Quality of Life in 807 Patients with Vestibular Schwannoma: Comparing Treatment Modalities

Quality-of-life assessment instruments for patients with vestibular schwannoma: A systematic review

OBJECTIVE

The European Association of Neuro-Oncology (EANO) indicated that different study designs and methodologies led to inconsistent conclusions about treatment methods and QoL in patients with Vestibular Schwannoma (VS). This study systematically reviews recent findings about QoL assessment instruments for patients with VS and provides recommendations for the measurement of QoL with standardized psychometric tools.

METHODS

This study was conducted based on the PRISMA 2020 guideline for reporting systematic reviews. The key words used were as follows: quality of life, health-related quality of life, vestibular schwannomas, acoustic neuroma. Studies were included when the following eligibility criteria were met.

RESULTS

Our search finally yielded 48 articles published in years 2014-2024 that measured QoL in patients with VS using standardized psychometric tools. The studies examined various dimensions of QoL. The most frequently used disease-specific questionnaire was the Penn Acoustic Neuroma Quality of Life (PANQOL). As a generic tool, authors preferred to use the Short-Form 36-Item Health Survey (SF-36).

CONCLUSION

Recent findings and data on Quality of Life (QoL) tools for patients with VS emphasize the importance of using standardized and disease specific tool like PANQOL, due to their frequent use and large amount of patient data. Although the SF-36 is commonly used for general assessments, it may not be sensitive enough for a complete QoL evaluation and should not be the only tool used. The GBI is effective for assessing changes after specific medical treatments. Using methods similar to those in past studies helps medical professionals make reliable conclusions about QoL and evaluate the effects of different treatments in VS patients.

Genetic Alterations in Patients with NF2-Related Schwannomatosis and Sporadic Vestibular Schwannomas

Background: Unilateral (uVS) and bilateral vestibular schwannoma (bVS) are distinct disease types, yet share tumorigenic features. This study examined causative genetic alterations in three groups: patients with NF2-related schwannomatosis (NF2), young patients with uVS (≤30 years), and older patients with uVS (≥40 years). Methods: Lymphocyte and vestibular schwannoma DNA was genetically analyzed. Outcomes included gene involvement, pathogenicity classification, variant type, effect, and location, and loss of heterozygosity (LOH) of chromosome 22. Results: Among 93 patients, 17% had NF2, 39% were ≤30 years with uVS, and 44% were ≥40 years with uVS. In all patients with NF2 (100%), two or more hits were detected in the tumor DNA, whereas patients with uVS had a slightly lower detection rate (89-98%). NF2-related tumors had a higher frequency of nucleotide variants (76%), while LOH events were more common in uVS (64-69%). Variants were mostly identified in NF2, with nonsense variants over-represented in patients with NF2 (38%) and frameshift variants more prevalent in uVS (44-51%). Conclusions: Biallelic NF2 inactivation primarily drives vestibular schwannoma tumorigenesis. In patients with NF2, two pathogenic NF2 variants or one NF2 variant with LOH are common, whereas patients with uVS often exhibit one NF2 variant with LOH. Additionally, variant types differ between patient groups.

Hearing preservation and quality of life in small to medium sized vestibular schwannomas after a wait and scan approach or stereotactic radiosurgery: a systematic review and meta-analysis

BACKGROUND

The management of vestibular schwannomas (VS) encompasses a choice between conservative "wait-and-scan" (WAS) approach, stereotactic radiosurgery (SRS) or open microsurgical resection. Currently, there is no consensus on the optimal management approach for small to medium sized VS. This study aims to compared outcomes related to hearing in patients with small and medium sized VS who underwent initial treatment with WAS versus SRS.

METHODS

A systematic review of the available literature was conducted using PubMed/MEDLINE, Embase, and Cochrane up December 08, 2023. Meta-analysis was performed using a random-effect model to calculate mean difference (MD) and relative risk (RR). A leave-one-out analysis was conducted. The risk of bias was assessed via the Risk of Bias in Non-randomized Studies-Interventions (ROBINS-I) and Cochrane Risk of Bias assessment tool (RoB-2). Ultimately, the certainty of evidence was evaluated using the GRADE assessment. The primary outcomes were serviceable hearing, and pure-tone average (PTA). The secondary outcome was the Penn Acoustic Neuroma Quality of Life Scale (PANQOL) total score.

RESULTS

Nine studies were eligible for inclusion, comprising a total of 1,275 patients. Among these, 674 (52.86%) underwent WAS, while 601 patients (47.14%) received SRS. Follow-up duration ranged from two to eight years. The meta-analysis indicated that WAS had a better outcome for serviceable hearing (0.47; 95% CI: 0.32 - 0.68; p < 0.001), as well as for postoperative functional measures including PTA score (MD 13.48; 95% CI 3.83 - 23.13; p < 0.01), and PANQOL total score (MD 3.83; 95% CI 0.42 - 7.25; p = 0.03). The overall certainty of evidence ranged from "very low" to "moderate".

CONCLUSIONS

Treating small to medium sized VS with WAS increases the likelihood of preserving serviceable hearing and optimized PANQOL overall postoperative score compared to SRS. Nevertheless, the limited availability of literature and the methodological weakness observed in existing studies outline the need for higher-quality studies.

Health-Related Quality of Life in Patients With a Stable or Growing Vestibular Schwannoma Managed by Wait and Scan or Stereotactic Radiosurgery

OBJECTIVE

To assess the effect of wait and scan (W&S) and stereotactic radiosurgery (SRS) on health-related quality of life (HRQoL) over time in patients with a stable vestibular schwannoma (VS) and growing VS.

STUDY DESIGN

Longitudinal, multicenter, observational study.

SETTING

Tertiary expert center for VS (Radboudumc Nijmegen) and Gamma-Knife center ETZ Hospital Tilburg.

METHODS

Changes in HRQoL, measured with the Penn Acoustic Neuroma Quality-of-Life (PANQOL), and the physical and mental component summary scores (PCS and MCS, respectively) derived from the 36-Item Short Form Health Survey (SF-36), were compared among patients managed by W&S and SRS between 2017 and 2022. Second, HRQoL over time in patients with a growing VS was compared between W&S and SRS.

RESULTS

Differences in PANQOL total and subdomain scores, PCS and MCS scores over time in the W&S (n = 73) and SRS (n = 170) groups were nonsignificant and on average did not exceed the minimal clinically important differences (mean difference of -2.56 [PANQOL total], 1.22 [PCS], and -1.76 [MCS]; all P > .05). In growing VS, comparison of W&S (n = 29) and SRS (n = 154) also revealed no significant difference (mean difference of 1.19 (PANQOL total), 1.83 (PCS) and -0.12 (MCS); all P > .05).

CONCLUSION

Differences in HRQoL in patients with VS are minor and not significantly different or clinically relevant between patients managed with W&S or SRS. Similarly, patients with a growing VS managed with W&S or SRS exhibit no significant or clinical relevant difference in HRQoL during follow-up. This can aid clinicians in the counseling of patients regarding HRQoL when deciding on a management strategy after diagnosis or documented growth.

Quality of Life for Patients with Sporadic Small Vestibular Schwannomas Following Middle Fossa Craniotomy

OBJECTIVE

To evaluate quality-of-life outcomes for patients with vestibular schwannomas (VS) undergoing a middle cranial fossa (MCF) approach.

STUDY DESIGN

Prospective study from 2018 to 2023.

SETTING

Tertiary academic institution.

PATIENTS

Adults with sporadic VS.

INTERVENTIONS

MCF.

MAIN OUTCOME MEASURES

The primary outcome measure was the change in preoperative and 1-year postoperative Penn Acoustic Neuroma Quality-of-life (PANQOL) scores. Secondary outcome measures included hearing preservation and facial nerve function.

