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Objective: To evaluate quality-of-life outcomes for patients with vestibular schwannomas (VS) undergoing a middle cranial fossa (MCF) approach., Study Design: Prospective study from 2018 to 2023., Setting: Tertiary academic institution., Patients: Adults with sporadic VS., Interventions: MCF., Main Outcome Measures: The primary outcome measure was the change in preoperative and 1-year postoperative Penn Acoustic Neuroma Quality-of-life (PANQOL) scores. Secondary outcome measures included hearing preservation and facial nerve function., Results: Of the 164 patients who underwent MCF for sporadic VS, 78 patients elected to voluntarily complete preoperative PANQOL assessments prior to surgery. Seventy-one (91%) of those 78 patients completed postoperative PANQOL surveys. Fifty (70%) of the respondents were female and the median age was 48 years (range, 27-71 years). Overall, at 1-year postsurgery, a minimal clinically important difference (MCID) was obtained in the hearing (mean difference, 10.5; 95% confidence interval [CI], 4.3-16.7) and anxiety (mean difference, 18.8; 95% CI, 11.7-25.9) domains. For patients with hearing preservation (n = 48, 68%), MCIDs were reached in the hearing (mean difference, 13.4; 95% CI, 6.3-20.6), anxiety (mean difference, 20.8; 95% CI, 11.8-29.9), energy (mean difference, 13.7; 95% CI, 3.6-23.8), pain (mean difference, 13.7; 95% CI, 3.6-23.8) domains, and overall PANQOL scores (mean difference, 12.7; 95% CI, 7.1-18.3). Postoperatively, 64 (90%) patients maintained a House-Brackmann I., Conclusions: To our knowledge, this is the largest study examining disease-specific QOL for VS patients undergoing MCF. Based on our institution's experience, MCF approach for small VS is associated with clinically meaningful improvements in QOL, hearing preservation, and excellent facial nerve outcomes., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: Cystic vestibular schwannomas (cVSs) have more variable and less favorable clinical outcomes after microsurgical resection compared with solid VS (sVS). This study compares the preoperative presentation and postoperative outcomes between cVS and sVS., Study Design: Retrospective cohort study., Setting: Two tertiary skull base referral centers., Methods: Consecutive adult patients who underwent VS resection from 2016 to 2021 were included. Univariate and multivariate analyses compared differences in baseline symptoms and postoperative outcomes between cVS and sVS., Results: There were a total of 315 patients (64% female; mean age, 54 yrs) and 46 (15%) were cystic. cVS were significantly larger than sVS (maximum diameter, 28 vs. 18 mm, p < 0.001) and had higher rates of dysphagia and dysphonia preoperatively (p < 0.02). cVSs were more likely to undergo translabyrinthine resection (76 vs. 50%, p = 0.001) and have a higher rate of subtotal resection (STR) compared with sVS (30 vs. 13%, p = 0.003). At latest follow-up, fewer cVS achieved good facial nerve (FN) outcome (House-Brackmann [HB] I/II) (80 vs. 90%, p = 0.048). Subanalysis of cVS and sVS matched in tumor size, and surgical approach did not show differences in the rate of STR or FN outcomes (HB I/II, 82 vs. 78%, p = 0.79)., Conclusion: In this large multi-institutional series, cVSs represent a distinct entity and are characterized by larger tumor size and higher incidence of atypical symptoms. Although cVSs were more likely to undergo STR and portend worse FN outcomes than sVSs, this may be due to their larger tumor size rather than the presence of the cystic component., Competing Interests: Conflicts of interest and source of funding: None declared., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: Increased institutional surgical resection case volume for vestibular schwannomas (VSs) has been associated with improved patient outcomes, including reduced risk of prolonged hospital stay and readmission. Socioeconomic disparities in the pursuit of care at these high-volume institutions remain unknown., Study Design: Retrospective cohort epidemiological study., Setting: National Cancer Database, a hospital-based registry of over 1,500 facilities in the United States., Patients: Adult VS patients (age, >18 years) treated surgically., Interventions: High- versus low-volume facilities, defined using a facility case volume threshold of 25 cases per year. A risk-adjusted restricted cubic spline model was previously used to identify this risk threshold beyond which the incremental benefit of increasing case volume began to plateau., Main Outcome Measures: Sociodemographic factors, including race, ethnicity, income, insurance status, and rurality. Multivariable analyses were adjusted for patient and tumor characteristics, including age, sex, Charlson-Deyo score, and tumor size., Results: A totoal of 10,048 patients were identified (median [interquartile range] age = 51 [41-60] years, 54% female, 87% Caucasian). Patients with Spanish/Hispanic ethnicity (OR = 0.71, 95% confidence interval [CI] = 0.52-0.96), income below median (OR = 0.63, 95% CI = 0.55-0.73]), and Medicare, Medicaid, or other government insurance versus private insurance (OR = 0.63, 95% CI = 0.53-0.74) had reduced odds of treatment at a high-volume facility. Further sensitivity analyses in which facility volume was operationalized continuously reinforced direction and significance of these associations., Conclusions: Socioeconomic disparities exist in the propensity for VS patients to be treated at a high-volume facility. Further work is needed to understand the nature of these associations and whether interventions can be designed to mitigate them., Competing Interests: Conflict of interest: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: Evaluate for differences in postoperative hearing in patients who undergo immediate versus delayed hearing preservation microsurgical resection of vestibular schwannomas (VS)., Study Design: Retrospective single-institution cohort study spanning November 2017 to November 2021., Setting: Single-institution tertiary care hospital., Patients: Sporadic VS in patients with American Academy of Otolaryngology-Head and Neck Surgery hearing classification A or B, with tumor size less than or equal to 2 cm and undergoing hearing preservation microsurgical resection., Interventions: Delayed surgical intervention defined by time from first diagnostic MRI to date of surgery being greater than 3 months., Main Outcome Measures: Preoperative and postoperative audiometric performance., Results: In total, 193 patients met inclusion criteria. Within the cohort, 70 (36%) proceeded with surgery within 3 months of diagnostic MRI with a mean observation time of 62 days, whereas 123 (63%) underwent surgery after 3 months with a mean observation time of 301 days. There was no difference in preoperative hearing between the two groups with word recognition score 99% in early intervention group and 100% in delayed intervention group ( p = 0.6). However, 64% of those who proceeded with immediate surgery had successful hearing preservation, compared to a 42% of those who had delayed intervention ( p < 0.01). In a multivariable logistic regression accounting for preoperative word recognition score, tumor size, and age at diagnosis, the odds of hearing preservation were lower in those who delayed surgery compared to immediate surgery (odds ratio, 0.31; 95% confidence interval, 0.15-0.61)., Conclusions: Patients who underwent microsurgical resection within 3 months of diagnosis demonstrated a hearing preservation advantage compared to those who did not. Findings of this study highlight the counseling challenges associated with the timing of surgical treatment of VS in patients presenting with good preoperative hearing and small tumors., Competing Interests: Conflict of interest: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Neurofibromatosis type 2 (NF2) is an autosomal dominant syndrome caused by a mutation in the NF2 suppressor gene and is characterized by the development of multiple benign tumors throughout the central nervous system. Bilateral vestibular schwannomas (VSs) are pathognomonic for NF2 and are associated with progressive hearing loss and eventual deafness in most patients. This review presents current management options for NF-2-associated VSs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: High-volume hospitals are associated with improved surgical outcomes for acoustic neuromas (ANs). Due to the benign and slow-growing nature of ANs, many patients travel to geographically distant cities, states, or countries for their treatment. However, the impact of travel burden to high-volume centers, as well as its relative benefit are poorly understood. We compared post-operative outcomes between AN patients that underwent treatment at local, low-volume hospitals with those that traveled long distances to high-volume hospitals., Methods: The National Cancer Database was used to analyze AN patients that underwent surgery (2004-2015). Patients in the lowest quartile of travel distance and volume (Short-travel/Low-Volume: STLV) were compared to patients in the highest quartile of travel distance and volume (Long-travel/High-Volume: LTHV). Only STLV and LTHV cases were included for analysis., Results: Of 13,370 cases, 2,408 met inclusion criteria. STLV patients (n = 1,305) traveled a median of 6 miles (Interquartile range [IQR] 3-9) to low-volume centers (median 2, IQR 1-3 annual cases) and LTHV patients (n = 1,103) traveled a median of 143 miles [IQR 103-230, maximum 4,797] to high-volume centers (median 34, IQR 28-42 annual cases). LTHV patients had lower Charlson/Deyo scores (p = 0.001), mostly received care at academic centers (81.7% vs. 39.4%, p < 0.001), and were less likely to be minorities (7.0% vs. 24.2%, p < 0.001) or underinsured (4.2% vs. 13.8%, p < 0.001). There was no difference in average tumor size. On multivariable analysis, LTHV predicted increased likelihood of gross total resection (odds ratio [OR] 5.6, 95% confidence interval [CI] 3.8-8.4, p < 0.001), longer duration between diagnosis and surgery (OR 1.3, 95% CI 1.0-1.6, p = 0.040), decreased length of hospital stay (OR 0.5, 95% CI 0.4-0.7, p < 0.001), and greater overall survival (Hazard Ratio [HR] 0.6, 95% CI 0.4-0.95, p = 0.029). There was no significant difference in 30-day readmission on adjusted analysis., Conclusion: Although traveling farther to high-volume centers was associated with greater time between diagnosis and treatment for AN patients, they experienced superior postoperative outcomes compared to patients who received treatment locally at low-volume centers. Enabling access and travel to high-volume centers may improve AN patient outcomes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: High surgical vestibular schwannoma case volume in a medical institution may decrease the risk of adverse outcomes among patients undergoing vestibular schwannoma surgery., Objective: To study the association between surgical vestibular schwannoma case volume and excess time in the hospital after vestibular schwannoma surgery., Design, Setting, and Participants: This cohort study evaluated data from the National Cancer Database from January 1, 2004, through December 31, 2019, on Commission on Cancer-accredited facilities in the US. The hospital-based sample comprised adult patients aged 18 years or older with a vestibular schwannoma treated with surgery., Exposures: Facility case volume, defined as the mean number of surgical vestibular schwannoma cases per year in the 2 years preceding the index case., Main Outcomes and Measures: The primary outcome was a composite of prolonged hospital stay (>90th percentile) or 30-day readmission. Risk-adjusted restricted cubic splines were used to model the probability of the outcome according to facility volume. The inflection point (in cases per year) when the declining risk of excess time in the hospital began to plateau was selected as the threshold to define high- and low-volume facilities. Outcomes were compared among patients treated at high- and low-volume facilities, with mixed-effects logistic regression models adjusting for patient sociodemographic characteristics, comorbidities, tumor size, and clustering within facilities. Collected data were analyzed between June 24 and August 31, 2022., Results: Among 11 524 eligible patients (mean [SD] age, 50.2 [12.8] years; 53.5% female; 46.5% male) who underwent surgical resection of vestibular schwannoma at 66 reporting facilities, the median length of stay was 4 (IQR, 3-5) days, and 655 patients (5.7%) were readmitted within 30 days. The median case volume was 16 (IQR, 9-26) cases per year. An adjusted restricted cubic spline model identified a downtrending probability of excess time in the hospital with increasing volume. The declining risk of excess time in the hospital began to plateau at a facility volume of 25 cases per year. Surgery at a facility with an annual case volume at or above this threshold was independently associated with a 42% reduction in the odds of excess time in the hospital compared with surgery at a low-volume center (odds ratio, 0.58; 95% CI, 0.44-0.77)., Conclusions and Relevance: This cohort study found that among adults undergoing vestibular schwannoma surgery, a higher facility case volume was associated with a reduced risk of prolonged hospital stay or 30-day readmission. A facility case volume of 25 cases per year may represent a risk-defining threshold.

