1
|
Esser J, Walger M, Pollet N, Klußmann JP, Ruge M, Goldbrunner R, Lüers JC. [Vestibular Schwannoma: Factors in Therapy Decision-Making]. Laryngorhinootologie 2024; 103:176-186. [PMID: 38128578 DOI: 10.1055/a-2222-0878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
The treatment of vestibular schwannomas (VS) has always posed a challenge for physicians. Three essential treatment principles are available: wait-and-scan, surgery, and stereotactic radiotherapy. In addition to the type of treatment, decisions must be made regarding the optimal timing of therapy, the combination of different treatment modalities, the potential surgical approach, and the type and intensity of radiation. Factors influencing the therapy decision include tumor location and size or stage, patient age, comorbidities, symptoms, postoperative hearing rehabilitation options, patient preferences, and, not least, the experience of the surgeons and the personnel and technical capabilities of the clinical site. This article begins with a brief overview of vestibular schwannomas, then outlines the fundamental interdisciplinary treatment options, and finally discusses the ENT (ear, nose, and throat)-relevant factors in the therapy decision.
Collapse
Affiliation(s)
- Julia Esser
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, DE 50937, Germany
| | - Martin Walger
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, DE 50937, Germany
| | - Naomi Pollet
- Universität zu Köln, Medizinische Fakultät, Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf und Hals-Chirurgie, Uniklinik Köln, Köln, DE 50937, Germany
| | - Jens Peter Klußmann
- Klinik und Poliklinik für HNO-Heilkunde, Kopf- und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, DE 50937, Germany
| | - Maximilian Ruge
- Klinik für Stereotaxie und Funktionelle Neurochirurgie, Universität zu Köln Medizinische Fakultät, Köln, Germany
| | - Roland Goldbrunner
- Universität zu Köln, Medizinische Fakultät, Zentrum für Neurochirurgie, Klinik für Allgemeine Neurochirurgie, Universität zu Köln Medizinische Fakultät, Köln, Germany
| | - Jan Christoffer Lüers
- Klinik und Poliklinik für HNO-Heilkunde, Kopf- und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, Germany
| |
Collapse
|
2
|
Lassaletta L, Acle Cervera L, Altuna X, Amilibia Cabeza E, Arístegui Ruiz M, Batuecas Caletrio Á, Benítez Del Rosario J, Cabanillas Farpón R, Costales Marcos M, Escada P, Espinosa-Sánchez JM, García Leal R, Gavilán J, Gómez Martínez J, González-Aguado R, Martinez-Glez V, Guerra Jiménez G, Harguindey Antolí-Candela A, Hernández García BJ, Orús Dotú C, Polo López R, Manrique M, Martín Sanz E, Martínez Álvarez R, Martínez H, Martínez-Martínez M, Rey-Martinez J, Ropero Romero F, Santa Cruz Ruiz S, Vallejo LÁ, Soto Varela A, Varela-Nieto I, Morales Puebla JM. Clinical practice guideline on the management of vestibular schwannoma. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2024; 75:108-128. [PMID: 38346489 DOI: 10.1016/j.otoeng.2023.10.005] [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: 08/23/2023] [Accepted: 10/19/2023] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Vestibular schwannoma (VS) is the most common tumour of the cerebellopontine angle. The greater accessibility to radiological tests has increased its diagnosis. Taking into account the characteristics of the tumour, the symptoms and the age of the patient, three therapeutic strategies have been proposed: observation, surgery or radiotherapy. Choosing the most appropriate for each patient is a frequent source of controversy. MATERIAL AND METHODS This paper includes an exhaustive literature review of issues related to VS that can serve as a clinical guide in the management of patients with these lesions. The presentation has been oriented in the form of questions that the clinician usually asks himself and the answers have been written and/or reviewed by a panel of national and international experts consulted by the Otology Commission of the SEORL-CCC. RESULTS A list has been compiled containing the 13 most controversial thematic blocks on the management of VS in the form of 50 questions, and answers to all of them have been sought through a systematic literature review (articles published on PubMed and Cochrane Library between 1992 and 2023 related to each thematic area). Thirty-three experts, led by the Otology Committee of SEORL-CCC, have analyzed and discussed all the answers. In Annex 1, 14 additional questions divided into 4 thematic areas can be found. CONCLUSIONS This clinical practice guideline on the management of VS offers agreed answers to the most common questions that are asked about this tumour. The absence of sufficient prospective studies means that the levels of evidence on the subject are generally medium or low. This fact increases the interest of this type of clinical practice guidelines prepared by experts.