RESULTS

Of the 164 patients who underwent MCF for sporadic VS, 78 patients elected to voluntarily complete preoperative PANQOL assessments prior to surgery. Seventy-one (91%) of those 78 patients completed postoperative PANQOL surveys. Fifty (70%) of the respondents were female and the median age was 48 years (range, 27-71 years). Overall, at 1-year postsurgery, a minimal clinically important difference (MCID) was obtained in the hearing (mean difference, 10.5; 95% confidence interval [CI], 4.3-16.7) and anxiety (mean difference, 18.8; 95% CI, 11.7-25.9) domains. For patients with hearing preservation (n = 48, 68%), MCIDs were reached in the hearing (mean difference, 13.4; 95% CI, 6.3-20.6), anxiety (mean difference, 20.8; 95% CI, 11.8-29.9), energy (mean difference, 13.7; 95% CI, 3.6-23.8), pain (mean difference, 13.7; 95% CI, 3.6-23.8) domains, and overall PANQOL scores (mean difference, 12.7; 95% CI, 7.1-18.3). Postoperatively, 64 (90%) patients maintained a House-Brackmann I.

CONCLUSIONS

To our knowledge, this is the largest study examining disease-specific QOL for VS patients undergoing MCF. Based on our institution's experience, MCF approach for small VS is associated with clinically meaningful improvements in QOL, hearing preservation, and excellent facial nerve outcomes.

Fall-related injury among patients with vestibular schwannoma

Vestibular schwannoma can cause vestibular dysfunction; however, conflicting evidence exists regarding whether this affects the incidence of fall-related injuries in this patient population. This matched cross-sectional and cohort study assess the risk of fall-related injuries in patients with vestibular schwannoma. The study included patients with vestibular schwannoma treated at a tertiary referral hospital in Sweden between 1988 and 2014. Information on fall-related injuries was obtained from the National Patient Register, and matched population comparisons were randomly selected in a 1:25 ratio. Fall-related injuries occurring pre- (within 5 years before the diagnosis of vestibular schwannoma) and post-diagnostically (up to 3 years after diagnosis or intervention) were registered. The association between vestibular schwannoma and fall-related injuries was estimated using logistic regression and Cox proportional hazards analyses. We identified 1153 patients with vestibular schwannoma (569 [49%] women and 584 [51%] men), and 28815 population comparisons. Among the patients, 9% and 7% had pre- and post-diagnostic fall-related injuries, respectively, and among the comparisons, 8% and 6% had pre- and post-diagnostic fall-related injuries, respectively. There was no increased risk of pre- (OR 1.14; CI 0.92-1.41) or post-diagnostic 1 year (HR 1.16; CI 0.87-1.54) or 3 years (HR 1.11; CI 0.89-1.29) fall-related injury among the total patient cohort. In age-stratified analyses, we found an increased risk of pre-diagnostic fall-related injury among patients aged 50-69 years (OR 1.42; CI 1.10-1.88). Patients who underwent middle fossa surgery, regardless of age, had an increased risk of post-surgery fall-related injury within 3 years of follow-up (HR 2.68; CI 1.06-6.81). We conclude that patients with vestibular schwannoma have a low risk of enduring fall-related injuries. Middle-aged patients with dizziness and fall-related injuries should be considered for a vestibular clinical evaluation. Our results highlight the importance of rehabilitation in avoiding future fall-related injuries among patients undergoing middle fossa surgery.

The added value of the artificial intelligence patient-reported experience measure (AI-PREM tool) in clinical practise: Deployment in a vestibular schwannoma care pathway

Objectives

Patient-reported experience measures (PREMs) can be used for the improvement of quality of care. In this study, the outcome of an open-ended question PREM combined with computer-assisted analysis is compared to the outcome of a closed-ended PREM questionnaire.

Methods

This survey study assessed the outcome of the open-ended questionnaire PREM and a close-ended question PREM of patients with unilateral vestibular schwannoma in a tertiary vestibular schwannoma expert centre.

Results

The open-ended questions PREM, consisting of five questions, was completed by 507 participants and resulted in 1508 positive and 171 negative comments, categorised into 27 clusters. The close-ended questions PREM results were mainly positive (overall experience graded as 8/10), but did not identify specific action points. Patients who gave high overall scores (>8) on the close-ended question provided points for improvement in the open-ended question PREM, which would have been missed using the close-ended questions only.

Conclusions

Compared to the close-ended question PREM, the open-ended question PREM provides more detailed and specific information about the patient experience in the vestibular schwannoma care pathway.

Innovation

Automated analysis of feedback with the open-ended question PREM revealed relevant insights and identified topics for targeted quality improvement, whereas the close-ended PREM did not.

Patient-preferred outcomes in patients with vestibular schwannoma: a qualitative content analysis of symptoms, side effects and their impact on health-related quality of life

PURPOSE

During counseling and management of patients with vestibular schwannoma (VS), the emphasis is shifting from tumour control and nerve preservation towards maintaining or improving health-related quality of life (HRQoL). Understanding the patients' perspective and impact of VS is, therefore, of utmost importance. The current study aimed to identify treatment outcomes preferred by patients and to explore the patient-reported VS symptoms and management-related side effects and their impact on HRQoL.

METHODS

Patients with VS were contacted through the Dutch VS association Stichting Hoormij and questioned using a semi-structured, cross-sectional online survey. Patients were asked to report and rank symptoms and side effects, with their impact on HRQoL and frequency of occurrence. Results were structured through qualitative content analysis. Coded symptoms, side effects, impacts, frequencies, and patient-preferred outcomes were analysed and summarized with descriptive statistics.

RESULTS

Of the 231 respondents, 71% were actively treated. Hearing (symptoms vs. side effects: 78.8% vs. 63.6%), balance (62.3%; 48.8%), and energy issues (33.8%; 32.6%) were the most frequently mentioned symptoms and management-related side effects. Fatigue, deafness, headaches, and hearing loss had the highest impact on HRQoL. The majority of patients identified hearing preservation (61%), balance preservation (38.5%), and reduced tinnitus (34.6%) to be the patient-preferred outcomes.

CONCLUSION

This qualitative study demonstrates that in this population many patients with VS encounter participation difficulties in their daily physical and social activities and value hearing and balance preservation, reduced tinnitus, and restored energy as preferred outcomes as they are hampered by symptoms and side effects related to hearing, balance, and energy. Healthcare professionals should consider these key points and use these and the patient-preferred outcomes in consultation, shared decision making, treatment, and follow-up to optimize patient-centred care.

Trading mental and physical health in vestibular schwannoma treatment decision

Objective

Observation, radiotherapy and surgery are treatment options in vestibular schwannomas (VS). Decision making differs between centers and is usually based on tumor characteristics (e.g., size) and the expected physical health (PH) outcome (i.e., hearing and facial function). However, mental health (MH) is often under-reported. The objective of the present study was to ascertain the impact of VS treatment on PH and MH.

Methods

PH and MH were assessed in a prospective cross-sectional study including 226 patients with unilateral sporadic VS before and after surgical removal (SURG). Quality-of-life (QoL) was estimated by self-rating questionnaires: general Short-Form Health Survey (SF-36), Penn Acoustic Neuroma Quality-of-Life Scale (PANQOL), Dizziness Handicap Inventory (DHI), Hearing Handicap Inventory (HHI), Tinnitus Handicap Inventory (THI), and Facial Disability Index (FDI). QoL changes over time as well as predictive factors were accessed by multivariate analyses of covariance (MANCOVA).

Results

In total, 173 preoperative and 80 postoperative questionnaires were analyzed. There was a significant PH deterioration related to facial function (FDI, PANQOL-face) after surgery. In line with facial rehabilitation, however, FDI improved within the first five years after surgery and did not differ compared to the preoperative patient cohort, eventually. In contrast, MH (i.e., PANQOL-anxiety) and general health (i.e., PANQOL-GH) improved with surgery and correlated with the extent-of-resection.

Conclusion

Physical and mental health is significantly influenced by VS surgery. While PH might decrease after surgery, MH potentially increases when patient is cured. Practitioners should take MH into account before advising an incompletely VS treatment (e.g., subtotal resection, observation or radiosurgery).

