Quality of Life After Acoustic Neuroma Surgery

Customized Vestibular Rehabilitation for Vestibular Schwannoma Excision via Translabyrinthine Approach: A Single-Center Experience

Objectives: To evaluate the effectiveness of intensive customized vestibular rehabilitation after vestibular schwannoma (VS) excision. Methods: 52 patients who underwent VS removal via a translabyrinthine approach from 2020 to 2022 were involved in this study. Bedside examination, video head impulse test (vHIT), functional head impulse test (fHIT), and the dizziness handicap inventory (DHI) were performed before and after the rehabilitation, which consisted of 10 sessions of specifically designed vestibular, visual, and physical integrated training. Results: After rehabilitation, the vHIT showed overall unchanged values on the affected and healthy side. In contrast, the scores of fHIT, which explores the higher connection of the vestibular system with visual and cerebellar pathways, improved on both the pathological and healthy sides after training (p-value 0.004 and 0.000, respectively). The effectiveness of the rehabilitation was reinforced by the DHI scores, which were considerably lower after training. Conclusions: To our knowledge, this is the first study to explore fHIT outcomes after removal of VS, estimating the impact of rehabilitation on the overall compensation process. The outcomes support the role of extensive postsurgical rehabilitation in the compensatory process, even just a few days after surgery.

Emotional Lability as a Symptom of Extra-axial Posterior Fossa Tumors: a Case-Control Review of Neuroanatomy and Patient-Reported Quality of Life

Introduction  Emotional lability (EL), the uncontrollable and unmotivated expression of emotion, is a rare and distressing symptom of brainstem compression. In published case reports, EL from an extra-axial posterior fossa tumor was alleviated by tumor resection. The primary aim herein was to radiographically establish the degree of compression from mass lesions onto brainstem structures. Secondarily, we compared changes in patient-reported quality of life (QOL) pre- and postoperatively. Methods  A retrospective review of posterior fossa tumors treated between 2002 and 2018 at Vancouver General Hospital revealed 11 patients with confirmed EL. Each case was matched to three controls. A lateral brainstem compression scale characterized mass effect at the level of the medulla, pons, and midbrain in preoperative axial T2-weighted fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR MRI) scans. Compression and clinical variables were compared between patient groups. Short Form-36 version 1 health surveys were retrospectively obtained from patient charts to compare pre- versus postoperative changes in survey scores between EL and control patients. Results  EL symptoms ceased postoperatively for all EL patients. EL tumors exert greater compression onto the pons ( p  = 0.03) and EL patients more commonly have cerebellar findings preoperatively ( p  = 0.003). Patients with EL-causing tumors experienced greater improvement postoperatively in "Health Change" ( p  = 0.05), which was maintained over time. Conclusion  Findings suggest that compression onto the pons inhibits control over involuntary, stereotyped expression of emotion. This adds to evidence that EL may be attributed to cerebellum deafferentation from cortical and limbic structures through the basis pontis, leading to impaired modulation of emotional response. QOL results augment benefits of offering patients EL-alleviating tumor resection surgery.

A first exploration of the economic consequences of an autonomous surgical robot for lateral skull base surgery: an early health technology assessment

OBJECTIVES

Lateral skull base procedures, such as translabyrinthine approach (TLA), are challenging. An autonomous surgical robot might be a solution to these challenges. Our aim is to explore in an early phase the economic consequences of an autonomous surgical robot compared with conventional TLA.

METHODS

An early decision analytic model was constructed in order to perform a step-wise threshold analyses and a sensitivity analysis to analyze the impact of the several factors on the incremental costs.

RESULTS

Using surgical robot results in incremental costs - EUR 5,562 per procedure - compared to conventional TLA. These costs are most reduced by higher number of procedures, followed by lower price of the robot, saved operation time, and reduced risk of complication, respectively.

CONCLUSIONS

The incremental costs of using an autonomous surgical robot can be decreased by choosing applications with a high turnover rate, a long operation time, and a high complication rate.

Quality of life reporting in the management of posterior fossa tumours: A systematic review

Introduction

Survival amongst posterior fossa tumour (PFT) patients is improving. Clinical endpoints such as overall survival fail to depict QoL. There is yet to be a review of current QoL instruments used for adult PFTs. Aim of this review is to outline the QoL reporting in the management of PFTs and measure participation level.

Methods

This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis. A search strategy to identify adult patients with PFTs who took part in QoL metrics was conducted. Observational and experimental studies published from 1990 to date were included. Studies with a sample size less than 10 and performance measures such as Karnofsky Performance Status were not considered.

Results

A total of 116 studies were included in the final analysis. Vestibular schwannomas were the most common tumour pathology (n = 23,886, 92.6%) followed by pilocytic astrocytomas (n = 657, 2.5%) and meningiomas (n = 437, 1.7%) Twenty-five different QoL measures were used in the study pool. SF-36 was the most common (n = 55, 17 47.4%) QoL metric in the whole study pool, followed by the Penn Acoustic Neuroma QoL scale (n = 24, 20.7%) and Dizziness Handicap Inventory (n = 16, 13.8%). Seventy-two studies reported less-than 100% participation in QoL evaluation. The commonest reason for non-participation was a lack of response (n = 1,718, 60.8%), incomplete questionnaires (n = 268, 9.4%) and cognitive dysfunction (n = 258, 9.1%).

Conclusion

Informed clinical decision-making in PFT patients requires the development of specific QoL outcomes. Core outcome sets, and minimal clinically important differences (MCID) are essential for these metrics to show clinically significant improvements in patient QoL.

