Imaging Post Stereotactic Radiosurgery for Vestibular Schwannomas-When Should We Scan?

OBJECTIVE: To identify the optimal time for imaging following stereotactic radiosurgery (SRS) in patients with vestibular schwannomas (VS). STUDY DESIGN: Retrospective case series. SETTING: Tertiary, university center. PATIENTS: Patients with VS treated with SRS. INTERVENTIONS: Pre- and post-SRS surveillance with magnetic resonance imaging (MRI); patients should have at least two pre- and two post-SRS scans available to be included. MAIN OUTCOME MEASURES: Patient demographics, tumor size, and growth per month ratio pre- and post-SRS and time interval between serial MRI. RESULTS: Forty-two patients fulfilled the inclusion criteria. The average tumor size before the treatment was 16.9 mm (range, 10-28 mm) while 2 years posttreatment it was 16 mm (range, 7-25 mm) (p = 0.5). Average time of the first MRI post-SRS was 11 months (range, 5-14) with an average change in tumor size at that time of +0.53 mm (range, -5-8). Average time to second MRI was 22.3 months (range, 12-33) with an average change in tumor size at second scan of -1.14 (range, -5-2) mm (p = 0.117). The average growth/mo ratio before SRS was 0.26 mm/mo (range, 0-1), while post-SRS 0.05 mm/mo (range, -0.3-0.5) and -0.16 mm/mo (range, -18-0.25) at the time of the first and second scan, respectively (p < 0.001). CONCLUSIONS: Given the initial increase in size following SRS, unless clinically indicated, MRI post-SRS at less than 1 year has no clinical value. The growth per month ratio provides more meaningful values for response to treatment than tumor size measurements.

Not 'just' a foreign body in the ear canal.

Foreign bodies are commonly seen by the Ear, Nose and Throat emergency team with cotton wool being the most common aural foreign body seen in the adult population. Most complications secondary to aural foreign bodies described in the literature are minor and rarely require any surgical intervention. Here, we present two cases with impacted cotton wool as aural foreign bodies which resulted in suppurative labyrinthitis and osteomyelitis causing profound sensorineural hearing. These cases highlight the importance of considering aural foreign bodies in the differential diagnosis in those presenting with unilateral symptoms as significant complications, although rare, can occur, particularly in those with delayed diagnosis.

Spontaneous Vestibular Schwannoma Regression: A Case-Control Study.

OBJECTIVE: To explore the nature of spontaneously regressing vestibular schwannomas (VS) and identify possible predictive factors for such behavior. STUDY DESIGN: Retrospective case control study. SETTING: Tertiary referral center, university teaching hospital. PATIENTS: Patients with sporadic VS demonstrating spontaneous regression compared with a control group of patients with growing VS. INTERVENTIONS: Review of serial magnetic resonance imaging of the internal auditory meatus (MRI IAM) and case notes and direct comparison of possible related factors between the two groups using univariate analysis. MAIN OUTCOME MEASURES: Presenting symptoms, VS size and consistency, patients' age and sex, tumor laterality and location, and the neutrophil-to-lymphocyte ratio between the two groups. RESULTS: Of the 540 patients on the database 28 (5.2%) showed spontaneous regression with a mean follow-up of 122 months. Mean absolute and relative regression was 3.9 mm and 25.7%, respectively. 60% of tumors showed gradual regression while 25% showed growth followed by regression. Regressing VS had a significantly larger size than the control group; while the regressing tumors were located further from the fundus than the control group. The remaining examined factors did not reach a statistical level of significance. CONCLUSION: This is, to our knowledge, the first study comparing a cohort of regressing tumors with a control group of growing VS. The finding that the location of tumors around the porous, is more common in regressing VS has implications for patients' counselling.

Audiological Outcomes in Growing Vestibular Schwannomas Managed Either Conservatively, or With Stereotactic Radiosurgery.

