Trading mental and physical health in vestibular schwannoma treatment decision

Prospective Symptom Changes in Sporadic Vestibular Schwannoma: A Comparison of Observation, Microsurgery, and Radiosurgery

OBJECTIVE

To compare differences in sporadic vestibular schwannoma (VS)-associated patient-reported symptom scores among patients receiving observation, microsurgery, or radiosurgery.

STUDY DESIGN

Prospective longitudinal survey.

SETTING

Tertiary referral center and the national Acoustic Neuroma Association.

PATIENTS

Adults with sporadic VS.

INTERVENTION

Observation, microsurgery, or radiosurgery.

MAIN OUTCOME MEASURE

Baseline and follow-up surveys on patient-reported severity of tinnitus, dizziness/imbalance, and headaches scored on a 10-point numeric scale, with higher scores indicating more severe symptoms; changes of 2 or more points from baseline were considered clinically important.

RESULTS

A total of 455 patients were eligible for study with a mean (SD) follow-up of 4.5 (2.4) years, including 122 (27%) managed with observation, 226 (50%) undergoing microsurgery, and 107 (23%) undergoing radiosurgery. Changes in tinnitus severity scores differed significantly among management groups ( p = 0.006), with severity scores increasing significantly in the radiosurgery (+0.8, p = 0.005) group but not in the observation (+0.2, p = 0.5) or microsurgery (-0.2, p = 0.18) groups. The changes in dizziness/imbalance and headache severity scores did not differ significantly among management groups. When comparing clinically important improvements (decrease of 2 or more points), the microsurgery and observation cohorts had a greater proportion of patients experiencing a clinically important improvement in tinnitus compared with the radiosurgery cohort; no other clinically important changes were significantly different among management groups.

CONCLUSIONS

In this prospective study of 455 patients comparing patient-reported symptoms after VS management, radiosurgery was associated with worsening tinnitus severity scores overall and resulted in fewer patients reporting clinically important improvements in tinnitus compared with observation and microsurgery. As there was substantial variability in the effect of management modality on changes in symptom severity scores, possible treatment effects on subjective symptoms, including tinnitus, dizziness/imbalance, and headache, should not be used in isolation to inform clinical decision-making for management of sporadic VS.

Surface Electromyographic Features for Severity Classification in Facial Palsy: Insights from a German Cohort and Implications for Future Biofeedback Use

Facial palsy (FP) significantly impacts patients' quality of life. The accurate classification of FP severity is crucial for personalized treatment planning. Additionally, electromyographic (EMG)-based biofeedback shows promising results in improving recovery outcomes. This prospective study aims to identify EMG time series features that can both classify FP and facilitate biofeedback. Therefore, it investigated surface EMG in FP patients and healthy controls during three different facial movements. Repeated-measures ANOVAs (rmANOVA) were conducted to examine the effects of MOTION (move/rest), SIDE (healthy/lesioned) and the House-Brackmann score (HB), across 20 distinct EMG parameters. Correlation analysis was performed between HB and the asymmetry index of EMG parameters, complemented by Fisher score calculations to assess feature relevance in distinguishing between HB levels. Overall, 55 subjects (51.2 ± 14.73 years, 35 female) were included in the study. RmANOVAs revealed a highly significant effect of MOTION across almost all movement types (p < 0.001). Integrating the findings from rmANOVA, the correlation analysis and Fisher score analysis, at least 5/20 EMG parameters were determined to be robust indicators for assessing the degree of paresis and guiding biofeedback. This study demonstrates that EMG can reliably determine severity and guide effective biofeedback in FP, and in severe cases. Our findings support the integration of EMG into personalized rehabilitation strategies. However, further studies are mandatory to improve recovery outcomes.

Innovative mobile app solution for facial nerve rehabilitation: a usability analysis

Background

Facial palsy after vestibular schwannoma surgery is temporary in many cases but can significantly affect patients' quality of life. Physical training-initially guided and subsequently performed by the patient-is of paramount importance for recovery of facial nerve function. The introduction of medical application software (apps) might improve therapy by maintaining motivation for daily home-based training and surveilling patients' rehabilitation progress.

Methods

We developed a mobile app, "FACEsemper", for home-based facial nerve rehabilitation. This app guides patients through a daily training program comprising six variable exercises, each performed in three repetitions. The app allows the user to customize the exercise intensity for different facial areas and includes a reminder function for daily training. Additional features include photo documentation, a calendar function, training report generation, and the possibility of direct communication with the attending physician. The app's usability was prospectively investigated with 27 subjects, including 8 physicians, 9 patients with facial palsy and 10 healthy subjects, over a two-week period. Usability was assessed using various self-rating questionnaires (i.e., mHealth App Usability Questionnaire, MAUQ; System Usability Scale, SUS; Visual Aesthetics of Apps Inventory, VisAAI) and scores were compared across the groups.

Results

The participants reported an average smartphone use of 12.19 years and completed a mean number of 290 ± 163 facial exercises during the study period. Patients used the app significantly more frequently than the other two groups (p = 0.017). The average total scores of the questionnaires were: MAUQ 5.67/7, SUS 89.6/100, VisAAI 5.88/7 and specific rating 6.13/7. In particular, the simplicity of use and craftsmanship of the app were rated very highly. Usability scores did not significantly differ between groups. A primary limitation identified was malfunction of the daily reminder feature in some Android versions.