Vestibular Schwannoma Cerebellopontine Angle Position Impacts Facial Outcome

OBJECTIVES/HYPOTHESIS

To determine the impact of vestibular schwannoma (VS) position relative to the internal auditory canal (IAC) on postoperative facial nerve function and extent of surgical resection.

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective review of patients undergoing resection of large (≥25 mm) VSs. Outcome measures included early (≤1 month) facial function, long-term (≥1 year) facial function and extent of resection. Tumor measurements included the greatest dimension, dimension anterior to the IAC axis, dimension posterior to the IAC axis, and a ratio of posterior-to-anterior dimension (PA ratio).

RESULTS

A total of 127 patients met inclusion criteria. In early follow-up, 60% patients had good (House-Brackmann I-II), and 40% patients had poor (House-Brackmann III-VI) facial function. In long-term follow-up, 71% patients had good, and 29% patients had poor facial function. A total of 72% of patients underwent gross total resection (GTR) of their tumors. Patients with good facial function had significantly larger PA ratios than patients with poor function both early and long term; however, greatest dimension was the more clearly significant independent predictor of facial outcomes. A larger PA ratio was observed in patients in whom GTR was achieved, but this association was potentially confounded by surgeon preferences and was not statistically significant after controlling for surgical site.

CONCLUSIONS

This study demonstrates that VS position relative to the IAC axis can be used along with tumor size to predict postoperative facial outcomes. A greater proportion of tumor posterior to the IAC axis was associated with significantly better facial outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Quality of life in patients of unilateral vestibular schwannoma treated with microsurgery: A South-Asian tertiary care Hospital experience

Majority of the published literature on the impact of microsurgery over quality-of-life (QOL) in vestibular schwannoma (VS) patients is retrospective in nature, with variable results, and there has been very little contribution from South-Asia. The authors designed this study to investigate the role of microsurgery in QOL alterations in VS patients, and to compare obtained QOL scores with that of control population. Between February 2017 and March 2018, a prospective/retrospective study was done at our institute. Prospective and retrospective cohorts included, 30 and 34 consecutive patients, respectively, of unilateral VS undergoing microsurgery. QOL assessment was done using Short Form-36 (SF-36), and the Penn Acoustic Neuroma Quality-Of-Life (PANQOL) questionnaires. Prospective cohort underwent QOL assessment at 3 junctures - pre-surgery, 3-months & 1-year post-surgery; while retrospective cohort was assessed only once, at 1-year post-surgery. Age- & sex- matched normal population and diabetic patients were used as controls. In the prospective cohort, patients showed drop in all PANQOL domain/ SF-36 dimension scores at 3-month post-surgery, exception being vitality and general health in SF-36; showed improvement at 1-year follow-up, with majority either levelling or improving their respective pre-surgery scores. Gross total resection, tumors ≤ 3 cm, and age ≤ 45 years had better PANQOL scores at 1-year post-surgery across all the domains. Patients in both the cohorts showed worse QOL compared to normal population, but the gap got narrower at 1-year post-surgery. Our study adds a South-Asian perspective to the pool of prospective knowledge available on QOL following microsurgery in VS patients.

Quality of life in vestibular schwannoma: a comparison of three surgical techniques

OBJECTIVE

Through years, interest in quality of life (QoL) among patients affected by vestibular schwannoma (VS) has increased. The expansion of the indications for endoscopic ear surgery allowed the development of the transcanal transpromontorial surgery (TTS) for VS removal. The objective of the present study was to assess QoL in a cohort of VS patients operated on by translabyrinthine (TL), retrosigmoid (RS) and TTS approach.

METHODS

The study was conducted on 111 patients who underwent surgery for VS between January 2017 and January 2020 at two different institutions. Patients fulfilled three questionnaires during follow-up: Glasgow Benefit Inventory, Depression Anxiety Stress Scales-21 and Penn Acoustic Neuroma Quality-Of-Life. The association between sex, age, date of surgery, tumor size, post-operative facial nerve (FN) function and QoL outcomes was assessed.

RESULTS

An overall subjective impairment was demonstrated in all groups. Age, Koos staging and FN functions were associated to distinct QoL outcomes.

CONCLUSIONS

QoL decreases in patients surgically treated for VS. The TTS may allow improved scores in many domains, confirming to be a subjectively well-tolerated technique.

Role of the neurotologist in posterior fossa meningioma surgery

Posterior fossa meningiomas that impinge on structures of the temporal bone or clivus may be difficult to access for optimal resection that maximizes tumor control and minimizes short- and long-term morbidities. To address this challenge, the contemporary neurosurgery-neurotology team works collaboratively by managing patients jointly at every stage of care: preoperative evaluation, intraoperative intervention, and postoperative treatment. The neurotologist is important at all stages of posterior fossa meningioma surgery. First, detailed preoperative evaluation of auditory, facial, vestibular, and lower cranial nerve integrity enables assessment of new neurologic deficit risk, prognosis of functional recovery, and pros and cons of candidate surgical approaches. Second, intraoperative partitioning of surgical steps by provider and adopting an overlapping tumor resection philosophy creates an efficient and confident surgical team built on trust. Third, postoperative closure of cerebrospinal fluid leak and treatment of facial weakness, audiovestibular dysfunction, and voicing and swallowing impairments organized by the neurotologist reduces the impact of negative outcomes. The role of the neurotologist in posterior fossa meningioma surgery is to deliver nuanced evaluative metrics, facilitate shared decision making, perform precise bone and soft tissue microsurgery, and mitigate perioperative morbidities.

