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The Journal of Laryngology and Otology Aug 2019To review the literature regarding screening for vestibular schwannoma in the context of demographic changes leading to increasing numbers of elderly patients presenting...
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.
Topics: Aged; Aging; Evidence-Based Medicine; Female; Hearing Loss; Humans; Magnetic Resonance Imaging; Male; Neuroma, Acoustic; Population Surveillance; Tinnitus
PubMed: 31366414
DOI: 10.1017/S0022215119000963 -
Otology & Neurotology : Official... Apr 2021Facial nerve preservation is critical in vestibular schwannoma (VS) surgery. Direct electrical stimulation (DES) is a widely used method for intraoperative localization... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Facial nerve preservation is critical in vestibular schwannoma (VS) surgery. Direct electrical stimulation (DES) is a widely used method for intraoperative localization of the facial nerve and assessment of nerve integrity. We sought to assess the predictive ability of DES parameters on facial nerve function post-VS surgery.
DATABASES REVIEWED
A systematic literature search of English-language studies published from 1946 to 2019 was undertaken using EMBASE, MedLine/PubMed, and the Cochrane Central Register of Controlled Trials.
METHODS
Included studies involved patients undergoing VS surgery and assessed predictive ability of any DES parameter on postoperative facial function. Two authors independently reviewed studies and extracted data. Meta-analysis of diagnostic accuracy of DES parameters was used to calculate pooled sensitivities and specificities of common cutoffs. For DES parameters reported by less than four studies, outcomes were reported descriptively.
RESULTS
A MST cutoff of 0.10 mA had sensitivity of 0.76 (95% CI 0.53-0.90) and specificity 0.68 (95% CI 0.42-0.87) for facial function in the long term, and MST 0.05 mA had sensitivity 0.73 (95% CI 0.58-0.84) and specificity 0.74 (95% CI 0.59-0.85). CMAP amplitude < 500 μV had sensitivity of 0.87 (95% CI 0.78-0.93) for poor short-term facial function.
CONCLUSIONS
A CMAP amplitude response < 500 μV is sensitive for poor short-term facial function, whereas MST values of 0.05 mA and 0.10 mA are both sensitive and specific in the long term. Other DES parameters may be able to accurately predict both short- and long-term postoperative facial function, but have been less studied.
Topics: Electric Stimulation; Facial Nerve; Facial Nerve Injuries; Humans; Neuroma, Acoustic; Sensitivity and Specificity
PubMed: 33394939
DOI: 10.1097/MAO.0000000000003007 -
American Journal of Otolaryngology 2021The anti-angiogenic agent bevacizumab is currently the only drug used clinically for neurofibromatosis type 2-related vestibular schwannomas (NF2-VS). Though benefits... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The anti-angiogenic agent bevacizumab is currently the only drug used clinically for neurofibromatosis type 2-related vestibular schwannomas (NF2-VS). Though benefits have been demonstrated in several cases, the standardized dosage remains unclear.
OBJECTIVE
Our meta-analysis was performed to systematically and comprehensively investigate the reliability and toxicity of bevacizumab in the treatment of NF2-VS, with particular emphasis on the impact of dosage.
METHODS
The literature search was conducted for studies providing data on patients treated with bevacizumab for NF2-VS across PubMed, Embase, and Cochrane Library until December 31, 2020. Two reviewers extracted the incidence rate of results independently. Then we calculated and pooled unadjusted incidence rate with 95% CIs for each study. The subgroups analyzed were conducted.
RESULTS
Fourteen citations (prospective or retrospective observational cohort studies) were eligible based on data from a total of 247 patients with NF2 and 332 related VSs. The pooled results showed that the radiographic response rate (RRR) was 30% [95% CI (20%-42%)], the hearing response rate (HRR) was 32% [95% CI (21%-45%)]. The incidence of major complications was: hypertension 29% [95% CI (23%-35%)], proteinuria 30% [95% CI (18%-44%)], menstrual disorders 44% [95% CI (16%-73%)], hemorrhage 14% [95% CI (4%-26%)], grade3/4 events 12% [95% CI (4%-22%)].
CONCLUSIONS
Nearly one-third of NF2-VS patients may benefit significantly from bevacizumab due to hearing improvement and tumor reduction. Menstrual disorders were the most common adverse events. The high-dose regimen didn't show better efficacy, but results varied considerably according to age.
