1
|
Jones A, Saputra L, Matthews T. Reduced Cochlear MRI Signal and Hearing Outcomes in Conservatively Managed Vestibular Schwannoma Patients. Otol Neurotol 2024:00129492-990000000-00570. [PMID: 38924020 DOI: 10.1097/mao.0000000000004239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
OBJECTIVE This study aimed to determine if hypointense cochlear magnetic resonance imaging (MRI) constructive interference in steady-state (CISS) signal correlates with hearing outcomes in conservatively managed vestibular schwannoma (VS) patients. STUDY DESIGN Retrospective review of 657 cases from 1992 to 2020. SETTING Tertiary academic referral center. PATIENTS A retrospective review was performed to identify conservatively managed VS patients with appropriate baseline MRI, audiology, and at least 12-month audiological follow-up. Patients were excluded if they progressed to surgery or radiotherapy in less than 12 months, bilateral tumors, or surgery on the contralateral ear. INTERVENTION Conservatively managed patients with CISS imaging studies and audiology testing. MAIN OUTCOME MEASURES Primary outcome measure change in pure-tone average (PTA) and word recognition score (WRS). Secondary outcome measures tumor size, presence of lateral fluid cap, or cystic changes. RESULTS A total of 92 individuals (47% male, 58 ± 11.6 yr) met the inclusion criteria, with 36 (39%) of patients demonstrating abnormal cochlear CISS signal. At baseline, abnormal cochlear CISS signal was associated with higher intracanalicular (IC) length (7.9 versus 6.6 mm, p = 0.0177) and lower WRS (55.7 versus 78.8 dBHL, p = 0.0054). During follow-up, individuals with abnormal cochlear CISS signal had significantly higher PTA (62.4 versus 46.4 dBHL, p = 0.0010). After adjusting for baseline covariates, abnormal cochlear CISS signal was consistently associated with a greater increase in PTA of 8.3 dBHL (95% confidence interval, 2.9-13.7; p = 0.0032) from baseline when compared with the normal group. CONCLUSIONS Abnormal cochlear signal on MRI CISS sequences is associated with poorer hearing outcomes in conservatively managed VS patients.
Collapse
Affiliation(s)
- Arthur Jones
- Department of Otolaryngology, Head and Neck Surgery, Canberra Hospital, Garran, ACT, Australia
| | - Lydia Saputra
- Wagga Wagga Base Hospital, Wagga Wagga, NSW, Australia
| | | |
Collapse
|
2
|
El Sayed Ahmad Y, Gallois Y, Sol JC, Boetto S, Attal J, Sabatier J, Debs R, Deguine O, Marx M. Evolution in the management of vestibular schwannoma: a single-center 15-year experience. Eur Arch Otorhinolaryngol 2023; 280:4885-4894. [PMID: 37195345 DOI: 10.1007/s00405-023-08009-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE To highlight the changes in the management of vestibular schwannoma (VS) since 2004 with a focus on small- to middle-size VS. METHODS Retrospective analysis of the decisions made in skull base tumor board between 2004 and 2021. RESULTS 1819 decisions were analyzed (average age 59.25, 54% females). Overall, 850 (47%) cases were allocated to a Wait and Scan (WS) approach, 416 (23%) received radiotherapy and 553 (30%) were treated surgically (MS). All stages considered WS increased from 39% before 2010 to 50% after 2010. Similarly, Stereotactic Radio Therapy (SRT) increased from 5 to 18%. MS decreased from 46 to 25%. It was more commonly proposed to younger patients and larger tumors, p < 0.001. For Koos stages 1, 2, and 3 there was a statistically significant increase in SRT, and a decrease in MS, p < 0.001. WS also increased for stages 1 and 2. However, such a trend was not observed for stage 3. MS remained the primary treatment modality for stage 4 tumors throughout the study period, p = 0.057. The significance of advanced age as a factor favoring SRT decreased over time. The opposite is true for serviceable hearing. There was also a decrease in the percentage of the justification "young age" in the MS category. CONCLUSION The is a continuing trend towards non-surgical treatment. Small- to medium-sized VS witnessed an increase in both WS and SRT. There is only an increase in SRT for moderately large VS. Physicians are less and less considering young age as a factor favoring MS over SRT. There is a tendency towards favoring SRT when hearing is serviceable.
