Growth Patterns of Residual Tumor in Preoperatively Growing Vestibular Schwannomas.

Objectives To analyze growth of residual vestibular schwannoma (VS) following incomplete tumor resection and determine the influence of residual location and size. Design Retrospective case note and scan review. Setting Tertiary skull base unit. Participants Patients with residual tumor following primary surgery for medium and large unilateral growing vestibular schwanomas between 2006 and 2009. Main Outcome Measures Location of residual VS and post-operative growth, comparing those with more (>5%) or less than 5% of tumor residual (<5%). Results Fifty-two patients had visible residual tumor left behind at surgery. Twenty had < 5% and 32 had > 5% residual. The residual growth rates were 38% overall, 20% in < 5%, and 50% in > 5% residuals. There was no significant difference in growth rates at different residual locations. Median follow-up was 6.4 years. Conclusions There is a greater risk of regrowth of residuals > 5%. All positions of residual tumor can regrow, and the preoperative tumor size plays a role in this. Further data is needed to confirm if residual tumor in the fundus is less likely to grow.

The impact of acoustic neuroma on long-term quality-of-life outcomes in the United Kingdom.

OBJECTIVE: To quantify the impact of acoustic neuroma on the quality-of-life (QOL) patients in the United Kingdom. STUDY DESIGN: Online questionnaire survey. PATIENTS: Members of the British Acoustic Neuroma Association received PANQOL questionnaires. RESULTS: Of the 880 BANA members contacted, 397 (45.1%) responded, although only 359 had complete datasets for analysis. Composite QOL scores were as follows: for microsurgery 58 (SD 35), for radiotherapy 56 (SD18), for combination of surgery and radiotherapy 49 (SD 14), and for the observation group 54 (SD 20). No statistical significance with ANOVA (p = 0.532). Mean (SD) composite QOL scores were as follows: for follow-up < 6 52 (SD 18), for follow-up 6-10 55 (SD 20) and follow-up > 10 years 65 (SD 45). Overall, these values were significantly different compared by ANOVA (p < 0.001). Patients with facial paralysis showed no statistical significant differences between the different treatment groups. CONCLUSIONS: Short- (< 6 years) and long-term (> 10 years) QOL outcomes show no significant differences between the different treatment groups.

Validation of the facial dysfunction domain of the Penn Acoustic Neuroma Quality-of-Life (PANQOL) Scale.

The objective of this study is to evaluate the strength of content validity within the facial dysfunction domain of the Penn Acoustic Neuroma Quality-of-Life (PANQOL) Scale and to compare how it correlates with a facial dysfunction-specific QOL instrument (Facial Clinimetric Evaluation, FaCE). The study design is online questionnaire survey. Members of the British Acoustic Neuroma Association received both PANQOL questionnaires and the FaCE scale. 158 respondents with self-identified facial paralysis or dysfunction had completed PANQOL and FaCE data sets for analysis. The mean composite PANQOL score was 53.5 (range 19.2-93.5), whilst the mean total FaCE score was 50.9 (range 10-95). The total scores of the PANQOL and FaCE correlated moderate (r = 0.48). Strong correlation (r = 0.63) was observed between the PANQOL's facial dysfunction domain and the FaCE total score. Of all the FaCE domains, social function was strongly correlated with the PANQOL facial dysfunction domain (r = 0.66), whilst there was very weak-to-moderate correlation (range 0.01-0.43) to the other FaCE domains. The current study has demonstrated a strong correlation between the facial dysfunction domains of PANQOL with a facial paralysis-specific QOL instrument.

Linear accelerator radiosurgery for vestibular schwannomas: Results of medium-term follow-up.

BACKGROUND: To examine tumour control, via volume changes, and the complications of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) treatment of vestibular schwannomas (VSs) on medium-term follow-up. METHODS: Between September 2003 and November 2009 fifty consecutive patients with VSs treated with SRS using a marginal dose of 12.5 Gy utilizing a LINAC equipped with a micro-multileaf collimator were identified. Evaluation included serial magnetic resonance imaging (MRI), and neurological and hearing examinations. RESULTS: The median tumour volume at treatment was 2.4 (range: 0.24-10.59) cm3. The intracranial diameter of the tumours ranged between 7.7 and 28.7 (median: 15.8) mm. Follow-up MRI was available for analysis on 49 patients. The median radiological follow-up period was 5.8 (range: 1.4-9.2) years. The median tumour volume at last follow-up was 1.1 (range: 0.03-5.3) cm3. VS decreased in size in 45 (90%) patients, with a median reduction in tumour volume of 1.46 (range: 0.06-9.29) cm3 or a median tumour size reduction of 59% of the baseline (range: 6-90%) in these patients. VS remained stable in 2 patients and increased in size in 2 patients. Only 1 patient (2%) required additional intervention (surgery). 15 patients had useful hearing pre-treatment; 10 post-treatment pure-tone audiograms of these patients were available. 5 (50%) patients still had useful hearing post treatment. Non-auditory adverse radiation effects included new (House-Brackmann grade II) or worsened facial nerve palsy (House-Brackmann grade II to grade V) in 2 (4%) patients and trigeminal sensory disturbance in 2 (4%) patients. CONCLUSIONS: At medium term, the vast majority of VSs treated with LINAC-based SRS exhibit tumour shrinkage. The slightly higher rate of facial nerve palsy compared with Gamma Knife surgery (GKS) results may be related to the learning curve. Other complications were similar to reported GKS results for VSs of comparable sizes.