Topics: Adult; Age Factors; Bevacizumab; Dose-Response Relationship, Drug; Female; Hearing; Hemorrhage; Humans; Hypertension; Male; Menstruation Disturbances; Neurofibromatosis 2; Neuroma, Acoustic; Prospective Studies; Proteinuria; Retrospective Studies; Vestibulocochlear Nerve; Young Adult
PubMed: 34214711
DOI: 10.1016/j.amjoto.2021.103148 -
Otology & Neurotology : Official... Jul 2022To characterize the natural history of hearing loss for patients presenting with serviceable hearing (SH) who undergo a wait-and-scan approach for sporadic vestibular...
OBJECTIVE
To characterize the natural history of hearing loss for patients presenting with serviceable hearing (SH) who undergo a wait-and-scan approach for sporadic vestibular schwannoma (VS) using aggregate time-to-event survival analysis.
STUDY DESIGN
Systematic review.
SETTING
Published international English literature, January 1, 2000 to May 31, 2020.
PATIENTS
Patients with sporadic VS entering a wait-and-scan approach with SH at diagnosis.
INTERVENTIONS
Observation with serial MRI and audiometry.
RESULTS
In total, 3,652 patients from 26 studies were included for analysis. Mean age at diagnosis was 58.8 years (SD, 4.1). Mean follow-up was 49.2 months (SD, 26.5). In total, 755 patients (21%) failed conservative treatment and underwent radiosurgery or microsurgery at the time of last follow-up. The average loss to follow-up was 6.9% (SD, 11.1). A total of 1,674 patients had SH at the time of diagnosis. Survival rates for maintaining SH were 96% at 1 year, 77% at 3 years, 62% at 5 years, and 42% at 10 years following diagnosis.
CONCLUSION
In this systematic review, aggregate data from 3,652 patients across 26 studies show consistent patterns in progression of hearing loss during observation for patients with sporadic VS as a function of time. As an easy-toremember conservative benchmark for those presenting with SH at diagnosis: approximately 75% retain SH at 3 years, 60% at 5 years, and 40% at 10 years.
Topics: Follow-Up Studies; Hearing; Hearing Loss; Hearing Tests; Humans; Neuroma, Acoustic; Radiosurgery; Retrospective Studies; Treatment Outcome
PubMed: 35261385
DOI: 10.1097/MAO.0000000000003520 -
Otology & Neurotology : Official... Oct 2020Hearing loss remains a significant morbidity for patients with vestibular schwannomas (VS). A growing number of reports suggest audibility with cochlear implantation...
OBJECTIVE
Hearing loss remains a significant morbidity for patients with vestibular schwannomas (VS). A growing number of reports suggest audibility with cochlear implantation following VS resection; however, there is little consensus on preferred timing and cochlear implant (CI) performance.
DATA SOURCES
A systematic literature search of the Ovid Medline, Embase, Scopus, and clinicaltrails.gov databases was performed on 9/7/2018. PRISMA reporting guidelines were followed.
STUDY SELECTION
Included studies reported CI outcomes in an ear that underwent a VS resection. Untreated VSs, radiated VSs, and CIs in the contralateral ear were excluded.
DATA EXTRACTION
Primary outcomes were daily CI use and attainment of open-set speech. Baseline tumor and patient characteristics were recorded. Subjects were divided into two groups: simultaneous CI placement with VS resection (Group 1) versus delayed CI placement after VS resection (Group 2).
DATA SYNTHESIS
Twenty-nine articles with 93 patients met inclusion criteria. Most studies were poor quality due to their small, retrospective design. Group 1 had 46 patients, of whom 80.4% used their CI on a daily basis and 50.0% achieved open-set speech. Group 2 had 47 patients, of whom 87.2% used their CI on a daily basis and 59.6% achieved open-set speech. Group 2 had more NF2 patients and larger tumors. CI timing did not significantly impact outcomes.
CONCLUSIONS
Audibility with CI after VS resection is feasible. Timing of CI placement (simultaneous versus delayed) did not significantly affect performance. Overall, 83.9% used their CI on a daily basis and 54.8% achieved open-set speech.
Topics: Cochlear Implantation; Cochlear Implants; Hearing Loss; Humans; Neuroma, Acoustic; Retrospective Studies; Treatment Outcome
PubMed: 32925835
DOI: 10.1097/MAO.0000000000002784 -
Journal of Neurosurgery Feb 2023The goal of microsurgical resection of vestibular schwannoma (VS) is gross-total resection (GTR) to provide oncological cure. However, a popular strategy is to halt the...
OBJECTIVE
The goal of microsurgical resection of vestibular schwannoma (VS) is gross-total resection (GTR) to provide oncological cure. However, a popular strategy is to halt the resection if the surgical team feels the risk of cranial nerve injury is imminent, achieving a maximally safe subtotal resection (STR) instead. The tumor remnant can then be treated with stereotactic radiosurgery (SRS) once the patient has recovered from the immediate postoperative period, or it can be followed with serial imaging and treated with SRS in a delayed fashion if residual tumor growth is seen. In this study, the authors evaluated the efficacy of this multimodality approach, particularly the influence of timing and dose of SRS on radiological tumor control, need for salvage treatment, and cranial nerve function.