Collapse
Affiliation(s)
- Youssef El Sayed Ahmad
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France.
| | - Yohan Gallois
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France
| | | | - Sergio Boetto
- Neuro-Surgery Department, CHU de Toulouse, Purpan, 31000, Toulouse, France
| | - Justine Attal
- Radiotherapy Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Jean Sabatier
- Department of Neuroradiology, Purpan Hospital, Toulouse, France
| | - Rachel Debs
- Department of Neurology, Pierre-Paul Riquet/Purpan University Hospital, Toulouse, France
| | - Olivier Deguine
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France
| | - Mathieu Marx
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France
| |
Collapse
|
3
|
Koetsier KS, Locher H, Koot RW, van der Mey AGL, van Benthem PPG, Jansen JC, Hensen EF. The Course of Hearing Loss in Patients With a Progressive Vestibular Schwannoma. Otolaryngol Head Neck Surg 2023; 169:622-632. [PMID: 36939458 DOI: 10.1002/ohn.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study evaluates the natural course of hearing loss (HL) prior to treatment in patients with progressive tumors and an indication for active intervention. Evaluating this patient group specifically can put hearing outcomes after vestibular schwannoma therapy into an adequate context. STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral center. METHODS Inclusion criteria comprised unilateral vestibular schwannomas prior to active treatment, with ≥2 mm extracanalicular (EC) tumor growth and ≥2 audiograms. We performed a comprehensive assessment of hearing using multiple outcome parameters including (the annual decrease in) pure-tone averages (PTAs; an average of 0.5, 1, 2, and 3 kHz). Predictors for HL were evaluated (patient age, tumor size/progression, follow-up duration, baseline hearing). RESULTS At presentation, 86% of patients suffered from sensorineural HL on the affected side (≥20 dB PTA) with a median of 39 dB (interquartile rate [IQR]: 27-51 dB). The median follow-up duration was 21 months (IQR: 13-34 months), after which 58% (187/322) of patients experienced progressive HL (≥10 dB), with a median increase of 6.4 dB/year. At the last follow-up, the median PTA was 56 dB (IQR: 37-73). Median speech discrimination scores deteriorated from 90% (IQR: 70%-100%) to 65% (IQR: 35%-100%). Tumor progression (maximal EC diameter) was significantly correlated to the progression of sensorineural HL, corrected for follow-up (F(2,228) = 10.4, p < .001, R2 = 8%). CONCLUSION The majority of patients (58%) with radiologically confirmed progressive vestibular schwannomas experience progressive sensorineural HL during observation. Tumor progression rate, EC tumor extension, and longer follow-up are factors associated with more sensorineural HL.
Collapse
Affiliation(s)
- Kimberley S Koetsier
- Department of Otorhinolaryngology-Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Heiko Locher
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Radboud W Koot
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Andel G L van der Mey
- Department of Otorhinolaryngology-Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Peter-Paul G van Benthem
- Department of Otorhinolaryngology-Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jeroen C Jansen
- Department of Otorhinolaryngology-Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Erik F Hensen
- Department of Otorhinolaryngology-Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
4
|
Budohoski KP, Rennert RC, Gordon SA, Raheja A, Brandon C, Henson JC, Azab MA, Patel NS, Karsy M, Gurgel RK, Shelton C, Couldwell WT. Factors associated with hearing outcomes after a middle fossa approach in 131 consecutive patients with vestibular schwannomas. J Neurosurg 2023; 139:432-441. [PMID: 36461828 DOI: 10.3171/2022.10.jns221525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs. METHODS In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors. RESULTS Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1-180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05-0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11-0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97-0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes. CONCLUSIONS The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients' risk of hearing loss.