Collapse
Affiliation(s)
- Luis Lassaletta
- Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain.
| | | | - Xabier Altuna
- Servicio de Otorrinolaringología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
| | - Emilio Amilibia Cabeza
- Servicio de Otorrinolaringología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Miguel Arístegui Ruiz
- Servicio de Otorrinolaringología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ángel Batuecas Caletrio
- Servicio de Otorrinolaringología, Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca, Salamanca, Spain
| | - Jesús Benítez Del Rosario
- Servicio de Otorrinolaringología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | - María Costales Marcos
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Pedro Escada
- Servicio de Otorrinolaringología, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Juan Manuel Espinosa-Sánchez
- Servicio de Otorrinolaringología, Hospital Universitario Virgen de las Nieves, Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain
| | - Roberto García Leal
- Servicio de Neurocirugía, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Gavilán
- Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Justo Gómez Martínez
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Rocío González-Aguado
- Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Victor Martinez-Glez
- Center for Genomic Medicine, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autónoma de Barcelona, Sabadell, Barcelona, Spain
| | - Gloria Guerra Jiménez
- Servicio de Otorrinolaringología, Complejo Hospitalario Universitario Insular Materno Infantil de las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | | | - Cesar Orús Dotú
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Rubén Polo López
- Servicio de Otorrinolaringología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Manuel Manrique
- Servicio de Otorrinolaringología, Clínica Universitaria de Navarra, Pamplona, Navarra, Spain
| | - Eduardo Martín Sanz
- Servicio de Otorrinolaringología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | | | - Henry Martínez
- Servicio de Otorrinolaringología, Hospital Universitario Clínica San Rafael, Sur Bogotá D. C., Colombia; Servicio de Otorrinolaringología, Hospital San José, Bogotá, Colombia
| | | | - Jorge Rey-Martinez
- Servicio de Otorrinolaringología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
| | | | - Santiago Santa Cruz Ruiz
- Servicio de Otorrinolaringología, Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca, Salamanca, Spain
| | - Luis Ángel Vallejo
- Servicio de Otorrinolaringología, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Andrés Soto Varela
- Servicio de Otorrinolaringología, Departamento de Cirugía y Especialidades Médico-Quirúrgicas, Complexo Hospitalario Universitario de Santiago, Universidade de Santiago de Compostela, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, Spain
| | - Isabel Varela-Nieto
- Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras, Instituto de Salud Carlos III, Madrid, Spain; Grupo de Audición y Mielinopatías, Instituto de Investigaciones Biomédicas Alberto Sols, CSIC-UAM, CIBERER-ISCIII, Madrid, Spain
| | - José Manuel Morales Puebla
- Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
3
|
Zhang H, Wang J, Liu J, Cao Z, Liu X, Jin H, Liu W, Xue Z, Yang N, Li C, Wang X. Fully neuroendoscopic resection of cerebellopontine angle tumors through a retrosigmoid approach: a retrospective single-center study. Neurosurg Rev 2023; 47:14. [PMID: 38102367 DOI: 10.1007/s10143-023-02244-5] [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: 07/15/2023] [Revised: 11/01/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
The objective of this study is to preliminarily investigate the surgical safety, efficacy, techniques, and clinical value of fully neuroendoscopic surgery for the resection of cerebellopontine angle (CPA) tumors via a retrosigmoid approach. The clinical data of 47 cerebellopontine angle area (CPA) tumors that were treated by full neuroendoscopic surgery from June 2014 to June 2023 were retrospectively analyzed. The efficacy and advantages of the surgical techniques were evaluated based on indicators such as duration of the surgery, neuroendoscopic techniques, intraoperative integrity of nerves and blood vessels, extent of tumor resection, outcomes or postoperative symptoms, and incidence of complications. The 47 cases of cerebellopontine angle tumors include 34 cases of epidermoid cysts, 7 cases of vestibular schwannomas, and 6 cases of meningiomas. All patients underwent fully neuroendoscopic surgery. Twenty tumors were removed using the one-surgeon two-hands technique, and 27 tumors were removed using the two-surgeons four-hands technique. The anatomical integrity of the affected cranial nerves was preserved in all 47 cases. None of the patients suffered a postoperative hemorrhage, cerebrospinal fluid leak, and aseptic or septic meningitis, or died. The rate of total tumor resection was 72.3% (34/47), and the symptom improvement rate was 89.4% (42/47). All patients were followed up for 2 to 12 months, and none died nor showed any signs of tumor recurrence. By analyzing 47 fully neuroendoscopic resections of CPA tumors using the posterior sigmoid sinus approach in our center, we believe that such method allows complete, safe, and effective resection of CPA tumors and is thereby worthy of clinical promotion.