Conclusion

This usability study demonstrated a positive user experience and excellent usability of the FACEsemper app. However, some limitations and areas for improvement were identified. As a next step, the app should be evaluated in a large patient cohort with facial palsy to determine its potential medical benefits for facial rehabilitation compared to traditional training methods.

Outpatient care for facial palsy-a survey on patient satisfaction in uni- and interdisciplinary approaches

Objective

The various causes of facial palsy, diagnostic methods and treatment approaches frequently involve different medical specialities. Nevertheless, there exist only few specialized consultation and therapy services for patients with facial palsy (FP) in Germany. The aim of the present study was to evaluate factors affecting quality of life (QoL) and treatment satisfaction of patients presenting to an interdisciplinary facial nerve outpatient clinic.

Methods

The study analyzed patients presenting to the interdisciplinary facial palsy outpatient clinic in Tuebingen between February 2019 and December 2022. General satisfaction and QoL was estimated by numerous self-rating questionnaires: ZUF-8, SF-36, FDI, FaCE, PHQ-9. An ANOVA was performed to analyze determinants affecting the ZUF-8. Correlation analyses between cause and regeneration of FP as well as questionnaire scores were performed. Results were compared with a group of patients who were managed in an unidisciplinary setting.

Results

In total, 66 patients with FP were enrolled. FP patients showed increased levels of depression (PHQ-9: 14.52 ± 3.8) correlating with recovery of the palsy (p = 0.008), FaCE (p < 0.001) and FDI ratings (p < 0.001). There was a high level of satisfaction with the services provided during the uni-and interdisciplinary consultation (ZUF-8: 24.59 ± 6.2), especially among the 12/66 patients who received reconstructive, surgical treatment. However, some patients requested more psychological and ophthalmological support.

Conclusion

High levels of treatment satisfaction can be achieved in both an uni-and interdisciplinary setting. However, multimodal therapy approaches should be applied, considering physical and psychological aspects. In the absence of recovery, surgical interventions must be considered as treatment options. Further studies should continue to investigate potential differences between uni-and interdisciplinary treatment.

Predictive value of facial motor-evoked potential and electromyography for facial motor function in vestibular schwannoma surgery

PURPOSE

Intraoperative neuromonitoring (IONM) aims to preserve facial nerve (FN) function during vestibular schwannoma (VS) surgery. However, current techniques such as facial nerve motor evoked potentials (FNMEP) or electromyography (fEMG) alone are limited in predicting postoperative facial palsy (FP). The objective of this study was to analyze a compound fEMG/FNMEP approach.

METHODS

Intraoperative FNMEP amplitude and the occurrence of fEMG-based A-trains were prospectively determined for the orbicularis oris (ORI) and oculi (OCU) muscle in 322 VS patients. Sensitivity and specificity of techniques to predict postoperative FN function were calculated. Confounding factors as tumor size, volume of intracranial air, or IONM duration were analyzed.

RESULTS

A relevant immediate postoperative FP was captured in 105/322 patients with a significant higher risk in large VS. While fEMG demonstrated a high sensitivity (77% and 86% immediately and 15 month postoperative, respectively) for identifying relevant FP, specificity was low. In contrast, FNMEP have a significantly higher specificity of 80.8% for predicting postoperative FP, whereas the sensitivity is low. A retrospective combination of techniques demonstrated still an incorrect prediction of FP in ~ 1/3 of patients.

CONCLUSIONS

FNMEP and fEMG differ in sensitivity and specificity to predict postoperative FP. Although a combination of IONM techniques during VS surgery may improve prediction of FN function, current techniques are still inaccurate. Further development is necessary to improve IONM approaches for FP prediction.

Sex Differences in Vestibular Schwannoma

Vestibular schwannoma (VS) are equally common in men and woman. A number of epidemiological studies have reported on sex-specific aspects of incidence, tumor size, tinnitus and hearing loss. However, data on sex-specific, pre- and post-surgically quality of life (QoL) are rare. The objective of the present study was to determine sex-specific aspects on QoL in VS. Health-related QoL was analyzed in 260 patients (112 male/148 female) with unilateral sporadic VS using general (SF-36: general Short-Form Health Survey), disease-specific (PANQOL: Penn Acoustic Neuroma Quality-of-Life Scale, PANQOL) and symptom-specific (DHI: Dizziness Handicap Inventory; HHI: Hearing Handicap Inventory; THI: Tinnitus Handicap Inventory; FDI: Facial Disability Index) QoL questionnaires. Sex differences were evaluated pre- and postoperative by multi- and univariate analyses based on 200 preoperative and 88 postoperative questionnaires. Female patients were significantly more affected by dizziness, headaches, reduced energy and anxiety. Energy and balance changed similarly in both sexes after surgery. However, postoperative women tended to be more affected by facial palsy and headaches than men. Despite the greater physical impairment, general health improved equivalently or even more in female patients than in males. In conclusion, self-rated QoL in VS is significantly affected by sex and surgery. This should be taken into account when counseling VS patients regarding observation, radiotherapy, and surgery.