Conservative Management Of Vestibular Schwannoma Research Articles

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

To study the development of dizziness, caloric function, and postural sway during long-term observation of untreated vestibular schwannoma patients. Retrospective review of a prospectively maintained longitudinal cohort. Tertiary referral hospital. 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. 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). 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.

Conservative management of vestibular schwannoma: Predictors of growth and hearing.

To describe the clinical outcomes of patients undergoing serial observation for vestibular schwannoma (VS) and identify factors that may predict tumor growth or hearing loss. Retrospective review. A retrospective review was conducted of patients seen at a tertiary care medical center between 2002 and 2013 with an International Classification of Diseases-9 diagnosis code of 225.1. Patients electing observation as initial management, with at least two documented imaging results, were included. Exclusion criteria comprised bilateral VS, diagnosis of neurofibromatosis type 2, and neoplasms other than VS. Decline in serviceable hearing, tumor growth, and changes in management strategy were recorded. Survival analysis to assess median time to outcomes and multiple logistic regression analyses were performed. A total of 94 patients met inclusion criteria. While undergoing observation, 22.3% of patients underwent a change in management strategy to microsurgical excision or stereotactic radiotherapy. For patients with initial serviceable hearing, 24.3% observed a decline to a nonserviceable level. No significant clinical factors were identified to predict changes in hearing. Survival analysis revealed that an estimated 69.1% of patients electing observation as initial management continued to do so at 5 years. Imbalance or disequilibrium at presentation was found to be associated with an increased adjusted odds ratio (OR) (OR 2.96; 95% confidence interval, 1.03-8.50; P = 0.04) for tumor growth. Serial observation of VS is a viable treatment strategy for selected patients, with two-thirds of patients electing to continue this management option after 5 years. Disequilibrium as a presenting symptom may be associated with subsequent tumor growth. 4.

Conservative Management of Vestibular Schwannoma in the West of Scotland: A 20‐Year Experience

Objectives: In our skull base unit, large vestibular schwannomas (VS) over 30 mm at presentation are usually offered surgery but the remainder have their growth monitored by interval imaging with treatment (surgery or stereotactic radiotherapy) being offered to patients whose tumors are growing significantly. Methods: A prospective database of consecutive patients diagnosed with sporadic VS and referred to the Skull Base unit in South Glasgow, United Kingdom, over the last 20 years was retrospectively reviewed. Patients with neurofibromatosis type II were excluded. Patients who consented to being managed conservatively by initial interval imaging using 6-monthly axial T1-weighted post-gadolinium magnetic resonance imaging (MRI) had the growth of their VS assessed. Growth (defined as >2mm) was the primary outcome measure. Intracanalicular tumors were compared to cerebellopontine angle (CPA) ones. Results: There were 62 intracanalicular (IC) tumors, mean size of 8mm, and 102 CPA VS, mean size of 11mm. One third of patients managed conservatively showed evidence of growth and 50% showed no change (IC > CPA). Twenty percent reduced in size (CPA > IC). Two-thirds of the VS showing growth stabilized or regressed over time. Audiometry was not found to be a useful tool to predict growth but interval MRI scans were. The quality of life of the VS group managed conservatively was found to be comparable across all domains of the short-form 36 (SF-36) with an age and sex match control group. Conclusions: All asymptomatic patients and symptomatic ones with a VS size of <30 mm should initially be offered conservative management with interval imaging.

Expectant Management of Vestibular Schwannoma: A Retrospective Multivariate Analysis of Tumor Growth and Outcome

We conducted a retrospective observational study to assess the consequences of conservative management of vestibular schwannoma (VS). Data were collected from tertiary neuro-otological referral units in United Kingdom. The study included 59 patients who were managed conservatively with radiological diagnosis of VS. The main outcome measures were growth rate and rate of failure of conservative management. Multivariate analysis sought correlation between tumor growth and (i) demographic features, (ii) tumor characteristics. The mean tumor growth was 0.66 mm/y. 11 patients (19%) required intervention. Mean time to intervention was 37 months with two notable late "failures" occurring at 75 and 84 months. Tumors extending into the cerebellopontine angle (CPA) grew significantly faster than intracanalicular tumors (p = 0.0045). No association was found between growth rate and age, sex, tumor laterality, facial nerve function, and grade of hearing loss. Conservative management is acceptable for a subset of patients. Tumors extending into the CPA at diagnosis grow significantly faster than intracanalicular tumors. No growth within 5 years of surveillance does not guarantee a continued indolent growth pattern; surveillance must therefore continue.

