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Schiff E, Friedman SA, Al-Mulki K, Lin J, Moskowitz HS. Practice Patterns in Asymmetric Sensorineural Hearing Loss: Survey Data. Laryngoscope 2024. [PMID: 38877834 DOI: 10.1002/lary.31573] [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: 02/21/2024] [Revised: 05/20/2024] [Accepted: 05/31/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE Although screening protocols for patients who present with asymmetric sensorineural hearing loss (ASNHL) exist, there are no clear guidelines to direct practitioners. In particular, various thresholds have been proposed for the degree of hearing loss that should prompt MRI studies, but the topic remains understudied. This project aims to compare protocols followed by practitioners to guide their imaging practices. STUDY DESIGN Web-based survey. SETTING Otolaryngology faculty at academic medical centers. METHODS A list of 530 otolaryngologists (276 otology/neurotology specialists, 254 general otolaryngologists) was compiled. A survey consisting of three parts: demographics, general practice patterns, and simulated patient cases was distributed. RESULTS A total of 468 surveys were successfully distributed, resulting in 88 (18.8%) responses. The majority of respondents (63.8%) self-reported their definition of ASNHL as ">30 dB hearing asymmetry at one frequency OR >20 dB hearing asymmetry at two continuous frequencies OR >10 dB hearing asymmetry at three contiguous frequencies." Overall, general otolaryngologists were more likely to observe asymmetric findings with serial audiogram alone, whereas otology/neurotology specialists were more likely to obtain imaging. CONCLUSION There is significant variability between providers with regard to managing patients with ASNHL and evidence-based guidelines would be useful in guiding imaging practices. LEVEL OF EVIDENCE N/A Laryngoscope, 2024.
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Affiliation(s)
- Elliot Schiff
- Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Sara A Friedman
- Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Kareem Al-Mulki
- Albert Einstein College of Medicine, New York, New York, U.S.A
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, New York, New York, U.S.A
| | - Juan Lin
- Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Howard S Moskowitz
- Albert Einstein College of Medicine, New York, New York, U.S.A
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, New York, New York, U.S.A
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2
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Koester SW, Bishay AE, Rogers JL, Dambrino RJ, Liles C, Feldman M, Chambless LB. Cost considerations for vestibular schwannoma screening and imaging: a systematic review. Neurosurg Rev 2024; 47:59. [PMID: 38252395 DOI: 10.1007/s10143-024-02305-3] [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: 10/01/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
Vestibular schwannomas (VS) account for approximately 8% of all intracranial neoplasms. Importantly, the cost of the diagnostic workup for VS, including the screening modalities most commonly used, has not been thoroughly investigated. Our aim is to conduct a systematic review of the published literature on costs associated with VS screening. A systematic review of the literature for cost of VS treatment was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The terms "vestibular schwannoma," "acoustic neuroma," and "cost" were queried using the PubMed and Embase databases. Studies from all countries were considered. Cost was then corrected for inflation using the US Bureau of Labor Statistics Inflation Calculator, correcting to April 2022. The search resulted in an initial review of 483 articles, of which 12 articles were included in the final analysis. Screening criteria were used for non-neurofibromatosis type I and II patients who complained of asymmetric hearing loss, tinnitus, or vertigo. Patients included in the studies ranged from 72 to 1249. The currency and inflation-adjusted mean cost was $418.40 (range, $21.81 to $487.03, n = 5) for auditory brainstem reflex and $1433.87 (range, $511.64 to $1762.15, n = 3) for non-contrasted computed tomography. A contrasted magnetic resonance imaging (MRI) scan was found to have a median cost of $913.27 (range, $172.25-$2733.99; n = 8) whereas a non-contrasted MRI was found to have a median cost of $478.62 (range, $116.61-$3256.38, n = 4). In terms of cost reporting, of the 12 articles, 1 (8.3%) of them separated out the cost elements, and 10 (83%) of them used local prices, which include institutional costs and/or average costs of multiple institutions. Our findings describe the limited data on published costs for screening and imaging of VS. The paucity of data and significant variability of costs between studies indicates that this endpoint is relatively unexplored, and the cost of screening is poorly understood.
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Affiliation(s)
| | | | - James L Rogers
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert J Dambrino
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Campbell Liles
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Feldman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Kortebein S, Gu S, Dai K, Zhao E, Riska K, Kaylie D, Hoa M. MRI Screening in Vestibular Schwannoma: A Deep Learning-based Analysis of Clinical and Audiometric Data. OTOLOGY & NEUROTOLOGY OPEN 2023; 3:e028. [PMID: 38516318 PMCID: PMC10950172 DOI: 10.1097/ono.0000000000000028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/05/2022] [Indexed: 03/23/2024]
Abstract
Objective To find a more objective method of assessing which patients should be screened for a vestibular schwannoma (VS) with magnetic resonance imaging (MRI) using a deep-learning algorithm to assess clinical and audiometric data. Materials and Methods Clinical and audiometric data were collected for 592 patients who received an audiogram between January 2015 and 2020 at Duke University Health Center with and without VS confirmed by MRI. These data were analyzed using a deep learning-based analysis to determine if the need for MRI screening could be assessed more objectively with adequate sensitivity and specificity. Results Patients with VS showed slightly elevated, but not statistically significant, mean thresholds compared to those without. Tinnitus, gradual hearing loss, and aural fullness were more common in patients with VS. Of these, only the presence of tinnitus was statistically significant. Several machine learning algorithms were used to incorporate and model the collected clinical and audiometric data, but none were able to distinguish ears with and without confirmed VS. When tumor size was taken into account the analysis was still unable to distinguish a difference. Conclusions Using audiometric and clinical data, deep learning-based analyses failed to produce an adequately sensitive and specific model for the detection of patients with VS. This suggests that a specific pattern of audiometric asymmetry and clinical symptoms may not necessarily be predictive of the presence/absence of VS to a level that clinicians would be comfortable forgoing an MRI.
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Affiliation(s)
- Sarah Kortebein
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
| | - Shoujun Gu
- Auditory Development and Restoration Program, NIDCD Otolaryngology Surgeon-Scientist Program, Division of Intramural Research, NIDCD/NIH, Bethesda, MD
| | - Kathy Dai
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
| | - Elizabeth Zhao
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
| | - Kristal Riska
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
| | - David Kaylie
- Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC
| | - Michael Hoa
- Auditory Development and Restoration Program, NIDCD Otolaryngology Surgeon-Scientist Program, Division of Intramural Research, NIDCD/NIH, Bethesda, MD
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Gheorghe L, Negru D, Cobzeanu MD, Palade OD, Botnariu EG, Cobzeanu BM, Cobzeanu ML. The Diagnostic Accuracy of Pure-Tone Audiometry Screening Protocols for Vestibular Schwannoma in Patients with Asymmetrical Hearing Loss-A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:diagnostics12112776. [PMID: 36428836 PMCID: PMC9689241 DOI: 10.3390/diagnostics12112776] [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: 10/10/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Magnetic resonance imaging (MRI) is the gold standard investigation for all patients who present with asymmetrical hearing loss (AHL) and a high index of suspicion for vestibular schwannoma (VS). However, pure-tone audiometry (PTA) is an investigation that can be used for the screening of these patients in order to reduce the costs. The aim of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of different PTA protocols for VS in patients with ASHL, when compared with MRI; (2) Methods: Medline, Embase, and Cochrane databases were used to find relevant studies. All prospective and retrospective observational studies that evaluated the accuracy of PTA protocols for the screening of VS were assessed, according to the international guidelines; (3) Results: We analyzed seven studies (4369 patients) of poor-to-moderate quality. Their pooled sensitivity was good (0.73-0.93), but their specificity was low (0.31-0.60). All protocols were located in the right lower quadrant on the likelihood scattergram, and the post-test probabilities for positive and negative diagnosis of these protocols were extremely low; (4) Conclusions: PTA protocols cannot be used for a proper screening or diagnosis of vestibular schwannoma despite their good sensibility, and MRI remains the gold standard for this purpose.