OBJECTIVE: Recent studies have suggested good hearing preservation following stereotactic radiosurgery (STRS) in patients with vestibular schwannomas (VS). This study aims to assess audiological outcomes in patients with growing VS treated either with STRS, or managed conservatively. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Out of 540 patients with VS, 69 patients with growing VS fulfilled the inclusion criteria; 24 treated conservatively and 45 with STRS. VS were considered growing if demonstrating more than 15% tumor volume increase during 1 year of watchful waiting. INTERVENTION: American Association of Otolaryngology-Head and Neck Surgery (AAOHNS) hearing threshold (dB averaged over 500-3000 Hz) deterioration and Gardner-Robertson class deterioration over time were used as the primary outcome measures. Rate of progression to loss of functional hearing (Gardner-Robertson class I-II) was also determined between cohorts. RESULTS: Mean follow-up was similar between treatment cohorts (STRS = 69.6 mo, conservative management = 71.7 mo). There was no significant difference in AAOHNS deterioration (t = 1.05, df = 53, p = 0.301) or Gardner-Robertson deterioration (χ = 0.47, df = 1, p = 0.492) between cohorts. Furthermore, rate of progression to loss of functional hearing was similar between cohorts (Hazard ratio = 0.704, 95% CI 0.287-1.728, p = 0.44). In STRS patients, AAOHNS deterioration was greater in those with lower AAOHNS thresholds at diagnosis (t = -2.683, df = 28, p = 0.0121). Similarly, Gardner-Robertson deterioration was significantly more likely in STRS patients with functional hearing (Gardner-Robertson class I-II) (Adjusted odds ratio = 32.14, 95% CI 3.15-328, p = 0.0034). CONCLUSIONS: STRS results in similar audiological outcomes compared with patients managed conservatively; Consequently, STRS given to patients with VS to preserve hearing is not justified. In contrast to recent studies, patients with preserved hearing at diagnosis have significantly greater audiological deterioration when undergoing STRS.

Delayed Vestibular Schwannoma Regrowth Following Shrinkage After Stereotactic Radiosurgery: Implication for Life-Long Surveillance.

OBJECTIVE: To enhance understanding of the behavior of vestibular schwannomas (VS) after stereotactic radiosurgery (SRS), including the potential for late tumor regrowth, and the need for lifelong radiological and clinical surveillance. PATIENTS: From a total of 540 patients with VS and out of 95 patients receiving SRS for their growing VS, the cases of two women patients aged 58 and 59 years with medium sized, growing VS are presented. INTERVENTION: Both patients were treated with SRS. Following treatment, both patients had close clinical follow-up and serial magnetic resonance imaging (MRI). MAIN OUTCOME MEASURES: Post-SRS clinical assessment and serial MRI to determine VS size and respond to treatment. RESULTS: Close clinical follow-up after SRS identified no change in symptoms in one patient; the other developed ipsilateral facial nerve twitching without weakness. Serial MRI identified that in both patients, VS that had initially decreased in size following SRS, exhibited significant late regrowth after a 3-year period, reaching the pretreatment size. CONCLUSIONS: This is the first report of late vestibular schwannoma regrowth following a period of significant shrinkage after SRS. Potential reason may be the presence of living cells within the tumor; the possibility of malignant transformation should also be taken into account. Following SRS, patients with VS warrant lifelong radiological and clinical surveillance, even following good response, as there seems to be a small chance of initial regression followed by further growth. Microsurgery for tumor removal and histological diagnosis is indicated in such cases.

Elastic airtight container for the compaction of air-sensitive materials.

We report on the design and fabrication of a simple and versatile elastic canister for the compaction and hot-pressing of air-sensitive materials. This device consists of a heated double-ended floating die assembly, enclosed in a compressible stainless steel bellows that allows the action of an external hydraulic press in a uniaxial motion. The enclosure is fitted with vacuum, gas, and electrical feedthroughs to allow for atmosphere control, heating, and in situ process monitoring. The overall chamber is compact enough to be portable and transferrable into and out of a standard laboratory glovebox, thus eliminating the problem of exposing samples to ambient atmosphere during loading and unloading. Our design has been tested up to 600 °C and 7500 kg-force applied load, conditions within which transparent ceramics of anhydrous halides can be produced.

Neutrophil to Lymphocyte Ratio as a Predictive Marker of Vestibular Schwannoma Growth.

OBJECTIVE: To examine the predictive value of neutrophil to lymphocyte ratio (NLR) for vestibular schwannoma (VS) growth. STUDY DESIGN: Retrospective case-control study. SETTING: Tertiary, referral center. PATIENTS: Patients with sporadic VS and available NLR obtained within 1 year from the diagnosis were divided into two groups with growing or non-growing tumor. Patients with known conditions affecting NLR were excluded. INTERVENTIONS: NLR and tumor growth as determined by linear measurements on serial magnetic resonance imaging. MAIN OUTCOME MEASURES: VS growth, demographic factors, and NLR were compared using multi-variant logistic regression and Receiver Operating Characteristic (ROC) curve analysis. RESULTS: A total of 161 patients fulfilled the inclusion criteria, 79 with growing VS (men:women ratio = 43:36, mean age, 61.8 years) and 82 with non-growing tumors (men:women ratio = 37:45, mean age, 64.9 years). Mean NLR for the group with growing VS was 3.34 (SD [standard deviation] = 1.5) and 2.31 (SD = 0.76) for the group with non-growing VS (p = 0.001; 0.03 when adjusted for all parameters). The optimal cut-off point was NLR = 3.05 with positive predictive value 83.8% and 100% for NLR greater than 5.3. ROC analysis of the adjusted data for age, sex, and side, gave an area under the curve of 0.768, indicating NLR as a good independent predictive marker. Interestingly, the size of tumor was statistically significantly higher for the growing VS group (p = 0.001). CONCLUSION: Despite the low specificity of low NLR, our results indicate high NLR as a good predictive marker for VS growth. Confirmation by prospective studies will have a significant impact on patients' management.