Collapse
Affiliation(s)
- Hengrui Zhang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Jiwei Wang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Junzhi Liu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Zexin Cao
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Xuchen Liu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Haoyong Jin
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Wenyu Liu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Zhiwei Xue
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Ning Yang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China
| | - Chao Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China.
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China.
| | - Xinyu Wang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, 250012, China.
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, 250117, China.
| |
Collapse
|
4
|
Koetsier KS, Oud M, de Klerck E, Hensen EF, van Vulpen M, van Linge A, Paul van Benthem P, Slagter C, Habraken SJ, Hoogeman MS, Méndez Romero A. Cochlear-optimized treatment planning in photon and proton radiosurgery for vestibular schwannoma patients. Clin Transl Radiat Oncol 2023; 43:100689. [PMID: 37867612 PMCID: PMC10585330 DOI: 10.1016/j.ctro.2023.100689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023] Open
Abstract
Objective To investigate the potential to reduce the cochlear dose with robotic photon radiosurgery or intensity-modulated proton therapy planning for vestibular schwannomas. Materials and Methods Clinically delivered photon radiosurgery treatment plans were compared to five cochlear-optimized plans: one photon and four proton plans (total of 120). A 1x12 Gy dose was prescribed. Photon plans were generated with Precision (Cyberknife, Accuray) with no PTV margin for set-up errors. Proton plans were generated using an in-house automated multi-criterial planning system with three or nine-beam arrangements, and applying 0 or 3 mm robustness for set-up errors during plan optimization and evaluation (and 3 % range robustness). The sample size was calculated based on a reduction of cochlear Dmean > 1.5 Gy(RBE) from the clinical plans, and resulted in 24 patients. Results Compared to the clinical photon plans, a reduction of cochlear Dmean > 1.5 Gy(RBE) could be achieved in 11/24 cochlear-optimized photon plans, 4/24 and 6/24 cochlear-optimized proton plans without set-up robustness for three and nine-beam arrangement, respectively, and in 0/24 proton plans with set-up robustness. The cochlea could best be spared in cases with a distance between tumor and cochlea. Using nine proton beams resulted in a reduced dose to most organs at risk. Conclusion Cochlear dose reduction is possible in vestibular schwannoma radiosurgery while maintaining tumor coverage, especially when the tumor is not adjacent to the cochlea. With current set-up robustness, proton therapy is capable of providing lower dose to organs at risk located distant to the tumor, but not for organs adjacent to it. Consequently, photon plans provided better cochlear sparing than proton plans.
Collapse
Affiliation(s)
- Kimberley S. Koetsier
- Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | - Michelle Oud
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Erik de Klerck
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
| | - Erik F Hensen
- Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | | | - Anne van Linge
- Department of Otorhinolaryngology and Head & Neck Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Peter Paul van Benthem
- Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | - Cleo Slagter
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
- HollandPTC, Delft, the Netherlands
| | - Steven J.M. Habraken
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
- HollandPTC, Delft, the Netherlands
| | - Mischa S. Hoogeman
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
- HollandPTC, Delft, the Netherlands
| | - A. Méndez Romero
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Radiotherapy, Rotterdam, the Netherlands
- HollandPTC, Delft, the Netherlands
| |
Collapse
|
5
|
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
|
6
|
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
|
7
|
Brooks KA, Vivas EX. Natural History of Hearing Loss in Sporadic Vestibular Schwannoma. Otolaryngol Clin North Am 2023; 56:435-444. [PMID: 37024333 DOI: 10.1016/j.otc.2023.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Hearing loss is the most common and earliest symptom of sporadic vestibular schwannoma (VS). The most common pattern of hearing loss is asymmetric sensorineural hearing loss. Throughout its natural history, patients with serviceable hearing (SH) maintain SH at 94% to 95% after 1 year, 73% to 77% after 2 years, 56% to 66% after 5 years, and 32% to 44% after 10 years. For patients newly diagnosed with VS, it is likely their hearing will worsen despite small initial tumor size or lack of tumor growth.
Collapse
Affiliation(s)
- Kaitlyn A Brooks
- Department of Otolaryngology- Head and Neck Surgery, Emory University Hospital Midtown, 11th Floor, Suite 1135, Medical Office Tower, 550 Peachtree Street NE, Atlanta, GA 30308, USA
| | - Esther X Vivas
- Department of Otolaryngology- Head and Neck Surgery, Emory University Hospital Midtown, 11th Floor, Suite 1135, Medical Office Tower, 550 Peachtree Street NE, Atlanta, GA 30308, USA.