Objective: To determine the usefulness of a personalized tool and its effect on the decision-making process for those with vestibular schwannoma (VS)., Study Design: Prospective study., Setting: Single institution, academic tertiary care lateral skull base surgery program., Patients: Patients diagnosed with VS., Interventions: A comprehensive clinical decision support (CDS) tool was constructed from a previously published retrospective patient-reported data obtained from members of the Acoustic Neuroma Association from January to March 2017. Demographic, tumor, and treatment modality data, including associated side effects, were collected for 775 patients and integrated in an interactive and personalized web-based tool., Main Outcome Measures: Pre- and posttool questionnaires assessing the process of deciding treatment for VS using a decisional conflict scale (DCS) and satisfaction with decision (SWD) scale were compared., Results: A pilot study of 33 patients evaluated at a single institution tertiary care center with mean ± SD age of 63.9 ± 13.5 years and with average tumor size of 7.11 ± 4.75 mm were surveyed. CDS implementation resulted in a mean ± SD total DCS score decrease from 43.6 ± 15.5 to 37.6 ± 16.4 ( p < 0.01) and total SWD score increase from 82.8 ± 16.1 to 86.2 ± 14.4 ( p = 0.04), indicating a significant decrease in decisional conflict and increase in satisfaction., Conclusions: Implementing a decision-making tool after diagnosis of VS reduced decisional conflict and improved satisfaction with decision. Patients considered the tool to be an aid to their medical knowledge, further improving their comfort and understanding of their treatment options. These findings provide a basis for developing predictive tools that will assist patients in making informed medical decisions in the future., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: Predict hearing preservation after middle cranial fossa approach for vestibular schwannomas., Study Design: Application of machine learning algorithms, including classification and regression trees and random forest models to observational data., Setting: Single-tertiary referral center., Participants: Patients (n = 144) with a previously untreated sporadic vestibular schwannoma who underwent microsurgical resection by middle cranial fossa approach between November 2017 and November 2021., Interventions: Middle cranial fossa approach., Main Outcome and Measures: Hearing preservation, defined by postoperative word recognition score of 50% or greater and pure tone average below 50 dB HL or less than 10% reduction in word recognition score. Model performance was evaluated with classification accuracy in an independent validation sample. Variable importance for the random forest model is reported according to entropy, a measure of mean decrease in model accuracy incurred by excluding each variable from the model., Results: Hearing preservation was achieved in 60% of patients (86 of 144) overall. The classification and regression tree model identified preoperative pure tone average with a cut point of 30 dB HL, and more posterior tumor position to be the most important prognostic features for hearing preservation. Model accuracy was 0.68. The random forest model demonstrated perfect accuracy (1). Baseline pure tone average, word recognition score, and anteroposterior tumor position were among the most influential features for hearing preservation prediction., Conclusion: Machine learning algorithms have the potential for accurate prediction of hearing preservation rates after middle fossa approach for vestibular schwannomas at a single institution. These models have the capacity for continued refinement with ongoing addition of data., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: Describe the effect of preoperative hearing on the likelihood of hearing preservation after middle cranial fossa (MCF) approach for resection of vestibular schwannoma (VS) and the effect of hearing preservation on disease-specific quality of life (QOL)., Study Design: Retrospective chart review., Setting: Academic tertiary care skull base surgery program., Patients: Sixty three adult patients with preoperative word recognition score (WRS) ≥50% who underwent MCF resection of VS between 2017 and 2020., Interventions: All patients underwent MCF VS resection with attempted hearing preservation., Main Outcome Measures: Hearing preservation (postoperative WRS ≥50%), hearing-related Penn Acoustic Neuroma Quality of Life (PANQOL) score., Results: Sixty three patients with mean age 47.4 (±9.6) years and tumor size 11.5 (±0.5) mm were analyzed. Hearing was preserved (+HP) and lost (-HP) in 37 (58.7%) and 26 (41.3%) patients, respectively. Preoperatively, pure tone average audiometry was significantly lower among the +HP group (20.0 dB) versus -HP (31.0 dB, p < 0.003). WRS was higher among +HP versus -HP (94% vs. 84%, respectively; p < 0.002). Linear regression showed that intra- versus extra-canalicular tumor location, sudden hearing loss history, fundal fluid cap thickness, and tumor size had no relationship to hearing preservation outcomes. When evaluating postoperative QOL data (n = 37) hearing-related PANQOL score differed between +HP and -HP (t35 = 2.458, p = 0.0191) groups., Conclusions: In this cohort of patients undergoing MCF resection of VS, rates of HP were higher for patients with excellent preoperative hearing. Postoperatively, +HP patients reported improved hearing-related PANQOL scores compared to -HP patients., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: Analyze delayed facial nerve palsy (DFNP) following resection of vestibular schwannoma (VS) to describe distinct characteristics and facial nerve (FN) functional course., Study Design: Prospective cohort with retrospective review., Setting: Academic medical center., Patients: Consecutive patients undergoing VS resection 11/2017 to 08/2020. Exclusion criteria: preoperative House-Brackmann (HB) ≥ III, postoperative HB ≥ III without delayed palsy, <30 days follow-up., Interventions: VS resection with intraoperative electromyographic monitoring., Main Outcome Measures: FN outcomes utilizing the HB scale; comparison between patients with DFNP (deterioration greater than one HB grade 24 hours to 30 days postoperatively) vs. those with HBI-II throughout., Results: Two hundred eighty-eight patients met criteria: mean age 47.6 years, 36.1% male; 24.0% middle cranial fossa, 28.5% retrosigmoid, 47.6% translabyrinthine. DFNP occurred in 31 (10.8%) patients with average time to onset of 8.1 days. Of these, 22 (71.0%) recovered HBI-II and 3 (9.7%) recovered HBIII. Patients who experienced DFNP, on average, had larger maximum tumor diameter (23.4 vs. 18.7 mm, p = 0.014), lower rate of gross-total resection (54.8% vs. 75.5%, p = 0.014), and lower rate of ≥100 μV FN response to 0.05 mA stimulus intraoperatively (80.6% vs. 94.9%, p = 0.002). Compared to overall incidence of DFNP, translabyrinthine approach demonstrated higher incidence (15.3%, p = 0.017) while retrosigmoid lower (3.7%, p = 0.014). In multivariable logistic regression, patients with FN response ≥100 μV to 0.05 mA stimulus were 72.0% less likely to develop DFNP (p = 0.021)., Conclusions: Intraoperative electromyographic facial nerve response, tumor size, surgical approach, and extent of resection may play a role in development of DFNP following resection of VS. Most patients who develop DFNP recover near-normal function., Competing Interests: The authors disclose no funding and conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Objective: Excessive opioid prescription is a source of prescription diversion and could contribute to chronic opioid abuse. This study describes the opioid prescribing patterns and risk factors for additional opioid prescription after surgical resection of vestibular schwannoma (VS)., Study Design: Retrospective chart review., Setting: Single tertiary referral center., Patients: Adult VS patients undergoing surgical resection between May 2019 and March 2020., Interventions: Opioid use postoperatively and up to 60 days following surgery were characterized from medical records and by querying the state-wide Controlled Substance Utilization Review and Evaluation System., Main Outcome Measures: The presence of additional opioid prescriptions within 60 days of surgery., Results: A total of 109 patients (mean age 50 yrs, 65.5% female) were prescribed an average of 138.2 ± 117.8 mg of morphine equivalents (MME). Twenty-two (20.9%) required additional prescriptions of 163.2 ± 103.2 MME. Age, gender, tumor size, or surgical approach (translabyrinthine, retrosigmoid, versus middle fossa) were not associated with additional prescriptions. Patients with additional prescriptions had higher body mass index (BMI 28.8 vs. 25.8 kg/m2, p = 0.015) and required more opioid medications during hospitalization (51.8 vs. 29.1 MME, p = 0.002). On multivariate logistic regression, higher BMI (odds ratio [OR] 1.32; p = 0.001), history of headaches (OR 11.9, p = 0.011), and history of opioid use (OR 29.3, p = 0.008) were associated with additional prescription., Conclusions: Additional opioid prescriptions may be necessary in a portion of VS patients undergoing surgery. The choice of surgical approach is not associated with excess opioid requirements. Patients with higher BMI, history of headaches, or preoperative opioid use may require additional prescriptions., Competing Interests: The authors disclose no funding and conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Objective: Examine the impact of preoperative cochlear Fast Imaging Employing Steady-state Acquisition (FIESTA) and Constructive Interference in Steady State (CISS) signal intensity on hearing outcomes after middle cranial fossa (MCF) resection of acoustic neuroma (AN)., Methods: Adult patients (≥18 years) who underwent MCF AN resection for hearing preservation (HP) between November 2017 and September 2019 were retrospectively reviewed. All patients had preoperative word recognition score (WRS) ≥50%. HP was defined as postoperative WRS ≥50%. A neuroradiologist blinded to patients' clinical and audiometric outcomes reviewed patients' preoperative magnetic resonance images. Ipsilateral-to-contralateral cochlear FIESTA/CISS signal intensity ratios were determined using hand-drawn regions of interest focused on the cochlear fluid. Preoperative and postoperative pure tone average (PTA) and WRS were reviewed., Results: Fifty-one patients were reviewed (60.8% female). Mean age was 47 years and mean tumor size 9.2 mm (±3.8). Hearing was preserved in 56.9% (n = 29). FIESTA/CISS signal ratios did not significantly differ between patients with and without HP. Lower FIESTA/CISS signal ratios correlated with greater declines in hearing (r = 0.322, p = 0.011 for PTA; and r = 0.384, p = 0.004 for WRS). On multivariate analysis accounting for tumor size and preoperative PTA/WRS, decreases in FIESTA/CISS signal ratios independently predicted greater declines in hearing by PTA (b = -100.9, p = 0.012) and WRS (b = 76.208), although the latter result was not statistically significant (p = 0.078)., Conclusions: Cochlear FIESTA/CISS signal intensity may be a predictor of postoperative hearing loss after MCF AN resection. In this cohort, degraded preoperative cochlear FIESTA/CISS signal strongly predicted postoperative hearing loss.Level of Evidence: IV., (Copyright © 2021, Otology & Neurotology, Inc.)

