Neuromonitoring of the cochlear nerve during vestibular schwannoma resection and simultaneous cochlear implantation

Unmasking vestibular schwannoma: A series of unusual cases

INTRODUCTION

Vestibular schwannoma (VS) is a benign, slow-growing tumor that accounts for 80-90 % of cerebellopontine angle (CPA) tumors. While classic symptoms like hearing loss, tinnitus, and vertigo are well-recognized, atypical presentations can delay diagnosis.

CASE PRESENTATION

We present four unusual cases of VS. The first patient, a 33-year-old woman, initially presented with transient tinnitus and later developed peripheral vertigo. The second case involved a 52-year-old man with sudden hearing loss, vertigo, and aural fullness. The third case was a 17-year-old female with unilateral auditory neuropathy. The fourth patient, a 39-year-old woman, presented with intermittent tinnitus, balance disturbances, and facial stiffness.

DISCUSSION

Detailed history, physical examination, and audiological evaluation are crucial for identifying patients at risk for vestibular schwannoma, especially with atypical audiological findings, to avoid misdiagnosis.

CONCLUSION

This case series emphasizes the significance of considering VS as a differential diagnosis for atypical symptoms. Early recognition and proper practice can lead to optimal outcomes for patients and contribute valuable insights to the scientific field by broadening the understanding of the diverse spectrum of VS symptoms.

Treatment options for unilateral vestibular schwannoma: a network meta-analysis

This study aimed to explore the effect of observation, microsurgery, and radiotherapy for patients with vestibular schwannoma (VS). We searched PubMed, Medline, Embase, Web of Science, and Cochrane library from their establishment to July 31, 2024. 34 non-RCTs and 1 RCT that included 6 interventions were analyzed. We found the MS, and different SRS all had better tumor local control rates. Regarding preserved hearing, the order from the highest to the lowest was FSRT 5 fractions, FSRT 3 fractions, SRS, ConFSRT, Observation, and MS. Regarding improvement in the rate of tinnitus, the order from the highest to the lowest was ConFSRT, FSRT 3 fractions, SRS, Observation, MS, and FSRT 5 fractions. In terms of improving the rate of disequilibrium/vertigo, the order from the highest to the lowest was SRS, Observation, FSRT 3 fractions, FSRT 5 fractions, MS, and ConFSRT. In terms of protection of the trigeminal nerve, the order from the highest to lowest was observation, SRS, ConFSRT, FSRT 3 fractions, FSRT 5 fractions, and MS. Lastly, in terms of protection of the facial nerve, the order from the highest to lowest was SRS, ConFSRT, Observation, FSRT 3 fractions, FSRT 5 fractions, and MS. In patients with VS, MS and radiosurgery showed better local tumor control rates; however, compared with MS, different SRS all provided better protection of nerve function and improved the symptoms of vestibular function and tinnitus, among which the best was SRS. Therefore, in these patients, SRS may be a promising alternative treatment.

Intraoperative Cochlear Nerve Monitoring in Cochlear Implantation after Vestibular Schwannoma Resection

BACKGROUND

The use of a cochlear implant (CI) for hearing rehabilitation after vestibular schwannoma (VS) resection is widely spreading. The procedure is usually performed simultaneously to tumor resection with a translabyrinthine approach. To ensure the best device function, assessing the integrity of the cochlear nerve is of primary importance.

METHODS

A narrative review of the literature on the present topic was carried out up to June 2022. Finally, nine studies were considered.

RESULTS

Electrically evoked auditory brainstem responses (eABR) is the most widely used method of intraoperative monitoring of cochlear nerve (CN) during VS resection, although its limits are known. It can be assessed through the CI electrode array or through an intracochlear test electrode (ITE). Variations of the graph are evaluated during the surgical procedure, in particular the wave V amplitude and latency. As tumor dissection progresses, the parameters may change, informing of the CN status, and the surgical procedure may be modulated.

CONCLUSION

An eABR positive result seems to be reliably correlated with a good CI outcome in those cases in which a clear wave V is recorded before and after tumor removal. On the contrary, in those cases in which the eABR is lost or altered during the surgical procedure, the positioning of a CI is still debatable.

Cochlear implantation: an effective modality for hearing restoration following vestibular schwannoma resection

PURPOSE OF REVIEW

Preservation of hearing is one of the tenets of vestibular schwannoma management. In recent years, cochlear implants have been employed with increasing use in patients who have suffered profound sensorineural hearing loss due to the natural history of vestibular schwannoma or due to injury to neurovascular anatomy at time of surgical resection.

RECENT FINDINGS

Cochlear implantation has been found to be an effective modality for hearing restoration following vestibular schwannoma. Simultaneous cochlear implantation has been employed by an increased number of centers around the world and has been shown to provide restoration of open set speech perception and return of binaural hearing. Ongoing use of electrically evoked auditory brainstem response (ABR) has improved our detection of viable cochlear nerves and provided insight into those who would benefit from this procedure. Finally, minimally invasive approaches to the internal auditory canal and intralabyrinthine tumors have been described. These methods frequently employ simultaneous cochlear implantation and have emphasized that hearing preservation remains possible with surgical excision despite the location of the tumor.

SUMMARY

Cochlear implantation is an effective modality for hearing restoration following vestibular schwannoma excision.

Current Understanding of Hearing Loss in Sporadic Vestibular Schwannomas: A Systematic Review

Objective

Hearing loss is the most common initial symptom in patients with sporadic vestibular schwannomas (SVS). Hearing preservation is an important goal of both conservative and surgical therapy. However, the mechanism of SVS-associated hearing loss remains unclear. Thus, we performed this systematic review to summarize the current understanding of hearing loss in the SVS and distill a testable hypothesis to further illuminate its underlying mechanism.

Methods

A systematic review querying four databases (PubMed, Medline, Embase, and Web of Science) was performed to identify studies evaluating hearing loss in patients with SVS and exploring the potential mechanisms of hearing impairment.

Results

A total of 50 articles were eligible and included in this review. After analysis, the retrieved studies could be categorized into four types: (1) 29 studies explore the relationship between hearing loss and the growth pattern of the tumor (e.g., tumor size/volume, growth rate, tumor location, etc.); (2) ten studies investigate the potential role of cochlear dysfunction in hearing deterioration, including structural abnormality, protein elevation in perilymph, and cochlear malfunctioning; (3) two studies looked into SVS-induced impairment of auditory pathway and cortex; (4) in the rest nine studies, researchers explored the molecular mechanism underlying hearing loss in SVS, which involves molecular and genetic alterations, inflammatory response, growth factors, and other tumor-associated secretions.

Conclusions

Multiple factors may contribute to the hearing impairment in SVS, including the growth pattern of tumor, cochlear dysfunction, impairment of auditory pathway and cortex, genetic and molecular changes. However, our current understanding is still limited, and future studies are needed to explore this multifactorial hypothesis and dig deeper into its underlying mechanism.