Quality of Life in Sporadic Vestibular Schwannoma

The focus of management in sporadic vestibular schwannoma has dramatically evolved over the last 100 years. The centrality of quality of life (QoL) is being underscored by an ongoing epidemiologic shift toward an older patient demographic that is being diagnosed with smaller tumors and often with few associated symptoms. Two disease-specific QoL instruments have been developed for sporadic vestibular schwannoma: the Penn Acoustic Neuroma Quality of Life Scale in 2010, and more recently, the Mayo Clinic Vestibular Schwannoma Quality of Life Index in 2022. The current article examines disease-specific quality-of-life outocmes in the management of ssporadic vestibular schwannoma.

Digital Patient-Reported Outcome Measures Assessing Health-Related Quality of Life in Skull Base Diseases-Analysis of Feasibility and Pitfalls Two Years after Implementation

Health-related quality of life (HRQoL) assessment is becoming increasingly important in neurosurgery following the trend toward patient-centered care, especially in the context of skull base diseases. The current study evaluates the systematic assessment of HRQoL using digital patient-reported outcome measures (PROMs) in a tertiary care center specialized in skull base diseases. The methodology and feasibility to conduct digital PROMs using both generic and disease-specific questionnaires were investigated. Infrastructural and patient-specific factors affecting participation and response rates were analyzed. Since August 2020, 158 digital PROMs were implemented in skull base patients presenting for specialized outpatient consultations. Reduced personnel capacity led to significantly fewer PROMs being conducted during the second versus (vs.) the first year after introduction (mean: 0.77 vs. 2.47 per consultation day, p = 0.0002). The mean age of patients not completing vs. those completing long-term assessments was significantly higher (59.90 vs. 54.11 years, p = 0.0136). Follow-up response rates tended to be increased with recent surgery rather than with the wait-and-scan strategy. Our strategy of conducting digital PROMs appears suitable for assessing HRQoL in skull base diseases. The availability of medical personnel for implementation and supervision was essential. Response rates during follow-up tended to be higher both with younger age and after recent surgery.

Long-Term Quality of Life of Vestibular Schwannoma Patients: A Longitudinal Analysis

OBJECTIVE

Vestibular schwannoma management aims to maintain optimal quality of life (QoL) while preventing severe sequelae of the tumor or its treatment. This study assessed long-term QoL of patients with vestibular schwannoma in relation to treatment modality and decisional regret.

STUDY DESIGN

A longitudinal study, in which clinical and QoL data were used that were cross-sectionally acquired in 2014 and again in 2020 from the same patient group.

SETTING

A tertiary expert center for vestibular schwannoma care in the Netherlands.

METHODS

QoL was measured by the Penn Acoustic Quality of Life (PANQOL) scale. Changes in time were assed using a linear mixed model. In addition, the Decision Regret Scale was analyzed.

RESULTS

Of 867 patients, 536 responded (62%), with a median follow-up of 11 years. All PANQOL subdomain scores remained stable over time and did not exceed minimal clinically important difference (MCID) levels. Time since treatment did not affect QoL. Patients had comparable average QoL scores and proportions of patients with changing QoL scores (ie, exceeding the MCID) over time, irrespective of the received initial treatment. Female patients and those who required salvage therapy (either by radiotherapy or surgery) reported a lower QoL. The latter patient group reported the highest decisional regret.

CONCLUSION

On average, the long-term QoL of patients with vestibular schwannoma is comparable for patients under active surveillance and those who have received active treatment, and it remains stable over time. This suggests that, on average, preservation of QoL of patients with vestibular schwannoma is feasible when adequately managed.

Vestibular Complaints Impact on the Long-Term Quality of Life of Vestibular Schwannoma Patients

OBJECTIVE

To analyze the effect of dizziness-related symptoms on the long-term quality of life (QoL) of patients with unilateral vestibular schwannoma.

METHODS

In this cross-sectional study, patients with a unilateral vestibular schwannoma diagnosed between 2004 and 2013 completed a disease-specific QoL questionnaire (Penn Acoustic Neuroma Quality of Life [PANQOL]) and the Dizziness Handicap Inventory (DHI) in 2020. Linear regression was performed to assess the correlation between QoL and the DHI total score, and the scores of the DHI functional, emotional, and physical subdomains. Potential confounders such as age, sex, tumor size at baseline, and treatment modality (active surveillance, surgery, or radiotherapy) were included in the model.

RESULTS

In total, 287 of 479 patients (59%) experienced dizziness with a median follow-up of 10 years. The DHI total score was significantly associated with the PANQOL total score. On average, we found a reduction of 0.7 points on the PANQOL for each additional point on the DHI. The DHI emotional subdomain was the most prominent determinant of poorer QoL. Each point on the DHI emotional subscale was associated with a reduction of 1.3 on the PANQOL score. Treatment modality did not have a clinically relevant effect on dizziness-related QoL.

CONCLUSIONS

Even mild dizziness can have a significant and clinically relevant effect on the QoL of patients with unilateral vestibular schwannoma in the long term. This holds true for all treatment modalities. Addressing the vestibular problems may improve QoL in vestibular schwannoma patients, and DHI subscale analysis may help tailor the optimal vestibular intervention.

Comparing Patient Satisfaction After Upfront Treatment Versus Wait-and-Scan for Small Sporadic Vestibular Schwannoma

OBJECTIVE

Management of small vestibular schwannoma (VS) remains controversial, as patients are typically candidates for all three management options including microsurgery, stereotactic radiosurgery, or wait-and-scan. This study compares patient satisfaction across treatment modalities in patients with small VS.

STUDY DESIGN

Cross-sectional study.

SETTING

Survey distributed to members of the Acoustic Neuroma Association and Mayo Clinic patients.

METHODS

Patients with small (<1 cm in any location) sporadic VS who completed at least one survey regarding treatment history and patient satisfaction were included.

RESULTS

Among 346 patients with small VS, 106 (31%) underwent microsurgery, 78 (23%) radiosurgery, 152 (44%) wait-and-scan, and 10 (3%) multimodal treatment. Collectively, 307 (89%) patients indicated "Yes, I am happy with my treatment type and in hindsight I would not change anything," and 39 (11%) indicated "No, in hindsight I would have chosen a different treatment type." Satisfaction differed significantly by treatment group with 85, 86, 96, and 40% of patients in the microsurgery, radiosurgery, wait-and-scan, and multimodal groups reporting that they were satisfied with treatment, respectively ( p < 0.001). Satisfaction also differed significantly among those undergoing upfront treatment with microsurgery or radiosurgery (81%), initial wait-and-scan followed by treatment (88%), and wait-and-scan only groups (96%; p = 0.001). Specifically, the wait-and-scan only group demonstrated greater satisfaction compared with the other two treatment strategies ( p < 0.05 for both).

CONCLUSIONS

Patient satisfaction with the management of small VS is generally high. Management with wait-and-scan, even if treatment is eventually pursued, may offer higher patient satisfaction compared with upfront treatment.

Use of a Novel Clinical Decision-Making Tool in Vestibular Schwannoma Treatment

OBJECTIVE

To determine the usefulness of a personalized tool and its effect on the decision-making process for those with vestibular schwannoma (VS).

STUDY DESIGN

Prospective study.

SETTING

Single institution, academic tertiary care lateral skull base surgery program.

PATIENTS

Patients diagnosed with VS.

INTERVENTIONS

A comprehensive clinical decision support (CDS) tool was constructed from a previously published retrospective patient-reported data obtained from members of the Acoustic Neuroma Association from January to March 2017. Demographic, tumor, and treatment modality data, including associated side effects, were collected for 775 patients and integrated in an interactive and personalized web-based tool.

MAIN OUTCOME MEASURES

Pre- and posttool questionnaires assessing the process of deciding treatment for VS using a decisional conflict scale (DCS) and satisfaction with decision (SWD) scale were compared.