Audiovestibular Factors Influencing Quality of Life in Patients With Conservatively Managed Sporadic Vestibular Schwannoma

To measure the health-related quality of life (QoL) of patients undergoing conservative management of a vestibular schwannoma and to identify audiovestibular factors that influence health-related QoL. Cross-sectional case-control study. Adult patients undergoing conservative management of a sporadic vestibular schwannoma were identified from a prospectively updated database. Each patient was asked to complete a series of questionnaires, including the Short Form 36 health-related QoL instrument, the Hearing Handicap Inventory, the Tinnitus Handicap Inventory, and the Dizziness Handicap Inventory. The QoL data obtained were compared with UK normal data. Multiple linear regression was performed to identify audiovestibular factors influencing QoL. Of 241 patients still undergoing conservative management, 165 completed the questionnaires. The mean age was 66.6 years. Mean duration of follow-up was 5.7 years. Physical component summary scores were significantly lower than those of the normal population. Mental component summary scores were significantly above the normal population. Regression analysis showed that dizziness handicap score and age were strong predictors of physical component summary (both p < 0.0001). Dizziness handicap score and tinnitus handicap score were significant predictors of mental component summary (p = 0.0004 and p = 0.027 respectively). However, the model only explained a small amount of the data, suggesting that there may be other factors influencing QoL. Dizziness is the most significant audiovestibular predictor of QoL in patients with vestibular schwannomas. Tinnitus also has an impact on mental QoL. Hearing loss does not seem to influence QoL. Other factors such as illness perception may have an important role to play in determining QoL.

CONSERVATIVE OR SURGICAL TREATMENT OF A VESTIBULAR SCHWANNOMA

To the Editor: In the recent publication of Malhotra et al. "Clinical, radiographic, and audiometric predictors in conservative management of vestibular schwannoma" (1), we have noticed 2 flaws. In their article, which we read with interest, the conservative management of 202 patients with a vestibular schwannoma is discussed, and univariate and multivariate analyses were performed. We subscribe the need and use of a wait-and-scan policy in vestibular schwannomas because their tendency for growth and complications is on average low. Our main remark is regarding their discussion. Regarding radiotherapy and surgical treatment of vestibular schwannomas, they are stating that "these treatments carry nonnegligible consequences in terms of morbidity, mortality and quality of life." For mortality and facial nerve preservation, the risk is quoted and referred to recent articles. However, cerebrospinal fluid (CSF) leakage is quoted as approximately 15% with no reference. This is a wrong presumption and, without reference, not a sustainable figure. We have studied our result for many years with one of the largest series of surgical removal of vestibular schwannomas with a CSF leak rate of 0 and 1.4% (2,3). Even when not quoting the least amount of CSF rate reported in literature (2,3), a recent review has calculated an overall rate of 9.5% (4). We think that CSF leak in vestibular schwannoma surgery can be reduced to an absolute minimum with the use of the right surgical procedure (5). Malhotra et al. is furthermore stating in their introduction that "the present article describes the largest single-institution series of VS patients followed by conservative management," whereas for many years, the ENT Department of the Gentofte University Hospital in Copenhagen, Denmark, has the largest series. They even quote and refer (ref. [29]) to this series of 552 patients in their own article (6). Paul Merkus, M.D., Ph.D. Mario Sanna, M.D. Department of Otology and Skull Base Surgery Grupo Otologico Piacenza, Italy

Clinical, Radiographic, and Audiometric Predictors in Conservative Management of Vestibular Schwannoma

Vestibular schwannomas (VS) can be managed by observation. The goals were to examine clinical, radiographic, and audiometric variables at presentation and during observation that may predict which patients fail conservative management. A retrospective chart review was performed of 202 patients who elected observation primarily. Data collection included presenting symptoms, symptom progression, tumor size, audiologic measures, and global clinical outcomes. Univariate and multivariate analyses were performed. Follow-up ranged from 1 month to 16 years (mean, 2.48 yr). Nineteen patients (9.4%) in the study group failed. Disequilibrium as a presenting symptom appeared more often in patients who failed observation (58% versus 32%; p = 0.039), as did new-onset disequilibrium. Presenting tumor size differed for patients who failed conservative management, with a mean of 14.0 versus 8.4 mm (p = 0.0006). Neurotologic complications compared favorably to those treated with primary surgery or radiotherapy. Patients with subjective disequilibrium at presentation and subjective disequilibrium developed during observation may be more likely to fail conservative management. Increased tumor size at presentation also may indicate the same, although no threshold could be achieved.

Conservative Management of Vestibular Schwannoma: Results and Suggestions after 20 Years of Experience

Introduction: There was a time when almost every vestibular schwannoma (VS) was surgically treated. Approximately 20 years ago, we started to adopt a conservative management in some cases of small intracanalicular tumors affecting elderly people. In this period, the development of neuroradiological techniques, combined with a greater awareness of its usefulness among physicians, caused an increase in the clinical incidence of VS. Small and medium tumors are today more frequently detected. The collective experience and reports from the literature seem to support the concept that conservative management of VS may sometimes be preferred to surgery or radiotherapy, even considering the increasing importance attributed to the quality of life of patients. We report an update of our experience with the conservative management of patients with VS.

Vascular Malformation (so-called Hemangioma) of Scarpa's Ganglion

Vascular malformations of the cerebello-pontine angle (CPA) arising from the capillary plexus surrounding Scarpa's ganglion are rare tumors. We report a case of so-called “hemangioma” of the CPA which was operated on via a trans-labyrinthine approach based on a preoperative diagnosis of vestibular schwannoma. Although there are some differences between these tumors in terms of the clinical, biological and especially MRI findings, surgery is usually performed based on an assumption of vestibular schwannoma. Surgery is the treatment of choice for these lesions as early intervention ensures better postoperative facial function. It is important to make the differential diagnosis if conservative management of vestibular schwannoma is adopted.