Abstract
Vestibular schwannomas, also called acoustic neuromas, are benign tumors of the vestibulocochlear nerve. Patients with these tumours almost always present with signs of hearing loss, and many also experience tinnitus, vertigo, and equilibrium problems. Following diagnosis with contrast enhanced MRI, patients may choose to observe the tumour with subsequent scans or seek active treatment in the form of microsurgery, radiosurgery, or radiotherapy. Unfortunately, definitive guidelines for treating vestibular schwannomas are lacking, because of insufficient evidence comparing the outcomes of therapeutic modalities.We present a contemporary case report, describing the finding of a vestibular schwannoma in a patient who presented with dizziness and a "clicking" sensation in the ear, but no hearing deficit. Audible clicking is a symptom that, to our knowledge, has not been associated with vestibular schwannoma in the literature. We discuss the diagnosis and patient's decision-making process, which led to treatment with Gamma Knife radiosurgery. Treatment resulted in an excellent radiographic response and complete hearing preservation. This case highlights an atypical presentation of vestibular schwannoma, associated with audible "clicks" and normal hearing. We also provide a concise review of the available literature on modern vestibular schwannoma treatment, which may be useful in guiding treatment decisions.
Highlights
Vestibular schwannomas (VS), or acoustic neuromas, are benign neoplasms of the myelin-forming Schwann cells of the vestibulocochlear nerve
We summarize a course in contemporary vestibular schwannoma management, involving a patient presenting with no hearing loss and a sensation of "clicking" in the ear
The absence of symptoms related to cochlear nerve function is infrequently encountered with vestibular schwannomas, with fewer than 5% of patients presenting without hearing impairment[2]
Summary
Vestibular schwannomas (VS), or acoustic neuromas, are benign neoplasms of the myelin-forming Schwann cells of the vestibulocochlear nerve. The predominant measure of such outcomes has been the preservation of hearing and facial nerve function; there is a desire to evaluate other measures of patients' experience and quality of life, including the symptoms of tinnitus, dizziness, and headache[4] This would provide patients a more complete picture to utilize in choosing a treatment strategy. Metaanalysis from early experience showed that 44% with serviceable hearing prior to treatment retained their ability after SRS, a statistically equivalent rate to the surgical data[13] This evidence suggest that 37.9% of patients have other complications[13]. A review of available evidence suggests that SRT may offer even better hearing preservation and lower cranial nerve toxicity than SRS based on biologic models[20] This includes similar tumour control rates with hearing preservation greater than 90%. Being a newer therapy, there are not yet long-term comparative outcome studies to evaluate the relative efficacy of SRT compared to SRS or microsurgery [16]
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