RESULTS

A pilot study of 33 patients evaluated at a single institution tertiary care center with mean ± SD age of 63.9 ± 13.5 years and with average tumor size of 7.11 ± 4.75 mm were surveyed. CDS implementation resulted in a mean ± SD total DCS score decrease from 43.6 ± 15.5 to 37.6 ± 16.4 ( p < 0.01) and total SWD score increase from 82.8 ± 16.1 to 86.2 ± 14.4 ( p = 0.04), indicating a significant decrease in decisional conflict and increase in satisfaction.

CONCLUSIONS

Implementing a decision-making tool after diagnosis of VS reduced decisional conflict and improved satisfaction with decision. Patients considered the tool to be an aid to their medical knowledge, further improving their comfort and understanding of their treatment options. These findings provide a basis for developing predictive tools that will assist patients in making informed medical decisions in the future.

Postoperative Impact of Pontocerebellar Angle Surgery on the Quality of Life in Patients with Vestibular Schwannoma

BACKGROUND

Vestibular Schwannomas are benign tumors arising from the VIII CN. Surgical treatment is indicated in case of tumors larger than 2.5 cm in the cerebellopontine angle or in the case of cranial nerve dysfunction. The aim of the present study was to evaluate the QoL by means of the PANQOL questionnaire in a group of surgically treated patients mainly affected by large and giant VS Methods: All patients underwent preoperative and postoperative otoneurological evaluation and gadolinium enhanced MRI and they completed, independently, the PANQOL questionnaire at last follow up.

RESULTS

70% of patients presented with large Koos III or IV VS Each domain of PANQOL showed a strong correlation with the total PANQOL score. In relation to the postoperative facial nerve function, patients with poorer function showed significantly lower score in the facial dysfunction and pain, patients with postoperative balance problems showed a significantly lower PANQOL score for domains of balance and pain.

CONCLUSIONS

This study showed that postoperative QoL of patients was acceptable even if there were some domains that were more affected, such as hearing and balance domains; therefore, the lowest scores suggest the need for vestibular rehabilitation programs and strategies that improve postoperative hearing.

Novel Multiportal Approach to the Internal Auditory Canal for Hearing-Preserving Surgery: Feasibility Assessment in Dissections

OBJECTIVE

State-of-the-art, minimally invasive endoscopic transcanal surgery of the internal auditory canal (IAC) sacrifices the cochlea with complete hearing loss. With a combination of the transcanal infracochlear and transmastoid retrolabyrinthine approaches, we aim to preserve hearing and enable minimally invasive surgical treatment of vestibular schwannoma. In this study, we investigate the anatomical indications and the feasibility of both approaches in dissections, in human whole head specimens.

METHODS

We operated whole head anatomical specimens with a four-handed technique, using the retrolabyrinthine approach as the main surgical corridor and the infracochlear approach for endoscopic visualization. We tested 4 different powered surgical systems. We collected intraoperative data on the size of the access windows, the surgical freedom, and the exposed area of the IAC. Finally, we evaluated the outcome in postoperative computed tomography scans.

RESULTS

Six out of 14 sides were anatomically suitable and qualified for the surgery based on preoperative computed tomography. In all attempted sides, the IAC could be reached and opened, leaving the ossicular chain and the labyrinth intact. 51%-75% of the length and 22%-40% of the circumference of the IAC could be exposed. All tested instruments were beneficial at different stages of the surgery. The four-handed technique enabled good maneuverability of the instruments.

CONCLUSIONS

The combined multiportal approach to the IAC is feasible with a good surgical exposure and full anatomical preservation of hearing. State-of-the-art surgical instruments in specimens with suitable anatomy are sufficient to perform this approach.

Preoperative Visual Impairment in Vestibular Schwannoma Patients: An Overlooked Entity of Developing World

Objective Visual impairment in vestibular schwannomas is an underreported entity. The plethora of literature focuses primarily on facial and hearing preservation. This study aims to describe our experience and find the possible reasons for visual impairment.

Materials and Methods This is a retrospective observational study. We evaluated 114 patients with vestibular schwannoma, operated during 2015 to 2020. Eight parameters were studied—age, gender, maximum tumor size, hydrocephalus, economic status, duration of symptoms, visual loss, and ease of access to the tertiary neurosurgical facility. JASP software (version 0.14.1, Amsterdam) was used for statistical analysis.

Results A total of 42/114 (36.84%) patients had a varying degree of impairment. Patients with impaired vision had significantly larger tumors (4.31 vs. 4.12 cm, p = 0.02), longer duration of symptoms (19.14 vs. 16.45 months, p = 0.02), hydrocephalus (p = 0.03), and were from remote areas (p = 0.009). In stepwise logistic regression analysis, longer duration of symptoms and difficult access to neurosurgical facility stand out as decisive factors for visual impairment. The follow-up data were available for 35/42 (83.33%) cases of visual impairment. Vision improved in 14/35 (40%) of cases. Vision improved in a significantly higher number of patients when a preoperative ventriculoperitoneal shunt was placed (p = 0.03).

Conclusion The visual handicap occurs in a significant number of patients with vestibular schwannoma. Delayed arrival at the neurosurgical facility due to difficult access appears to be the primary factor leading to blindness. Strengthening our healthcare systems in rural areas would go a long way in the timely detection and prevention of blindness in such cases.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Analyzing patient experiences using natural language processing: development and validation of the artificial intelligence patient reported experience measure (AI-PREM)

Background

Evaluating patients’ experiences is essential when incorporating the patients’ perspective in improving healthcare. Experiences are mainly collected using closed-ended questions, although the value of open-ended questions is widely recognized. Natural language processing (NLP) can automate the analysis of open-ended questions for an efficient approach to patient-centeredness.

Methods

We developed the Artificial Intelligence Patient-Reported Experience Measures (AI-PREM) tool, consisting of a new, open-ended questionnaire, an NLP pipeline to analyze the answers using sentiment analysis and topic modeling, and a visualization to guide physicians through the results. The questionnaire and NLP pipeline were iteratively developed and validated in a clinical context.

Results

The final AI-PREM consisted of five open-ended questions about the provided information, personal approach, collaboration between healthcare professionals, organization of care, and other experiences. The AI-PREM was sent to 867 vestibular schwannoma patients, 534 of which responded. The sentiment analysis model attained an F1 score of 0.97 for positive texts and 0.63 for negative texts. There was a 90% overlap between automatically and manually extracted topics. The visualization was hierarchically structured into three stages: the sentiment per question, the topics per sentiment and question, and the original patient responses per topic.

Conclusions

The AI-PREM tool is a comprehensive method that combines a validated, open-ended questionnaire with a well-performing NLP pipeline and visualization. Thematically organizing and quantifying patient feedback reduces the time invested by healthcare professionals to evaluate and prioritize patient experiences without being confined to the limited answer options of closed-ended questions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01923-5.

Wait and Scan Management of Intra-canalicular Vestibular Schwannomas: Analysis of Growth and Hearing Outcome

OBJECTIVE

To report on the results of intracanalicular vestibular schwannomas (ICVS) that were managed by wait and scan and to analyze the possible predictors of tumor growth and hearing deterioration throughout the observation period.

STUDY DESIGN

A retrospective case series.

SETTING

Quaternary referral center for skull base pathologies.

PATIENTS

Patients with sporadic ICVS managed by wait and scan.

INTERVENTION

Serial resonance imaging (MRI) with size measurement and serial audiological evaluation.

MAIN OUTCOME MEASURE

Tumor growth defined as 2 mm increase of maximal tumor diameter, further treatment, and hearing preservation either maintain initial modified Sanna hearing class, or maintain initial serviceable hearing (class A/B).

RESULTS

339 patients were enrolled. The mean follow-up was 36.5±31.7 months with a median of 24 months. Tumor growth occurred in 141 patients (40.6%) either as slow growth (SG) in 26.3% of cases or fast growth (FG) in 15.3% of cases. Intervention was performed in only 64 cases (18.8%). Out of 271 patients who underwent hearing analysis, 86 patients (33.5%) showed hearing deterioration to a lower hearing class of the modified Sanna classification. Tumor growth and older age were predictors of hearing deterioration. Of the 125 cases with initial serviceable hearing (Class A/B), 91 cases (72.8%) maintained serviceable hearing at last follow-up. Tumor growth and a worse initial pure tone average (PTA) were predictors of hearing deterioration.