| |
Collapse
|
8
|
Gu F, Yang X, Wang Z, Tan X, Xue T, Chen Z, Wang Z, Chen G. Diagnostic accuracy of intraoperative brainstem auditory evoked potential for predicting hearing loss after vestibular schwannoma surgery. Front Neurol 2022; 13:1018324. [PMID: 36588877 PMCID: PMC9797509 DOI: 10.3389/fneur.2022.1018324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022] Open
Abstract
Objective This meta-analysis evaluated the diagnostic value of intraoperative brainstem auditory evoked potential (BAEP) for predicting post-operative hearing loss. Methods Research articles in MEDLINE, Embase, and Cochrane Library databases were searched and selected up to 20 January 2022, and data were extracted following a standard procedure. A diagnostic accuracy test meta-analysis was performed using a mixed-effect binary regression model. Results A total of 693 patients from 15 studies were extracted. The change in intraoperative BAEP showed high sensitivity (0.95) but low specificity (0.37), with an area under the curve of 0.83. Diagnostic accuracy of the loss of potentials showed high sensitivity (0.82) and specificity (0.79). The area under the curve was 0.88. No factor was found to account for the heterogeneity of the results according to the meta-regression and subgroup analyses (all P-values > 0.05). Conclusions Our results showed that the loss of BAEP has meaningful value for predicting hearing loss after vestibular schwannoma surgery. The change in BAEP is also important for its high sensitivity during hearing preservation surgery.
Collapse
Affiliation(s)
- Feng Gu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xingyu Yang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zilan Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xin Tan
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Tao Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhouqing Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China,Zhouqing Chen
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China,*Correspondence: Zhong Wang
| | - Gang Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| |
Collapse
|
9
|
Yakkala VK, Mammi M, Lamba N, Kandikatla R, Paliwal B, Elshibiny H, Corrales CE, Smith TR, Mekary RA. Audiovestibular symptoms and facial nerve function comparing microsurgery versus SRS for vestibular schwannomas: a systematic review and meta-analysis. Acta Neurochir (Wien) 2022; 164:3221-3233. [PMID: 35962847 DOI: 10.1007/s00701-022-05338-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/02/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Surgery and radiosurgery represent the most common treatment options for vestibular schwannoma. A systematic review and meta-analysis were conducted to compare the outcomes of surgery versus stereotactic radiosurgery (SRS). METHODS The Cochrane library, PubMed, Embase, and clinicaltrials.gov were searched through 01/2021 to find all studies on surgical and stereotactic procedures performed to treat vestibular schwannoma. Using a random-effects model, pooled odds ratios (OR) and their 95% confidence intervals (CI) comparing post- to pre-intervention were derived for pre-post studies, and pooled incidence of adverse events post-intervention were calculated for case series and stratified by intervention type. RESULTS Twenty-one studies (18 pre-post design; three case series) with 987 patients were included in the final analysis. Comparing post- to pre-intervention, both surgery (OR: 3.52, 95%CI 2.13, 5.81) and SRS (OR: 3.30, 95%CI 1.39, 7.80) resulted in greater odds of hearing loss, lower odds of dizziness (surgery OR: 0.10; 95%CI 0.02, 0.47 vs. SRS OR: 0.22; 95%CI 0.05, 0.99), and tinnitus (surgery OR: 0.23; 95%CI 0.00, 37.9; two studies vs. SRS OR: 0.11; 95%CI 0.01, 1.07; one study). Pooled incidence of facial symmetry loss was larger post-surgery (14.3%, 95%CI 6.8%, 22.7%) than post-SRS (7%, 95%CI 1%, 36%). Tumor control was larger in the surgery (94%, 95%CI 83%, 98%) than the SRS group (80%, 95%CI 31%, 97%) for small-to-medium size tumors. CONCLUSION Both surgery and SRS resulted in similar odds of hearing loss and similar improvements in dizziness and tinnitus among patients with vestibular schwannoma; however, facial symmetry loss appeared higher post-surgery.
Collapse
Affiliation(s)
- Vinod Kumar Yakkala
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Marco Mammi
- Department of Neurosurgery, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Nayan Lamba
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
- Department of Radiation Oncology, Harvard Medical School, Boston, MA, USA
| | - Renuka Kandikatla
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Bhaskar Paliwal
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Hoda Elshibiny
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - C Eduardo Corrales
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA.