When does an enlarged cervical lymph node in a child need excision? A systematic review.

BACKGROUND: Palpable cervical lymphadenopathy is very common in children. The clinician's job is to exclude malignancy as a cause and reach a diagnosis. In children selected for open biopsy, reactive hyperplasia and other inflammatory causes are far more common as a final diagnosis than malignancy. Furthermore complications can occur after open biopsy. OBJECTIVE: To assess the diagnostic utility of clinical examination and investigations to exclude malignancy and other serious causes of paediatric cervical lymphadenopathy and minimise open biopsy. TYPE OF REVIEW: A systematic review of the literature with defined search strategy. SEARCH STRATEGY: A structured search of Medline, Embase, CINAHL and Cochrane databases. The references within standard paediatric ENT and head and neck textbooks were also examined. RESULTS: The quality of evidence regarding predictors of malignancy is poor. Large lymph nodes and supraclavicular nodes are potential indicators of serious pathology. Fever, weight loss and organomegaly may be indicators but duration of symptoms and consistency are not. Abnormalities on chest X-ray are associated with serious causes but the diagnostic utility of routine chest X-ray is unknown. Ultrasound assessment of nodal architecture, margins, and shape (and possibly vascularity) shows considerable promise as a means of differentiating reactive hyperplasia from malignancy but further studies in children are required. Abnormalities in the full blood count (FBC) seem to be uncommon but when present are associated with serious causes of cervical lymphadenopathy, again the diagnostic utility is unclear. Serological testing may identify a specific cause and therefore avoid excision biopsy in around 10% of cases. Cutting needle biopsy requires further evaluation before it can be recommended. Fine needle aspiration cytology (FNAC) is very specific, but sensitivity varies in different studies to the extent that it cannot yet be relied upon to exclude malignancy. CONCLUSIONS: Large and supraclavicular nodes should be biopsied. Ultrasound is likely to be useful but further study is required. FNAC cannot be relied upon to exclude malignancy in children. The diagnostic utility of chest X-ray and FBC are unclear. Work is required on multivariate predictive models.

Standardising reporting of cervical lymphadenopathy in paediatric neck ultrasound: a pilot study using an evidence-based reporting protocol.

OBJECTIVES: Cervical lymphadenopathy is common in children and can arise from a wide range of aetiologies. Ultrasound can be a useful imaging tool for initial investigation but is known to be operator dependent. We aimed to compare the content of ultrasound reporting in this clinical scenario before and after the introduction of an evidence-based reporting protocol. METHODS: We performed a prospective 8-month pilot study assessing the content of ultrasound reports generated from scans to investigate suspected cervical lymphadenopathy in children referred to our tertiary referral otolaryngology service. We found wide variation in report content and inconsistent reporting of certain radiological features. In response to this we performed a literature search to identify key, clinically relevant ultrasonographic features for cervical lymphadenopathy and then in consultation with our radiology colleagues, devised a protocol to facilitate the reporting of these key features. Content of reports was then prospectively re-audited over a further 8-month period. RESULTS: 23 reports were assessed before and 26 after introduction of the reporting protocol. Fisher's exact test was used to analyse the data. We found a statistically significant (p < 0.05) improvement in the frequency of reporting of various key features such as nodal distribution, shape, echogenicity, calcification, necrosis and vascular pattern. CONCLUSIONS: The introduction of a standardised protocol has helped to streamline the reporting of ultrasounds to investigate cervical lymphadenopathy within our department. In the absence of any national guidelines on the reporting of paediatric neck ultrasound in this scenario, we propose that our protocol could be used by other departments to improve standardisation and as a teaching aid.

Endoscopic full-thickness biopsy of the gastric wall with defect closure by using an endoscopic suturing device: survival porcine study.