A United Kingdom survey of concerns, needs, and priorities reported by patients diagnosed with acoustic neuroma.

INTRODUCTION: The Patient Concerns Inventory-Acoustic Neuroma (PCI-AN) was developed to explore specifically the concerns that patients would like to discuss during their clinic consultation. The PCI covers a range of issues including hearing, intimacy, fatigue, financial/benefits, relationships, regret, and support for family. It also lists multidisciplinary team (MDT) members that patients would like to see or be referred on to. METHOD: The PCI-AN was emailed to members of the British Acoustic Neuroma Association. RESULTS: A total of 465 complete (54.5%) responses were received. There were 284 female and 181 male subjects. Overall, the most common treatment modality was surgical excision (47%). A quarter of the study cohort had stereotactic radiosurgery, whereas 23% were conservatively managed with interval MRI scanning. The remaining 5% had both surgery and stereotactic radiosurgery. From the 55-item PCI-AN, the most commonly selected issues that patients wanted to talk about were related to the physical and functional well-being and treatment received. Tinnitus was the most frequently selected issue (46%), followed by fatigue/tiredness (43%), dizziness (33%), further investigation (39%), acoustic neuroma treatment (38%), and energy levels (32%). More than a quarter of the respondents had fears of their acoustic neuroma recurring (29%), had concerns about their facial appearance/ palsy (29%), or suffered pain in the head and neck region (26%). The 3 health-care professionals patients most wanted to talk with either in clinic or by referral were as follows: ENT/neurosurgeon (39%), vestibular (balance) physiotherapist (39%), and audiologist (39%). Although it was unknown how many respondents had facial palsy, 21% wanted to see a facial palsy physiotherapist, and another 10% sought referral to a plastic surgeon. CONCLUSION: The PCI-AN has shed light on an interesting array of issues, which may be overlooked by clinicians in busy skull base clinic. The PCI-AN allows for patient-directed consultation and ultimately empowers them to be actively involved in the management of their health.

A national survey of facial paralysis on the quality of life of patients with acoustic neuroma.

OBJECTIVE: The aim of this survey was to objectively quantify the impact of facial palsy on the quality of life of acoustic neuroma patients. METHODS: The Facial Clinimetric Evaluation (FaCE) Scale was emailed to all members of the British Acoustic Neuroma Association (BANA). RESULTS: Of the 880 BANA members contacted, 398 (45.2%) responded, of which, 178 indicated that they had facial paralysis. Surgery for acoustic neuroma accounted for 80% of facial paralysis. Treatment received for facial palsy varied considerably, although 33% reported not receiving any treatment. The commonest single treatment modality wads facial electrical stimulation (41%), followed by facial physiotherapy (39%). The most common surgical procedures were to the eye lid (50%), followed by nerve graft (12%), forehead lift (10%), muscle sling (9%), and face lift (9%). The overall mean total FaCE Scale score was 54.8 (range, 10-100, standard deviation [SD] 21.2). Both facial movement and eye comfort domains had the lowest mean scores of 41.3 (SD, 29.9) and 41.2 (SD 32.6) respectively. The mean total FaCE Scale score of female respondents was statistically lower (p = 0.03) than males (52.6 (SD 21.2) versus 58.8 (SD 20.7) respectively), as were the difference in mean domain scores for facial comfort, eye comfort and social function. The mean total FaCE Scale scores of respondents aged below 40 years were the lowest. Younger patients had the lowest social function domain scores of all age groups. CONCLUSION: Facial paralysis is a significant problem in patients with acoustic neuroma. Based on this survey, treatment for facial paralysis is often not offered and even when given, still leaves the patient with a significantly lowered quality of life. However, it should be remembered that this study has surveyed a skewed patient population and that overall, most acoustic neuroma patients do not suffer with facial paralysis.

Long-term outcomes of facial nerve function in irradiated and nonirradiated nerve grafts.