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
10
|
Gurgel RK, Couldwell WT, Patel NS, Cannon-Albright LA. Is There an Inherited Contribution to Risk for Sporadic Unilateral Vestibular Schwannoma? Evidence of Familial Clustering. Otol Neurotol 2022; 43:e1157-e1163. [PMID: 36113461 DOI: 10.1097/mao.0000000000003686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECT Unlike the autosomal dominant inheritance of neurofibromatosis 2, there are no known inherited risk factors for sporadic, unilateral vestibular schwannoma (VS), which comprise most VS cases. The authors tested a hypothesis positing a genetic contribution to predisposition to these lesions by analyzing familial clustering of cases. METHODS Familial clustering of individuals with unilateral VS was analyzed in two independent genealogical resources with linked diagnosis data: the Veterans Health Administration Genealogy Resource and the Utah Population Database. Tests for excess relatedness, estimation of relative risks (RRs) in close and distant relatives, and identification of pedigrees with a significant excess of unilateral VS among descendants were performed. RESULTS The average pairwise relatedness of the Veterans Health Administration Genealogy Resource VS cases significantly exceeded the expected relatedness ( p = 0.016), even when close relationships were ignored ( p = 0.002). RR for third- and fifth-degree relatives developing VS were significantly elevated (RR, 60.83; p = 0.0005; 95% confidence interval [CI], 7.37-219.73) and (RR, 11.88; p = 0.013; 95% CI, 1.44-42.90), respectively. No VS-affected first-, second-, or fourth-degree relatives were observed. In the Utah Population Database population, no first- or second-degree relatives with VS were observed. RR for fifth-degree relatives developing VS was significantly elevated (RR, 2.23; p = 0.009; 95% CI, 1.15-3.90). CONCLUSION These results provide strong evidence for an inherited predisposition to sporadic, unilateral VS. This study exhibits the value of genealogical resources with linked medical data for examining hypotheses regarding inherited predisposition. The high-risk unilateral VS pedigrees identified in two independent resources provide a powerful means of pursuing predisposition gene identification.
Collapse
Affiliation(s)
- Richard K Gurgel
- Division of Otolaryngology, University of Utah School of Medicine
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah
| | - Neil S Patel
- Division of Otolaryngology, University of Utah School of Medicine
| | | |
Collapse
|
11
|
Carlson ML, Lohse CM, Link MJ, Tombers NM, McCaslin DL, Saoji AA, Hutchins M, Yost KJ. Development and validation of a new disease-specific quality of life instrument for sporadic vestibular schwannoma: the Mayo Clinic Vestibular Schwannoma Quality of Life Index. J Neurosurg 2022; 138:981-991. [PMID: 36057121 DOI: 10.3171/2022.7.jns221104] [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: 05/10/2022] [Accepted: 07/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Facial nerve function, hearing preservation, and tumor control have been the primary benchmarks used to assess vestibular schwannoma (VS) outcomes. Acknowledging the frequent discrepancy between what physicians prioritize and what patients value, there has been increasing prioritization of patient-reported outcome measures when evaluating the impact of VS diagnosis and its treatment. Motivated by reported limitations of prior instruments used to assess quality of life (QOL) in patients with VS, the authors describe the development and validation of a new disease-specific QOL measure: the Vestibular Schwannoma Quality of Life (VSQOL) Index. METHODS The content development phase comprised identification of clinically important domains and prioritization of feelings or concerns individuals with VS may have. The validation phase encompassed determining how items were grouped into domains and eliminating redundant items. Both phases leveraged data from cross-sectional and longitudinal surveys, expertise from a multidisciplinary working group, and patients with a broad range of experiences with VS (n = 42 during content development and n = 263 during validation). Domain scores from the new instrument were assessed for reliability and correlation with other measures of similar constructs. RESULTS The VSQOL Index consists of 40 items that evaluate the impact of VS diagnosis and its management on QOL, treatment satisfaction, and employment and is estimated to take 8-10 minutes to complete. Domain scores range from 0 (worst) to 100 (best) and demonstrate excellent psychometric properties, including content, construct, and convergent validity and both internal consistency (Cronbach's alphas 0.83 to 0.91) and test-retest reliability (reliability coefficients 0.86 to 0.96). CONCLUSIONS The VSQOL Index is a valid and reliable measure that overcomes several limitations of prior instruments, including omission or underrepresentation of domains that frequently impact well-being, such as pain, cognition, satisfaction or regret surrounding treatment decisions, and occupational limitations, to comprehensively evaluate the impact of VS diagnosis or its treatment on QOL.