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Affiliation(s)
- Liliana Gheorghe
- Surgical Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Emergency Clinical Hospital “Sfântul Spiridon” Iasi, 700111 Iasi, Romania
| | - Dragos Negru
- Surgical Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Emergency Clinical Hospital “Sfântul Spiridon” Iasi, 700111 Iasi, Romania
| | - Mihail Dan Cobzeanu
- Surgical Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Emergency Clinical Hospital “Sfântul Spiridon” Iasi, 700111 Iasi, Romania
| | - Octavian Dragos Palade
- Surgical Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Emergency Clinical Hospital “Sfântul Spiridon” Iasi, 700111 Iasi, Romania
- Correspondence: (O.D.P.); (E.G.B.)
| | - Eosefina Gina Botnariu
- Emergency Clinical Hospital “Sfântul Spiridon” Iasi, 700111 Iasi, Romania
- Internal Medicine Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Correspondence: (O.D.P.); (E.G.B.)
| | - Bogdan Mihail Cobzeanu
- Surgical Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Maria-Luiza Cobzeanu
- Surgical Department, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Emergency Clinical Hospital “Sfântul Spiridon” Iasi, 700111 Iasi, Romania
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Abstract
OBJECTIVE The aim of this study is to compare machine learning algorithms and established rule-based evaluations in screening audiograms for the purpose of diagnosing vestibular schwannomas. A secondary aim is to assess the performance of rule-based evaluations for predicting vestibular schwannomas using the largest dataset in the literature. STUDY DESIGN Retrospective case-control study. SETTING Tertiary referral center. PATIENTS Seven hundred sixty seven adult patients with confirmed vestibular schwannoma and a pretreatment audiogram on file and 2000 randomly selected adult controls with audiograms. INTERVENTIONS Audiometric data were analyzed using machine learning algorithms and standard rule-based criteria for defining asymmetric hearing loss. MAIN OUTCOME MEASURES The primary outcome is the ability to identify patients with vestibular schwannomas based on audiometric data alone, using machine learning algorithms and rule-based formulas. The secondary outcome is the application of conventional rule-based formulas to a larger dataset using advanced computational techniques. RESULTS The machine learning algorithms had mildly improved specificity in some fields compared with rule-based evaluations and had similar sensitivity to previous rule-based evaluations in diagnosis of vestibular schwannomas. CONCLUSIONS Machine learning algorithms perform similarly to rule-based evaluations in identifying patients with vestibular schwannomas based on audiometric data alone. Performance of established rule-based formulas was consistent with earlier performance metrics, when analyzed using a large dataset.
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Celis-Aguilar E, Obeso-Pereda A, Castro-Bórquez KM, Dehesa-Lopez E, Vega-Alarcon A, Coutinho-De Toledo H. Multiple Audiometric Analysis in the Screening of Vestibular Schwannoma. Cureus 2022; 14:e21492. [PMID: 35103228 PMCID: PMC8783613 DOI: 10.7759/cureus.21492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2022] [Indexed: 01/14/2023] Open
Abstract
Introduction Asymmetric sensorineural hearing loss is the main early symptom of retrocochlear lesions, hence its importance in screening for vestibular schwannomas. Currently, there is no consensus regarding its definition. The objective was to identify the audiometric pattern that would serve as a predictor for vestibular schwannoma in patients with asymmetric hearing loss. Materials and methods A cross-sectional study was conducted that included patients with asymmetric hearing loss attending a secondary care center and a tertiary care center. Clinical, audiometric and imaging (MRI with gadolinium) variables were collected. Asymmetric hearing loss was defined as a difference of 15 dB in one or more frequencies between both ears. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of different audiometric patterns were analyzed. Results A total of 107 patients were studied and divided into two groups: group 1 without vestibular schwannoma (n=98); and group 2 with vestibular schwannoma (n=9). No significant difference in demographic characteristics or audiometric patterns was found in patients with and without vestibular schwannoma. The audiometric pattern with the best sensitivity as a screening test was a difference >20 dB in the 4,000 Hz frequency, with a sensitivity of 77.78%, specificity of 30.61%, PPV of 8.33%, NPV of 93.75% and accuracy of 34.50%. Conclusion The audiometric pattern with the best results was a difference >20 dB in the 4,000 Hz frequency range; however, patients with asymmetric hearing loss could not be differentiated from patients with retrocochlear lesions based only on audiometry. Asymmetrical hearing loss must be studied with MRI.
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MRI of IAM for vestibular schwannoma in ENT practice - a retrospective analysis with literature and guidelines review. The Journal of Laryngology & Otology 2021; 136:888-891. [PMID: 34666846 DOI: 10.1017/s0022215121003017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Evaluation of Vestibular Function in Diagnosis of Vestibular Schwannomas. Curr Med Sci 2021; 41:661-666. [PMID: 34403089 DOI: 10.1007/s11596-021-2407-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
Vestibular schwannomas (VS) are benign tumors of the vestibular nerve. The common first symptoms are hearing loss and tinnitus, followed by imbalance, vertigo, and facial nerve involvement. The subjective symptoms of VS patients are not consistent with the severity of vestibular lesions and the results of vestibular tests, which often interfere with clinicians' diagnoses. Thus, the main screening and diagnostic methods for VS are audiometry and magnetic resonance imaging (MRI), ignoring the evaluation of vestibular function at the source of pathological lesions. With the development and improvement of vestibular evaluation technology and its wide application in the clinic, modern vestibular examination technology can reflect the severity and frequency of vestibular lesions and compensation from multiple perspectives, providing an objective basis for the diagnosis and treatment of vestibular diseases. In this report, we review the results and characteristics of vestibular tests in VS patients and further clarify the clinical value of vestibular function assessment in the diagnosis and treatment of VS.
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Vnencak M, Huttunen E, Aarnisalo AA, Jero J, Liukkonen K, Sinkkonen ST. Evaluation of pure-tone audiometric protocols in vestibular schwannoma screening. J Otol 2020; 16:138-143. [PMID: 34220982 PMCID: PMC8241708 DOI: 10.1016/j.joto.2020.12.004] [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: 11/24/2020] [Revised: 12/13/2020] [Accepted: 12/17/2020] [Indexed: 11/22/2022] Open
Abstract
The objective was to evaluate the pure-tone audiogram-based screening protocols in VS diagnostics. We retrospectively analyzed presenting symptoms, pure tone audiometry and MRI finding from 246 VS patients and 442 controls were collected to test screening protocols (AAO-HNS, AMCLASS-A/B, Charing Cross, Cueva, DOH, Nashville, Oxford, Rule3000, Schlauch, Seattle, Sunderland) for sensitivity and specificity. Results were pooled with data from five other studies, and analysis of sensitivity, specificity and positive likelihood ratio (LR+) for each protocol was performed. Our results show that protocols with significantly higher sensitivity (AMCLASS-A/B, Nashville) show also significantly lowest specificity, and tend to have low association (positive likelihood ratio, LR+) to the VS. The highest LR+ was found for protocols AAO-HNS, Rule3000 and Seattle. In conclusions, knowing their properties, screening protocols are simple decision-making tools in VS diagnostic. To use the advantage of the highest sensitivity, protocols AMCLASS-A + B or Nashville can be of choice. For more reasonable approach, applying the protocols with high LR+ (AAO-HNS, Rule3000, Seattle) may reduce the overall number of MRI scans at expense of only few primarily undiagnosed VS.
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Affiliation(s)
- Matej Vnencak
- Department of Otorhinolaryngology - Head and Neck Surgery, Turku University Hospital, Turku, Finland.,Head and Neck Center, Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, And University of Helsinki, Helsinki, Finland
| | - Elina Huttunen
- Head and Neck Center, Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, And University of Helsinki, Helsinki, Finland
| | - Antti A Aarnisalo
- Head and Neck Center, Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, And University of Helsinki, Helsinki, Finland
| | - Jussi Jero
- Head and Neck Center, Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, And University of Helsinki, Helsinki, Finland
| | - Katja Liukkonen
- Head and Neck Center, Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, And University of Helsinki, Helsinki, Finland
| | - Saku T Sinkkonen
- Head and Neck Center, Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, And University of Helsinki, Helsinki, Finland
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Asymmetric sensorineural hearing loss and vestibular schwannoma: when to image? Curr Opin Otolaryngol Head Neck Surg 2020; 28:335-339. [PMID: 32841960 DOI: 10.1097/moo.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW We review the literature on the use of audiometric protocols in the guidance of when to obtain MRI for detection of vestibular schwannoma. This discussion will focus on the sensitivity, specificity, and cost-effective analysis of audiometric criteria of asymmetric sensorineural hearing loss (ASNHL) when used to decide when MRI scans should be performed. RECENT FINDINGS The sensitivity for detecting vestibular schwannomas when invoking published audiometric protocols for triggering MRI acquisition in ASNHL ranged from 50 to 100%. Specificity of these protocols ranged from 23 to 83%. Such audiometric protocols are efficient, achieving sensitivity and specificity at these rates while reducing the screening rate to 18 to 35%. The reduced procurement of MRI while using such audiometric protocols is associated with annual cost savings of between 23 and 82%. While no definitive recommendations can be made from this review, some audiometric protocols offer a better balance of sensitivity and specificity than others. SUMMARY Audiometric protocols for triggering MRI acquisition in ASNHL for evaluation of vestibular schwannoma can be both sensitive and specific. These are competitive measures, and so no protocol is both 100% sensitive and specific. Such protocols become less effective in populations with increased incidence of noise-induced hearing loss. Invocation of such audiometric protocols can considerably reduce the annual cost of MRI evaluation for vestibular schwannomas.
