Beatty, Charles W.

Objectives/HypothesisTo describe the natural history of primary inner ear schwannomas (PIES) and evaluate management outcomes and relationship between PIES location, clinical presentation, and time to diagnosis.Study DesignRetrospective chart review and systematic review of the literature.MethodsVestibular schwannoma confined to or arising from the inner ear were included. PIES classification was based on anatomic subsite(s) involved. Detailed clinical history and outcomes were recorded.ResultsIn a systematic review (1933–2011), including 14 patients from the authors' institution (1999–2009), a total of 72 studies comprising 234 patients were evaluated. Mean follow‐up was 32.8 ± 39.1 months (range, 0–183 months). The cochlea was the most commonly involved subsite (51%). Hearing loss was the most frequent presenting symptom (99%). Vertigo and abnormal balance were more common among tumors involving the vestibular system (P < .01). Average delay between symptom onset and diagnosis was 7.0 ± 8.0 years (median, 5 years; range, 0–40 years). Recent onset hearing loss was more likely to elicit an earlier diagnosis (P = .01). The majority of patients were observed without treatment (53%). Tumor progression was seen in 52% of patients.Conclusions PIES are rare tumors and most commonly involve the cochlea. Tumor location is often associated with clinical presentation and correlates with delay between symptom onset and diagnosis. A watch‐and‐scan approach is the management strategy of choice in the absence of intractable vertigo or extensive tumor growth. The majority of patients report stable or improved symptoms over time, regardless of treatment. Laryngoscope, 123:1957–1966, 2013

Object The goal of vestibular schwannoma surgery is tumor removal and preservation of neural function. Intraoperative facial nerve (FN) monitoring has emerged as the standard of care, but its role in predicting long-term facial function remains a matter of debate. The present report seeks to describe and critically assess the value of applying current at supramaximal levels in an effort to identify patients destined for permanent facial paralysis. Methods Over more than a decade, the protocol for stimulating and assessing the FN during vestibular schwannoma surgery at the authors' institution has consisted of applying pulsed constant-current stimulation at supramaximal levels proximally and distally following tumor resection to generate an amplitude ratio, which subtracted from 100% yields the degree to which the functional integrity of the FN “dropped off” intraoperatively. These data were prospectively collected and additional variables that might impact postoperative FN function were retrospectively reviewed from the medical record. Only patients with anatomically intact FNs and > 12 months of follow-up data were analyzed. Results There were 267 patients available for review. The average posterior fossa tumor diameter was 24 mm and the rate of long-term good (House-Brackmann Grade I–II) FN function was 84%. Univariate logistic regression analysis revealed that prior treatment, neurofibromatosis Type 2 status, tumor size, cerebellopontine angle extension, subjectively thinned FN at the time of operation, minimal stimulation threshold, percent dropoff by supramaximal stimulation (SMS), and postoperative FN function all correlated statistically (p < 0.05) with long-term FN function. When evaluating patients with significant FN weakness at the time of hospital discharge, only the percent dropoff by SMS remained a significant predictor of long-term FN function. However, the positive predictive value of SMS for long-term weakness is low, at 46%. Conclusions In a large cohort of patients, the authors found that interrogating intraoperative FN function with SMS is safe and technically simple. It is useful for predicting which patients will ultimately have good facial function, but is very limited in identifying patients destined for long-term facial weakness. This test may prove helpful in the future in tailoring less than gross-total tumor removal to limit postoperative facial weakness.

The authors report on 2 patients with bilateral vestibular schwannomas (VSs) who underwent unilateral surgical tumor removal. One patient was followed up for 4 years, the other for 9; in both cases, the contralateral VS regressed markedly without any additional treatment during the follow-up period. Serial MR imaging was performed to monitor the untreated tumor, which in both cases involved the only hearing ear. The tumors were assessed volumetrically. The contralateral tumors appeared to enlarge mildly at initial follow-up and then, with no treatment, regressed (to 23% of the original maximum volume in Case 1 and to 15% of the original maximum in Case 2). The largest posterior fossa diameter decreased from 30.1 mm to 18.6 mm in Case 1 over 4 years and from 27 mm to 16 mm over 8 years in Case 2. Hearing declined only mildly during follow-up in both patients. These cases demonstrate the first well-documented, long-term, spontaneous VS regressions in patients with neurofibromatosis Type 2. They underline the importance of careful observation of VS involving the only hearing ear in the management of bilateral VS to determine the natural growth pattern of the tumors. The mechanism of the dramatic spontaneous tumor regression is uncertain.

OBJECTIVETo review hearing results after implantation of a self‐crimping stapes prosthesis.STUDY DESIGN AND SETTINGAnalysis of hearing results in patients implanted with a self‐crimping stapes prosthesis at two academic hospitals from 2000 to 2004.RESULTSSeventy‐nine ears were divided into short‐term and intermediate follow‐up groups. The mean postoperative air‐bone gap (ABG), preoperative minus postoperative ABG, and preoperative minus postoperative bone conduction values were 5.7, 21.4, and 4.1 dB, respectively, for the short‐term group, and 6.3, 22.3, and 4.7dB, respectively, for the intermediate group. The ABG was <10 dB in 88 percent of the short‐term group and in 79 percent of the intermediate group.CONCLUSIONSThe self‐crimping Nitinol stapes prosthesis provides excellent short‐term and intermediate postoperative hearing results, and may overcome the limitations of stapes prostheses requiring manual crimping.SIGNIFICANCEThis paper provides evidence for the use of a self‐crimping Nitinol stapes prosthesis, which may simplify hearing restoration surgery for stapes fixation.

BACKGROUNDA 13‐year retrospective study was undertaken to determine the incidence of posttonsillectomy hemorrhage, to evaluate potential risk factors, and to assess the efficacy and safety of ambulatory tonsillectomy.METHODSFrom January 1985 to December 1997, 4662 patients underwent tonsillectomy at our institution. Ninety patients with posttonsillectomy bleeding were identified. For each patient with posttonsillectomy bleeding, 2 nonbleeding control subjects were selected and matched by age and sex to evaluate potential risk factors.RESULTSAge was the only factor found to be statistically significant among the bleeding patients and the control group. The highest incidence (3.61%) of posttonsillectomy hemorrhage occurred in patients 21 to 30 years of age. In our experience, secondary hemorrhage was more common than primary hemorrhage, presenting most frequently on postoperative days 5 to 7.CONCLUSIONSThe incidence of posttonsillectomy bleeding in this review was 1.93%, and about half (47%) of the patients with posttonsillectomy hemorrhage returned to the operating room for hemorrhage control. The highest incidence (3.61%) of posttonsillectomy hemorrhage occurred in patients 21 to 30 years of age. Patients with posttonsillectomy hemorrhage, regardless of management, had a 12% incidence of subsequent hemorrhage. We found no difference in the incidence of posttonsillectomy bleeding between outpatient and inpatient procedures.