Objective: To examine the relationship between the Functional Gait Assessment (FGA) and quality of life (QOL) measurements relating to balance before and after vestibular schwannoma (VS) resection and to assess the role of preoperative FGA in predicting postoperative QOL., Study Design: A prospective clinical study of adult patients undergoing VS resection between September 2018 and December 2019. FGA was administered 1 week before and after surgery. Dizziness Handicap Inventory (DHI) and Penn Acoustic Neuroma Quality of Life (PANQOL) were administered preoperatively and at 3 months postoperatively., Setting: Single tertiary center., Patients: Patients (age ≥ 18 years old) with VS undergoing microsurgical resection. Excluded were patient with previous surgery or radiation., Intervention: VS resection., Main Outcomes and Measures: Primary outcome: correlation between FGA and QOL surveys. Secondary outcome: correlation between preoperative measurements of balance and postoperative PANQOL., Results: One hundred thirty-eight patients were analyzed (mean age: 48 years old, 65.9% female). The translabyrinthine approach was most commonly performed. Under multivariate analysis, preoperative FGA significantly correlated with preoperative PANQOL balance score (p < 0.0001), preoperative PANQOL total score (p = 0.0002), and preoperative DHI (p < 0.0001). However, postoperative FGA did not significantly correlate with postoperative PANQOL balance or total scores (p = 0.446 and p = 0.4, respectively), or postoperative DHI (p = 0.3). Univariate analysis demonstrated that preoperative DHI and preoperative FGA were predictive of changes in postoperative PANQOL balance and total scores. However under multivariate analysis, preoperative FGA did not predict changes in postoperative PANQOL balance or total score (p = 0.24; p = 0.28, respectively). Preoperative DHI remained predictive of changes in postoperative PANQOL balance (p = 0.03) score but not of postoperative PANQOL total score (p = 0.37)., Conclusions: Although FGA and QOL data significantly correlated in the preoperative setting, our results did not suggest that preoperative FGA can be used to determine postoperative QOL. Additionally, the lack of correlation between FGA and QOL measurements in the acute postoperative setting suggests that further research is needed to determine contributors to postoperative QOL., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Objective: To identify clinical predictors of facial nerve (FN) outcomes after microsurgical resection of vestibular schwannoma (VS)., Study Design: Prospective cohort study., Setting: Academic medical center., Methods: Consecutive patients undergoing VS resection from November 2017 to October 2019 were included. FN function was evaluated with the House-Brackmann (HB) scale and stratified into good (HB I-II) and poor (HB III-VI) function. Analyses included descriptive statistics, correlation, and logistic regression., Results: Of 256 patients who met criteria (mean age, 47.7 years; 62.5% female), 227 (88.7%) achieved good FN function postoperatively and 238 (93.0%) at latest follow-up (mean, 154.8 days). Operative approaches consisted of translabyrinthine (50.8%), retrosigmoid (25.0%), and middle fossa craniotomies (24.2%). Extent of resection was decided intraoperatively, and gross or near total resection was accomplished in 237 (92.6%) cases. Postoperative HB grade correlated with latest HB grade (0.615, P < .001). Factors associated with good postoperative FN function included small tumor size (≤15 mm; odds ratio [OR], 2.425; P = .042), gross or near total resection (OR, 3.170; P = .041), and ≥100-µV intraoperative FN electromyographic response to a 0.05-mA stimulus (OR, 22.242; P < .001). Factors associated with good FN function at latest follow-up included gross total resection (OR, 7.764; P = .003) and ≥100-µV FN electromyographic response (OR, 8.518; P < .001), accounting for surgical approach and tumor size., Conclusion: Microsurgical resection of VS can be accomplished with excellent FN outcomes. Gross total resection and ≥100-µV intraoperative FN electromyographic response predicted excellent FN outcomes. Immediate postoperative FN function is a prognosticator of long-term FN function.