OBJECTIVES: We reviewed the long-term results of facial nerve repair in a tertiary head and neck institution in the north of England. METHODS: We performed a case notes review of patients who had facial nerve repair over a 10-year period and had completed 24 months of follow-up. RESULTS: The study population comprised 18 female patients and 24 male patients, with an overall mean age of 53.2 years (range, 16 to 80 years). Of the 24 patients who had a cable nerve graft, the greater auricular nerve was used in 15 cases. The sural nerve was used as the donor in a cross-facial nerve graft in 9 patients. Sixteen patients had transposition nerve repair: hypoglossal and ansa cervicalis in 7 and 9 cases, respectively. Two patients had primary anastomosis after surgery for extensive malignant tumors. In this series, no patients achieved a House-Brackmann (HB) grade of II. Overall, the HB grades III, IV, and V were the best postoperative facial nerve functions achieved in 11.9%, 33.3%, and 26.2% of patients, respectively. Failure (HB grade VI) was observed in 28.6% of patients. More than half of patients (62.5%) who had either a sural nerve cable graft or a faciohypoglossal transposition had a good outcome (HB grade III or IV). CONCLUSIONS: In the present series, 45% of patients had an HB grade of III or IV at long-term follow-up. The best outcome (HB grade III) was observed after cross-facial grafting with the sural nerve.

Antisecretory factor-inducing therapy improves patient-reported functional levels in Meniere's disease.

OBJECTIVES: The aim of this study was to evaluate the effectiveness of specially processed cereal (SPC) as a suitable adjunctive treatment for Meniere's disease. METHODS: We performed a randomized double-blinded, placebo-controlled, crossover study in a tertiary referral center of patients who had a diagnosis of Meniere's disease based on the guidelines of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). The main outcome measure was the AAO-HNS Functional Level Scale (FLS). RESULTS: Thirty-nine patients completed the study without any reported complications. The mean pretreatment FLS score for the entire study cohort was 3.8 (median, 4; range, 1 to 6). The overall FLS score improved significantly (p < 0.001), to 2.8 (median, 3), after SPC treatment. No patients showed worsening on the FLS during SPC or placebo treatment. Of the 39 patients, 23 showed improvement on the FLS, and no change was observed in the remaining 16. The median improvement on the FLS in these 23 patients was 2 points (mean, 1.7; range, 1 to 4). The mean FLS score after placebo cereal treatment was not significantly different from baseline (p = 0.452), but was significantly higher than that after SPC treatment (mean, 3.7; p < 0.001). The marginal difference observed between the baseline FLS score and the placebo FLS score was due to the fact that 5 patients reported 1-point improvements on the FLS after placebo treatment. Nevertheless, significantly fewer patients improved on placebo than on SPC (p < 0.001). CONCLUSIONS: Treatment with SPC appears to be well tolerated by most patients (91%) without any complications. More than half (59%) of the study cohort reported subjective improvement in functional level.

Squamous cell carcinoma of the temporal bone: outcomes of radical surgery and postoperative radiotherapy.

OBJECTIVES/HYPOTHESIS: To analyze the treatment outcomes for squamous cell carcinoma (SCC) of the temporal bone and to identify factors that may influence prognosis. STUDY DESIGN: Retrospective case series. METHODS: Case notes review of patients with histologically proven SCC of the temporal bone who had treatment with a curative intent at a tertiary referral center in the Northwest of England, United Kingdom. RESULTS: A total of 35 patients were treated in this unit over a 12-year period. The most common presentation was otorrhoea, which was present in all patients, followed by otalgia (66%), bleeding (54%), and facial palsy (46%). The overall survival for this series was 48.6%. There were four patients with stage I tumor, and one case each of stage II and stage III disease. The disease-free survival for patients with stage I to stage III disease in this series was 100%. The remaining 29 patients (84%) had stage IV disease, with an overall survival in this group of 41.4%. The average survival period of the 18 patients who succumbed to local disease was 9.2 months (range 3-22). Poorly differentiated SCC was associated with significantly poorer survival (P < 0.05) when compared to well and moderately differentiated SCC. Parotid involvement of SCC, node-positive neck, and the presence of preoperative facial palsy was not associated with poorer survival outcomes. CONCLUSIONS: SCC of the temporal bone is a highly malignant disease that is associated with high morbidity and mortality despite aggressive multimodal treatment. LEVEL OF EVIDENCE: 4.

Trans-mastoid facial nerve localisation for malignant neoplasms confined to the parotid gland.

Up to 32% of parotid neoplasms are malignant, and treatment for resectable parotid carcinomas remains primarily surgical. Resection is centred round the identification and preservation (where possible) of the main trunk of the facial nerve. Limited dissection of the temporal bone and identification of the facial nerve proximally in the mastoid portion can facilitate resection for all parotid carcinomas that occur in the preauricular portion of the gland. Dissection in the narrow space between the ear or base of the skull and the tumour reduces the risk of tumour spillage, and the margin for resection is optimised. Intramastoid localisation of the facial nerve allows a posterior approach, and access to the dissection plane lies medial to the nerve. We describe the technique in a series of eight patients undergoing resection for parotid malignancies. In our experience the technique promotes adequate resection margins, reduces the risk of tumour spillage, and allows better access for nerve grafting if the facial nerve has to be sacrificed.