Collapse
Affiliation(s)
- Matthew L Carlson
- Departments of1Otolaryngology-Head and Neck Surgery.,2Neurosurgery, and
| | | | | | | | - Devin L McCaslin
- 4Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Kathleen J Yost
- 3Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
12
|
Predicting Extent of Microsurgical Resection of Sporadic Vestibular Schwannoma. Otol Neurotol 2022; 43:950-955. [PMID: 35941666 DOI: 10.1097/mao.0000000000003593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Develop a predictive model for incomplete microsurgical resection of sporadic vestibular schwannoma (VS). STUDY DESIGN Historical cohort. SETTING Tertiary referral center. PATIENTS Patients with sporadic VS. INTERVENTIONS Microsurgery with preoperative intent of gross total resection. MAIN OUTCOME MEASURES Patient and tumor characteristics that influence extent of resection. RESULTS Among 603 patients, 101 (17%) had intracanalicular tumors and 502 (83%) had tumors with cerebellopontine angle (CPA) extension. For patients with CPA tumors, 331 (66%) underwent gross total resection and 171 (34%) underwent near-total or subtotal resection (NTR-STR). Multivariable modeling identified older age at surgery, larger linear tumor size, and absence of a fundal fluid cap as predictive of NTR-STR ( p < 0.001). From this model, one can estimate that a 20-year-old with a tumor that has less than 10 mm of CPA extension and a present fundal fluid cap has a predicted probability of NTR-STR of 0.01 (or 1%), whereas a 70-year-old with a tumor that has 30 mm or greater CPA extension and absence of a fundal fluid cap has a predicted probability of NTR-STR of 0.91 (or 91%). Among the 171 patients who underwent NTR-STR, 24 required secondary treatment at the time of last follow-up. CONCLUSION The primary predictors of incomplete microsurgical resection of VS include older age at surgery, larger linear tumor size, and absence of a fundal fluid cap. These factors can be used to estimate the likelihood of NTR-STR, aiding in preoperative discussions regarding future surveillance and potential need of secondary treatment, as well as shared clinical decision making.
Collapse
|
13
|
Macielak RJ, Wallerius KP, Lawlor SK, Lohse CM, Marinelli JP, Neff BA, Van Gompel JJ, Driscoll CLW, Link MJ, Carlson ML. Defining clinically significant tumor size in vestibular schwannoma to inform timing of microsurgery during wait-and-scan management: moving beyond minimum detectable growth. J Neurosurg 2022; 136:1289-1297. [PMID: 34653971 DOI: 10.3171/2021.4.jns21465] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Detection of vestibular schwannoma (VS) growth during observation leads to definitive treatment at most centers globally. Although ≥ 2 mm represents an established benchmark of tumor growth on serial MRI studies, 2 mm of linear tumor growth is unlikely to significantly alter microsurgical outcomes. The objective of the current work was to ascertain where the magnitude of change in clinical outcome is the greatest based on size. METHODS A single-institution retrospective review of a consecutive series of patients with sporadic VS who underwent microsurgical resection between January 2000 and May 2020 was performed. Preoperative tumor size cutpoints were defined in 1-mm increments and used to identify optimal size thresholds for three primary outcomes: 1) the ability to achieve gross-total resection (GTR); 2) maintenance of normal House-Brackmann (HB) grade I facial nerve function; and 3) preservation of serviceable hearing (American Academy of Otolaryngology-Head and Neck Surgery class A/B). Optimal size thresholds were obtained by maximizing c-indices from logistic regression models. RESULTS Of 603 patients meeting inclusion criteria, 502 (83%) had tumors with cerebellopontine angle (CPA) extension. CPA tumor size was significantly associated with achieving GTR, postoperative HB grade I facial nerve function, and maintenance of serviceable hearing (all p < 0.001). The optimal tumor size threshold to distinguish between GTR and less than GTR was 17 mm of CPA extension (c-index 0.73). In the immediate postoperative period, the size threshold between HB grade I and HB grade > I was 17 mm of CPA extension (c-index 0.65). At the most recent evaluation, the size threshold between HB grade I and HB grade > I was 23 mm (c-index 0.68) and between class A/B and C/D hearing was 18 mm (c-index 0.68). Tumors within 3 mm of the 17-mm CPA threshold displayed similarly strong c-indices. Among purely intracanalicular tumors, linear size was not found to portend worse outcomes for all measures. CONCLUSIONS The probability of incurring less optimal microsurgical outcomes begins to significantly increase at 14-20 mm of CPA extension. Although many factors ultimately influence decision-making, when considering timing of microsurgical resection, using a size threshold range as depicted in this study offers an evidence-based approach that moves beyond reflexively recommending treatment for all tumors after detecting ≥ 2 mm of tumor growth on serial MRI studies.