Objectives: To examine whether simple mobility assessments can predict functional limitations and length of hospitalization after acoustic neuroma (AN) resection., Study Design: Prospective case series., Methods: A prospective clinical study of adult patients undergoing AN resection by either the translabyrinthine, retrosigmoid, or middle fossa approach was conducted at a tertiary center. Preoperative mobility assessments included the functional gait assessment (FGA) and the 10-m walk (10 MW). Postoperatively, the Activity Measure for Post-Acute Care (AMPAC, at 48 hours), FGA, and 10 MW (at 1 week) were obtained. Demographic and medical data were collected., Results: One hundred and thirty-eight patients were analyzed (mean age: 48.3 years, 68.8% female). Mean length of stay (LOS) was 3.1 days. The translabyrinthine approach was most commonly performed (48.6%). On regression analyses, preoperative FGA (P = 0.03) and 48-hour postoperative AM-PAC (P < 0.001) independently predicted LOS, even after accounting for age, gender, body mass index, and tumor size. On receiver operating characteristic analysis, a preoperative FGA cut score of 25.5 predicted a protracted hospital stay (>4 days) with a sensitivity of 77% and specificity of 50% (area under curve: 68.5)., Conclusion: This study demonstrated that preoperative mobility assessments can predict functional limitations and LOS after AN resection. These objective tools can be used by clinicians to manage expectations and guide preoperative counseling in patients considering surgery., Level of Evidence: 3 Laryngoscope, 131:644-648, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine and itemize surgical costs associated with the translabyrinthine (TL), retrosigmoid (RS), and middle cranial fossa (MCF) approaches for microsurgical excision of vestibular schwannoma (VS)., Study Design: Retrospective cost analysis study., Setting: Tertiary referral center., Patients: Thirty consecutive adult patients underwent microsurgical excision of VS by either TL, RS, or MCF approach (10 per approach)., Interventions: Microsurgical excision of VS by one of the three major approaches. Medical and financial data were collected., Main Outcome Measures: Total operating room time (minutes), skin-to-skin time (minutes), operating room cost ($US), and surgical supplies cost ($US)., Results: The MCF approach was associated with the shortest skin-to-skin time (230.3 min, p < 0.001). Mean overall nonsurgical room time was 94.7 minutes and not significantly different among approaches (p = 0.55). Mean total surgical supplies cost was $5,028 and was the highest for the RS ($7,116; p < 0.001) but not significantly different between TL and MCF. Mean operating room services charges were $68,417 overall and were the lowest for the MCF group ($53,306; p = 0.01). Tumor size was not correlated with surgical supplies cost (p = 0.74). The items associated with the highest average cost per case were the surgical aspirator ($1,062), drill burs ($928), and titanium implants ($575). There was redundancy in multiple surgical items such as drill burs, hemostatic agents, and sutures., Conclusion: This study is the first to provide a detailed itemization of the surgical expenses specific to VS resection. Elevated nonsurgical room time and supply redundancy provides the opportunity for decreasing surgical costs and waste.

