Agazzi, Siviero

Objective The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. Study Design Survey. Setting A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. Results House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. Conclusions Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.

Abstract Introduction The American Association of Neurological Surgeons (AANS), North American Skull Base Society (NASBS), American Rhinologic Society (ARS), and American Neurotology Society (ANS) fellowship directories are important information repositories for skull base surgical fellowship programs. However, there is limited research on the amount and depth of information available through these resources. The objective of the present study is to assess Web site accessibility and information availability for individual fellowship programs listed within the AANS, NASBS, ARS, and ANS fellowship directories. Methods Lists of all accredited skull base surgical programs were obtained from the AANS and NASBS fellowship directories. Duplications in listed programs were removed, and systematic queries via an online search engine were conducted to identify fellowship Web sites. From each available Web site, information pertaining to 24 different variables was collected and organized into two categories—recruitment and education. Differences in the availability of information on recruitment and education were then compared across Web sites and contextualized relative to other surgical specialties. Results After excluding duplicates, 113 fellowship programs were identified, of which 99 (87.6%) had accessible Web sites. Of the 48 listed by the NASBS, direct Web site links were available for 33 (68.8%), email contacts were accessible for 32 (66.7%), and phone numbers were listed for 6 (12.5%). Of the 39 programs listed by the AANS, none included Web site links, 38 (97.4%) provided an email contact, and 39 (100%) listed a departmental contact telephone number. All 28 (100%) programs listed by the ANS provided a phone and email contact in addition to a Web site link to each institutional Web site. Of the 33 programs listed by the ARS, 29 (88%) had a departmental contact telephone number, 31 (94%) had an email contact available, and 4 (12%) had a program Web site link directly available from the database Web site. Of the 99 total programs, fellowship Web sites displayed an average of 5.46 (42.0%) of the 13 recruitment features and 4.80 (42.6%) of the 11 education features. Programs in the geographic Northeast were significantly less likely to present information pertaining to recruitment (p = 0.023). Furthermore, programs in geographic Northeast and West were significantly less likely to present information focused on surgical training and/or education (p = 0.006). Conclusion Although many skull base fellowship programs have maintained comprehensive program Web sites, certain critical aspects remain deficient, and some programs provide little to no information. Providing more detailed information about programs can prove mutually beneficial for fellowship program directors and candidates.

Objective:To address variance in clinical care surrounding sporadic vestibular schwannoma, a modified Delphi study was performed to establish a general framework to approach vestibular schwannoma care. A multidisciplinary panel of experts was established with deliberate representation from key stakeholder societies. External validity of the final statements was assessed through an online survey of registered attendees of the 8th Quadrennial International Conference on Vestibular Schwannoma.Study Design:Modified Delphi method.Methods:The panel consisted of 16 vestibular schwannoma experts (8 neurotology and 8 neurosurgery) and included delegates representing the AAOHNSF, AANS/CNS tumor section, ISRS, and NASBS. The modified Delphi method encompassed a four-step process, comprised of one prevoting round to establish a list of focus areas and three subsequent voting rounds to successively refine individual statements and establish levels of consensus. Thresholds for achieving moderate consensus, at ≥67% agreement, and strong consensus, at ≥80% agreement, were determined a priori. All voting was performed anonymously via the Qualtrics online survey tool and full participation from all panel members was required before procession to the next voting round.Results:Through the Delphi process, 103 items were developed encompassing hearing preservation (N = 49), tumor control and imaging surveillance (N = 20), preferred treatment (N = 24), operative considerations (N = 4), and complications (N = 6). As a result of item refinement, moderate (4%) or strong (96%) consensus was achieved in all 103 final statements. Seventy-nine conference registrants participated in the online survey to assess external validity. Among these survey respondents, moderate (N = 21, 20%) or strong (N = 73, 71%) consensus was achieved in 94 of 103 (91%) statements, and no consensus was reached in 9 (9%). Of the four items with moderate consensus by the expert panel, one had moderate consensus by the conference participants and three had no consensus.Conclusion:This modified Delphi study on sporadic vestibular schwannoma codifies 100% consensus within a multidisciplinary expert panel and is further supported by 91% consensus among an external group of clinicians who regularly provide care for patients with vestibular schwannoma. These final 103 statements address clinically pragmatic items that have direct application to everyday patient care. This document is not intended to define standard of care or drive insurance reimbursement, but rather to provide a general framework to approach vestibular schwannoma care for providers and patients.