CONCLUSIONS

Wait and scan management of ICVS is a viable option and only 18.8% of patients needed further treatment. Hearing tends to deteriorate over time.

Long non-coding RNA BRCAT54 sponges microRNA-21 in vestibular schwannoma to suppress cell proliferation

BRCAT54 (also known as MRPS30 divergent transcript) is an anti-tumor long non-coding RNA (lncRNA) in lung cancer, while its role in vestibular schwannoma (VS) is unclear. We predicted that BRCAT54 could interact with microRNA (miR)-21, which suppresses VS cell proliferation. This study was then carried out to study the interaction between BRCAT54 and miR-21 in VS. A total of 56 VS samples and 42 normal vestibular nerve (VN) samples were included in this study. The expression of BRCAT54 and miR-21 in these samples were analyzed with RT-qPCR. Subcellular location of BRCAT54 in primary VS cells was analyzed by subcellular fractionation assay. The direct interaction between BRCAT54 and miR-21 was analyzed through RNA pull-down assay. Overexpression assay was performed to explore the interaction between BRCAT54 and miR-21. The role of BRCAT54 and miR-21 in primary VS cell proliferation was analyzed using BrdU assay. We found that BRCAT54 was downregulated in VS samples than that in VN samples, while miR-21 was upregulated in VS samples. BRCAT54 and miR-21 were not closely correlated. BRCAT54 was detected in both nuclear and cytoplasm samples, and BRCAT54 directly interacted with miR-21. However, BRCAT54 and miR-21 did not affect the expression of each other. BRCAT54 suppressed primary VS cell proliferation and inhibited the role of miR-21 in promoting cell proliferation. Therefore, BRCAT54 may sponge miR-21 to suppress cell proliferation in VS.

Impact of Social Determinants of Health on Stereotactic Radiotherapy for Vestibular Schwannoma

OBJECTIVES/HYPOTHESIS

Linear accelerator (LINAC) and Gamma Knife (GK) are common stereotactic radiation therapies for treating vestibular schwannoma (VS). There is currently limited literature examining specific demographic and socioeconomic factors, which influence the type of stereotactic radiation therapy a patient with VS receives.

STUDY DESIGN

Retrospective database review.

METHODS

The National Cancer Database was queried for cases of VS between 2004 and 2016. Patient demographic characteristics were compared using chi-squared and t-tests between GK and LINAC treated groups. Multivariate regression analysis was performed to assess predictors of stereotactic radiation therapy received.

RESULTS

Of the 6,208 included patients, 5,306 (85.5%) received GK and 902 (14.5%) received LINAC. The mean age of GK patients was significantly lower than that of LINAC patients (58.0 vs. 59.7, P < .001). Individuals treated with GK had greater proportions of private insurance (P < .001) and incomes greater than $63,332 (P = .003). A greater proportion of GK patients were treated in academic centers (P < .001), in high-volume facilities (P < .001), in metropolitan areas (P < .001), and in the Northeastern United States (P < .001). On multivariate logistic regression analysis, region, metropolitan area, facility type, tumor size, and distance traveled by patients independently predict receipt of GK versus LINAC.

CONCLUSION

Differences in patient demographics and other social determinants of health influence choice of GK versus LINAC therapy for VS patients. Future studies focused on addressing barriers to care, which may influence postprocedural quality of life and clinical outcomes associated with these two treatments are necessary to better understand the impact of these social differences.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Hearing-Preserving Approaches to the Internal Auditory Canal: Feasibility Assessment from the Perspective of an Endoscope

OBJECTIVE

Minimally invasive transcanal transpromontorial endoscopic approaches to the internal auditory canal sacrifice the cochlea. Two hearing-preserving approaches, the exclusively endoscopic transcanal infracochlear approach and the endoscope-assisted transmastoid retrolabyrinthine approach, have been controversially discussed in the literature. In this study, we examine the feasibility of these 2 approaches by means of three-dimensional surface models, a population-based analysis of the available surgical space, and dissections in human whole-head specimens.

METHODS

We reconstructed three-dimensional surface models based on clinical high-resolution computed tomography scans of 53 adult temporal bones. For both approaches, we measured the maximal extensions and the area of the surgical access windows located between landmarks on the surrounding anatomic structures. We then identified the limiting extensions and derived the cumulative distribution to describe the available surgical space. Dissections were performed to validate the corridors and landmark selection.

RESULTS

The limiting extension for the infrachochlear approach is 7.0 ± 2.7 mm from the round window to the dome of the jugular bulb. The limiting extension for the retrolabyrinthine approach is 6.4 ± 1.5 mm from the dura of the posterior fossa to the facial nerve. The cumulative distribution shows that 80% of the cohort have access window extensions ≥3 mm for both approaches.

CONCLUSIONS

This study shows that in a high percentage of the measured cohort, the access windows are sufficiently large for endoscopic approaches to the internal auditory canal. With appropriate instrumentation, these hearing-preserving minimally invasive approaches may evolve into alternatives to surgical treatment.

Outcome and Toxicity of Proton Therapy for Vestibular Schwannoma: A Cohort Study

OBJECTIVE

To assess the efficacy and toxicity of proton radiotherapy in vestibular schwannoma.

STUDY DESIGN

Retrospective chart review and volumetric MRI-analyses.

SETTING

Tertiary referral center.

PATIENTS

Vestibular schwannoma patients treated with protons between 2003 and 2018.

INTERVENTION

Proton radiotherapy.

MAIN OUTCOME MEASURES

Tumor control was defined as not requiring salvage treatment. Progressive hearing loss was defined as a decrease in maximum speech discrimination score below the 95% critical difference in reference to the pretreatment score. Hearing assessment includes contralateral hearing and duration of follow-up. Dizziness and/or unsteadiness and facial and trigeminal nerve function were scored. Patients who had surgery prior to proton radiotherapy were separately assessed.

RESULTS

Of 221 included patients, 136 received single fraction and 85 fractionated proton radiotherapy. Actuarial 5-year local control rate was 96% (95% CI 90-98%). The median radiological follow-up was 4.5 years. Progressive postirradiation speech discrimination score loss occurred in 42% of patients with audiometric follow-up within a year. Facial paresis was found in 5% (usually mild), severe dizziness in 5%, and trigeminal neuralgia in 5% of patients receiving protons as primary treatment.

CONCLUSIONS

Proton radiotherapy achieves high tumor control with modest side effects aside from hearing loss in vestibular schwannoma patients. Limited and heterogeneous outcome reporting hamper comparisons to the literature. Potential sequelae of radiation therapy impacting vestibular function, cognitive function, and quality of life warrant further evaluation. Subgroups that benefit most from proton radiotherapy should be identified to optimize allocation and counterbalance its costs.

Cochlear Implantation in Vestibular Schwannoma: A Systematic Literature Review

Objective  Ipsilateral cochlear implantation (CI) in vestibular schwannoma (VS) has been an emerging trend over the last two decades. We conducted the first systematic review of hearing outcomes comparing neurofibromatosis 2 (NF2) and sporadic VS undergoing CI. A comparison of the two populations and predictor of outcome was assessed. This is an update to a previously presented study. Data Sources  Systemic data searches were performed in PubMed NCBI and Scopus by an academic librarian. No restrictions based on the year of publication were used. Study Selection  Studies were selected if patients had a diagnosis of NF2 and a CI placed in the affected side with reports of hearing outcome. Two independent reviewers screened each abstract and full-text article. Data Extraction  Studies were extracted at the patient level, and the assessment of quality and bias was evaluated according to the National Institutes of Health Quality Assessment Tool. Main Outcome Measures  Outcome predictors were determined by using the chi-square test and Student's t -test. Results  Overall, most CI recipients functioned in the high-to-intermediate performer category for both sporadic and NF2-related VS. Median AzBio (Arizona Biomedical Institute Sentence Test) was 72% (interquartile range [IQR]: 50) in NF2 patients and 70% (IQR: 7.25) in sporadic patients. Larger tumor size predicted a poorer final audiometric outcome. Conclusions  Categorization of hearing outcome into superior performance and inferior performance based on sentence recognition revealed a generally good hearing outcome regardless of treatment or patient population. Select patients with sporadic and NF2 VS may benefit from CI.