Hypothesis: We hypothesize that genomic variants including deletions, insertions, inversions, and tandem duplications beyond the changes in tumor suppressor NF2 gene affect gene expression of tumor-specific pathways in vestibular schwannomas (VS) patients with Neurofibromatosis type 2 (NF2), thus contributing to their clinical behavior., Background: Genomic variation could reconfigure transcription in NF2 transformation process. Therefore, genome-wide high-resolution characterization of structural variants (SV) landscapes in NF2 tumors can expand our understanding of the genes regulating the clinical phenotypes in NF2-associated VS., Methods: We performed whole-genome haplotype-specific structural variation analysis using synthetic linked reads generated through microfluidics-based barcoding of high molecular weight DNA followed by high-coverage Illumina paired-end whole-genome sequencing from 10 patients' tumors of different growth rates and their matching blood samples., Results: NF2 tumor-specific deletions and large SVs were detected and can be classified based on their association with tumor growth rates. Through detailed annotation of these mutations, we uncover common alleles affected by these deletions and large SVs that can be associated with signaling pathways implicated in cell proliferation and tumorigenesis., Conclusion: The genomic variation landscape of NF2-related VS was investigated through whole-genome linked-read sequencing. Large SVs, in addition to deletions, were identified and may serve as modulators of clinical behavior.