Intracanalicular Vestibular Schwannoma: A Systematic Review and Meta-analysis of Therapeutics Outcomes

OBJECTIVE

To perform a systematic review and meta-analysis summarizing the current evidence on the management of intracanalicular vestibular schwannoma.

DATA SOURCES

Embase (1947-), Medline (1946-), Cochrane library (1947-), Scopus (2010-), and CINAHL (1961-) were searched from 1969 to October 5, 2019 (50 years).

STUDY SELECTION

A search strategy was performed to identify patients with vestibular schwannoma confined to the internal auditory canal without extension to the cerebellopontine angle. Studies with patients aged less than 18, Neurofibromatosis type 2, revision cases, and non-English language were excluded.

DATA EXTRACTION

A standardized collection sheet was used for the extracted data and a quality assessment was performed using the Newcastle-Ottawa Scale with the comparability criterion omitted.

DATA SYNTHESIS

Seventy-one studies were included with 24 on observation, 14 on radiotherapy, and 34 on surgery. The primary outcome was serviceable hearing preservation. Secondary outcomes were preservation of facial nerve function, growth, involution, and dizziness. Sub-analysis on the type of surgery and type of radiotherapy were performed. Excel 2016 with MIX 2.0 Pro add-on package was used to analyze the data and create forest plots. Data were presented in proportion with a 95% confidence interval.

CONCLUSIONS

Serviceable hearing was observed in 31% of patients after observation, 56% after radiotherapy, and 51% after surgical treatment with mean follow-up time of 4.04 years, 4.92 years, and 2.23 years, respectively. Facial nerve function was found to be best preserved in both observation and radiotherapy groups. Vestibular schwannoma growth occurred in 33% of patients under observation. Involution occurred in 2% of patients under observation and in 38% after radiotherapy.

Quality of life, social function, emotion, and facial paresis in Dutch vestibular schwannoma patients

OBJECTIVES

The present study aimed to replicate the finding that vestibular schwannoma (VS) patients with facial paresis experience lower health related quality of life (QoL) than those without facial paresis in a Dutch sample, and to extend these findings by measuring VS patients' overall satisfaction with life, social function, and emotion.

METHODS

Forty-seven VS patients, differing in degree of facial functioning, half of them with and half of them without a facial paresis, answered questionnaires about health related QoL (SF-36 and PANQOL), overall satisfaction with life, fear of being evaluated negatively by others, social avoidance and distress, and characteristics and symptoms of depression.

RESULTS

We observed that VS patients with facial paresis experience lower health-related QoL as well negatively impacted social function and emotion compared to VS patients without facial paresis. VS patients with facial paresis experienced lower overall satisfaction with life, more characteristic symptoms of depression, and more fear of being evaluated negatively by others than VS patients without facial paresis.

CONCLUSION

These findings corroborate previous research showing an association between impaired facial functioning and lower QoL, but also extend them by showing differences on the quality of social function and emotion. Being aware of this difference between VS patients with and without facial paresis informs health practitioners regarding the specific support these patients might need. Moreover, it is also relevant to consider the influence of a facial paresis on patients' life when deciding between treatment options and in case of surgery the type of resection.

LEVEL OF EVIDENCE

3.

Cross-modal plasticity in adult single-sided deafness revealed by alpha band resting-state functional connectivity

Single-sided deafness (SSD) or profound unilateral hearing loss is the condition where the transfer of acoustic information to the brain is restricted to one ear. SSD impairment is most evident under adverse acoustic environments with overlapping interference, which burdens cognitive resources. It is known that bilateral deafness induces cross-modal brain plasticity within visual cortical areas. Here we investigate whether similar cross-modal plasticity is observed in adult-onset SSD. In SSD patients (n ​= ​29) and matched controls (n ​= ​29) we estimated voxel level resting-state power and functional connectivity in the alpha band (8-12 ​Hz) from magnetoencephalography (MEG) data. We examined both global functional connectivity (mean functional connectivity of each voxel with the rest of the brain), and seeded functional connectivity of primary auditory cortices (A1), primary visual cortices (V1) and posterior cingulate cortex (PCC) of the default mode network (DMN). Power reduction was observed in left auditory cortex. Global functional connectivity showed reduction in frontal cortices and enhancement in visual cortex. Seeded functional connectivity of auditory cortices showed reduction in temporal, frontal and occipital regions, and enhancement in parietal cortex. Interestingly, seeded functional connectivity of visual cortices showed enhancement in visual cortices, inferior parietal lobe, post-central gyrus, and the precuneus, and reduction in auditory cortex. Seeded functional connectivity of PCC showed reduction in frontal cortical regions that are part of the DMN, attention, and working memory networks. Adult-onset SSD exhibited widespread cross-modal brain plasticity involving alterations in auditory, visual, attention, working memory and default mode networks.

Long-term quality of life in patients with vestibular schwannoma managed with microsurgery

OBJECTIVE

Little is known about the long term (greater than 10 years) quality of life in patients with vestibular schwannoma. This study aimed to evaluate long-term outcomes in patients with vestibular schwannoma.

METHOD

A retrospective cohort study was performed across 2 academic institutions, with patients followed at least 10 years after vestibular schwannoma surgery (2000 to 2007). Telephone interviews were used to assess quality of life using the Glasgow Benefit Inventory and short form 12 item (version 2) health survey.

RESULTS

A total of 99 out of 110 patients were included. Increasing age and symptom burden were associated with poorer quality of life (p = 0.01 and 0.02, respectively). The presence of imbalance, headache and facial nerve dysfunction were all associated with poorer quality of life scores (p = 0.01, 0.04 and 0.02, respectively).