Collapse
Affiliation(s)
- Karol P Budohoski
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Robert C Rennert
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Steven A Gordon
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Amol Raheja
- 3Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Cameron Brandon
- 4College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - J Curran Henson
- 5University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Mohammed A Azab
- 6Biomolecular Sciences Graduate Programs, Boise State University, Boise, Idaho
| | - Neil S Patel
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Michael Karsy
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Richard K Gurgel
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - Clough Shelton
- 2Division of Otolaryngology, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| |
Collapse
|
5
|
Marinelli JP, Schnurman Z, Killeen DE, Nassiri AM, Hunter JB, Lees KA, Lohse CM, Roland JT, Golfinos JG, Kondziolka D, Link MJ, Carlson ML. Stratifying Risk of Future Growth Among Sporadic Vestibular Schwannomas. Otol Neurotol 2023; Publish Ahead of Print:00129492-990000000-00318. [PMID: 37367632 DOI: 10.1097/mao.0000000000003934] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE In certain cases, clinicians may consider continued observation of a vestibular schwannoma after initial growth is detected. The aim of the current work was to determine if patients with growing sporadic vestibular schwannomas could be stratified by the likelihood of subsequent growth based on initial growth behavior. STUDY DESIGN Slice-by-slice volumetric tumor measurements from 3,505 serial magnetic resonance imaging studies were analyzed from 952 consecutively treated patients. SETTING Three tertiary-referral centers. PATIENTS Adults with sporadic vestibular schwannoma. INTERVENTIONS Wait-and-scan. MAIN OUTCOME MEASURES Composite end point of subsequent growth- or treatment-free survival rates, where growth is defined as an additional increase of at least 20% in tumor volume from the volume at the time of initial growth. RESULTS Among 405 patients who elected continued observation despite documented growth, stratification, of volumetric growth rate into less than 25% (reference: n = 107), 25 to less than 50% (hazard ratio [HR], 1.39; p = 0.06; n = 96), 50 to less than 100% (HR, 1.71; p = 0.002; n = 112), and at least 100% (HR, 2.01; p < 0.001; n = 90) change per year predicted the likelihood of future growth or treatment. Subsequent growth- or treatment-free survival rates (95% confidence interval) at year 5 after detection of initial growth were 31% (21-44%) for those with less than 25% growth per year, 18% (10-32%) for those with 25 to less than 50%, 15% (9-26%) for those with 50 to less than 100%, and 6% (2-16%) for those with at least 100%. Neither patient age (p = 0.15) nor tumor volume at diagnosis (p = 0.95) significantly differed across stratification groups. CONCLUSIONS At the time of diagnosis, clinical features cannot consistently predict which tumors will ultimately display aggressive behavior. Stratification by volumetric growth rate at the time of initial growth results in a stepwise progression of increasing likelihood of subsequent growth. When considering continued observation after initial growth detection, almost 95% of patients who have tumors that double in volume between diagnosis and the first detection of growth demonstrate further tumor growth or undergo treatment if observed to 5 years.
Collapse
Affiliation(s)
- John P Marinelli
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Zane Schnurman
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Daniel E Killeen
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University Medical School, Cleveland, Ohio
| | - Ashley M Nassiri
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jacob B Hunter
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katherine A Lees
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Christine M Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - J Thomas Roland
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, New York
| | - John G Golfinos
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | | | | |
Collapse
|
6
|
Understanding the Molecular Mechanism of Vestibular Schwannoma for Hearing Preservation Surgery: Otologists’ Perspective from Bedside to Bench. Diagnostics (Basel) 2022; 12:diagnostics12051044. [PMID: 35626200 PMCID: PMC9140016 DOI: 10.3390/diagnostics12051044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
Vestibular schwannoma is a clinically benign schwannoma that arises from the vestibulocochlear nerve that causes sensorineural hearing loss. This tumor is clinically and oncologically regarded as a benign tumor as it does not metastasize or invade surrounding tissues. Despite being a benign tumor, its management is difficult and controversial due to the potential serious complications, such as irreversible sensorineural hearing loss, of current interventions. Therefore, preventing hearing loss due to the natural course of the disease and complications of surgery is a challenging issue for an otologist. Improvements have been reported recently in the treatment of vestibular schwannomas. These include advances in intraoperative monitoring systems for vestibular schwannoma surgery where the risk of hearing loss as a complication is decreased. Precise genomic analysis of the tumor would be helpful in determining the characteristics of the tumor for each patient, leading to a better hearing prognosis. These procedures are expected to help improve the treatment of vestibular schwannomas. This review summarizes recent advances in vestibular schwannoma management and treatment, especially in hearing preservation. In addition, recent advances in the understanding of the molecular mechanisms underlying vestibular schwannomas and how these advances can be applied in clinical practice are outlined and discussed, respectively. Moreover, the future directions from the bedside to the bench side are presented from the perspective of otologists.