Response rate of patient reported outcomes: the delivery method matters

BACKGROUND

Patient Reported Outcomes (PROs) are subjective outcomes of disease and/or treatment in clinical research. For effective evaluations of PROs, high response rates are crucial. This study assessed the impact of the delivery method on the patients' response rate.

METHODS

A cohort of patients with a unilateral vestibular schwannoma (a condition with substantial impact on quality of life, requiring prolonged follow-up) was assigned to three delivery methods: email, regular mail, and hybrid. Patients were matched for age and time since the last visit to the outpatient clinic. The primary outcome was the response rate, determinants other than delivery mode were age, education and time since the last consultation. In addition, the effect of a second reminder by telephone was evaluated.

RESULTS

In total 602 patients participated in this study. The response rates for delivery by email, hybrid, and mail were 45, 58 and 60%, respectively. The response rates increased after a reminder by telephone to 62, 67 and 64%, respectively. A lower response rate was associated with lower level of education and longer time interval since last outpatient clinic visit.

CONCLUSION

The response rate for PRO varies by delivery method. PRO surveys by regular mail yield the highest response rate, followed by hybrid and email delivery methods. Hybrid delivery combines good response rates with the ease of digitally returned questionnaires.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of Life in Vestibular Schwannoma Patients: A Longitudinal Study

OBJECTIVE

To examine differences in quality of life in patients with vestibular schwannoma following a single treatment modality: observation, stereotactic radiosurgery (SRS), or microsurgery.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary academic medical center.

PATIENTS

Patients diagnosed with sporadic vestibular schwannoma who had completed at least 2 Penn Acoustic Neuroma Quality of Life (PANQOL) surveys.

INTERVENTIONS

Treatment via SRS, microsurgery, or observation.

MAIN OUTCOME MEASURES

PANQOL total survey and subdomain scores.

RESULTS

One hundred and thirty-four patients (94 observations, 24 SRS, 16 microsurgeries) were included. The mean number of PANQOL surveys completed was 2.8 (range 2-5). The total PANQOL scores were significantly lower in the SRS group, but not the microsurgery group, compared with observation at the time of diagnosis (observation 550.4 ± 58.4; SRS 471.4 ± 37.4; microsurgery 492.6 ± 40.7; p = 0.03). Over time, there were no significant differences in the change of PANQOL scores across the 3 groups (SRS PANQOL score worsened 6.8/year compared with observation, p = 0.3; microsurgery PANQOL score worsened 7.8/year compared with observation, p = 0.5). Anxiety was the only subdomain that significantly worsened over time in the microsurgery group (microsurgery PANQOL score worsened 3.8/year compared with observation; p = 0.009).

CONCLUSION

Despite differences in PANQOL scores at baseline, changes in total PANQOL score over time were not found to be statistically significant, regardless of the treatment group chosen. Overall, these results hold implications for patient counseling when considering treatment choice and quality of life predictions.

Longitudinal Changes of Quality of Life and Hearing Following Radiosurgery for Vestibular Schwannoma

Simple Summary

Since vestibular schwannomas are slow-growing tumors that can be controlled with different treatment modalities such as neurosurgery or radiotherapy, preserving quality of life is an important consideration. In this study, we analyzed how quality of life (QoL) changes for patients who receive stereotactic radiation in the months and years after treatment and if there is a correlation between changes in QoL and changes in hearing function. The results suggest that proper hearing of the unaffected ear might compensate for a hearing loss of the other ear due to the tumor or the treatment and in turn preserve QoL. However, this association should be confirmed in additional studies.

Abstract

Background: Most existing publications on quality of life (QoL) following stereotactic radiosurgery (SRS) for vestibular schwannomas (VS) gather information retrospectively by conducting surveys several years after treatment. The purpose of this study is therefore to provide longitudinal QoL data and assess how changes in hearing impact QoL. Methods: Patients completed the 12-item short-form (SF-12) health survey prior to treatment and at every follow-up visit. One hundred and seventy-five patients who had complete forms prior to treatment as well as at an early and at a late follow-up were included in the analysis. For 51 of these patients, longitudinal audiometry data were available. Results: Median follow-up was 7.2 years. Patients experienced a significant reduction in the physical composite score (PCS, p = 0.011) compared to before treatment. The mental composite score (MCS) increased significantly (p = 0.032). A decrease in PCS was not significantly correlated with an increased hearing threshold on the affected but rather on the unaffected ear (r(49) = −0.32, p = 0.023). Conclusions: It is unclear whether the decline in the PCS is due to treatment-related toxicity or the normal decline of PCS with age. Ensuring proper hearing on the untreated ear might be crucial to ensure good QoL for patients treated with SRS for VS, though this association should be confirmed in additional studies.

Prospective Study of Disease-Specific Quality-of-Life in Sporadic Vestibular Schwannoma Comparing Observation, Radiosurgery, and Microsurgery

BACKGROUND

Previous cross-sectional studies analyzing quality of life (QOL) outcomes in patients with sporadic vestibular schwannoma (VS) have shown surprisingly little difference among treatment modalities. To date, there is limited prospective QOL outcome data available comparing baseline to posttreatment scores.

STUDY DESIGN

Prospective longitudinal study using the disease-specific Penn Acoustic Neuroma Quality of Life (PANQOL) scale.

SETTING

Large academic skull base center.

PATIENTS

Patients diagnosed with unilateral VS who completed a baseline survey before treatment and at least one posttreatment survey.

MAIN OUTCOME MEASURES

Change in PANQOL scores from baseline to most recent survey.

RESULTS

A total of 244 patients were studied, including 78 (32%) who elected observation, 118 (48%) microsurgery, and 48 (20%) stereotactic radiosurgery. Patients who underwent microsurgery were younger (p < 0.001) and had larger tumors (p < 0.001) than those who underwent observation or radiosurgery; there was no significant difference in duration of follow-up among management groups (mean 2.1 yrs; p = 0.28). When comparing the total PANQOL score at baseline to the most recent survey, the net change was only -1.1, -0.1, and 0.3 points on a 100-point scale for observation, microsurgery, and radiosurgery, respectively (p = 0.89). After multivariable adjustment for baseline features, there were no statistically significant changes when comparing baseline to most recent scores within each management group for facial function, general health, balance, hearing loss, energy, and pain domains or total score. However, the microsurgical group experienced a 10.8-point improvement (p = 0.002) in anxiety following treatment, compared with 1.5 (p = 0.73) and 5.3 (p = 0.31) for observation and radiosurgery, respectively.

CONCLUSIONS

In this prospective longitudinal study investigating differences in QOL outcomes among VS treatment groups using the disease-specific PANQOL instrument, treatment did not modify QOL in most domains. Microsurgery may confer an advantage with regard to patient anxiety, presumably relating to the psychological benefit of "cure" from having the tumor removed.

Management and Outcomes of Sporadic Vestibular Schwannoma: A Longitudinal Study Over 12 Years

OBJECTIVES

To evaluate the management of sporadic vestibular schwannomas (VS) with a 12-year follow-up.

STUDY DESIGN

Retrospective study of all VS patients initially treated in 2005 in a tertiary referent center.

METHODS

Initial decision making for microsurgical resection (MSR) or wait-and-scan (WaS) was according to VS size and hearing; subsequently, MSR or stereotactic radiosurgery (SRS) was proposed dependent on VS growth and size, hearing, and patient's age or willingness.