Abstract MEDICAL THERAPY Target Population Adults with histologically proven or suspected vestibular schwannomas with neurofibromatosis type 2 (NF2). Question What is the role of bevacizumab in the treatment of patients with vestibular schwannomas? Recommendations Level 3: It is recommended that bevacizumab be administered in order to radiographically reduce the size or prolong tumor stability in patients with NF2 without surgical options. Level 3: It is recommended that bevacizumab be administered to improve hearing or prolong time to hearing loss in patients with NF2 without surgical options. Question Is there a role for lapatinib, erlotinib, or everolimus in the treatment of patients with vestibular schwannomas? Recommendations Level 3: Lapatinib may be considered for use in reducing vestibular schwannoma size and improvement in hearing in NF2. Level 3: Erlotinib is not recommended for use in reducing vestibular schwannoma size or improvement in hearing in patients with NF2. Level 3: Everolimus is not recommended for use in reducing vestibular schwannoma size or improvement in hearing in NF2. Question What is the role of aspirin, to augment inflammatory response, in the treatment of patients with vestibular schwannomas? Target Population Any patient with a vestibular schwannoma undergoing observation. Recommendation Level 3: It is recommended that aspirin administration may be considered for use in patients undergoing observation of their vestibular schwannomas. Question Is there a role for treatment of vasospasm, ie, nimodipine or hydroxyethyl starch, perioperatively to improve facial nerve outcomes in patients with vestibular schwannomas? Target Population Adults with histologically proven or suspected vestibular schwannomas. Recommendation Level 3: Perioperative treatment with nimodipine (or with the addition of hydroxyethyl starch) should be considered to improve postoperative facial nerve outcomes and may improve hearing outcomes. PREHABILITATION Question Is there a role for preoperative vestibular rehab or vestibular ablation with gentamicin for patients surgically treated for vestibular schwannomas? Target Population Adults with histologically proven or suspected vestibular schwannomas. Recommendations Level 3: Preoperative vestibular rehabilitation is recommended to aid in postoperative mobility after vestibular schwannoma surgery. Level 3: Preoperative gentamicin ablation of the vestibular apparatus should be considered to improve postoperative mobility after vestibular schwannoma surgery. SURGICAL THERAPY Question Does endoscopic assistance make a difference in resection or outcomes in patients with vestibular schwannomas? Target Population Vestibular schwannoma patients, who are surgical candidates. Inclusion in this analysis required resection utilizing the endoscope, either as the primary operative visualization or microscopic assistance with more than 20 patients treated. Recommendation Level 3: Endoscopic assistance is a surgical technique that the surgeon may choose to use in order to aid in visualization. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_9.

Objectives We examined vestibular schwannoma tumor dimension and direction of growth to determine whether these correlate with facial nerve outcome as well as extent of resection (EOR). Design Retrospective review of prospectively maintained databases. Participants 206 patients were a part of this study. Main Outcome Measures Tumor dimensions were measured using preoperative magnetic resonance imaging, and a series of ratios were then calculated to further characterize tumor dimension. Regression analyses were performed to investigate correlation with facial nerve outcome and EOR. Results Patients with tumor extending >1.5 cm anterior to the internal auditory canal (IAC) (AB measurement) were three times more likely to have postoperative House-Brackman grades of 3 or worse. We also found that an EB/BF ratio (representing elongated growth parallel to the IAC axis) ≥1.1 was associated with half the risk of poor facial nerve outcome. Tumors with anterior-posterior diameter (AC measurement) >1.9 cm were five times less likely to undergo gross total resection (GTR). Furthermore, an increased degree of tumor extension into the IAC (DE measurement >2.4 cm) or an increased amount of brainstem compression (EB measurement >1.1 cm) were each associated with a nearly 3-fold decrease in the likelihood of GTR. Conclusion Our study demonstrates that anterior extent of the tumor is as important as tumor size to facial nerve outcome and degree of resection for vestibular schwannomas.