Collapse
|
7
|
The Natural History of Vestibular Schwannoma and When to Intervene. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00337-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
8
|
Selleck AM, Rodriguez JD, Brown KD. Predicting Hearing Outcomes in Conservatively Managed Vestibular Schwannoma Patients Utilizing Magnetic Resonance Imaging. Otol Neurotol 2021; 42:306-311. [PMID: 33290358 DOI: 10.1097/mao.0000000000002923] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Management of small vestibular schwannomas has evolved to where observation with interval imaging is an accepted treatment strategy. Loss of residual hearing is a known complication of observation. Magnetic resonance imaging (MRI) may provide critical information to assist in determining which tumors are at highest risk of hearing loss. We wished to determine what effect fundal cap size and cochlear fluid-attenuated inversion recovery (FLAIR) signal had on the progression of hearing loss in a large cohort of observed subjects. STUDY DESIGN Retrospective chart review. SETTING Tertiary academic referral center. PATIENTS Three hundred ninety-three adults with a vestibular schwannoma who underwent expectant management with serial audiograms and MRI. INTERVENTIONS Audiogram and MRI. MAIN OUTCOME MEASURES Hearing outcomes included pure-tone average and word discrimination score (WRS). Cochlear FLAIR signal was measured as a ratio between the affected and nonaffected cochlea. Cerebrospinal fluid fundal cap was measured from the most lateral aspect of the tumor to the fundus of the internal auditory canal. RESULTS An increased cochlear FLAIR ratio was associated with a worse initial WRS (p = 0.0001, β=-0.25). A multivariate regression analysis demonstrated the variables fundal cap and initial WRS to significantly predict change in WRS over time. The larger the fundal cap size, the smaller the change in the WRS (p = 0.047, β=-0.35). CONCLUSIONS Cerebrospinal fluid fundal cap size predicts the natural history of hearing in vestibular schwannoma patients. The presence of a smaller fundal cap is correlated with a greater risk of progression of hearing loss and should be a variable considered in the management of small vestibular schwannomas.
Collapse
Affiliation(s)
| | - Justin D Rodriguez
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | |
Collapse
|
9
|
Macielak RJ, Marinelli JP, Spear SA, Hahs-Vaughn DL, Link MJ, Nye C, Carlson ML. Hearing Status and Aural Rehabilitative Profile of 878 Patients With Sporadic Vestibular Schwannoma. Laryngoscope 2020; 131:1378-1381. [PMID: 33296080 DOI: 10.1002/lary.29315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/30/2020] [Accepted: 11/23/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To examine the hearing status and aural rehabilitative profile in a national cohort of patients with sporadic vestibular schwannoma (VS). STUDY DESIGN Cross-sectional survey METHODS: A cross-sectional survey of Acoustic Neuroma Association members diagnosed with sporadic VS was performed from February 2017 through January 2019. Self-reported results were used to determine the aural rehabilitative profile of respondents. RESULTS Among survey respondents, 62.2% (546/878) were not using any hearing-assistive device at time of survey. For the 37.8% (332/878) that were utilizing hearing-assistive devices, 32.8% (109/332) reported using a behind-the-ear hearing aid, 23.8% (79/332) used a contralateral routing of signal (CROS) hearing aid, and 21.7% (72/332) used a bone conduction device. Notably, 41.9% (278/663) of patients who previously underwent tumor treatment reported utilizing a hearing rehabilitation device at some point during VS management compared to 27.0% (58/215) of those undergoing observation with serial imaging (P < .001). Of 275 patients with functional hearing in the ipsilateral ear, 26.5% (73/275) reported having used at least one type of hearing device; 24.0% (66/275) reported use of a conventional hearing aid, 0.7% (2/275) a CROS aid, and 0.4% (1/275) a bone conduction device. Among respondents reporting ipsilateral nonfunctional hearing, 44.9% (258/575) reported having used at least one type of hearing device; 13.0% (75/575) a CROS aid, and 12.3% (71/575) a bone conduction device. CONCLUSIONS Even among a cohort with presumably elevated literacy surrounding hearing rehabilitation options, few patients with a history of unilateral vestibular schwannoma ultimately use hearing assistive devices long-term, suggesting that most patients sufficiently adjust to unilateral hearing loss or are unsatisfied with the benefits achieved with current device options. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1378-1381, 2021.
Collapse
Affiliation(s)
- Robert J Macielak
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - John P Marinelli
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, U.S.A
| | - Samuel A Spear
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas, U.S.A
| | - Debbie L Hahs-Vaughn
- Department of Learning Sciences and Educational Research, University of Central Florida, Orlando, Florida, U.S.A
| | - Michael J Link
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Chad Nye
- Acoustic Neuroma Association, Cumming, Georgia, U.S.A
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| |
Collapse
|