BACKGROUND: The pathogenesis of several common gastric motility diseases and functional GI disorders remains essentially unexplained. Gastric wall biopsies that include the muscularis propria to evaluate the enteric nervous system, interstitial cells of Cajal, and immune cells can provide important insights for our understanding of the etiology of these disorders. OBJECTIVES: To determine the technical feasibility, reproducibility, and safety of performing a full-thickness gastric biopsy (FTGB) by using a submucosal endoscopy with mucosal flap (SEMF) technique; the technical feasibility, reproducibility, and safety of tissue closure by using an endoscopic suturing device; the ability to identify myenteric ganglia in resected specimens; and the long-term safety. DESIGN: Single center, preclinical survival study. SETTING: Animal research laboratory, developmental endoscopy unit. SUBJECTS: Twelve domestic pigs. INTERVENTIONS: Animals underwent an SEMF procedure with gastric muscularis propria resection. The resultant offset mucosal entry site was closed by using an endoscopic suturing device. Animals were kept alive for 2 weeks. MAIN OUTCOME MEASUREMENTS: The technical feasibility, reproducibility, and safety of the procedure; the clinical course of the animals; the histological and immunochemical evaluation of the resected specimen to determine whether myenteric ganglia were present in the sample. RESULTS: FTGB was performed by using the SEMF technique in all 12 animals. The offset mucosal entry site was successfully closed by using the suturing device in all animals. The mean resected tissue specimen size was 11 mm. Mean total procedure time was 61 minutes with 2 to 4 interrupted sutures placed per animal. Histology showed muscularis propria and serosa, confirming full-thickness resections in all animals. Myenteric ganglia were visualized in 11 of 12 animals. The clinical course was uneventful. Repeat endoscopy and necropsy at 2 weeks showed absence of ulceration at both the mucosal entry sites and overlying the more distal muscularis propria resection sites. There was complete healing of the serosa in all animals with minimal single-band adhesions in 5 of 12 animals. Retained sutures were present in 10 of 12 animals. LIMITATIONS: Animal experiment. CONCLUSIONS: FTGB by using the SEMF technique and an endoscopic suturing device is technically feasible, reproducible, and safe. Larger tissue specimens will allow improved analysis of multiple cell types.

The external rhinoplasty approach for congenital nasal lesions in children.

OBJECTIVE: Congenital lesions of the nose can be challenging to excise. While some lesions carry infection risks, in most cases surgery is primarily performed for cosmesis. Some lesions may extend up to the skull base and this can occasionally be missed on MRI scans. Surgical access has to allow complete excision in all circumstances, but access must be balanced against cosmetic results. We present our experience of the external rhinoplasty approach which allows wide access with little visible scarring. METHODS: Retrospective chart review of all cases performed between November 2003 and October 2009. RESULTS: 15 children underwent excisional surgery using the external rhinoplasty approach. They were aged 1-5 years at the time of surgery, and 12 were male. Pathology comprised congenital midline nasal dermoid cysts in 13 (of which 4 extended intracranially), extranasal glioma in 1 and non-resolving haemangioma in 1. The surgical approach provided adequate visualisation in all cases. The children with intracranial dermoids had resection and repair of the dura as part of their procedure. No post-operative CSF leaks occurred. One child with nasal dermoid had a small cyst recurrence in the skin of the nasal tip requiring further surgery but no deep recurrences occurred. Follow up ranges from 3 months to 6 years. Children with widened nasal bones before surgery have all shown rapid bony remodelling after surgery. CONCLUSIONS: The external rhinoplasty approach offers excellent access in young children, even for intracranial lesions.

Shortening a survey and using alternative forms of prenotification: impact on response rate and quality.

BACKGROUND: Evidence suggests that survey response rates are decreasing and that the level of survey response can be influenced by questionnaire length and the use of pre-notification. The goal of the present investigation was determine the effect of questionnaire length and pre-notification type (letter vs. postcard) on measures of survey quality, including response rates, response times (days to return the survey), and item nonresponse. METHODS: In July 2008, the authors randomized 900 residents of Olmsted County, Minnesota aged 25-65 years to one of two versions of the Talley Bowel Disease Questionnaire, a survey designed to assess the prevalence of functional gastrointestinal disorders (FGID). One version was two pages long and the other 4 pages. Using a 2 x 2 factorial design, respondents were randomized to survey length and one of two pre-notification types, letter or postcard; 780 residents ultimately received a survey, after excluding those who had moved outside the county or passed away. RESULTS: Overall, the response rates (RR) did not vary by length of survey (RR = 44.6% for the 2-page survey and 48.4% for the 4-page) or pre-notification type (RR = 46.3% for the letter and 46.8% for the postcard). Differences in response rates by questionnaire length were seen among younger adults who were more likely to respond to the 4-page than the 2-page questionnaire (RR = 39.0% compared to 21.8% for individuals in their 20s and RR = 49.0% compared to 32.3% for those in their 30s). There were no differences across conditions with respect to item non-response or time (days after mailing) to survey response. CONCLUSION: This study suggests that the shortest survey does not necessarily provide the best option for increased response rates and survey quality. Pre-notification type (letter or postcard) did not impact response rate suggesting that postcards may be more beneficial due to the lower associated costs of this method of contact.