RESULTS

Two hundred and one sporadic VS were included. The first management apportionment was 120 WaS (61.5%), 72 MSR (37%), three SRS (1.5%), and six others refused MSR and were lost to follow-up (LFU). Within 1 year, 95 (47%) VS were surgically removed; 17 (8.5%) were treated by SRS; and 35 (17.5%) were LFU. The proportions for SRS and LFU were virtually unchanged for the following years, and the proportion under MSR increased slightly within 3 years and then remained stable. Finally, at 12 years, 104 (51.5%) cases had been operated on, 21 (10.5%) treated by SRS, 23 (11.5%) still under WaS, and 53 (26.5%) LFU, which were mainly intracanalicular. The initially and subsequently operated cases presented similar hearing preservation rates and good facial nerve function outcomes.

CONCLUSION

This longitudinal study of a large number of VS, which were diagnosed over a short period of time and followed for 12 years, provides new information on both the natural history of these benign tumors and individual patient concerns. This study recommends use of the WaS policy for small and mid-sized VS before active therapeutic decision making.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E970-E976, 2021.

Disease-Specific Quality of Life in Vestibular Schwannoma: A National Cross-sectional Study Comparing Microsurgery, Radiosurgery, and Observation

OBJECTIVE

To examine the impact of treatment on disease-specific health-related quality of life (HRQOL) among patients with sporadic vestibular schwannoma (VS).

STUDY DESIGN

National cross-sectional study.

SETTING

Tertiary referral center and the Acoustic Neuroma Association.

SUBJECTS AND METHODS

Adult patients with VS who completed the Penn Acoustic Neuroma Quality of Life (PANQOL) survey. Patients were classified by treatment at the most recent survey as microsurgery, radiosurgery, observation, or recently diagnosed (RD). PANQOL scores were compared among VS treatment groups and with nontumor controls using analysis of covariance.

RESULTS

A total of 1362 respondents with VS were analyzed. Total PANQOL scores differed significantly by treatment (P = .024) with adjusted means of 60, 63, 65, and 62 for the microsurgery, radiosurgery, observation, and RD groups, respectively. Subdomain scores for facial function, balance, hearing loss, and pain differed significantly (P < .05) by treatment. Comparisons that surpassed thresholds for clinical significance included microsurgery compared to radiosurgery and observation for facial function, microsurgery compared to observation and RD for hearing loss, and microsurgery compared to radiosurgery and observation for pain. Subdomain scores for anxiety, facial function, balance, hearing loss, energy, and pain and total PANQOL scores for nontumor controls were significantly higher (ie, more favorable) compared to the VS groups (P < .05). General health scores did not differ significantly between the nontumor controls and the VS groups (P = .19).

CONCLUSION

Differences in HRQOL among treatment modalities are small and variably exceed the minimal clinically important difference. The impact of a VS diagnosis on HRQOL supersedes that of the treatment type.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

3.

Screening for vestibular schwannoma in the context of an ageing population

Objective

To review the literature regarding screening for vestibular schwannoma in the context of demographic changes leading to increasing numbers of elderly patients presenting with asymmetric auditory symptoms.

Methods

A systematic review of the literature was performed, with narrative synthesis and statistical analysis of data where appropriate.

Results

Vestibular schwannomas diagnosed in patients aged over 70 years exhibit slower growth patterns and tend to be of smaller size compared to those tumours in younger age groups. This fact, combined with reduced life expectancy, renders the probability of these tumours in the elderly requiring active treatment with surgery or stereotactic radiotherapy to be extremely low. Vestibular schwannomas in the elderly are much more likely to be managed by serial monitoring with magnetic resonance imaging. The weighted yield of magnetic resonance imaging in the diagnosis of vestibular schwannoma in all age groups is 1.18 per cent, with almost 85 scans required to diagnose 1 tumour.

Conclusion

An evidence-based approach to the investigation of asymmetric hearing loss and tinnitus in the elderly patient can be used to formulate guidelines for the rational use of magnetic resonance imaging in this population.

Long-term Effects of Conservative Management of Vestibular Schwannoma on Dizziness, Balance, and Caloric Function

Objectives

To study the development of dizziness, caloric function, and postural sway during long-term observation of untreated vestibular schwannoma patients.

Study Design

Retrospective review of a prospectively maintained longitudinal cohort.

Setting

Tertiary referral hospital.

Subjects and Methods

Patients with vestibular schwannoma undergoing wait-and-scan management were included—specifically, those who did not require treatment during a minimum radiologic follow-up of 1 year. Baseline data and follow-up included magnetic resonance imaging, posturography, bithermal caloric tests, and a dizziness questionnaire. Main outcomes were prevalence of moderate to severe dizziness, canal paresis, and postural instability at baseline and follow-up, as compared with McNemar’s test.

Results

Out of 433 consecutive patients with vestibular schwannoma, 114 did not require treatment during follow-up and were included. Median radiologic follow-up was 10.2 years (interquartile range, 4.5 years). Age ranged from 31 to 78 years (mean, 59 years; SD, 10 years; 62% women). Median tumor volume at baseline was 139 mm3(interquartile range, 314 mm3). This did not change during follow-up ( P = .446). Moderate to severe dizziness was present in 27% at baseline and 19% at follow-up ( P = .077). Postural unsteadiness was present in 17% at baseline and 21% at follow-up ( P = .424). Canal paresis was present in 51% at baseline and 56% at follow-up ( P = .664).

Conclusions

There was no significant change in the prevalence of dizziness, postural sway, or canal paresis during conservative management of vestibular schwannoma, while tumor volume remained unchanged. This indicates a favorable prognosis in these patients with regard to vestibular symptoms.

Identification of Differentially Expressed miRNAs and mRNAs in Vestibular Schwannoma by Integrated Analysis

BACKGROUND

Vestibular schwannoma (VS) is benign, slow-growing brain tumor that negatively impacts patient quality of life, which may cause even death. This study aimed to explore key genes and microRNAs (miRNAs) associated with VS.

METHODS

The mRNA and miRNA expression profiles of VS downloaded from Gene Expression Omnibus (GEO) database were included in this study to perform an integrated analysis. The differentially expressed mRNAs (DEmRNAs) and miRNAs (DEmiRNAs) were identified. Then, functional annotation and protein-protein interaction networks (PPI) of DEmRNAs were constructed. DEmiRNA-target DEmRNAs analysis and functional annotation of DEmiRNA-target DEmRNAs were performed.

RESULTS

A total of 2627 DEmRNAs (1194 upregulated and 1433 downregulated DEmRNAs) and 21 DEmiRNAs (12 upregulated and 9 downregulated DEmiRNAs) were identified. ISG15, TLE1, and XPC were three hub proteins of VS-specific PPI network. A total of 2970 DEmiRNAs-DEmRNAs pairs were obtained. Among which, hsa-miR-181a-5p, hsa-miR-106-5p, and hsa-miR-34a-5p were the top three DEmiRNAs that covered most DEmRNAs. The functional annotation of DEmiRNA-target DEmRNAs revealed that the DEmiRNA-target DEmRNAs were significantly enriched in cGMP-PKG signaling pathway, adrenergic signaling in cardiomyocytes, and pathways in cancer.

CONCLUSION

The results of this present study may provide a comprehensive understanding for the roles of DEmRNAs and DEmiRNAs in the pathogenesis of VS and developing potential biomarkers of VS.

Quality of Life in Jugular Paraganglioma Following Radiosurgery

OBJECTIVE

The treatment paradigm for jugular paraganglioma (JP) has changed considerably over time with the wider adoption of stereotactic radiosurgery (SRS). To the best of the authors' knowledge, there are no published studies that use validated patient-reported outcome measures to ascertain quality of life (QoL) outcomes following SRS for JP when used in single or combined modality treatment regimens.

STUDY DESIGN

Cross-sectional survey.

SETTING

Tertiary referral center.

PATIENTS

Adult patients with JP treated with primary SRS or SRS following primary surgery between 1990 and 2017.

INTERVENTIONS(S)

Surgery and/or Gamma Knife SRS.

MAIN OUTCOME MEASURES

Global and treatment-related QoL and differences in QoL based on treatment approach.