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Vellutini EDAS, Teles Gomes MDQ, Brock RS, Oliveira MFD, Salomone R, Godoy LFDS, Ruschel LG. Radiologic Features of Spontaneous Regression of Vestibular Schwannomas. World Neurosurg 2019; 135:e488-e493. [PMID: 31843724 DOI: 10.1016/j.wneu.2019.12.034] [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: 10/23/2019] [Revised: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Vestibular schwannoma (VS) is the most common benign tumor originating in the cerebellopontine angle. In most cases, tumors tend to grow and deserve proper treatment. Sometimes they stabilize, and rarely they decrease in size spontaneously. METHODS We evaluated retrospectively the images of patients with spontaneous tumor regression. We describe the common neuroimage findings of patients with spontaneous tumoral regression. RESULTS Four patients with diagnosis of VS were followed with magnetic resonance imaging (MRI). There were some relevant features in MRI: a heterogeneous contrast enhancement in the outer layer of the tumor and presence of a cerebrospinal fluid column between the tumor and the entrance of the internal auditory canal. The percentage of tumor diameter reduction ranged from 20% to 40%. CONCLUSIONS Some MRI features may demonstrate a spontaneous involution of VS and may be closely followed in asymptomatic or oligosymptomatic patients.
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Affiliation(s)
| | - Marcos de Queiroz Teles Gomes
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Roger Schmidt Brock
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Matheus Fernandes de Oliveira
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
| | - Raquel Salomone
- Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Leonardo Gilmone Ruschel
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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Waterval J, Kania R, Somers T. EAONO Position Statement on Vestibular Schwannoma: Imaging Assessment. What are the Indications for Performing a Screening MRI Scan for a Potential Vestibular Schwannoma? J Int Adv Otol 2019; 14:95-99. [PMID: 29764782 DOI: 10.5152/iao.2018.5364] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jérôme Waterval
- Department of Otorhinolaryngology, Radboud University Medical Center, Netherlands
| | - Romain Kania
- Department of ENT, Lariboisiere University Hospital, APHP, Paris Sorbonne University, Paris, France
| | - Thomas Somers
- Department of ENT, Sint-Augustinus Ziekenhuis, Wilrijk, Antwerp, Belgium
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To Scan or Not to Scan—A Cross-Sectional Analysis of the Clinical Efficacy and Cost-Effectiveness of Audiometric Protocols for Magnetic Resonance Imaging Screening of Vestibular Schwannomas. Otol Neurotol 2019; 40:S59-S66. [DOI: 10.1097/mao.0000000000002215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Carrier DA, Arriaga MA. Cost-Effective Evaluation of Asymmetric Sensorineural Hearing Loss with Focused Magnetic Resonance Imaging. Otolaryngol Head Neck Surg 2018; 116:567-574. [DOI: 10.1016/s0194-5998(97)70229-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The poor sensitivity of audiometric brain stem response for small vestibular schwannomas (acoustic neuromas) creates a dilemma for the physician evaluating a patient with signs and symptoms of retrocochlear disease. Magnetic resonance imaging is recognized as the gold standard for the evaluation of these problems, but if a complete examination of the internal auditory canals and head is done on every patient, the cost is high. Although less expensive, screening with audiometric brain stem response risks missing up to 33% of small tumors. Therefore we developed a focused magnetic resonance imaging sequence for evaluation of patients with asymmetric sensorineural hearing loss and/or nonpulsatile tinnitus. The protocol includes a T1-weighted sagittal localizer, pregadolinium and post-gadolinium T1-weighted 3-mm contiguous axial slices through the internal auditory canal and the region of the cerebellopontine angle, and T2-weighted axial images through the entire brain. Total scanning time is about 12 minutes, and the estimated cost is $300 to $500. We retrospectively reviewed the imaging records of 485 screening examinations done during an 18-month period. Twenty-four patients had diagnoses definitely or probably producing the hearing loss for an overall positive rate of 5%. By eliminating the need for follow-up audiometric or electrophysiologic studies, we believe a focused magnetic resonance imaging-based diagnostic scheme is actually more cost-effective on a cost-per-patient basis.
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Affiliation(s)
- David A. Carrier
- Department of Neuroradiology, Wilford Hall Medical Center; Lackland AFB, Texas, and Pittsburgh, Pennsylvania
| | - Moises A. Arriaga
- Department of Otology/Neurotology Pittsburgh Ear Associates, Wilford Hall Medical Center Lackland AFB, Texas, and Pittsburgh, Pennsylvania
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Coelho DH, Tang Y, Suddarth B, Mamdani M. MRI surveillance of vestibular schwannomas without contrast enhancement: Clinical and economic evaluation. Laryngoscope 2017; 128:202-209. [DOI: 10.1002/lary.26589] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Daniel H. Coelho
- Department of Otolaryngology-Head and Neck Surgery; Virginia Commonwealth University School of Medicine; Richmond Virginia U.S.A
| | - Yang Tang
- Department of Radiology; Virginia Commonwealth University School of Medicine; Richmond Virginia U.S.A
| | - Brian Suddarth
- Department of Radiology; Virginia Commonwealth University School of Medicine; Richmond Virginia U.S.A
| | - Mohammed Mamdani
- Department of Otolaryngology-Head and Neck Surgery; Virginia Commonwealth University School of Medicine; Richmond Virginia U.S.A
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16
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Diagnostic Criteria for Detection of Vestibular Schwannomas in the VA Population. Otol Neurotol 2016; 37:1510-1515. [DOI: 10.1097/mao.0000000000001251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Hojjat H, Svider PF, Davoodian P, Hong RS, Folbe AJ, Eloy JA, A. Shkoukani M. To image or not to image? A cost-effectiveness analysis of MRI for patients with asymmetric sensorineural hearing loss. Laryngoscope 2016; 127:939-944. [DOI: 10.1002/lary.26231] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/23/2016] [Accepted: 07/18/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Houmehr Hojjat
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Peter F. Svider
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Pedram Davoodian
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Robert S. Hong
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Michigan Ear Institute; Farmington Hills Michigan U.S.A
| | - Adam J. Folbe
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Department of Neurosurgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Department of Neurological Surgery; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Department of Ophthalmology and Visual Science; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery; Neurological Institute of New Jersey; Newark New Jersey U.S.A
| | - Mahdi A. Shkoukani
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Surgical Service, Section of Otolaryngology; John D. Dingell VA Medical Center; Detroit Michigan U.S.A
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von Kirschbaum C, Gürkov R. Audiovestibular Function Deficits in Vestibular Schwannoma. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4980562. [PMID: 27747231 PMCID: PMC5055915 DOI: 10.1155/2016/4980562] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/12/2016] [Accepted: 08/24/2016] [Indexed: 11/28/2022]
Abstract
Introduction. Vestibular schwannomas (VS) are benign tumours of the vestibular nerve and can lead to hearing loss, tinnitus, vertigo, facial palsy, and brainstem compression. Audiovestibular diagnostic tests are essential for detection and treatment planning. Methods. Medline was used to perform a systematic literature review with regard to how audiovestibular test parameters correlate with symptoms, tumour size, and tumour location. Results. The auditory brainstem response can be used to diagnose retrocochlear lesions caused by VS. Since hearing loss correlates poorly with tumour size, a retrocochlear lesion is probably not the only cause for hearing loss. Also cochlear mechanisms seem to play a role. This can be revealed by abnormal otoacoustic emissions, despite normal ABR and new MRI techniques which have demonstrated endolymphatic hydrops of the inner ear. Caloric and head impulse tests show frequency specific dynamics and vestibular evoked myogenic potentials may help to identify the location of the tumour regarding the involved nerve parts. Conclusion. In order to preserve audiovestibular function in VS, it is important to stop the growth of the tumour and to avoid degenerative changes in the inner ear. A detailed neurotological workup helps to diagnose VS of all sizes and can also provide useful prognostic information.
