Quality of life in sporadic vestibular schwannoma: a review.

Quality of life (QoL) measures are increasingly used as outcome measures in the assessment of different treatment options in clinical practice and as endpoints in clinical trials. Methods and questionnaires currently used for QoL assessment in vestibular schwannoma (VS) patients, studies evaluating QoL before and after treatment, studies on patients managed conservatively and studies evaluating facial-nerve-function-related QoL in VS patients are reviewed. Current methodological controversial issues in QoL studies on VS patients include the lack of a planned prospective comparison between QoL values before and after treatment, a need for the inclusion of additional questions along with standard questionnaires and the need to report on both the statistical and the clinical significance of QoL data. QoL assessments merit being included in more trials along with standardized interpretation and complete reporting of results.

Diagnosis and therapy of vestibular schwannoma.

MRI studies are of paramount importance for diagnosis and follow-up measurements during conservative and postinterventional management of vestibular schwannomas (VS). MRI findings that convey important information for hearing-preservation VS surgery are: length of tumor-cochlear nerve contact, involvement of the internal auditory canal, incomplete filling of internal auditory canal, tumor size less than 15 mm and the intralabyrinthine signal intensity on 3DFT-CISS gradient-echo images. Functional neuro-otologic studies of facial nerve function, hearing and vestibular/balance function provide a valuable means of assessment of the actual impairment of the functional status of the VS patient. Intraoperative monitoring of facial nerve function and hearing has been refined, resulting in improved final postoperative facial nerve and hearing outcomes in VS patients treated with microsurgery. Long-term results reported by teams practicing stereotactic radiosurgery or fractionated stereotactic radiotherapy have been very encouraging. On the other hand, conservative management appears to be a viable option for a select group of VS patients. The refinement of surgical technique has rendered surgery safer and less invasive, resulting in better functional outcomes. Steroid use is currently used postinterventionally to improve final hearing outcome, although with questionable effectiveness. Physical rehabilitation programs are applied to accelerate vestibular functional recovery postoperatively and there is weak evidence that early physical rehabilitation may improve the final facial nerve outcome. Quality-of-life measures have emerged as important determinants of final therapeutic decision-making. More studies with high levels of evidence are needed to support clinical decisions.

Histological and radiological signs indicative for chronic sinus mucosal inflammation in Graves' ophthalmopathy.

Orbital decompression and, in some cases, decompression of the optic nerve are the principal surgical procedures used for treatment of moderate or severe Graves' orbitopathy (GO). Histological examination of the surgical specimens of the ethmoid revealed a wide spectrum of inflammatory mucosal changes. The charts of 68 GO patients (55 female and 13 male; age range: 14 - 85 years) were retrospectively reviewed. Lund - Mackay scores were calculated for each patient based on findings of pre-operative computer tomography (CT) sinus scans, and the incidence of histological changes associated with polypoid and eosinophilic inflammation was assessed. Files did not reveal any evidence of chronic rhinosinusitis with or without nasal polyps based on endoscopic findings. Sinus opacification on CT (of any extent) was found in 20 out of the 68 patients (29.4%). On histological exam, histological changes of the sinus mucosa indicative for chronic rhinosinusitis were found in 31 out of the 68 GO patients (45.5%). A histological examination of the sinus mucosa indicative for chronic polypoid inflammation was present in 25 patients. Fourteen out of these 25 patients showed mucosal tissue eosinophilia on histology. Six patients had mucosal changes suggesting chronic non-polypoid inflammation with tissue eosinophilia on histological exam. The incidence of chronic rhinosinusitis in individuals without GO ranges between 10 and 15%. The incidence of histological changes of the sinus mucosa indicative for chronic rhinosinusitis described in this investigation suggests that chronic inflammatory disease is considerably more frequent in GO patients, when compared to the incidence of chronic rhinosinusitis in individuals without GO. Additionally, our data underline that CT imaging of the paranasal sinuses underestimates (29.4%) the incidence of inflammatory changes of the sinus mucosa (45.5%) of any extent in GO patients.

Successful rigid endoscopic removal of an esophageal subtotally covered nitinol stent 11 months after initial placement.

Formation of granulation tissue and stricture at the stent's ends are well-known long-term complications of esophageal subtotally covered externally self-expandable metal stents (SEMS). Removal is associated with an increased risk of mucosal injury, severe bleeding, mediastinis, and consecutive stenosis. We report on a case of successful endoscopic removal of an esophageal SEMS 11 months after original placement to cover an iatrogenic esophageal perforation created during rigid esophagoscopy in a patient with cancer of unknown primary (CUP) syndrome. This case shows that safe SEMS late removal is achievable and at the same time illustrates the disadvantages of using SEMS for benign esophageal pathology. Particularly in cases of accidental esophageal injury during endoscopy, esophageal SEMS placement should be considered as a therapeutic option only if conventional surgery is contraindicated.

Cochlear origin of early hearing loss in vestibular schwannoma.

OBJECTIVE: To test whether early hearing loss (HL) is cochlear in origin in patients with vestibular schwannoma (VS). STUDY DESIGN: Retrospective case review in an academic tertiary referral center. METHODS: A group of 19 VS patients with normal/symmetrical hearing and a group of 20 VS patients with mild HL (threshold at any tested frequency better than 45 dB HL) on the tumor ear side. Differences of the amplitudes of the distortion products of otoacoustic emissions (DPOAEs) between the tumor ear and the nontumor ear were studied at frequencies of 1, 1.4, 2, 2.8, and 4 kHz. The Wilcoxon test was used to compare the ears for both groups and to test for possible differences in tumor size between groups. RESULTS: DPOAE amplitudes do not differ strongly between the ears in VS patients with normal/symmetrical hearing (two-sided P values: .050 at 1 kHz, .182 at 1.4 kHz, .378 at 2 kHz, .293 at 2.8 kHz, and .238 at 4 kHz) but are decreased compared with the nontumor ear at frequencies 1, 1.4, 2, and 2.8 kHz in VS patients with even mild HL (two-sided P values: .013 at 1 kHz, .007 at 1.4 kHz, .033 at 2 kHz, .010 at 2.8 kHz, and .156 at 4 kHz). Tumor size did not differ significantly between the two groups (P = .436). CONCLUSION: Amplitudes of DPOAEs begin to decrease even at the early stages of HL in VS patients, which suggests a cochlear origin of early HL in these patients. DPOAEs may be used in a clinical setting to monitor progression of cochlear damage at the early stages of hearing impairment in VS patients.