METHODS
VS patients treated with initial microsurgery and subsequent radiosurgery were retrospectively included from two tertiary treatment centers and dichotomized depending on whether SRS was given upfront (defined as before 12 months) or later. Radiological tumor control was defined as less than 20% tumor volume expansion and oncological tumor control as an absence of salvage treatment. Facial and cochlear nerve functions were assessed after surgery, at the time of SRS, and at last follow-up. Finally, a systematic literature review was conducted according to PRISMA guidelines.
RESULTS
A total of 110 VS patients underwent SRS following microsurgical resection, with a mean preradiosurgical tumor volume of 2.2 cm3 (SD 2.5 cm3) and mean post-SRS follow-up time of 5.8 years (SD 4.1 years). The overall radiological tumor control and oncological tumor control were 77.3% and 90.9%, respectively. Thirty-five patients (31.8%) received upfront SRS, while 75 patients (68.2%) were observed for a minimum of 12 months prior to SRS. The timing of SRS did not influence the radiological tumor control (p = 0.869), the oncological tumor control (p = 0.560), or facial nerve (p = 0.413) or cochlear nerve (p = 0.954) function. An escalated marginal dose (> 12 Gy) was associated with greater tumor shrinkage (p = 0.020) and superior radiological tumor control (p = 0.020), but it did not influence the risk of salvage treatment (p = 0.904) or facial (p = 0.351) or cochlear (p = 0.601) nerve deterioration.
CONCLUSIONS
Delayed SRS after close observation of residuals following STR is a safe alternative to upfront SRS regarding tumor control and cranial nerve preservation in selected patients.
Topics: Humans; Neuroma, Acoustic; Radiosurgery; Retrospective Studies; Treatment Outcome; Microsurgery; Follow-Up Studies
PubMed: 35907189
DOI: 10.3171/2022.5.JNS22249 -
Journal of Neurological Surgery. Part... Dec 2019This study was aimed to perform a systematic literature review by examining outcomes in patients with sporadic vestibular schwannoma (VS) undergoing ipsilateral...
This study was aimed to perform a systematic literature review by examining outcomes in patients with sporadic vestibular schwannoma (VS) undergoing ipsilateral cochlear implant (CI). PubMed-NCBI (National Center for Biotechnology Information) and Scopus databases were searched through October 2017. Studies reporting auditory outcomes for each patient when a CI was placed with an ipsilateral sporadic VS were included. Demographic variables, VS characteristics, preoperative hearing metrics, duration of deafness, CI type, approach to tumor resection, postoperative auditory outcomes, and postoperative tinnitus outcomes were reported for each eligible patient within studies. Each study was evaluated for quality and bias. Fifteen studies and 45 patients met inclusion criteria. Mean speech discrimination score (SDS) improved from 30.0 to 56.4% after CI placement. The majority when reported had an improvement in tinnitus. Preoperative ipsilateral SDS was a negative predictor of postoperative SDS, while neither tumor resection status, tumor location, duration of deafness, ipsilateral pure tone average, nor timing of CI placement had a significant effect on patient outcome. Notwithstanding the challenges inherent with surveillance magnetic resonance imaging (MRI) in the setting of a cochlear implant magnet, select sporadic vestibular schwannoma patients can be considered for cochlear implantation.
PubMed: 31750050
DOI: 10.1055/s-0038-1676768 -
Otology & Neurotology : Official... Oct 2019This study aimed to evaluate the diagnostic accuracy of high-resolution T2-weighted magnetic resonance imaging (T2wi) in terms of detecting vestibular schwannoma... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
This study aimed to evaluate the diagnostic accuracy of high-resolution T2-weighted magnetic resonance imaging (T2wi) in terms of detecting vestibular schwannoma compared with gadolinium-enhanced T1-weighted MRI (GdT1wi).
DATA SOURCES
Five databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database).
DATA SELECTION
Two authors independently searched five databases up to January 2019 on diagnosis of vestibular schwannomas via T2wi.
DATA EXTRACTION
In the included studies, tumor diameters reported using T2wi were compared with those revealed by GdT1wi and correlation coefficients were calculated. Data on true-positives, true-negatives, false-positives, and false-negatives were extracted from the relevant articles. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Inter-rater agreement among different observers and intra-rater agreement among different measurements made by a single observer was assessed.