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Affiliation(s)
- Constantin von Kirschbaum
- Department of Otorhinolaryngology and Head and Neck Surgery, Grosshadern Medical Center, University of Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Robert Gürkov
- Department of Otorhinolaryngology and Head and Neck Surgery, Grosshadern Medical Center, University of Munich, Marchioninistr. 15, 81377 Munich, Germany
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Evaluation of Magnetic Resonance Imaging Diagnostic Approaches for Vestibular Schwannoma Based on Hearing Threshold Differences Between Ears: Added Value of Auditory Brainstem Responses. Otol Neurotol 2016; 36:1610-5. [PMID: 26485589 DOI: 10.1097/mao.0000000000000876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study investigates the most appropriate audiometric criterion in deciding which patients with asymmetric hearing loss should be referred to MRI to exclude a lesion in the cerebellopontine angle (CPA). Careful selection of patients could improve resource utilization while preventing unnecessary investigations with accompanying burden and costs. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS Of all the patients who were referred to our clinic between 1997 and 2012, the records were reviewed of those who underwent pure-tone audiometry, auditory brainstem response (ABR) testing, and had a Gadolinium-enhanced MRI of the CPA. INTERVENTION Regarding interaural pure-tone threshold differences at single or multiple (averaged) frequencies, we assigned multiple possible cut-off values (dB) defining an aberrant result, suggestive for CPA lesions. Results were compared with MRI to calculate sensitivity and specificity for every cut-off value. These were visualized as ROC curves enabling qualitative comparison. Added value of ABR was assessed as well. MAIN OUTCOME MEASURES Sensitivity and specificity of various criteria to decide which patients with asymmetric hearing loss to send to MRI to exclude a CPA lesion. RESULTS In total, 1016 records were reviewed. Two hundred ninety-four subjects (29%) were diagnosed with a CPA lesion on MRI. Sensitivity and specificity for audiometry results differed greatly depending on the predefined cut-off value for hearing threshold difference (40-95% sensitivity and 20-90% specificity). Best ROC curves were obtained when threshold differences at two or three higher frequencies were averaged. Adding results of ABR to the threshold criterion yielded a slightly better ROC curve, although sensitivity decreased. CONCLUSIONS The best criterion to decide which patient with asymmetric hearing loss should be referred to MRI is based on the average bone conduction threshold difference at multiple (two or three) higher frequencies. The extent of the average threshold difference between ears that is used as a cutoff will mainly depend on treatment modality and (eventually) on resource costs and on the burden of Gadolinium-enhanced magnetic resonance imaging. Results of ABR can have little added value when only patients with a unilateral abnormal ABR at the worse hearing ear are referred to MRI. However, a lower sensitivity must then be accepted.
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Kurtcan S, Alkan A, Kilicarslan R, Bakan AA, Toprak H, Aralasmak A, Aksoy F, Kocer A. Auditory Pathway Features Determined by DTI in Subjects with Unilateral Acoustic Neuroma. Clin Neuroradiol 2015; 26:439-444. [PMID: 25813527 DOI: 10.1007/s00062-015-0385-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/04/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE In the studies concerning the pathology of the auditory pathway in the vestibulocochlear system, few use advanced neuroimaging applications of magnetic resonance imaging (MRI) such as diffusion tensor imaging (DTI). Those who did use reported DTI changes only at the lateral lemniscus and inferior colliculus level. The aim of our study was to determine diffusion changes in the bilateral auditory pathways of subjects with unilateral acoustic neuroma (AN) and compare them with healthy controls. MATERIAL AND METHODS A total of 15 subjects with unilateral AN along with 11 controls underwent routine MRI and DTI. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values obtained from the lateral lemniscus, inferior colliculus, corpus geniculatum mediale, and Heschl's gyrus of the auditory pathway were then compared. RESULTS The subjects' ADC values measured from the contralateral side were significantly higher at the lateral lemniscus, inferior colliculus, and corpus geniculatum mediale compared with those of the controls. Also, decreased FA values were noted at the inferior colliculus for both the contralateral and ipsilateral sides. The highest ADC values were detected in the inferior colliculus of the auditory pathway. CONCLUSIONS In the auditory pathway of subjects with AN, the contralateral side is more affected than the ipsilateral side, the most affected region being the inferior colliculus. DTI is an advanced neuroimaging technique that can be used to determine the presence of microstructural damage to the auditory pathway in subjects with AN, whereas conventional MRI is not sensitive enough to detect damage.
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Affiliation(s)
- S Kurtcan
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, 34093, Istanbul, Turkey.
| | - A Alkan
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, 34093, Istanbul, Turkey
| | - R Kilicarslan
- Department of Radiology, Faculty of Medicine, Medipol University, Istanbul, Turkey
| | - A A Bakan
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, 34093, Istanbul, Turkey
| | - H Toprak
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, 34093, Istanbul, Turkey
| | - A Aralasmak
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, 34093, Istanbul, Turkey
| | - F Aksoy
- Department of Otorhinolaryngology, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - A Kocer
- Department of Neurology, Faculty of Medicine, Medeniyet University, Istanbul, Turkey
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Lee SH, Choi SK, Lim YJ, Chung HY, Yeo JH, Na SY, Kim SH, Yeo SG. Otologic manifestations of acoustic neuroma. Acta Otolaryngol 2015; 135:140-6. [PMID: 25578127 DOI: 10.3109/00016489.2014.952334] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Many patients with acoustic neuroma (AN) experience hearing loss and tinnitus. Time from first symptoms to diagnosis can be considerable. AN should be suspected, and MRI scans performed, in patients with hearing loss accompanied by asymmetry, tinnitus, low speech discrimination score (SDS), and abnormal auditory brainstem response (ABR). OBJECTIVES To determine the otorhinolaryngological factors associated with AN by analyzing the clinical manifestations and diagnostic test results of patients with AN before MRI scanning. METHODS This study enrolled 114 patients definitively diagnosed with AN after visiting the Ear-Nose-and-Throat and Neurosurgery Departments of Kyung Hee University Medical Center from 2001 to 2013. Factors retrospectively analyzed included patient age, gender, major symptoms, accompanying symptoms, symptom duration, pure-tone audiometry, SDS, asymmetry, tinnitogram, ABR, and MRI scan results. RESULTS The main symptom of AN was hearing loss, and the most frequent accompanying symptom was tinnitus. More severe deafness correlated significantly with lower SDS (p < 0.05). Asymmetric hearing was observed in 75 of 116 patients (64.6%), and mean SDS was 73.1 ± 34.1%. Of patients with latencies of waves I, III, and V on ABR tests, 56.1%, 92.4%, and 92.4%, had interaural latency differences ≥0.2 ms. However, audiometry results did not correlate with lesion site or tumor size (p > 0.05).
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Affiliation(s)
- Sung Ho Lee
- Department of Neurosurgery, School of Medicine
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Koors PD, Thacker LR, Coelho DH. ABR in the diagnosis of vestibular schwannomas: a meta-analysis. Am J Otolaryngol 2013; 34:195-204. [PMID: 23332407 DOI: 10.1016/j.amjoto.2012.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 11/15/2012] [Accepted: 11/16/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The aim of this study is to rigorously evaluate the role of auditory brainstem response (ABR) testing in the diagnosis of vestibular schwannomas (VS). MATERIALS AND METHODS Searches were conducted in multiple online databases, supplemented by hand searches. From the studies chosen for final inclusion, relevant data were extracted and meta-analysis of pooled data was performed. RESULTS 623 studies were identified from which 43 met inclusion criteria for analysis (1978 to 2009) including 3314 patients. Pooled sensitivity for ABR detection of vestibular schwannomas was 93.4% (95% CI 92.6-94.3, P=0.0000). For tumors less than 1cm (8 studies, 176 patients) sensitivity was 85.8% (95% CI 80.6-90.1, P=0.0116). For tumors greater than 1cm (6 studies, 251 patients) pooled sensitivity was 95.6% (95% CI 93.1-98.2, P=0.0660). Sensitivity of ABR to detect extracanalicular tumors was higher than for intracanalicular tumors, though pooled data were not statistically valid. Pooled specificity (8 studies, 2432 patients) was 82.0% (95% CI 80.5-83.6, P=0.0000). CONCLUSIONS Although MRI remains the gold standard, emerging trends towards more conservative management coupled with limited financial resources may prompt many clinicians to review the role of ABR testing in screening for retrocochlear pathology. In light of the high sensitivity and specificity of ABR testing for VS, we strongly urge its reconsideration as a useful diagnostic tool for patients with clinically suspected VS.
