTING

Tertiary, hospital-based neurotology practice.

PATIENTS

All 62 patients who had undergone primary SCD repair at Massachusetts Eye and Ear Infirmary with follow-up time of at least 3 months were contacted, with 38 responses from 22 women and 16 men. The average follow-up was 34 months (range, 3-155 mo).

INTERVENTIONS

Patient surveys.

MAIN OUTCOME MEASURES

Dizziness Handicap Inventory and Autophony Index.

SECONDARY OUTCOME MEASURES

Hearing Handicap Survey, MIDAS headache survey, and Short Form-36 Quality of Life Survey.

RESULTS

Twenty patients reported low DHI scores, whereas 18 patients reported elevated DHI scores corresponding to moderate-to-severe dizziness. Autophony was less prevalent, as 3 patients experienced autophony in the operated ear, whereas 3 patients experienced "unmasking" of autophony in the contralateral ear. HHI scores were not significantly different between the low DHI and high DHI group. There were significantly more female subjects in the high DHI group, which was also characterized by significantly more severe MIDAS grades and significantly worse SF-36 scores.

CONCLUSION

Dizziness is more prevalent than autophony among patients who have undergone SCD repair, although the majority of these patients are satisfied with their decision to undergo surgery. Female sex and migraine headaches are associated with dizziness in this patient population. Further work is necessary to determine causal relationships among these associations.

Preoperative audiovestibular handicap in patients with vestibular schwannoma

OBJECTIVES

To evaluate preoperative hearing, dizziness, and tinnitus handicap in patients with unilateral vestibular schwannoma (VS).

DESIGN

Prospective administration of the Hearing Handicap Inventory (HHI), Dizziness Handicap Inventory (DHI), and Tinnitus Handicap Inventory (THI), prior to surgical intervention.

SETTING

A tertiary referral neuro-otology clinic.

PARTICIPANTS

A total of 145 consecutive patients who were admitted for excision of their vestibular schwannomas between May 1998 and July 2002.

MAIN OUTCOME MEASURES

HHI, THI, and DHI scores.

RESULTS

HHI, THI, and DHI scores were all found to be significantly correlated. There was no significant association between tumor size and any of the questionnaire scores. When data were categorized to give a measure of handicap severity, 68% had mild to significant hearing handicap, 30% had mild to severe tinnitus handicap, and 75% had mild to severe dizziness handicap. Eighty-eight percent of patients had some handicap in at least one domain, and 23% had some handicap in all three domains. Seven percent of patients had severe or significant handicap in all three domains.

CONCLUSIONS

A considerable proportion of patients with unilateral VS have hearing, tinnitus, and dizziness handicap. These patients should optimally be offered appropriate rehabilitation, something that is especially important as conservative management by "watch, wait, and rescan" becomes more common.

Audiovestibular factors influencing quality of life in patients with conservatively managed sporadic vestibular schwannoma

OBJECTIVES

To measure the health-related quality of life (QoL) of patients undergoing conservative management of a vestibular schwannoma and to identify audiovestibular factors that influence health-related QoL.

STUDY DESIGN

Cross-sectional case-control study.

INTERVENTION

Adult patients undergoing conservative management of a sporadic vestibular schwannoma were identified from a prospectively updated database. Each patient was asked to complete a series of questionnaires, including the Short Form 36 health-related QoL instrument, the Hearing Handicap Inventory, the Tinnitus Handicap Inventory, and the Dizziness Handicap Inventory. The QoL data obtained were compared with UK normal data. Multiple linear regression was performed to identify audiovestibular factors influencing QoL.

PATIENTS

Of 241 patients still undergoing conservative management, 165 completed the questionnaires. The mean age was 66.6 years. Mean duration of follow-up was 5.7 years.

RESULTS

Physical component summary scores were significantly lower than those of the normal population. Mental component summary scores were significantly above the normal population. Regression analysis showed that dizziness handicap score and age were strong predictors of physical component summary (both p < 0.0001). Dizziness handicap score and tinnitus handicap score were significant predictors of mental component summary (p = 0.0004 and p = 0.027 respectively). However, the model only explained a small amount of the data, suggesting that there may be other factors influencing QoL.

CONCLUSION

Dizziness is the most significant audiovestibular predictor of QoL in patients with vestibular schwannomas. Tinnitus also has an impact on mental QoL. Hearing loss does not seem to influence QoL. Other factors such as illness perception may have an important role to play in determining QoL.

Quality of Life After Acoustic Neuroma Surgery

OBJECTIVE

The aim of this study is to assess patients' quality of life after acoustic neuroma surgery, and if some patients' characteristics, parameters of tumor and surgical parameters affect patients' quality of life.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care center.

PATIENTS

A group of 386 patients who underwent acoustic neuroma surgery.

INTERVENTION

Patients included were derived from a population of 459 subjects operated for acoustic neuroma by the Otologic Group of Piacenza.

MEAN OUTCOME MEASURE

The outcome of the questionnaires on quality of life (SF 36), the Dizziness Handicap Inventory (DHI) and a questionnaire of patients' histories were analyzed.

RESULTS

In our sample a group of 231 patients were asymptomatic after surgery, while 155 patients reported very really disabling symptoms. Hearing loss was perceived as the most disabling symptom. The scores of questionnaire on quality of life were lower than scores for the normal population. The indices of disablement influenced the perception of quality of life.

CONCLUSION

Our study has shown that patients perceived a worsening of their quality of life, in particular women and patients over 45. Surgery caused a higher percentage of disability. Patients' quality of life can be used as a parameter for the timing of surgery. Our data indicate that an early surgical approach for intrameatal tumor is better than waiting for an increase in the tumor size. A "wait-and-scan" strategy for extrameatal neuromas which do not affect the brainstem is preferable, since these patients have a worsening of their quality of life after surgery independently of the tumor size.

The evidence base for the application of contralateral bone anchored hearing aids in acquired unilateral sensorineural hearing loss in adults

. Acquired unilateral sensorineural hearing loss reduces the ability to localize sounds and to discriminate in background noise. . Four controlled trials attempt to determine the benefit of contralateral bone anchored hearing aids over contralateral routing of signal (CROS) hearing aids and over the unaided condition. All found no significant improvement in auditory localization with either aid. Speech discrimination in noise and subjective questionnaire measures of auditory abilities showed an advantage for bone anchored hearing aid (BAHA) > CROS > unaided conditions. . All four studies have material shortfalls: (i) the BAHA was always trialled after the CROS aid; (ii) CROS aids were only trialled for 4 weeks; (iii) none used any measure of hearing handicap when selecting subjects; (iv) two studies have a bias in terms of patient selection; (v) all studies were underpowered (vi) double reporting of patients occurred. . There is a paucity of evidence to support the efficacy of BAHA in the treatment of acquired unilateral sensorineural hearing loss. Clinicians should proceed with caution and perhaps await a larger randomized trial. . It is perhaps only appropriate to insert a BAHA peg at the time of vestibular schwanoma tumour excision in patients with good preoperative hearing, as their hearing handicap increases most.