CONCLUSION

Identifying and managing post-operative symptoms may improve quality of life in vestibular schwannoma patients and can guide clinical decision making.

Self-Evaluated Quality of Life and Functional Outcomes After Microsurgery, Stereotactic Radiation or Observation-Only for Vestibular Schwannoma of the Adult Patient: A Systematic Review

OBJECTIVE

To evaluate the impact of different management options on health-related quality of life (HRQoL) in vestibular schwannoma patients.

DATA SOURCES

A systematic search of the Cochrane Database, Database of Abstracts of Reviews of Effectiveness, and the Ovid Medline & EMBASE was performed. English and German language studies published between 1980 and 2015 were considered.

STUDY SELECTION

This is a systematic review of HRQoL of patients managed for vestibular schwannoma. Studies in which HRQoL after one management option were evaluated or compared with other managements or with control populations using validated or reliable questionnaires, were included.

DATA EXTRACTION

The included studies were independently evaluated by two reviewers. The quality of studies was assessed and graded as per Oxford Centre of Evidence Based Medicine System.

RESULTS

Ten prospective and 29 retrospective studies were identified: microsurgery initially exerted a negative effect on HRQoL but this tended to improve with follow up. Radiotherapy had a less negative effect but with minimal change over follow up. A significant limitation was that studies did not present results stratified by tumor size. Many patients will need active treatment despite the potential for negative effects on their QoL. The concept of a minimal clinically important difference has been introduced into this field and was compared with five studies.

CONCLUSION

A number of prospective studies are available but none yet with a disease-specific questionnaire. Heterogeneity and the methodological weaknesses of the included studies constitute the principle limitation of this review. The introduction of the minimal clinically important difference should improve the relevance of studies and allow a sensitive comparison of treatments.

The changing landscape of vestibular schwannoma diagnosis and management: A cross-sectional study

OBJECTIVES

To assess the current state of the diagnosis and management of vestibular schwannoma (VS) as well as treatment trends, and to evaluate the role of treatment setting and various specialists in treatment plan.

METHODS

Patients diagnosed with VS completed a voluntary and anonymous survey. The questionnaires were distributed through Acoustic Neuroma Association website, Facebook page, and e-mail newsletters from January to March 2017.

RESULTS

In total, 789 VS patients completed the survey. Of those, 414 (52%) underwent surgery; 224 (28%) underwent radiotherapy; and 121 (15%) were observed. General otolaryngologists diagnosed 62% of responders, followed by primary care (11%) and neurotologists (10%). Patients who underwent surgery were significantly younger and had larger tumors compared to those treated with radiation or observation. The ratio of patients having nonsurgical versus surgical resection changed from 1:2 to 1:1 for the periods of 1979 through 2006 versus 2007 through 2017, respectively. Neurosurgeons (40%) and neurotologists (38%) were the most influential in treatment discussion. Neurotologists (P < 0.001) and general otolaryngologists (P = 0.04) were more influential than neurosurgeons for the decision process in patients with smaller tumors. Patients treated at academic versus nonacademic private institutions reported similar tumor sizes (P = 0.27), treatment decisions (P = 0.09), and decision satisfaction (P = 0.78).

CONCLUSION

There is a continuing trend toward nonsurgical management, with approximately half of the patients opting for nonsurgical management. In this cohort, the patients commonly presented with otologic symptoms and otolaryngologists made the most diagnoses. Neurotologists and neurosurgeons were the most influential in treatment discussion.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:482-486, 2020.

Temporal Bone Paraganglioma: Hearing Outcomes and Rehabilitation

Despite numerous advancements in the treatment of skull base tumors, the management of jugular paragangliomas remains controversial and nuanced. Contemporary treatment objectives focus not only on achieving durable tumor control but also on maximizing post-treatment quality of life. While this philosophy places appropriate attention on limiting cranial neuropathies, less discussed morbidities such as hearing loss can have a profound impact on quality of life outcomes. The objective of this retrospective review is to provide a comprehensive review of hearing outcomes following the treatment of tympanojugular paragangliomas. A particular focus is placed on the variable audiologic outcomes as it relates to disease pathology, extent of disease, as well as chosen treatment modality. This review underscores the importance of considering treatment-related effects on hearing.

Comparison of balance outcomes according to treatment modality of vestibular schwannoma

OBJECTIVES

We sought to compare balance outcomes according to treatment modality of vestibular schwannoma (VS) via a meta-analysis that divided measuring tools of balance outcomes into three categories based on type.

METHODS

A comprehensive review of the literature from January 1966 to September 2017 was performed, looking for studies about long-term balance outcomes after microsurgery (MS), radiotherapy (RT), or observation for VS. A comprehensive meta-analysis was used to analyze effect sizes, explore possible causes of heterogeneity, and check publication bias with a funnel plot and Egger's regression.

RESULTS

Among 633 references, 34 were included in the meta-analysis. Perceived dizziness improvement rate was significantly higher in the MS group than in the RT group (odds ratio [OR]: 1.61; 95% confidence interval [CI]: 1.08 to 2.40; P < .05, I² = 4.18], but no significant difference was observed between the two groups with regard to validated dizziness questionnaire score (standardized mean difference: 0.04; 95% CI: -0.36 to 0.44; P = .84, I² = 69.61) or dizziness or disequilibrium-related symptom incidence rate (OR: 0.91; 95% CI: 0.50 to 1.68; P = .77, I² = 0). In a subanalysis conducted within the groups after intervention, the MS group demonstrated a lower vertigo incidence rate (P < .001), and the RT group experienced a significant reduction in validated dizziness questionnaire score (P < .05).