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Incidence of vestibular schwannoma and incidental findings on the magnetic resonance imaging and computed tomography scans of patients from a direct referral audiology clinic. The Journal of Laryngology & Otology 2012; 126:658-62. [PMID: 22578280 DOI: 10.1017/s0022215112000680] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To identify the incidence of vestibular schwannoma amongst patients referred from a direct referral audiology clinic, and also the number of incidental findings, as seen on magnetic resonance imaging or computed tomography scans. METHOD Prospective data collection for patients referred from a direct referral audiology clinic due to audiological evidence of asymmetrical hearing loss. The audiograms, magnetic resonance imaging and computed tomography scans of patients with diagnosed vestibular schwannoma were subsequently reviewed. RESULTS A total of 4100 patients were seen during the study period, with 396 scans performed. Six (1.5 per cent) patients had vestibular schwannoma, while 12 (3 per cent) had significant incidental findings. CONCLUSION Patients referred from the direct referral audiology clinic had a low incidence of vestibular schwannoma detection. Their detection rate for significant incidental findings was similar to previous reports. If the current protocol had not been in place, over 300 patients would have been needlessly added to the ENT clinic list. Thus, general practitioner referral to direct referral audiology clinics provides a cost-effective way of managing asymmetrical sensorineural hearing loss in older patients. The number of such clinics could be expanded.
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Stucken EZ, Brown K, Selesnick SH. Clinical and Diagnostic Evaluation of Acoustic Neuromas. Otolaryngol Clin North Am 2012; 45:269-84, vii. [DOI: 10.1016/j.otc.2011.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Cheng TC, Wareing MJ. Three-Year Ear, Nose, and Throat Cross-sectional Analysis of Audiometric Protocols for Magnetic Resonance Imaging Screening of Acoustic Tumors. Otolaryngol Head Neck Surg 2011; 146:438-47. [DOI: 10.1177/0194599811427384] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives. (1) Evaluate audiometric protocols and recommend protocols with best sensitivity and specificity for magnetic resonance imaging (MRI) screening of acoustic tumors; (2) determine clinical risks (false negative) of missing acoustic tumors and potential wastes in screening (false positive) nonacoustic tumors or radiologically “normal” cases; and (3) identify the decibel difference and range of frequencies compared by the best-performing protocols. Study Design. Cross-sectional study with chart review. Setting. Ear, nose, and throat (ENT); audiology; and radiology departments in a tertiary-care hospital. Subjects and Methods. Three-year cohort (2006-2009) of 1751 ENT patients underwent MRI screening and pure-tone audiometry indicating sensorineural hearing loss. Audiometric protocols were ranked by highest sensitivity to acoustic tumors, specificity A to nonacoustic tumors, and specificity B to “radiologically normal” cases. Results. No audiometric protocols achieved 100% sensitivity or specificity rates. Only 2 protocols achieved ≥90% sensitivity: the AMCLASS-A-Urben protocol (93.16%) and the Mangham protocol (91.58%). Eleven of 15 protocols for specificity A and 12 of 15 protocols for specificity B achieved ≥50%. Clinical risks ranged from 6.84% to 18.95%, whereas potential wastes ranged from 33.56% to 68.37% for specificity A and 31.76% to 66.86% for specificity B. Interaural difference parameters indicating highest mean sensitivity were on the order of ≥10 dB, ≥15 dB, and ≥20 dB. For frequency comparison parameters, “2 or more adjacent frequency” and “single-frequency” comparison indicated higher mean sensitivity than the “averaged multifrequency” comparison. Mean specificity showed an opposite pattern. Conclusions. For optimum sensitivity, the Mangham protocol is preferred (sensitivity, 91.58%; specificity A, 44.23%; specificity B, 44.91%), which proposes a ≥10-dB interaural difference, averaging 1 to 8 kHz. For optimum specificity, the American Academy of Otolaryngology–Head and Neck Surgery protocol is preferred (sensitivity, 87.37%; specificity A, 65.38%; specificity B, 66.04%), which proposes ≥15 dB between ears, averaging 0.5 to 3 kHz.
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Abstract
The growth rate of acoustic neuromas was studied in a series of 50 patients who underwent follow-up imaging studies, since surgery was not performed after the initial diagnostic study or only performed after the follow-up studies. In 50% of the cases the tumor did not grow during the length of the follow-up. In the other patients the growth was less than 50% of the original tumor size in all but four. No correlation was observed between tumor growth, length of the follow-up, and age of the patient. Our results suggest a change in the management of this benign tumor.
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Newton JR, Shakeel M, Flatman S, Beattie C, Ram B. Magnetic resonance imaging screening in acoustic neuroma. Am J Otolaryngol 2010; 31:217-20. [PMID: 20015748 DOI: 10.1016/j.amjoto.2009.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 02/03/2009] [Accepted: 02/15/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Magnetic resonance imaging (MRI) is the definitive investigation for detection of an acoustic neuroma. It is however an expensive resource, and pick-up rate of a tumor can be as low as 1% of all patients scanned. This study aims to examine referral patterns for MRI screening for patients presenting with asymmetrical sensorineural hearing loss (ASHL). A second aim was to suggest appropriate screening criteria. METHOD All 132 MRI scans performed for ASHL in the year 2005 were reviewed retrospectively along with their case records and audiograms. In addition, MRI scans and case records were reviewed for the last 30 patients diagnosed with acoustic neuromas. Information was analyzed using 2 published protocols and additional frequency-specific defined criteria. RESULTS Two acoustic neuromas were picked up out of 132 scans performed. Of the scans performed for ASHL, a third did not fit with any of the published criteria. Of the 30 positive scans for a tumor, the patients/audiograms revealed that 10% did not fit the published criteria despite the patients having no other audiovestibular symptoms. CONCLUSIONS There appears to be no universally accepted guidelines on screening in ASHL with clinical acumen being used by most ENT consultants in this region. Applying protocols may reduce the amount of scans performed, but up to 10% of tumors may be missed by this approach.
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Affiliation(s)
- Jonathan R Newton
- Department of Otolaryngology, Royal Eye and Ear Hospital, Melbourne, Victoria, Australia.
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Abstract
OBJECTIVES (1) To compare audiometric parameters in patients with vestibular schwannoma and in those with asymmetric hearing loss from other causes; and (2) to assess proposed screening criteria by comparing published protocols. METHODS Audiometric data from 199 vestibular schwannoma patients and 225 non-tumour patients were compared. Eight screening protocols were tested on these 424 patients. RESULTS Vestibular schwannoma and non-tumour patients with little or no hearing loss in the unaffected ear were inseparable; however, vestibular schwannoma patients with hearing loss in the unaffected ear had greater audiometric asymmetry, compared with non-tumour patients with the same pattern of hearing loss. The sensitivity of screening protocols varied from 73 to 100 per cent; parallelism was observed between sensitivity and screening rate. CONCLUSION As regards vestibular schwannoma screening protocols, the best compromise between sensitivity and screening rate was offered by a criterion comprising either: (1) > or =20 dB asymmetry at two neighbouring frequencies, or unilateral tinnitus, or (2) > or =15 dB asymmetry at two frequencies between 2 and 8 kHz.