Collapse
Affiliation(s)
| | | | | | | | | | - Brian A Neff
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jamie J Van Gompel
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Colin L W Driscoll
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
14
|
Wallerius KP, Macielak RJ, Lawlor SK, Lohse CM, Neff BA, Van Gompel JJ, Driscoll CLW, Link MJ, Carlson ML. Hearing Preservation Microsurgery in Vestibular Schwannomas: Worth Attempting in "Larger" Tumors? Laryngoscope 2021; 132:1657-1664. [PMID: 34854492 DOI: 10.1002/lary.29968] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS To review hearing preservation after microsurgical resection of sporadic vestibular schwannomas according to tumor size. STUDY DESIGN Retrospective cohort. METHODS Baseline, intraoperative, and postoperative patient and tumor characteristics were retrospectively collected for a cohort who underwent hearing preservation microsurgery. Serviceable hearing was defined by a pure tone average ≤50 dB and word recognition score ≥50%. RESULTS A total of 243 patients had serviceable hearing preoperatively. Fifty (21%) tumors were confined to the internal auditory canal, and the median tumor size was 16.2 mm (interquartile range [IQR] 11.3-23.2) for tumors with cerebellopontine angle extension. Serviceable hearing was maintained in 64% of patients with tumors confined to the internal auditory canal, 28% with cerebellopontine angle extension <15 mm, and 9% with cerebellopontine angle extension ≥15 mm. On multivariable analysis, the odds ratios of acquiring nonserviceable hearing postoperatively for tumors extending <15 mm and ≥15 mm into the cerebellopontine angle were 5.75 (95% confidence interval [CI] 2.13-15.53; P < .001) and 22.11 (95% CI 7.04-69.42; P < .001), respectively, compared with intracanalicular tumors. CONCLUSIONS The strongest predictor of hearing preservation with microsurgery after multivariable adjustment is tumor size. Approximately 10% of patients with tumors ≥15 mm of cerebellopontine angle extension will retain serviceable hearing after microsurgery. Furthermore, hearing preservation techniques offer cochlear nerve preservation and cochlear patency allowing for possible future cochlear implantation. An attempt at hearing preservation, including avoiding surgical approaches that necessarily sacrifice hearing, is worthwhile even in larger tumors if serviceable hearing is present preoperatively. LEVEL OF EVIDENCE IV Laryngoscope, 2021.
Collapse
Affiliation(s)
- Katherine P Wallerius
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Robert J Macielak
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Skye K Lawlor
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christine M Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Brian A Neff
- 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
| | - Jamie J Van Gompel
- 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
| | - Colin L W Driscoll
- 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
| | - 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
| | - 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
|
15
|
Yoon J, Billings H, Wi CI, Hall E, Sohn S, Kwon JH, Ryu E, Shrestha P, Liu H, Juhn YJ. Establishing an expert consensus for the operational definitions of asthma-associated infectious and inflammatory multimorbidities for computational algorithms through a modified Delphi technique. BMC Med Inform Decis Mak 2021; 21:310. [PMID: 34749701 PMCID: PMC8573872 DOI: 10.1186/s12911-021-01663-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/13/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A subgroup of patients with asthma has been reported to have an increased risk for asthma-associated infectious and inflammatory multimorbidities (AIMs). To systematically investigate the association of asthma with AIMs using a large patient cohort, it is desired to leverage a broad range of electronic health record (EHR) data sources to automatically identify AIMs accurately and efficiently. METHODS We established an expert consensus for an operational definition for each AIM from EHR through a modified Delphi technique. A series of questions about the operational definition of 19 AIMS (11 infectious diseases and 8 inflammatory diseases) was generated by a core team of experts who considered feasibility, balance between sensitivity and specificity, and generalizability. Eight internal and 5 external expert panelists were invited to individually complete a series of online questionnaires and provide judgement and feedback throughout three sequential internal rounds and two external rounds. Panelists' responses were collected, descriptive statistics tabulated, and results reported back to the entire group. Following each round the core team of experts made iterative edits to the operational definitions until a moderate (≥ 60%) or strong (≥ 80%) level of consensus among the panel was achieved. RESULTS Response rates for each Delphi round were 100% in all 5 rounds with the achievement of the following consensus levels: (1) Internal panel consensus: 100% for 8 definitions, 88% for 10 definitions, and 75% for 1 definition, (2) External panel consensus: 100% for 12 definitions and 80% for 7 definitions. CONCLUSIONS The final operational definitions of AIMs established through a modified Delphi technique can serve as a foundation for developing computational algorithms to automatically identify AIMs from EHRs to enable large scale research studies on patient's multimorbidities associated with asthma.
Collapse
Affiliation(s)
- Jungwon Yoon
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Precision Population Science Lab, Mayo Clinic, Rochester, MN, USA
- Department of Pediatrics, Myongji Hospital, Goyang-si, South Korea
| | - Heather Billings
- Office of Applied Scholarship and Education Science, Mayo Clinic, Rochester, MN, USA
| | - Chung-Il Wi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Precision Population Science Lab, Mayo Clinic, Rochester, MN, USA
| | - Elissa Hall
- Office of Applied Scholarship and Education Science, Mayo Clinic, Rochester, MN, USA
| | - Sunghwan Sohn
- Division of Digital Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Jung Hyun Kwon
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Pediatrics, Korea University College of Medicine, Seoul, South Korea
| | - Euijung Ryu
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Pragya Shrestha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
- Precision Population Science Lab, Mayo Clinic, Rochester, MN, USA
| | - Hongfang Liu
- Division of Digital Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Young J Juhn
- Precision Population Science Lab, Mayo Clinic, Rochester, MN, USA.