CONCLUSIONS

Our results indicate that MS should be considered at least equal to RT in regard to resolving long-term dizziness and improving balance outcomes. Furthermore, well-designed studies are necessary to predict balance outcomes after VS treatment and to choose from among possible treatment options.

LEVEL OF EVIDENCE

2a Laryngoscope, 130:178-189, 2020.

Functional and Structural Brain Plasticity in Adult Onset Single-Sided Deafness

Single-sided deafness (SSD) or profound unilateral hearing loss obligates the only serviceable ear to capture all acoustic information. This loss of binaural function taxes cognitive resources for accurate listening performance, especially under adverse environments or challenging tasks. We hypothesized that adults with SSD would manifest both functional and structural brain plasticity compared to controls with normal binaural hearing. We evaluated functional alterations using magnetoencephalographic imaging (MEGI) of brain activation during performance of a moderately difficult auditory syllable sequence reproduction task and assessed structural integrity using diffusion tensor imaging (DTI). MEGI showed the SSD cohort to have increased induced oscillations in the theta band over the left superior temporal cortex and decreased induced gamma band oscillations over the frontal and parietal cortices between 175 and 475 ms following stimulus onset. DTI showed the SSD cohort to have extensive fractional anisotropy (FA) reduction in both auditory and non-auditory tracts and regions. Overlaying functional and structural changes revealed by the two imaging techniques demonstrated close registration of cortical areas and white matter tracts that expressed brain plasticity. Hence, complete loss of input from one ear in adulthood triggers both functional and structural alterations to dorsal temporal and frontal-parietal areas.

Long-term Quality of Life Following Vestibular Schwannoma Excision Via the Translabyrinthine Approach

OBJECTIVE

To assess postoperative quality of life (QOL) and other patient-reported outcomes following surgery for vestibular schwannoma.

STUDY DESIGN

Cross-sectional retrospective case review using postal questionnaires.

SETTING

Tertiary referral center.

PATIENTS

Five hundred consecutive patients undergoing surgery for vestibular schwannoma.

INTERVENTION(S)

Patients undergoing surgery via the translabyrinthine approach (excluding neurofibromatosis type 2) under the senior author, with a minimum of 5 years follow-up, were included.

MAIN OUTCOME MEASURE(S)

QOL was assessed using the Short Form 36 (SF-36) questionnaire and a disease-specific survey to assess patients' subjective outcomes.

RESULTS

The SF-36 scores in this group were significantly lower than the general UK population, though 24% of respondents reported a subjective improvement in overall QOL. Tumors larger than 4 cm were related to a reduced SF-36 total mental component score (p = 0.037). Increased age at time of surgery correlated with a reduced physical component of QOL (correlation coefficient = -0.26) and an improved mental component (correlation coefficient = 0.26). Subjective reports of postoperative symptoms and return to work, driving and social activities were similar to other published studies. 35% of patients reported vivid dreams or nightmares following surgery; the first reported incidence of this phenomenon in a large group of vestibular schwannoma patients.

CONCLUSIONS

Generic measures of QOL in patients following translabyrinthine surgery for vestibular schwannoma do not always match subjective reports, reflecting the complexity of QOL assessment and the range of outcomes in this group. Increased time since surgery appears to be associated with an improvement in mental health.

Quality of life in patients with unilateral vestibular schwannoma on wait and see - strategy

OBJECTIVE

A 'wait and see' strategy is an option when managing patients with small vestibular schwannomas (VS). A risk of growth and worsening of hearing may influence a patient's daily quality of life (QOL). Therefore, the present study focused on QOL parameters in patients who are on a 'wait and see' strategy following magnetic resonance imaging (MRI)-based diagnosis of small unilateral VS.

PATIENTS AND METHODS

Sixty-five patients (mean age 64.4 years; male:female, 32:33) who suffered from a small unilateral VS (9.34 mm, range 1.5-23 mm) between 2013 and 2016 were included in a prospective single center study. During follow-up, in addition to clinical and neurological examinations and MRI imaging, all patients answered the Short Form 36 questionnaire once to characterize QOL. Additionally, the severity of tinnitus was determined by the Mini-TQ-12 from Hiller and Goebel.

RESULTS

It was found during follow-up that there was no lowering of QOL in patients with small VS who were on 'wait and see' strategy compared with Germany's general population and no tumor growth was detected in 53 patients (81.5%). Patients with a tumor diameter larger than 10 mm did not suffer from stronger tinnitus, vertigo or unsteadiness than the group with an average tumor size, which is smaller than 10 mm. Sixty-two patients (95.4%) showed ipsilateral hearing loss and three of these reported deafness (4.6%). Severe vertigo or tinnitus is connected with lower levels of mental component scale and physical component scale. These findings reduced the QOL (p = 0.05).

CONCLUSION

In our series, QOL is not influenced in patients with unilateral untreated small VS in comparison to Germany's general population. This is helpful information when advising patients during follow-up and finding out the optimal timing of individual treatment.