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Ozgen B, Oguz B, Dolgun A. Diagnostic accuracy of the constructive interference in steady state sequence alone for follow-up imaging of vestibular schwannomas. AJNR Am J Neuroradiol 2009; 30:985-91. [PMID: 19193761 DOI: 10.3174/ajnr.a1472] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Vestibular schwannoma (VS) is a benign, slow-growing tumor, and radiologic monitoring is an acceptable alternative to surgery in small lesions and in elderly patients. MR imaging with contrast is the study of choice in the follow-up of these lesions. However, gadolinium-based contrast agents have side effects and should be used only when definitely indicated. The purpose of this study was to evaluate the diagnostic accuracy of the constructive interference in steady state (CISS) sequence used without postcontrast sequences for the follow-up imaging of VS. MATERIALS AND METHODS MR imaging examinations of 18 patients were retrospectively evaluated by 2 radiologists. VS masses were measured on both CISS and the postcontrast images by each observer. For each patient, the masses were also assessed qualitatively for possible progression between every consecutive study. RESULTS Fifty MR images of 18 patients were evaluated. Patients had 1-5 follow-up studies. The mean time interval between the consecutive studies was 23 months (6-55 months). The sensitivity, specificity, and accuracy of the CISS sequence for the detection of progression were 100%. There was good interobserver and intraobserver (CISS and postcontrast) correlation. The CISS sequence had, however, limited sensitivity for the detection of changes in the internal architecture. CONCLUSIONS Noncontrast CISS-only technique may be a viable alternative to routine contrast-enhanced sequences for the follow-up of overall lesion size in patients with VS; however, treatment-related changes internal to the tumor are less noticeable using the CISS sequence.
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Affiliation(s)
- B Ozgen
- Department of Radiology, Hacettepe University, Faculty of Medicine, Sihhiye, Ankara, Turkey.
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Cueva RA. Auditory Brainstem Response versus Magnetic Resonance Imaging for the Evaluation of Asymmetric Sensorineural Hearing Loss. Laryngoscope 2009; 114:1686-92. [PMID: 15454755 DOI: 10.1097/00005537-200410000-00003] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS Auditory brainstem response (ABR) testing and magnetic resonance imaging (MRI) are compared for the evaluation of patients with asymmetric sensorineural hearing loss (SNHL). MRI with gadolinium administration is the current gold standard for identifying retrocochlear lesions causing asymmetric SNHL. The study seeks to determine the sensitivity and specificity of ABR in screening for possible retrocochlear pathology. Most important among SNHL etiologies are neoplastic lesions such as vestibular schwannomas, cerebellopontine angle (CPA) tumors, as well as multiple sclerosis, stroke, or other rare nonneoplastic causes. The study results will allow the author to recommend a screening algorithm for patients with asymmetric SNHL. STUDY DESIGN The study is a multi-institutional, institutional review board approved, prospective, nonrandomized comparison of ABR and MRI for the evaluation of patients with asymmetric SNHL. METHODS Three hundred twelve patients (between the ages of 18 and 87) with asymmetric SNHL completed the study. Asymmetric SNHL was defined as 15 dB or greater asymmetry in two or more frequencies or 15% or more asymmetry in speech discrimination scores (SDS). These patients prospectively underwent both ABR and MRI. The ABR and MRI were interpreted independently in a blinded fashion. In addition to the ABR and MRI results, a variety of clinical and demographic data were collected. RESULTS Thirty-one (9.94%) patients of the study population of 312 were found on MRI to have lesions causing their SNHL. Of the 31 patients with causative lesions on MRI there were 24 vestibular schwannomas, 2 glomus jugulare tumors, 2 ectatic basilar arteries with brainstem compression, 1 petrous apex cholesterol granuloma, 1 case of possible demyelinating disease, and 1 parietal lobe mass. Twenty-two of the 31 patients had abnormal ABRs, whereas 9 patients (7 with small vestibular schwannomas) had normal ABRs. This gives an overall false-negative rate for ABR of 29%. The false-positive rate was found to be 76.84%. Sensitivity of ABR as a screening test was 71%, and specificity was 74%. CONCLUSIONS Ten percent of patients with asymmetric SNHL (by this study's criteria) are likely to have causative lesions found on MRI. Although the recently reported annual incidence of vestibular schwannoma in the general population is 0.00124%, for patients with asymmetric SNHL in this study, the incidence was 7.7% (nearly 4 orders of magnitude higher). ABR has been demonstrated to have low sensitivity and specificity in the evaluation of these patients and cannot be relied on as a screening test for patients with asymmetric SNHL. Keeping the use of MRI conditional on the results of ABR will annually result in missed or delayed diagnosis of causative lesions in 29 patients per 1,000 screened. The author recommends abandoning ABR as a screening test for asymmetric SNHL and adoption of a focused MRI protocol as the screening test of choice (within certain guidelines).
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Affiliation(s)
- Roberto A Cueva
- Department of Head and Neck Surgery, Southern California Permanente Medical Group, 4647 Zion Avenue, San Diego, CA 92120, U.S.A
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Abstract
Recent advances in molecular biology have led to a better understanding of the etiology of vestibular schwannomas. The underlying purpose of vestibular schwannoma research is the development of new treatment options; however, such options have not yet been established. A fundamental understanding of the underlying molecular events leading to tumor formation began when mutations in the neurofibromatosis type 2 (NF2) tumor suppressor gene were identified in vestibular schwannomas. The clinical characteristics of vestibular schwannomas and neurofibromatosis type 2 (NF2) syndromes have both been related to alterations in the NF2 gene. Genetic screening for NF2 is now available. When utilized with clinical screening, such as magnetic resonance imaging (MRI), conventional audiometry, and auditory brainstem response (ABR), the early detection of NF2 can be made, which consequently makes a significant difference in the ability to successfully treat vestibular schwannomas. Additionally, the signaling pathways affected by merlin, the product of the NF2 gene, are becoming better understood. Nf2-transgenic and knockout mice as well as vestibular schwannoma xenograft models are now ready for novel therapeutic testing. Hopefully, better treatment options will be forthcoming soon.
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Affiliation(s)
- Long-Sheng Chang
- Department of Pediatrics, The Ohio State University College of Medicine, Center for Childhood Cancer Research Institute at National Childen's Hospital, Columbus, OH, USA
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Analysis of causes for late presentation of Indian patients with vestibular schwannoma. The Journal of Laryngology & Otology 2008; 123:502-8. [PMID: 18808730 DOI: 10.1017/s0022215108003575] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the causes of delay in diagnosis and treatment of Indian patients with vestibular schwannomas. METHODS In a prospective study from 2003 to 2005, 50 patients with a confirmed diagnosis of vestibular schwannoma were interviewed to determine the causes for (1) the delay between the patient noting the initial symptom and the definitive diagnosis, and (2) the reasons for delayed diagnosis. RESULTS In 90 per cent of patients, the initial symptom was either hearing loss (62 per cent), vertigo (24 per cent) or tinnitus (4 per cent). However, most patients had been diagnosed and had presented for surgery only after neurological symptoms had became apparent. The delay between the initial medical consultation and the final diagnosis ranged from one month to 204 months (mean +/- standard deviation, 32.2 +/- 38.9 months). After the patient had noted symptoms, the diagnosis of vestibular schwannoma was delayed due to doctor-related causes in 80 per cent of cases, and due to patient-related causes in 20 per cent. Delay following diagnosis was minimal. CONCLUSIONS Delay in the diagnosis of vestibular schwannoma in Indian patients is due to both doctor- and patient-related factors.
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Abstract
OBJECTIVES The literature on delays in vestibular schwannoma diagnosis is from the era before the routine use of magnetic resonance imaging. We evaluated such diagnostic delays and their impact on tumour size and on pre- and post-treatment morbidity, in a relatively recent patient series. STUDY DESIGN Retrospective review. METHODS A two-centre study was conducted, including 91 consecutive vestibular schwannoma patients diagnosed between 1992 and 2006. Data on the presenting symptom and the initial medical visit were obtained from primary care records completed at the time of the initial visit; data on the tumour and the clinical course were obtained from review of the hospital chart. Data on diagnostic delays were available for 59 patients. RESULTS The median patient, professional and total diagnostic delays were three, four and 14 months, respectively. Unilateral hearing loss as the presenting symptom predicted an lengthened total diagnostic delay. Diagnostic delay had no impact on the tumour size at time of diagnosis or on the pre- and post-treatment morbidity. CONCLUSIONS Delays in the diagnosis of vestibular schwannoma have shortened since the introduction of magnetic resonance imaging. Longer diagnostic delays do not seem to have significant consequences.