RESULTS

Sixty-nine surveys were distributed and a total of 26 completed surveys were received (38% response rate). Among respondents, the median age at SRS was 53 years and 16 of the 26 patients (62%) were female. Median follow-up was 97 months. Nineteen patients (73%) were treated with primary SRS or staged SRS following intentional subtotal resection (STR; hereafter referred to as "staged SRS"), while the remainder (n = 7, 27%) were treated with SRS for recurrent JP. Median physical and mental health QoL PROMIS-10 T-scores regardless of treatment strategy were 39.8 and 38.8, respectively, while median SF36 physical and mental component subscores were similar to national averages and non-tumor controls. When comparing general physical and mental health QoL scores, there was no significant difference between patients treated with primary or staged SRS and those treated with SRS for recurrent JP. However, age-adjusted swallowing function among patients treated with primary or staged SRS was better than in those patients treated with SRS for recurrent JP (p = 0.05).

CONCLUSIONS

Patients treated with primary or staged SRS for JP tend to exhibit better swallowing outcomes than those treated with SRS for recurrent JP. However, the majority of overall and disease-specific quality of life measures were not different between groups. Based on the low incidence of new cranial neuropathy following SRS, it is likely that initial surgical morbidity is the primary contributor to this outcome. Disease-specific overall quality of life measures, akin to those already used for other benign skull base tumors, are necessary to better gauge physical and mental health outcomes following treatment for JP. Though limited by small sample size, this represents the first study to gauge QoL outcomes following treatment for JP.

Severity of Tinnitus Distress Negatively Impacts Quality of Life in Patients With Vestibular Schwannoma and Mimics Primary Tinnitus

Objective: Quality of life (QoL) and subjective symptoms are predominantly used to evaluate treatment outcome of patients with vestibular schwannoma (VS). However, for patients undergoing conservative treatment-the most frequently used intervention-the association between QoL and subjective symptoms is unclear. Moreover, it is unknown whether VS-related tinnitus could be associated with the audiological and psychological status of the patient. Our overall aim is to provide objective evidence of this association to better guide treatment of VS. Methods: In a prospective study, we analyzed factors that influence VS-related tinnitus and QoL in 72 patients receiving conservative management of unilateral sporadic VS. This was done through questionnaires that assessed QoL, anxiety, depression, and audiological examinations. We used the SF-36 Short Form to assess QoL; the Tinnitus Handicap Inventory, Dizziness Handicap Inventory, Facial Clinimetric Evaluation Scale, Visual Analog Scale for hearing impairment to assess symptoms subjectively; and pure tone audiometry, the speech discrimination for hearing measurements. For psychological status, we used the Hospital Anxiety and Depression Scale. For analyses, we used Pearson correlation analysis and multiple regression between variables and QoL. Results: Correlation and regression analyses revealed that the severity of tinnitus distress had the largest negative impact on QoL in all domains of SF-36. The severity of tinnitus was significantly associated with subjective hearing impairment and the degree of depression and anxiety. Hearing thresholds had no statistical association with severity of tinnitus. Conclusions: To our knowledge, this is the first study to investigate VS-related tinnitus with respect to both patients' hearing status and psychological condition. Our results suggest that tinnitus distress strongly affects VS patients' QoL and that its characteristics are similar to primary tinnitus. An intervention for VS-related tinnitus, therefore, should assess to what extent tinnitus bothers patients, and it should reduce any unpleasant emotions that may exacerbate symptoms. This approach should improve their QoL.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

NA Laryngoscope, 130:482-486, 2020.

Risk Recall of Complications Associated with Vestibular Schwannoma Treatment

OBJECTIVE

To assess the risk recall of complications among patients who underwent different vestibular schwannoma (VS) treatments.

STUDY DESIGN

Patients with VS completed a voluntary and anonymous survey.

SETTING

Survey links were distributed via the Acoustic Neuroma Association (ANA) website, Facebook, and email list.

SUBJECTS AND METHODS

Surveys were distributed to ANA members from January to March 2017. Of the 3200 ANA members with a VS diagnosis at the time of survey distribution, 789 (25%) completed the survey.

RESULTS

Subjects reported the following incidence of posttreatment complications: imbalance (60%), hearing issues (51%), dry eyes (30%), headache (29%), and facial weakness (27%). Overall, 188 (25%) recalled remembering all the risks associated with their treatment. Among those in the surgical cohort (52%) who experienced balance issues, facial weakness, cerebrospinal fluid leak, meningitis, and stroke, 73%, 91%, 77%, 67%, and 33% claimed recall of these associated risks. Among those in the radiosurgery cohort (28%) who experienced balance issues, facial weakness, and hydrocephalus, 56%, 52%, and 60% recalled discussions of those risks. Patients with higher-level education (P = .026) and those who underwent surgery (P = .001) had a significantly higher risk recall ratio, while sex, age, and tumor size were not significant contributing factors.

CONCLUSION

Not all patients with VS who experienced treatment complications recalled remembering those risks being discussed with them. Patients with higher education and those who underwent surgery had a better recall of risks associated with different treatment modalities. The risk recall ratio of patients experiencing complications ranged 33% to 91%, suggesting an opportunity for decision-making and discussion improvement.

Recent Trends in Vestibular Schwannoma Management: An 11-Year Analysis of the National Cancer Database

Objective

A better understanding of the natural history of vestibular schwannoma (VS) has resulted in a change in treatment paradigms. It has also been proposed that increased use of high-resolution magnetic resonance imaging has allowed for an increased identification of small tumors. The aim of this study was to evaluate recent trends in the presentation and primary management of VS in the United States.

Study Design

Retrospective analysis of the National Cancer Database (NCDB).

Setting

NCDB database.

Subjects and Methods

All patients with a diagnosis of VS between 2004 and 2014 were included. Data were analyzed with univariable and multivariable logistic regression.

Results

In total, 28,190 patients (mean age 55 years, 52.9% female) with VS were analyzed. Linear regression showed a small decrease in average tumor size over time (–0.06 mm/year, P = .03). Overall, 11,121 patients (40%) received surgery, 8512 (30%) radiation, and 7686 (27%) observation. Controlling for patient, tumor, and treatment center factors, the odds ratio (OR) for receiving surgery in 2014 was 0.60 (confidence interval [CI], 0.50-0.71) while the OR for receiving radiation was 0.75 (CI, 0.64-0.87) as compared to those diagnosed in 2004. The largest increases in observation rates occurred among tumors ≤2 cm ( P < .001).

Conclusion

There was not a clinically significant change in the average tumor size at diagnosis. Although surgery remained the most common treatment modality in the United States, there was a strong shift in the management of VS away from primary surgery and radiation and toward a “wait-and-scan” approach.

Comparison of balance outcomes according to treatment modality of vestibular schwannoma

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Quality of life in the management of small vestibular schwannomas: Observation, radiotherapy and microsurgery

OBJECTIVE

The aim of this study was to compare quality of life (QOL) in small unilateral vestibular schwannoma (VS) patients managed by microsurgery, radiotherapy or observation.

STUDY DESIGN

A retrospective chart review.

METHODS

The study included a total of 142 patients with VS stage 1 or 2 according to the Koos classification and treated between January 2004 and December 2015. Microsurgery, radiotherapy and observation groups comprised 43, 46 and 53 patients, respectively. All patients completed four QOL (questionnaires: Short-Form Health Survey 36, Hearing Handicap Inventory, Tinnitus Handicap Inventory and Dizziness Handicap Inventory Short-Form). Clinical symptoms and QOL were compared among groups.

RESULTS

The average time interval between management and filling in the questionnaires was 66 months. There was no difference in QOL between the three groups on any of the four questionnaires. The most debilitating symptom was vertigo for all three groups. Tinnitus was a pejorative factor in the surgery group. Hearing level was deteriorated after microsurgery but there was no significant difference between the radiotherapy group and the middle fossa approach.

CONCLUSION

Patients with small VS stage 1 and 2 had similar QOL, irrespective of management by observation, radiotherapy or microsurgery. The overall predictor for long-term reduced QOL was vertigo. Vestibular rehabilitation could improve QOL in symptomatic patients.