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

Purpose

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

Study Design

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

Results

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

Conclusions

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

Psychological status and quality of life in acoustic neuroma patients with facial palsy after microsurgery: a 1-year postoperative follow-up study

Psychological status and quality of life in postoperative acoustic neuroma patients were well documented. However, few studies have been proceed in China and investigated in a relative homogenous group. To assess the psychological status and quality of life in patients with facial palsy operated by an identical surgeon in Shanghai, China. We retrospectively reviewed 24 patients who had undergone microsurgery via a retrosigmoid approach in 2009-2010. Each patient was followed up with MRI/CT image and facial palsy evaluation. A mailed comprehensive questionnaire was used to assess the psychological status and quality of life for these patients. Meanwhile, a telephone interview was previously carried out for the consents. Statistical analysis was performed using Stata software. We found that a proportion of anxiety and depression existed among the postoperative acoustic neuroma patients, although a relative physical health was reserved. Facial palsy caused by microsurgery treatment may be a key factor triggered and involved in the psychiatric symptoms and clinicians must be aware that early involvement of a clinical psychologist may be very helpful.

Management of vestibular schwannoma: focus on vertigo

This article reviews published literature on vertigo and a 'sense of imbalance' affecting patients who are treated with radiosurgery (RS) for vestibular schwannoma. This is a relatively understudied complaint, along with tinnitus, in this patient population, despite its significant impact on quality of life. It is also a symptom that is most inconsistently impacted by either RS or surgery. This article aims to highlight the importance of this symptom in patients managed for vestibular schwannoma primarily with RS to encourage a more systematic study of vertigo as an outcome measure and to help elucidate its potential etiology.

Quality of life following surgery for large and giant vestibular schwannomas: a prospective study

OBJECT

Prospective studies of quality of life (QOL) are infrequently performed in patients undergoing surgery for vestibular schwannoma (VS). The authors designed this to study to investigate health-related QOL (HR-QOL) in patients with large and giant VSs before and after surgery.

METHODS

Between January 2009 and December 2012, HR-QOL was measured prospectively before and after surgery, using the 36-Item Short Form Health Survey (SF-36), in 100 patients who underwent surgery for unilateral large or giant VS (tumor size≥3 cm). The Glasgow Benefit Inventory (GBI) was also used to evaluate the effect of surgery.

RESULTS

A total of 100 patients were included in the study (65 men and 35 women). Their mean age (±SD) was 44.2±11.5 years. The preoperative QOL was decreased in all SF-36 domains. A 1-year follow-up evaluation was conducted for all patients (mean 13.5±5.3 months after surgery). The results showed an improvement in HR-QOL compared with preoperative status in all cases, with 63%-85% of patients showing a minimum clinically important difference (MCID) in various domains. A second follow-up evaluation was performed in 51 cases (mean time after surgery, 29.0±8.3 months) and showed sustained improvement in SF-36 scores. In some domains there was further improvement beyond the first follow-up. On the GBI, 87% of patients reported improvement, 1% felt no change, and 12% of patients reported deterioration.

CONCLUSIONS

Patients harboring large or giant VSs score lower on all the QOL domains compared with the normative population. More than 60% showed a clinically significant improvement in HR-QOL 1 year after surgery, a result that was sustained at subsequent follow-up.

Age, gender and tumour size predict work capacity after surgical treatment of vestibular schwannomas

AIMS

The aim of the present study was to identify predictive factors for outcome after surgery of vestibular schwannomas.

DESIGN

This is a retrospective study with partially collected prospective data of patients who were surgically treated for vestibular schwannomas at a single institution from 1979 to 2000. Patients with recurrent tumours, NF2 and those incapable of answering questionnaires were excluded from the study. The short form 36 (SF36) questionnaire and a specific questionnaire regarding neurological status, work status and independent life (IL) status were sent to all eligible patients.

PATIENTS AND METHODS

The questionnaires were sent to 430 eligible patients (out of 537) and 395 (93%) responded. Scores for work capacity (WC) and IL were compared with SF36 scores as outcome estimates. Patients were divided into two groups (<64, ≥64-years-old) in order to assess them for either WC or IL. Putative preoperative and postoperative predictive factors were tested in univariate and multivariable regression analysis for the outcome scores of WC, IL and SF36.

RESULTS

In the group <64 years, age, gender and tumour diameter were independent predictive factors for postoperative WC in multivariate analysis. A high-risk group was identified in women with age >50 years and tumour diameter >25 mm. In patients ≥64, gender and tumour diameter were significant predictive factors for IL in univariate analysis. Perioperative and postoperative objective factors as length of surgery, blood loss and complications did not predict outcome in the multivariable analysis for any age group. Patients' assessment of change in balance function was the only neurological factor that showed significance both in univariate and multivariable analysis in both age cohorts. While SF36 scores were lower in surgically treated patients in relation to normograms for the general population, they did not correlate significantly to WC and IL.

CONCLUSIONS

The SF36 questionnaire did not correlate to outcome measures as WC and IL in patients undergoing surgery for vestibular schwannomas. Women and patients above 50 years with larger tumours have a high risk for reduced WC after surgical treatment. These results question the validity of quality of life scores in assessment of outcome after surgery of benign skullbase lesions.

Factors associated with symptom-specific psychological and functional impact among acoustic neuroma patients

INTRODUCTION

The main purpose of this study was to investigate the psychological and functional impact attributed to acoustic neuroma symptoms.

MATERIALS AND METHODS

A sample of 207 acoustic neuroma patients completed a study-specific questionnaire about the severity, frequency, and psychological and functional impact of 9 acoustic neuroma symptoms.

RESULTS

The survey response rate was 56.4 per cent. All symptoms had some degree of psychological impact for the majority of participants; hearing loss was the symptom most often reported to have a severe psychological impact. The majority of respondents reported functional impact attributed to hearing loss, balance disturbance, dizziness, eye problems, headache and fatigue; balance disturbance was the symptom most often reported to have a severe functional impact. For most symptoms, psychological and functional impact were related to severity and frequency.