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Mahrous AK, Kalepu R. Positive findings on MRI in patients with asymmetrical SNHL. Eur Arch Otorhinolaryngol 2008; 265:1471-5. [DOI: 10.1007/s00405-008-0704-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 04/29/2008] [Indexed: 11/29/2022]
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Chatrath P, Frosh A, Gore A, Nouraei R, Harcourt J. Identification of predictors and development of a screening protocol for cerebello-pontine lesions in patients presenting with audio-vestibular dysfunction. Clin Otolaryngol 2008; 33:102-7. [DOI: 10.1111/j.1749-4486.2008.01667.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Respuesta. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2007. [DOI: 10.1016/s0001-6519(07)74952-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nouraei SAR, Huys QJM, Chatrath P, Powles J, Harcourt JP. Screening patients with sensorineural hearing loss for vestibular schwannoma using a Bayesian classifier. Clin Otolaryngol 2007; 32:248-54. [PMID: 17651265 DOI: 10.1111/j.1365-2273.2007.01460.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Selecting patients with asymmetrical sensorineural hearing loss for further investigation continues to pose clinical and medicolegal challenges, given the disparity between the number of symptomatic patients, and the low incidence of vestibular schwannoma as the underlying cause. We developed and validated a diagnostic model using a generalisation of neural networks, for detecting vestibular schwannomas from clinical and audiological data, and compared its performance with six previously published clinical and audiological decision-support screening protocols. DESIGN Probabilistic complex data classification using a neural network generalization. SETTINGS Tertiary referral lateral skull base and a computational neuroscience unit. PARTICIPANTS Clinical and audiometric details of 129 patients with, and as many age and sex-matched patients without vestibular schwannomas, as determined with magnetic resonance imaging. MAIN OUTCOME MEASURES The ability to diagnose a patient as having or not having vestibular schwannoma. RESULTS A Gaussian Process Ordinal Regression Classifier was trained and cross-validated to classify cases as 'with' or 'without' vestibular schwannoma, and its diagnostic performance was assessed using receiver operator characteristic plots. It proved possible to pre-select sensitivity and specificity, with an area under the curve of 0.8025. At 95% sensitivity, the trained system had a specificity of 56%, 30% better than audiological protocols with closest sensitivities. The sensitivities of previously-published audiological protocols ranged between 82-97%, and their specificities ranged between 15-61%. DISCUSSION The Gaussian Process ORdinal Regression Classifier increased the flexibility and specificity of the screening process for vestibular schwannoma when applied to a sample of matched patients with and without this condition. If applied prospectively, it could reduce the number of 'normal' magnetic resonance (MR) scans by as much as 30% without reducing detection sensitivity. Performance can be further improed through incorporating additional data domains. Current findings need to be reproduced using a larger dataset.
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Affiliation(s)
- S A R Nouraei
- Department of Otolaryngology, Charing Cross Hospital, London, UK.
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Coscarón Blanco E. Reply. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2007. [DOI: 10.1016/s2173-5735(07)70374-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Neff BA, Welling DB. Current Concepts in the Evaluation and Treatment of Neurofibromatosis Type II. Otolaryngol Clin North Am 2005; 38:671-84, ix. [PMID: 16005725 DOI: 10.1016/j.otc.2005.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article presents the current diagnostic and treatment options for the hereditary disease neurofibromatosis type II, reviews clinical presentation and diagnosis, highlights indications for and methods of clinical and genetic screening, discusses treatment approaches for surgery and stereotactic radiation, and summarizes potential future therapeutic avenues.
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Affiliation(s)
- Brian A Neff
- Department of Otolaryngology, Mayo Clinic, Rochester, MN, USA
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Baker R, Stevens-King A, Bhat N, Leong P. Should patients with asymmetrical noise-induced hearing loss be screened for vestibular schwannomas? CLINICAL OTOLARYNGOLOGY AND ALLIED SCIENCES 2003; 28:346-51. [PMID: 12871250 DOI: 10.1046/j.1365-2273.2003.00721.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Peterborough ENT department receives many referrals for MoD personnel who have suffered hearing loss from occupational noise exposure. Those patients with asymmetrical sensorineural hearing loss are routinely screened for vestibular schwannomas by MRI scanning. Scan reports from the past 5 years have been reviewed and out of 152 scans, four revealed vestibular schwannomas giving a pick-up rate of 2.5%, which compares favourably with other published pick-up rates. Review of the audiograms in these cases suggests that they can be misleading in this context. The conclusion is that patients with noise-induced asymmetrical hearing loss should be screened for acoustic neuromas.
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Affiliation(s)
- R Baker
- Department of ENT Surgery, Edith Cavell Hospital, Peterborough, UK.
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Rupa V, Job A, George M, Rajshekhar V. Cost-Effective Initial Screening for Vestibular Schwannoma: Auditory Brainstem Response or Magnetic Resonance Imaging? Otolaryngol Head Neck Surg 2003; 128:823-8. [PMID: 12825033 DOI: 10.1016/s0194-59980300358-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: Our goal was to determine the cost-effectiveness of including auditory brainstem response (ABR) testing in a screening protocol for the diagnosis of vestibular schwannoma (VS) in patients with asymmetric auditory symptoms at the Christian Medical College and Hospital, Vellore, India, where, commonly, patients with VS have tumors greater than 2 cm at the time of diagnosis.
METHODS: Ninety patients with asymmetric audiovestibular symptoms were investigated prospectively with both ABR and gadolinum-enhanced magnetic resonance imaging (GdMRI).
RESULTS: Of these 90 patients, 6 were diagnosed with VS on GdMRI. On ABR testing, 4 patients with VS had retrocochlear pathology and 2 with profound sensorineural hearing loss had no responses. ABR was found to have a sensitivity of 100% and specificity of 61.9%. A protocol involving screening of all patients with asymmetric audiovestibular symptoms using ABR and only subjecting those patients with no responses or retrocochlear pathology to GdMRI would effect a savings of $1200 for every patient detected to have a VS.
CONCLUSIONS: In our hospital setting, including ABR as the preliminary screen for patients with asymmetric audiovestibular symptoms is a cost-effective strategy.
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Affiliation(s)
- Vedantam Rupa
- Department of ENT, Christian medical College and Hospital, Vellore, India.
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Murphy MR, Selesnick SH. Cost-effective diagnosis of acoustic neuromas: a philosophical, macroeconomic, and technological decision. Otolaryngol Head Neck Surg 2002; 127:253-9. [PMID: 12402001 DOI: 10.1067/mhn.2002.128071] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our goals were to define the most sensitive techniques of acoustic neuroma diagnosis, to examine their relative costs, and to propose diagnostic modality selection given the rarity of acoustic neuroma incidence and given the other costs that society faces in more commonly encountered diseases. METHODS We conducted a MEDLINE search of the English language from 1966 to 2001 using the following keywords: acoustic neuroma, acoustic tumor, vestibular schwannoma, diagnosis, cost effectiveness, MRI, auditory brainstem response, brainstem audiometric evoked response, incidence, and prevalence. RESULTS Although magnetic resonance imaging with gadolinium remains the most sensitive diagnostic modality in the discovery of acoustic neuromas, its cost may be prohibitive for some societies. CONCLUSION Which modality to use in acoustic neuroma diagnosis is just as much a philosophical and macroeconomic question as a technological one. CLINICAL SIGNIFICANCE The cost of a timely diagnosis of acoustic neuromas must be weighed against using resources for other, more pressing, health concerns.
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Affiliation(s)
- Mark R Murphy
- Department of Otorhinolaryngology, Weill College of Medicine of Cornell University, New York, New York 10021, USA
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Abstract
Acoustic neuroma results from abnormal proliferation of Schwann cells. These tumors originate in the region of Scarpa's ganglion at the junction of peripheral and central myelin of the vestibular nerve located in the internal auditory canal (IAC). The bony confine of the IAC houses the VII and the VIII cranial nerves. The presence of tumor mass compresses these structures. The growing tumor mass may also prolapses into the cerebellopontine angle (CPA). With continued growth, the tumor eventually compresses on the brain stem and cerebellum. Despite the benign nature of these tumors, the clinical course of this disease may be fraught with complications.