OBJECTIVE Translabyrinthine resection is one of a number of treatment options available to patients with vestibular schwannomas. Though this procedure is hearing destructive, the authors have noted excellent clinical outcomes for patients with small tumors. The authors review their experience at a tertiary acoustic neuroma referral center in using the translabyrinthine approach to resect small vestibular schwannomas. All operations were performed by a surgical team consisting of a single neurosurgeon and 1 of 7 neurotologists. METHODS Data from a prospectively maintained clinical database were extracted and reviewed. Consecutive patients with a preoperative diagnosis of vestibular schwannoma that had less than 1 cm of extension into the cerebellopontine angle, operated on between 2008 and 2013, were included. Patents with neurofibromatosis Type 2, previous treatment, or preexisting facial weakness were excluded. In total, 107 patients were identified, 74.7% of whom had poor hearing preoperatively. RESULTS Pathologically, 6.5% of patients were found to have a tumor other than vestibular schwannoma. Excluding two malignancies, the tumor control rates were 98.7%, as defined by absence of radiographic disease, and 99.0%, as defined by no need for additional treatment. Facial nerve outcome was normal (House-Brackmann Grade I) in 97.2% of patients and good (House-Brackmann Grade I-II) in 99.1%. Complications were cerebrospinal fluid leak (4.7%) and sigmoid sinus thrombosis (0.9%), none of which led to long-term sequelae. CONCLUSIONS Translabyrinthine resection of small vestibular schwannomas provides excellent results in terms of complication avoidance, tumor control, and facial nerve outcomes. This is a hearing-destructive operation that is advocated for selected patients.

OBJECTIVE The CO 2 laser has been used on an intermittent basis in the microsurgical resection of brain tumors for decades. These lasers were typically cumbersome to use due to the need for a large, bulky design since infrared light cannot be transmitted via fiber-optic cables. Development of the OmniGuide cable, which is hollow and lined with an omnidirectional dielectric mirror, has facilitated the reintroduction of the CO 2 laser in surgical use in a number of fields. This device allows for handheld use of the CO 2 laser in a much more ergonomically favorable configuration, holding promise for microneurosurgical applications. This device was introduced into the authors' practice for use in the microsurgical resection of skull base tumors, including vestibular schwannomas. METHODS The authors reviewed the initial 41 vestibular schwannomas that were treated using the OmniGuide CO 2 laser during an 8-month period from March 2010 to October 2010. The laser was used for all large tumors, and select medium-sized tumors were treated via both the translabyrinthine and retrosigmoid approaches. The estimated time of tumor resection and estimated blood loss were obtained from operating room records. Data regarding complications, facial nerve and hearing outcomes, and further treatment were collected from hospital and clinic records, MRI reports, and direct review of MR images. Time of resection and blood loss were compared to a control group (n = 18) who underwent surgery just prior to use of the laser. RESULTS A total of 41 patients with vestibular schwannomas were surgically treated. The median estimated time of tumor resection was 150 minutes, and the median estimated blood loss was 300 ml. The only operative complication was 1 CSF leak. Thirty-eight patients had normal facial nerve function at late follow-up. The median MRI follow-up was 52 months, and, during that time, only 1 patient required further treatment for regrowth of a residual tumor. CONCLUSIONS The OmniGuide CO 2 laser is a useful adjunct in the resection of large vestibular schwannomas. This device was used primarily as a cutting tool rather than for tumor vaporization, and it was found to be of most use for very large and/or firm tumors. There were no laser-associated complications, and the results compared favorably to earlier reports of vestibular schwannoma resection.

Objective: To report the preliminary outcomes of auditory brainstem implantation (ABI) under a compassionate use protocol for two ABI devices that are not approved by the US Food and Drug Administration., Methods: A retrospective review was performed of neurofibromatosis type 2 (NF2) patients who underwent microsurgery for vestibular schwannoma (VS) and placement of either the Cochlear ABI541 or Med-El Synchrony ABIs. Peri-operative and device- related complications were reviewed. Audiometric performance was also evaluated., Results: Seven patients received either the Cochlear ABI541 (6) or the Med-El Synchrony ABI (1) after the resection of VS. No device or patient-related complications occurred to date. Surgical times and early audiological performance are similar to our previous experience with the Cochlear ABI24 device., Conclusions: Early experience with the Cochlear ABI541 and Med-El Synchrony ABI devices under a compassionate use protocol suggest that both devices are safe with comparable utility to the Cochlear ABI24 device.

Objective: To describe the clinical and radiographic characteristics in a series of patients with non-vestibular schwannoma cerebellopontine angle (CPA) and intracanalicular (IAC) masses, who underwent microsurgery for presumed vestibular schwannoma (VS)., Study Design: Retrospective case series., Setting: Tertiary neurotologic referral center., Patients: One thousand five hundred ninety-three patients underwent microsurgery for apparent VS from 2002 to 2013. Of these, 53 patients (3%) were discovered to have a diagnosis other than VS., Interventions: Middle fossa, translabyrinthine, and retrosigmoid craniotomy., Main Outcome Measures: Clinical presentation, radiologic analysis, and histopathology examination., Results: There were 17 facial schwannomas, 15 meningiomas, 9 hemangiomas, 6 lipochoristomas, 3 inflammatory reactions, and one each of lymphoma, glial heterotopia, solitary fibrous tumor, ependymoma, and a non-diagnostic mass. Excluding facial schwannomas, 23 cases were misdiagnosed as VS in the first half of the study period, compared to only 15 cases in the latter half (p = 0.09). Ninety-six percent of patients presented with some combination of sensorineural hearing loss, balance disturbance, and tinnitus. In the subset of patients with available preoperative MRI scans for retrospective review, only 4 of 28 patients had radiologic findings suggestive of pathology other than VS. The most common missed radiologic diagnoses were facial schwannoma, lipochoristoma, and meningioma., Conclusion: A subgroup of patients with CPA and IAC masses who present with radiologic findings diagnostic of VS will have an alternative histopathologic diagnosis. Optimal radiologic imaging and experienced interpretation can improve diagnostic accuracy. The most common tumors that mimic VS despite ideal radiologic imaging are facial schwannomas, meningiomas, and hemangiomas.

We present video of gross-total resection of a large cerebellopontine angle tumor consisting of both vestibular and facial schwannoma components via the translabyrinthine route in a patient with neurofibromatosis type 2. The facial nerve is reconstructed using a greater auricular nerve graft, and an auditory brainstem implant is placed. Prior to surgery the patient had no facial nerve function on the operative side and had lost useful hearing. He also had usable vision only on the ipsilateral side and had contralateral vocal cord paralysis. The video can be found here: http://youtu.be/IOkEND-0vhI .