CONCLUSION

Of the acoustic neuroma symptoms investigated, hearing loss and balance disturbance were the most likely to have a severe psychological and functional impact, respectively.

Surgery of the ear and the lateral skull base: pitfalls and complications

Surgery of the ear and the lateral skull base is a fascinating, yet challenging field in otorhinolaryngology. A thorough knowledge of the associated complications and pitfalls is indispensable for the surgeon, not only to provide the best possible care to his patients, but also to further improve his surgical skills. Following a summary about general aspects in pre-, intra-and postoperative care of patients with disorders of the ear/lateral skull base, this article covers the most common pitfalls and complications in stapes surgery, cochlear implantation and surgery of vestibular schwannomas and jugulotympanal paragangliomas. Based on these exemplary procedures, basic "dos and don'ts" of skull base surgery are explained, which the reader can easily transfer to other disorders. Special emphasis is laid on functional aspects, such as hearing, balance and facial nerve function. Furthermore, the topics of infection, bleeding, skull base defects, quality of life and indication for revision surgery are discussed. An open communication about complications and pitfalls in ear/lateral skull base surgery among surgeons is a prerequisite for the further advancement of this fascinating field in ENT surgery. This article is meant to be a contribution to this process.

Tenotomy of the stapedius and tensor tympani muscles reduces subjective dizziness handicap in definite Meniere's disease

CONCLUSION

Tenotomy is a promising surgical alternative with a high reduction in dizziness handicap in the short and long term.

OBJECTIVES

To investigate the immediate and the long-term effect of tenotomy of the stapedius and tensor tympani muscles on subjective dizziness as measured by the Dizziness Handicap Inventory (DHI).

METHODS

A retrospective follow-up study of 42 patients with definite, unilateral Meniere's disease (19 males, 23 females, average age = 58.1 ± 14.1 years) had undergone tenotomy under general anesthesia through an endaural approach. Pre- and postoperative DHI values were compared for all patients, with postoperative follow-up ranging from 6 months to 9 years. Additionally, results were divided into three postoperative subgroups (A = 0-3 years, B = 3-6 years, C = 6-9 years).

RESULTS

A statistically significant reduction of 48 DHI points, from a median preoperative DHI = 52 to DHI = 4 postoperatively, was noted (p < 0. 001). In all, 40/42 patients reported a reduction of dizziness handicap, while in 33/42 the difference was > 12 points. A statistically significant reduction of DHI scores was noted (A = 60, B = 34, C = 33) in all subgroups. It was also noted that the higher the preoperative DHI score, the greater the subjective success of the surgery.

Intraoperative neuromonitoring techniques in the surgical management of acoustic neuromas

Unfavorable outcomes such as facial paralysis and deafness were once unfortunate probable complications following resection of acoustic neuromas. However, the implementation of intraoperative neuromonitoring during acoustic neuroma surgery has demonstrated placing more emphasis on quality of life and preserving neurological function. A modern review demonstrates a great degree of recent success in this regard. In facial nerve monitoring, the use of modern electromyography along with improvements in microneurosurgery has significantly improved preservation. Recent studies have evaluated the use of video monitoring as an adjunctive tool to further improve outcomes for patients undergoing surgery. Vestibulocochlear nerve monitoring has also been extensively studied, with the most popular techniques including brainstem auditory evoked potential monitoring, electrocochleography, and direct compound nerve action potential monitoring. Among them, direct recording remains the most promising and preferred monitoring method for functional acoustic preservation. However, when compared with postoperative facial nerve function, the hearing preservation is only maintained at a lower rate. Here, the authors analyze the major intraoperative neuromonitoring techniques available for acoustic neuroma resection.

Factors associated with anxiety and depression in the management of acoustic neuroma patients

The objectives of this study were to describe anxiety and depression levels among acoustic neuroma patients; examine differences in anxiety and depression across the acoustic neuroma management options of microsurgery, radiation and observation; and to investigate management, medical and demographic factors that might predict anxiety and depression in this patient group. A cross-sectional questionnaire was completed by 205 adults diagnosed with, or treated for, a unilateral acoustic neuroma within five years of questionnaire distribution. Median age of participants was 57.0 years, and 120 (58.5%) were female. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). Clinically significant anxiety was reported by 29.8% of participants and 10.2% were depressed. Mean anxiety and depression scores did not differ from general population norms. No significant differences in anxiety and depression were found across management options. Time since management, number of symptoms and comorbid medical conditions predicted anxiety, while depression was predicted by number of symptoms. This appears to be the first study among acoustic neuroma patients in which anxiety and depression were compared across management options. Treating physicians should be aware that as the number of acoustic neuroma symptoms increases, so may the likelihood of clinically significant anxiety and depression.

The Effect of Observation versus Microsurgical Excision on Quality of Life in Unilateral Vestibular Schwannoma: A Prospective Study

With the emergence of three effective management options for vestibular schwannoma and the drastic reduction in mortality rate, the last two decades have seen increasing attention being paid to health-related quality of life. The vast majority of quality of life studies have been retrospective. We prospectively assessed quality of life of vestibular schwannoma patients before and after conservative or microsurgical management. We performed a prospective observational study conducted at a tertiary referral center between October 2001 and October 2003. Patients were divided into two groups: conservative management and microsurgery. Quality of life was assessed using the Medical Outcome Study 36-Item Short Form (SF-36) and Glasgow Benefit Inventory (GBI). The questionnaires were administered at initial assessment, 1 month, 3 months, and 6 months in both groups. Thirty-three patients completed the study, 18 in the conservative group and 15 in the microsurgical group. One month after microsurgery, SF-36 scores were significantly reduced within three of eight domains; however, 3 months after microsurgery, no significant difference existed in patients' scores on any of the SF-36 domains compared with preoperatively, and at 6 months there was a significant improvement in one domain compared with preoperatively. There was no significant difference in overall quality of life alteration (GBI total score) between microsurgery and conservative management. The improved quality of life of patients 6 months after microsurgery (relative to preoperatively, and in comparison with an age- and sex- matched population) is a new finding that has not been previously documented in the literature.