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Affiliation(s)
- Steven Y Ho
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT 06520, USA
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Plaza G, López Lafuente J, Aparicio JM, Herraiz C, Mate MA, Toledano A, de los Santos G. [Magnetic resonance: first choice test in the screening of internal auditory canal and cerebellopontine angle tumors]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2001; 52:651-6. [PMID: 11771359 DOI: 10.1016/s0001-6519(01)78262-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although internal auditory canal (IAC) and cerebellopontine angle (CPA) tumors are rare, their clinical suspicion is quite common in the otolaryngology office. MRI is the imaging modality of choice in diagnosing these tumors. Perceived high costs may prevent clinicians from using it as a screening tool. A protocol designed to improve cost-effectiveness in such diagnosis results in a more rationale clinical practice. Our aim was to evaluate the usefulness of MRI as screening tool in diagnosis of IAC and CPA tumors in our population. Between March 1998 and March 2000, a prospective series of 200 cases had a MRI screening requested. MRI were performed following Fast Spin Echo technique, providing T2-weighted images. Gadolinium enhanced MRI was reserved for selected cases. We report on 190 MRI done. We found 7 neuromas (3.5%), one CPA metastasis, one epidermoid cyst and 9 IAC vascular anomalies. Only 138 cases (69%) had normal MRI images. When used following a designed protocol, MRI is our procedure of choice while screening IAC and CPA tumors because it is a cost-effective tool.
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Affiliation(s)
- G Plaza
- Unidad de Otorrinolaringologia, Fundación Hospital, Alcorcón. o
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Kezirian EJ, Yueh B. Accuracy of terminology and methodology in economic analyses in otolaryngology. Otolaryngol Head Neck Surg 2001; 124:496-502. [PMID: 11337651 DOI: 10.1067/mhn.2001.114675] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Economic studies increasingly guide health care resource allocation decisions. Because rigorous adherence to accepted definitions and research techniques is critical to ensure accuracy, we evaluated the terminology and methods of otolaryngology economic analyses. STUDY DESIGN A total of 71 articles published from 1990 to 1999 in 6 peer-reviewed otolaryngology journals with terms such as "cost-effective" in their title or representing economic analyses were reviewed for terminology and use of established methodology guidelines. RESULTS Over half (35 of 66) of terms such as "cost-effective" were used incorrectly, and 60% of articles (39 of 64) confused "charge" and "cost" data. Eleven percent (7 of 64) of papers specified the perspective of their analysis. About half (17 of 30) reported a summary measure such as a cost-effectiveness ratio. Only one third (23 of 63) performed sensitivity analyses. CONCLUSION Adherence to accepted definitions and research methods is inconsistent, although we did note moderate improvements in making the distinction between costs and charges, defining of study perspective, and performing sensitivity analysis. SIGNIFICANCE Greater attention to both terminology and methodology can enhance the quality of economic analyses and ultimately improve certain resource allocation decisions.
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Affiliation(s)
- E J Kezirian
- University of Washington, Seattle 98195-6515, USA.
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Dort JC, Sadler D, Hu W, Wallace C, La Forge P, Sevick R. Screening for cerebellopontine angle tumours: conventional MRI vs T2 fast spin echo MRI. Can J Neurol Sci 2001; 28:47-50. [PMID: 11252294 DOI: 10.1017/s0317167100052549] [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: 11/07/2022]
Abstract
BACKGROUND Unilateral audiovestibular symptoms are commonly seen in clinical practice and are rarely caused by retrocochlear pathology. However, clinicians are often required to rule out potentially serious causes of these unilateral symptoms. Gadolinium enhanced magnetic resonance imaging (GdMRI) is the most accurate test for detecting small cerebellopontine angle lesions and also screens the adjacent CNS structures. Its main disadvantage is the cost of the procedure. METHODS We studied 100 consecutive patients with both GdMRI and a newer MRI screening study utilizing unenhanced T2-weighted fast spin echo (fse) MRI. Acquired images were randomly assessed by a panel of three neuro-radiologists. RESULTS We found that the screening (fse) MRI was as sensitive and specific when detecting cerebellopontine angle tumors. CONCLUSIONS We conclude that T2-weighted fse MRI is a safe and cost-effective alternative to GdMRI and offers better diagnostic utility when compared to auditory brain stem response (ABR) and CT scans.
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Affiliation(s)
- J C Dort
- Department of Surgery, University of Calgary, Alberta, Canada
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Massick DD, Welling DB, Dodson EE, Scholfield M, Nagaraja HN, Schmalbrock P, Chakeres DW. Tumor growth and audiometric change in vestibular schwannomas managed conservatively. Laryngoscope 2000; 110:1843-9. [PMID: 11081597 DOI: 10.1097/00005537-200011000-00015] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To prospectively define the correlation between changes in tumor volume and audiometric function in vestibular schwannomas managed conservatively. STUDY DESIGN Prospective longitudinal study. METHODS Twenty-one patients (age range, 15-84 y; mean age, 63.3 y) with newly diagnosed vestibular schwannomas were enrolled between 1994 and 1999 in a protocol at The Ohio State University Hospital (Columbus, OH) to evaluate the correlation between tumor volume and audiometric change during a period of observation. Patients were evaluated yearly by clinical examination, a standardized internal auditory canal magnetic resonance imaging scan with gadolinium contrast for volumetric analysis, and audiometric function testing. Demographic data, historical features, neurofibromatosis type 2 (NF2) status, initial testing results, and serial testing results were recorded. RESULTS An increase in tumor volume occurred in 14 of the 21 patients (66%). The pattern of volumetric change was found to be extremely variable. Multiple regression analysis revealed significant correlations of changes in tumor volume with changes in pure-tone average and speech discrimination score (P < .0001 and P = .0021, respectively). Change in tumor volume had greater effect on pure-tone average and speech discrimination score in patients initially with class D audiometric function when compared with those initially in class A (P = .0083 and P = .0245, respectively). The presence of NF2 had an independent protective effect against deterioration of the pure-tone average when compared with patients without NF2 (P = .0125). CONCLUSIONS This study demonstrated a significant correlation between a change in volume and auditory deterioration in vestibular schwannomas being managed with a trial of observation. A given change in tumor volume appeared to have a greater effect on pure-tone average and speech discrimination score as initial auditory classification declined.
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Affiliation(s)
- D D Massick
- Department of Otolaryngology, The Ohio State University, Columbus 43210, USA
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Kaylie DM, Horgan MJ, Delashaw JB, McMenomey SO. A meta-analysis comparing outcomes of microsurgery and gamma knife radiosurgery. Laryngoscope 2000; 110:1850-6. [PMID: 11081598 DOI: 10.1097/00005537-200011000-00016] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS Surgery has been the most common treatment for acoustic neuromas, but gamma knife radiosurgery has emerged as a safe and efficacious alternative to microsurgery. This meta-analysis compares the outcomes of the two modalities. STUDY DESIGN A retrospective MEDLINE search was used to find all surgical and gamma knife studies published from 1990 to 1998 and strict inclusion criteria were applied. RESULTS For tumors less than 4 cm in diameter, there is no difference in hearing preservation (P = .82) or facial nerve outcome (P = .2). Surgery on all sized tumors has a significantly lower complication rate than radiosurgery performed on tumors smaller than 4 cm (P = 3.2 x 10(-14)). Surgery also has a lower major morbidity rate than gamma knife radiosurgery (P = 2.4 x 10(-14)). Tumor control was defined as no tumor recurrence or no tumor regrowth. Surgery has superior tumor control when tumors are totally resected (P = 9.02 x 10(-11)). Assuming that all partially resected tumors will recur, surgery still retains a significant advantage over radiosurgery for tumor control (P = .028). CONCLUSION Data from these studies date back to the late 1960s and do not completely reflect outcomes using current imaging and procedures. A major difficulty encountered in this study is inconsistent data reporting. Future surgical and radiation reports should use standardized outcomes scales to allow valid statistical comparisons. In addition, long-term results from gamma knife radiosurgery using lower dosimetry have not been reported. Surgery should remain the therapy of choice for acoustic neuromas until tumor control rates can be established.
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Affiliation(s)
- D M Kaylie
- Department of Otolaryngology--Head and Neck Surgery, Oregon Health Sciences University, Portland 97201-3098, USA
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Sundaramoorthy V, Pont MJ, Degg C, Cook JA. A computerized database of 'normal' auditory brainstem responses. BRITISH JOURNAL OF AUDIOLOGY 2000; 34:197-201. [PMID: 10905453 DOI: 10.3109/03005364000000129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A computerized database of auditory brainstem responses (ABRs) from 'normal-hearing' volunteers is described. The database contains 'raw' responses recorded from 81 individuals; subjects varied in age from 20 to 56 years. The database is currently being used in a study to aid in the interpretation of ABRs for diagnostic purposes. Copies of the database are available over the world-wide web (http:¿¿www.engg.le.ac.uk¿abrdata).
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