Prognostic factors for the incidence and recovery of delayed facial nerve palsy after vestibular schwannoma resection.

OBJECT: Preservation of facial nerve function in vestibular schwannoma (VS) resections remains a significant operative challenge. Delayed facial palsy (DFP) is one specific challenge yet to be fully elucidated. The aim of this study was to evaluate DFP among VS resection cases to identify significant prognostic factors associated with its incidence and clinical recovery. METHODS: This investigation involves a retrospective review of 104 cases of VS resection that occurred between December 2005 and May 2007. Patients who developed DFP were compared with patients exhibiting no facial palsy postoperatively with regard to surgical approach, severity and day of palsy onset, tumor size, intraoperative facial nerve monitoring, and postoperative recovery and treatment. Patients who demonstrated immediate facial palsy (IFP) following VS resection were also analyzed. Furthermore, specific analyses were performed in 2 distinct DFP patient groups: those who developed DFP after postoperative Day 3 ("late onset DFP"), and those whose palsy worsened after initial DFP identification ("deteriorators"). RESULTS: Of the 104 patients who underwent VS resection, 25.0% developed DFP and 8.6% demonstrated IFP postoperatively. The DFP group did not differ significantly in any measure when compared with patients with no postoperative facial palsy. However, patients with DFP presented with significantly smaller tumor sizes than patients with IFP. This IFP group averaged significantly smaller intraoperative facial nerve responses than patients without facial palsy, and larger tumor sizes than both the DFP and no facial palsy groups. Within the DFP group, patients with late onset DFP showed diminished intraoperative facial nerve responses when compared with the total DFP patient population. In total, 25 (96.2%) of 26 patients with DFP and 7 (77.8%) of 9 patients with IFP recovered to normal or near-normal facial function (House-Brackmann Grade I or II) at longest clinical follow-up. CONCLUSIONS: Although patients with DFP did not exhibit any distinguishable characteristics when compared with patients without postoperative facial palsy, our analysis identified significant differences in patients with palsy presenting immediately postoperatively. Further study of patients with DFP should be undertaken to predict its incidence following VS resection.

Hearing preservation in the resection of vestibular schwannomas: patterns of hearing preservation and patient-assessed hearing function.

OBJECT: No extant literature documents the analysis of patient perceptions of hearing as a corollary to objective audiometric measures in patients with vestibular schwannoma (VS), or acoustic neuroma. Therefore, using objective audiometric data and patient perceptions of hearing function as outlined on a questionnaire, the authors evaluated the hearing of patients who underwent VS resection. METHODS: This investigation involved a retrospective review of 176 patients who had undergone VS resections in which hearing preservation was a goal. Both pre- and postoperative audiometry, expressed as a speech discrimination score (SDS) and pure tone threshold average (PTA), were performed, and the results were analyzed. Intraoperative auditory brainstem responses were also recorded. Eighty-seven of the patients (49.4%) completed a postoperative questionnaire designed to assess hearing function in a variety of social and auditory situations. Multiple linear regression analyses were completed to compare available audiometric results with questionnaire responses for each patient. RESULTS: One hundred forty-two patients (80.7%) had PTA and SDS audiometric data pertaining to the surgically treated ear; 94 of these patients (66.2%) had measurable postoperative hearing, as defined by a PTA < 120 dB or SD > 0%. Eighty-seven patients (49.4%) completed the retrospective questionnaire, and 74 of them had complete audiometric data and thus were included in a comparative analysis. Questionnaire data showed major postoperative subjective hearing decrements, even among patients with the same pre- and postoperative objective audiometric hearing status. Moreover, the subscore reflecting hearing while exposed to background noise, or the "cocktail party effect," characterized the most significant patient-perceived hearing deficit following VS resection. CONCLUSIONS: The authors' analysis of a patient-perceived hearing questionnaire showed that hearing during exposure to background noise, or the cocktail party effect, represents a significant postoperative hearing deficit and that patient perception of this deficit has a strong relation with audiometric data. Furthermore, questionnaire responses revealed a significant disparity between subjective hearing function and standard audiometrics such that even with similar levels of audiometric data, subjective measures of hearing, especially the cocktail party effect, decreased postoperatively. The authors posit that the incorporation of patient-perceived hearing function evaluation along with standard audiometry is an illustrative means of identifying subjective hearing deficits after VS resection and may ultimately aid in specific and subsequent treatment for these patients.

Modafinil : a review of its use in excessive sleepiness associated with obstructive sleep apnoea/hypopnoea syndrome and shift work sleep disorder.

Modafinil (Provigil is a wake-promoting agent that is pharmacologically distinct from CNS stimulants, such as amfetamine, dexamfetamine and methylphenidate. Modafinil is approved for use in the US and certain European countries for use in patients with excessive sleepiness associated with narcolepsy, obstructive sleep apnoea/hypopnoea syndrome (OSA/HS) or shift work sleep disorder (SWSD). Oral modafinil promotes wakefulness in patients with OSA/HS and SWSD. It is an effective adjunctive therapy in patients with residual excessive sleepiness associated with OSA/HS who are receiving nasal continuous positive airway pressure (nCPAP) therapy. In SWSD, the drug improves night-time wakefulness without disrupting daytime sleep. Modafinil is generally well tolerated in patients with OSA/HS or SWSD and has a low abuse potential. Thus, modafinil is a valuable new treatment option for use in patients with excessive sleepiness associated with OSA/HS (as an adjunct to nCPAP) or SWSD.

Diagnosis and management of post-traumatic vertigo.

OBJECTIVES/HYPOTHESIS: Patients with post-traumatic vertigo can be difficult to treat secondary to the chronicity of their symptoms. Patients can have peripheral, central, and combined vestibular deficits. Furthermore, no comprehensive guidelines exist for returning these patients to work. The objectives of the study were to discuss diagnosis, management techniques, and guidelines for returning these patients to work. STUDY DESIGN: Retrospective analysis of a tertiary referral neurotology and balance clinic. METHODS: Between July 1997 and July 2003, 2390 patients with chief complaints of vertigo and/or dizziness were analyzed. Of these, 16 patients met the requirements for inclusion in the study, including head trauma and/or concussion and residual vertigo. Their inpatient and outpatient charts, imaging studies, audiograms, vestibular tests, and physical therapy evaluations were reviewed. All patients had at least 6 months of follow-up. RESULTS: There were 5 women and 11 men, with an average age of 42 years. Five patients had symptoms consistent with traumatic perilymphatic fistulas, and two patients had symptoms consistent with post-traumatic Meniere's syndrome. Surgical therapy was not beneficial in relieving dysequilibrium. Balance testing results did not predict return-to-work status. Eleven patients were not allowed to return to work in any capacity, two patients were allowed to return to work with limited duties, and three patients were allowed to return to work with no restrictions. CONCLUSION: Post-traumatic vertigo can result in chronic symptoms. Balance testing did not predict the ability of patients to return to work. Surgical intervention might not control patient symptoms. Many patients were unable to return to work.