DATA SYNTHESIS
Outcomes subjected to analysis included diagnostic accuracy (the diagnostic odds ratio); summary receiver operating characteristic curve and area under the curve values. The summary intra-class correlation coefficient was used for various random-effects models. The quality of each study was analyzed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.
CONCLUSIONS
T2wi performed without the use of a contrast agent is a highly accurate diagnostic and monitor tool compared with GdT1wi and also demonstrated high reliability. However, further studies are required to confirm the results of this study.
Topics: Humans; Magnetic Resonance Imaging; Neuroimaging; Neuroma, Acoustic; ROC Curve; Reproducibility of Results; Sensitivity and Specificity
PubMed: 31469788
DOI: 10.1097/MAO.0000000000002416 -
A Systematic Review of Interventions for Balance Dysfunction in Patients With Vestibular Schwannoma.Otology & Neurotology : Official... Mar 2020Dizziness is a major contributing factor to poor quality of life for patients with vestibular schwannoma (acoustic neuroma). We wished to review the literature on...
OBJECTIVE
Dizziness is a major contributing factor to poor quality of life for patients with vestibular schwannoma (acoustic neuroma). We wished to review the literature on interventions for balance dysfunction in these patients.
DATA SOURCES
A systematic literature review was performed identifying studies that measured balance function before and after treatment for vestibular schwannoma. Data sources include Medline (1950-present), EMBASE (1974-present), Cochrane Library (issue 3, 2008), NHS Centre of reviews and dissemination, Clinical Evidence, Cochrane central register of controlled trial, and CINAHL.
STUDY SELECTION
A minimum follow-up of 6 months was required, to estimate long-term balance function. Eight articles were identified, including five studies with surgical intervention, two studies with stereotactic radiotherapy, and one comparing the two. Study design was generally poor with a high risk of bias. These studies all utilized the Dizziness Handicap Inventory (DHI) as a measure of pre- and postintervention balance function.
DATA EXTRACTION
Results showed that overall DHI scores are not statistically affected by intervention irrespective of modality (surgery or stereotactic radiotherapy). Patients selected with severe dizziness, who undergo surgery, improved postoperatively. No other studies for severe dizziness were noted for comparison.
CONCLUSIONS
Age, sex, and tumor size have no statistically significant effect on DHI outcomes, and no evidence to suggest which treatment modality has better dizziness related outcomes.No specific treatment modality was superior in terms of long-term balance function. Patients with severe dizziness may benefit from surgery, although no comparator studies were identified.
Topics: Dizziness; Humans; Neuroma, Acoustic; Postural Balance; Quality of Life; Vertigo
PubMed: 31834215
DOI: 10.1097/MAO.0000000000002530 -
Acta Neurochirurgica Apr 2023Hybrid peripheral nerve sheath tumors (HPNST) are a newly recognized class of peripheral nerve sheath tumor, composed of at least two areas characteristic of...
PURPOSE
Hybrid peripheral nerve sheath tumors (HPNST) are a newly recognized class of peripheral nerve sheath tumor, composed of at least two areas characteristic of perineurioma, schwannoma, or neurofibroma. The literature consists only of case reports and small series; therefore, we present an illustrative case and an analysis of all reported cases of HPNST with a perineurioma component in the literature.
METHODS
A systematic search of the literature was performed to identify all reported cases of hybrid perineurioma-schwannoma or perineurioma-neurofibroma in the world's literature. Individual cases were analyzed for demographics, clinical features, imaging, and outcomes.
RESULTS
A total of 159 cases were identified across 41 studies. Hybrid tumors tended to present in mid-adulthood (median 38.5 years), predominantly affected females (57%, 89/156), as a painless (63%, 63/100) mass, or swelling. Ten patients (10/74, 14%) had a history of neurofibromatosis 1, and 2 patients a history of neurofibromatosis 2 (2/74, 3%). The majority (78%, 122/157) of cases occurred superficially, most commonly in the lower extremity (25%, 39/157). Perineurioma-schwannoma was the most reported (86%, 137/159) pathologic diagnosis, with 3 cases presenting with malignant features. Two cases reocurred after resection.
CONCLUSION
HPNST tend to occur in mid-adulthood and present as slowly progressive, painless, superficial masses, with a heterogeneous appearance on imaging. These entities pose a unique diagnostic challenge and likely remain under-recognized in the literature and current clinical practice. They pose low risk of recurrence or malignant transformation, and future work regarding the association with neurofibromatosis and genetic profiles is needed.
Topics: Female; Humans; Adult; Nerve Sheath Neoplasms; Neurilemmoma; Neurofibroma; Neurofibromatosis 2; Neurofibromatosis 1
PubMed: 36396843
DOI: 10.1007/s00701-022-05413-5