Objective: To determine whether partial tumor removal in large vestibular schwannoma improves facial nerve outcomes while maintaining a low risk of tumor regrowth/recurrence., Study Design: Retrospective chart review and prospective database., Setting: Tertiary neurotologic referral center., Patients: Four hundred patients with a vestibular schwannoma of 2.5 cm or greater in maximum diameter undergoing translabyrinthine microsurgical resection from 2001 to 2011. There were 325 gross total resections (GTR), 44 near total resections (NTR), and 31 subtotal resections (STR), with an overall mean tumor size of 3.2 cm (standard deviation, 0.7)., Intervention(s): Translabyrinthine surgical tumor resection., Main Outcome Measures: House-Brackmann (H-B) facial nerve grade postoperatively and at 1 year, tumor regrowth/recurrence (≥2 mm), additional treatment, and complications., Results: Higher rates of H-B facial nerve Grades I and II were achieved at both the postoperative and 1-year follow-ups in the NTR (78%, 97%) and STR (71%, 96%) groups compared with GTR (53%, 77%) (p ≤ 0.001). Eye treatment, medical or surgical, was required more often in GTR (28.0%) than NTR and STR (8% and 21%, respectively, p ≤ 0.04), with no other differences in complications. The NTR and STR groups had a significantly higher rate of regrowth than GTR resection (21% and 22% versus 3%) (p ≤ 0.001) at average follow-up times of 3.7, 3.7, and 5.1 years, respectively, and need for further treatment occurred at a higher rate, although infrequently, in NTR and STR (2% and 10% versus 0%) (p ≤ 0.001)., Conclusion: Near total and subtotal removal in large tumors are viable treatment options to maintain facial nerve function. During the follow-up period examined in this study, there was a low risk of need for further treatment. Longer-term follow-up is needed to better assess the need for retreatment in patients treated with NTR and STR.

With the increasing prevalence and decreasing cost of MRI scans, incidental discovery of vestibular schwannoma (VS) has become more common. Scarce literature exists regarding management of the tumors in those patients with incidentally discovered VSs, and clear guidelines for management do not exist. In this review, the authors examine the available literature for insights into management of incidentally diagnosed VS and provide an algorithm for their management.

Objectives: To examine hearing preservation rates, facial nerve outcomes, and tumor recurrence rates in patients with neurofibromatosis Type 2 undergoing a primary middle cranial fossa approach for vestibular schwannoma removal., Study Design: Retrospective chart review., Setting: Private practice tertiary neurotology referral center., Patients: All patients with neurofibromatosis Type 2 undergoing attempted hearing preservation via a middle cranial fossa approach for removal of vestibular schwannoma from January 1, 2000, to June 1, 2010., Intervention: Primary middle cranial fossa approach for removal of vestibular schwannoma., Main Outcome Measures: Preoperative, postoperative, and change in hearing thresholds, word recognition scores, and American Academy of Otolaryngology-Head and Neck Surgery hearing class, House-Brackmann facial nerve grade, and tumor recurrence., Results: Class A or B hearing according to the American Academy of Otolaryngology-Head and Neck Surgery was maintained in 50% of cases, whereas 63.6% had Class A, B, or C hearing, with an average word recognition score of 93.8% at an average follow-up period of 32.5 months. Facial nerve outcomes were excellent; 75% of cases maintained House-Brackmann Grade 1, whereas 94.3% had Grade 1 or 2 at an average of 25 months after surgery. Tumor growth within the surgical field was observed radiographically in 59% of cases., Conclusion: In patients with neurofibromatosis Type 2, proactive treatment of smaller tumors provides a chance to maintain serviceable hearing and obtain tumor control for extended periods. When examining hearing outcomes, it is important to use word recognition scores, in addition to American Academy of Otolaryngology-Head and Neck Surgery hearing class, to better assess functionality. Although facial nerve outcomes tend to be favorable, the growth of new tumors, including facial schwannomas, may occur within the surgical field. Continued surveillance with serial magnetic resonance scans after surgery is mandatory.

Objective: Determine whether more conservative management for surgical salvage after failed radiation leads to better facial nerve outcomes., Study Design: "Retrospective" review using prospectively planned database., Setting: Private practice, tertiary neurotology/neurosurgery referral center., Patients: A series of 73 patients with vestibular schwannoma, who underwent primary radiosurgery with no other intervention and then surgical salvage tumor removal using the translabyrinthine approach., Intervention(s): Translabyrinthine craniotomy for vestibular schwannoma salvage surgery after failed radiation, with either gross total or partial tumor removal., Main Outcome Measures: Long-term (1 yr) House-Brackmann (H-B) facial nerve grade and change in facial nerve grade from before to after surgery., Results: Of the 73 patients, 79.5% had gross total removal, 5.5% had planned partial resection (subtotal or near total), and 15.1% had intraoperatively elected partial removal with most of these being near total removal. At 1 year of follow-up, good facial nerve function (H-B I/II) was found in 50% of patients with gross total removal and 85.7% of those with partial removal (p ≤ 0.03). The H-B grade was maintained postoperatively in 45.8% and 78.6% of the 2 groups, respectively (p ≤ 0.037), with 21.7% of the total removal group having unsatisfactory outcomes (H-B V or VI) compared with 7.1% of patients with partial removal. To date, no patient has required additional treatment., Conclusion: Failed radiosurgery is an increasing indication for salvage surgery in patients with posterior fossa tumors. A conservative approach with a willingness to perform partial and near-total tumor removals leads to better facial nerve outcomes with no current evidence of treatment compromise.

Objective: To assess the duration of hearing preservation from time of vestibular schwannoma middle fossa decompression with short-term and 1-year hearing preservation rates., Study Design: Retrospective case review., Setting: Tertiary referral center., Patients: Patients with and without neurofibromatosis type 2 who underwent middle fossa decompression. We excluded patients without tumor size or audiograms at initial diagnosis or follow-up less than 3 months., Interventions: Middle cranial fossa decompression, audiometry, and magnetic resonance imaging., Main Outcome Measures: Period of hearing maintenance (from surgery to longest time point that preoperative American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] hearing class maintained or improved), short-term hearing preservation (within 3 mo of surgery), and 1-year hearing preservation., Results: A total of 49 patients underwent middle fossa decompression of vestibular schwannoma. Approximately 90% of patients had documented hearing loss before surgery, and more than 50% of patients exhibited significant tumor growth before surgery. Of these surgeries, more than 90% were performed in patients with hearing loss in an only hearing ear, and more than 90% were patients with neurofibromatosis type 2. The mean period of hearing maintenance was 2.1 years. The short-term hearing preservation rate as measured by the change from preoperative AAO-HNS hearing class was approximately 90%. The 1-year hearing preservation rate as measured by change from preoperative AAO-HNS hearing class was 63%., Conclusion: Middle fossa decompression for vestibular schwannoma can prolong hearing in patients with hearing changes in an only hearing ear. Understanding the duration of hearing preservation can enable more effective counseling of patients considering middle cranial fossa decompression for vestibular schwannoma.