- Department of Pediatric and Adolescent Medicine and Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
16
|
Vergara Olmos G, Dabiri S, Rutka J. Editorial. Decision-making in the surgical management of a vestibular schwannoma: when timing is everything (cum sincere omnia). J Neurosurg 2021; 136:1285-1286. [PMID: 34653982 DOI: 10.3171/2021.5.jns21981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gabriela Vergara Olmos
- 1Division of Otology/Neurotology, Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Ontario, Canada
| | - Sasan Dabiri
- 1Division of Otology/Neurotology, Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Ontario, Canada
| | - John Rutka
- 1Division of Otology/Neurotology, Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Ontario, Canada
| |
Collapse
|
17
|
Macielak RJ, Thao V, Borah BJ, Moriarty JP, Marinelli JP, Van Gompel JJ, Carlson ML. Lifetime Cost and Quality-Adjusted Life-Years Across Management Options for Small- and Medium-Sized Sporadic Vestibular Schwannoma. Otol Neurotol 2021; 42:e1369-e1375. [PMID: 34282100 DOI: 10.1097/mao.0000000000003266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite the growing emphasis on healthcare costs, limited data address this aspect of care within the vestibular schwannoma (VS) literature. We sought to determine which strategy confers the lowest lifetime cost and greatest quality-adjusted life-years (QALYs) for patients with small- to medium-sized sporadic VS tumors. STUDY DESIGN A Markov model was created to determine the most cost-effective management algorithm. Tumor characteristics, magnetic resonance imaging surveillance schedule, treatment outcomes, and health-related quality of life values were derived from previously published data. Cost estimates were based on CMS Fee Schedule reimbursement rates. SETTING Economic Evaluation Service within the Kern Center for the Science of Healthcare Delivery. PATIENTS Patients diagnosed with small- to medium-sized sporadic VS. INTERVENTIONS Upfront microsurgery following diagnosis, upfront radiosurgery following diagnosis, observation with microsurgery reserved for observed tumor growth, and observation with radiosurgery reserved for observed tumor growth. RESULTS Across patient ages at time of diagnosis ranging from 18 to 70 years, observation with subsequent radiosurgery used for tumor growth was the most cost-effective management algorithm while upfront microsurgery was the least. When presented with a hypothetical 50-year-old patient, the strategy with the lowest lifetime cost and highest QALYs was observation with subsequent radiosurgery reserved for tumor growth ($32,161, 14.11 QALY), followed by observation with microsurgery reserved for tumor growth ($34,503, 13.94 QALY), upfront radiosurgery ($43,456, 14.02 QALY), and lastly, upfront microsurgery ($47,252, 13.60 QALY). Sensitivity analyses varying mortality rates, estimated costs, health-related quality of life, and progression to nonserviceable hearing demonstrated consistent ranking among treatments. CONCLUSIONS When considering initial management of small- and medium-sized sporadic VSs, neither lifetime cost nor QALYs support upfront microsurgery or radiosurgery, even for younger patients. Initial observation with serial imaging, reserving radiosurgery or microsurgery for patients exhibiting tumor growth, confers the greatest potential for optimized lifetime healthcare cost and QALY outcomes.
Collapse
Affiliation(s)
| | - Viengneesee Thao
- Division of Health Care Policy Research, Department of Health Sciences Research
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - Bijan J Borah
- Division of Health Care Policy Research, Department of Health Sciences Research
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - James P Moriarty
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | - Jamie J Van Gompel
- Department of Otolaryngology-Head and Neck Surgery
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
18
|
Amin-Hanjani S, Riina HA, Barker FG. Editorial. Delphi studies in neurosurgery. J Neurosurg 2021; 136:1217-1218. [PMID: 34598163 DOI: 10.3171/2021.4.jns21622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Howard A Riina
- 2Departments of Neurosurgery and Radiology, New York University School of Medicine, New York, New York; and
| | - Fred G Barker
- 3Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
19
|
Affiliation(s)
| | - Roy T Daniel
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marc Levivier
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| |
Collapse
|
20
|
Affiliation(s)
- Matthew L Carlson
- From the Departments of Otolaryngology-Head and Neck Surgery and Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Michael J Link
- From the Departments of Otolaryngology-Head and Neck Surgery and Neurologic Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|