Quality of life in patients with skull base tumors: current status and future challenges

In selection of the right treatment for a specific patient, the surgeon should consider not only the best approach to remove a tumor but also the impact of treatment on the quality of life (QOL) of the patient. Procedures involving extirpation of skull base tumors may be associated with high morbidity. It is therefore important to study patients with skull base neoplasms, because survival differences between various treatment modalities may be small, yet larger differences are expected regarding morbidity. The overall QOL in the majority of patients after skull base tumor resection can be classified as "good," with significant improvement taking place within 12 months following surgery. Patients with carcinomas, acoustic schwannoma, or Cushing's disease suffer from more significant deterioration in their QOL after any intervention. Data retrieved from disease-specific questionnaires revealed that the financial and emotional domains have the worse impact on patients QOL. Old age, malignancy, comorbidity, radiotherapy, and extensive surgery were found to be also negative prognostic factors for QOL. Pain control regimens, antidepressants, and other psychological modalities, including group support, can improve QOL measures in these patients. It is critical that surgeons understand that they cannot assess their patients' perspectives on QOL correctly without asking them. For adequate assessment, validated disease-specific instruments addressing multiple domains of QOL should be utilized.

Long-term outcomes of Gamma Knife radiosurgery in patients with vestibular schwannomas

Object

The authors sought to determine the long-term tumor control and side effects of Gamma Knife radiosurgery (GKRS) in patients with vestibular schwannomas (VS).

Methods

One hundred seventeen patients with VS underwent GKRS between January 1997 and February 2003. At the time of analysis, at least 5 years had passed since GKRS in all patients. The mean patient age was 60.9 years. The mean maximal tumor diameter was 1.77 ± 0.71 cm. The mean tumor volume was 1.95 ± 2.42 ml. Eighty-two percent of lesions received 1300 cGy and 14% received 1200 cGy. The median dose homogeneity ratio was 1.97 and the median dose conformality ratio was 1.78. Follow-up included MR imaging or CT scanning approximately every 6–12 months. Rates of progression to surgery were calculated using the Kaplan-Meier method.

Results

Of the 117 patients in whom data were analyzed, 103 had follow-up MR or CT images and 14 patients were lost to follow-up. Fifty-three percent of patients had stable tumors and 37.9% had a radiographically documented response. Imaging-documented tumor progression was present in 8 patients (7.8%), but in 3 of these the lesion eventually stabilized. Only 5 patients required a neurosurgical intervention. The estimated 1-, 3-, and 5-year rates of progression to surgery were 1, 4.6, and 8.9%, respectively. One patient (1%) developed trigeminal neuropathy, 4 patients (5%) developed permanent facial neuropathy, 3 patients (4%) reported vertigo, and 7 patients (18%) had new gait imbalance following GKRS.

Conclusions

Gamma Knife radiosurgery results in excellent local control rates with minimal toxicity for patients with VS. The authors recommend standardized follow-up to gain a better understanding of the long-term effects of GKRS.

Decision analysis of treatment options for vestibular schwannoma

Object

Widespread use of MR imaging has contributed to the more frequent diagnosis of vestibular schwannomas (VSs). These tumors represent 10% of primary adult intracranial neoplasms, and if they are symptomatic, they usually present with hearing loss and tinnitus. Currently, there are 3 treatment options for quality of life (QOL): wait and scan, microsurgery, and radiosurgery. In this paper, the authors' purpose is to determine which treatment modality yields the highest QOL at 5- and 10-year follow-up, considering the likelihood of recurrence and various complications.

Methods

The MEDLINE, Embase, and Cochrane online databases were searched for English-language articles published between 1990 and June 2008, containing key words relating to VS. Data were pooled to calculate the prevalence of treatment complications, tumor recurrence, and QOL with various complications. For parameters in which incidence varied with time of follow-up, the authors used meta-regression to determine the mean prevalence rates at a specified length of follow-up. A decision-analytical model was constructed to compare 5- and 10-year outcomes for a patient with a unilateral tumor and partially intact hearing. The 3 treatment options, wait and scan, microsurgery, and radiosurgery, were compared.

Results

After screening more than 2500 abstracts, the authors ultimately included 113 articles in this analysis. Recurrence, complication rates, and onset of complication varied with the treatment chosen. The relative QOL at the 5-year follow-up was 0.898 of normal for wait and scan, 0.953 for microsurgery, and 0.97 for radiosurgery. These differences are significant (p < 0.0052). Data were too scarce at the 10-year follow-up to calculate significant differences between the microsurgery and radiosurgery strategies.

Conclusions

At 5 years, patients treated with radiosurgery have an overall better QOL than those treated with either microsurgery or those investigated further with serial imaging. The authors found that the complications associated with wait-and-scan and microsurgery treatment strategies negatively impacted patient lives more than the complications from radiosurgery. One limitation of this study is that the 10-year follow-up data were too limited to analyze, and more studies are needed to determine if the authors' results are still consistent at 10 years.

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.