Objectives: Determine if the presence of cerebrospinal fluid in the fundal region of the internal auditory canal on preoperative magnetic resonance imaging (MRI) scans is predictive of improved hearing preservation after removal of vestibular schwannoma through the middle cranial fossa approach. Relationships between fundal fluid, tumor nerve of origin, tumor size, and hearing preservation also are examined., Study Design: Retrospective review., Setting: Private practice tertiary neurotology referral center., Patients: One hundred one patients with preoperative MRI, complete preoperative and postoperative audiologic data, and histopathologically confirmed vestibular schwannoma treated with a middle cranial fossa approach between January 1, 2006, and June 30, 2009., Interventions: Primary middle cranial fossa approach for removal of vestibular schwannoma., Main Outcome Measures: Fundal fluid status (presence or absence), preoperative and postoperative pure-tone average, and speech discrimination scores and tumor nerve of origin., Results: Fundal fluid was present in 75% of cases. Those with fluid had a higher rate of postoperative measurable hearing (77.6%) compared with those without fundal fluid (52%) (p

Objective: To describe the case of a true false-positive finding on magnetic resonance imaging, mimicking a vestibular schwannoma, and review the pertinent literature., Patients: The case of a single patient with a suspicion of a vestibular schwannoma., Intervention: A middle fossa craniotomy was performed for resection of the presumed schwannoma., Main Outcome Measures: Intraoperative findings and postoperative magnetic resonance imaging (MRI)., Results: : Intraoperative findings and a postoperative MRI confirm the absence of a neoplasm., Conclusion: False-positive findings on MRI, though rare, do occur. The clinician should have a high index of suspicion and consider reimaging in some cases.

Objectives/hypothesis: Compare vestibular schwannoma (VS) surgical outcome between patients with prior irradiation and those not previously treated., Study Design: Retrospective review with matched control group., Methods: Review of tumor adherence to the facial nerve, facial nerve grade, and complications in 38 patients with radiotherapy as a primary procedure before VS surgical removal and a matched random sample of 38 patients with primary surgery. The majority of the irradiated group had gamma knife radiation therapy. Mean time from irradiation to surgical salvage was 3.3 years (SD = 3.2), with a minimum of 5.2 months and a maximum of 15.8 years. Most (89.5%) patients in each group underwent a translabyrinthine approach. Mean tumor size at surgery was 2.6 cm in each group., Results: The irradiated group had more moderate to severe adherence of tumor than the controls (89% vs. 63%, P < or = .01). They also had a lower rate of good facial function (House-Brackmann grade I/II) (37% vs. 70%) and a higher rate of poor function (grades V or VI) (50% vs. 18%) at follow-up (P < or = .019). Results were similar when including only those with good preoperative function (50% vs. 72% and 32% vs. 15%) but did not achieve statistical significance. Surgical time and complications did not differ., Conclusion: Patients who have undergone irradiation for VS and require surgical salvage may have a more difficult surgery and poorer outcomes than those not previously irradiated. When making their initial choice of treatment, patients should be counseled that surgery might be more difficult after failed stereotactic irradiation.

Context: Successful outcome of complex surgical techniques depend on the surgical team's level of experience. However, unless benefit is demonstrated in the presence of cost savings, insurance companies are reluctant to approve care from highly experienced hospitals and surgical teams., Objective: To determine the relationship between the number of acoustic neuroma surgeries performed at California hospitals with surgical outcome and hospital stay cost., Design: Acoustic neuroma surgery information was extracted from the California hospital discharge database and was grouped according to the number of surgeries performed at each hospital., Setting: A database review of California hospitals., Patients: Persons (n=1,213) undergoing acoustic neuroma surgery at a California hospital between 1996 and 1998. Main outcome measures Outcome measures included discharge status (routine vs. not routine), medical procedures indicating surgical complications, total cost of hospitalization, and average cost per hospitalization day. Odds ratios were used to compare the hospital volume groups on likelihood of a routine surgical outcome., Results: The frequency of routine surgical outcome increased as hospital acoustic neuroma surgical volume increased, ranging from 68% among patients in the lowest volume group to 97% in the highest hospital volume group. Patients in the highest hospital volume group were 15 times more likely to have a routine surgical outcome than patients in the lowest hospital volume group. Patients in the second highest volume group were 5 times more likely to have a routine surgical outcome than in the lowest volume group. The two highest volume hospital groups had lower total charges and average charges per day than the two lower volume hospital groups., Conclusions: Acoustic neuroma surgeries at higher volume hospitals had higher frequency of routine discharge, lower frequency of apparent complications, and lower average cost of hospitalization.

Neurofibromatosis type 2 (NF 2) typically results in deafness due to disruption of the cochlear nerves, making peripheral devices such as cochlear implants ineffective. Auditory brainstem implants (ABIs), for direct electrical stimulation of the cochlear nucleus, have been used to provide auditory stimulation in this group of patients. Currently, 141 patients have been implanted in our institution, most recently using an advanced multichannel device. We report results of a recent series of 86 patients who received ABIs. Of this group, 60 had successful implantation, recovered from surgery, responded successfully to stimulation and underwent a full course of device programming and audiologic testing. This group had significant improvement in scores on several audiologic tests compared to baseline. When used to augment lip reading, improvement was also seen. The degree of improvement varied considerably among patients. ABI is a useful device for deaf patients with NF 2. As measured by audiologic testing, many patients receive substantial benefit with regard to sound and speech comprehension., (Copyright 2003 S. Karger AG, Basel)