Carlson, Matthew L.

Objective: To systematically review studies evaluating systemic medical therapies for sporadic vestibular schwannoma (VS) and perform meta-analyses to assess associations with tumor control. Study design: Systematic review and meta-analysis. Setting: Not applicable. Patients: Sporadic VS patients. Interventions: Systemic medical therapies. Main outcome measures: Tumor growth. Results: Nine retrospective studies met criteria: 5 on nonsteroidal anti-inflammatory drugs (NSAIDs), 3 on metformin, and 1 on losartan (all level 3 evidence). A meta-analysis of ORs from 5 studies demonstrated no significant association between aspirin use and tumor growth (pooled OR: 0.77; 95% CI: 0.48-1.23; I²: 76%). Conversely, a meta-analysis of ORs from 3 studies on metformin showed significantly lower odds of tumor growth (pooled OR: 0.46; 95% CI: 0.30-0.72; I²: 0%). The study on losartan did not identify a statistically significant association of losartan with tumor growth. Less than half of the studies reported HRs to appropriately reflect the inherently time-dependent nature of tumor growth. Conclusions: Evidence for systemic therapies in sporadic VS remains preliminary. Our meta-analysis of ORs demonstrates that NSAID use is not significantly associated with tumor growth, metformin users had lower odds of tumor growth, and evidence for losartan remains limited; however, all available studies provide only level 3 evidence. At present, there is insufficient data to recommend routine use of aspirin, metformin, or losartan with the intent of mitigating VS tumor growth during wait-and-scan management. High-quality prospective studies with appropriate time-to-event methodology to assess tumor growth are required to establish the clinical utility of systemic therapies in the management of patients with sporadic VS.

Objective: Quality of life (QOL) is an important consideration in vestibular schwannoma (VS) patients when assessing management options. Understanding sex-based differences in QOL may facilitate patient counseling. Study design: Prospective cohort. Setting: Tertiary academic medical center and Acoustic Neuroma Association. Patients: Sporadic VS patients. Interventions: Observation, microsurgery, or radiation. Main outcome measures: Penn Acoustic Neuroma Quality of Life (PANQOL) scores. Results: A total of 481 patients were analyzed. In the observation group, women reported worse anxiety, facial function, and total PANQOL scores at baseline. At follow-up, men declined more in facial function (−5 vs. +3, P =0.01). For microsurgery, women reported worse facial function and balance scores at baseline. At follow-up, men declined more in facial function (−16 vs. −3, P <0.001), balance (−7 vs. +2, P =0.04), energy (−4 vs. +5, P =0.03), and total (−5 vs. +2, P =0.02) PANQOL scores. For radiation, women reported worse anxiety, balance, pain, and total scores at baseline. At follow-up, anxiety improved in women but worsened in men (+5 vs. −6, P =0.008). Sex-based differences exceeding the minimally important difference thresholds established for the PANQOL were observed for the following: anxiety at baseline in the observation group, anxiety and pain at baseline in the radiation group, and change in anxiety from baseline to follow-up in the radiation group. Conclusions: Women had worse anxiety, balance, facial function, pain, and overall QOL at baseline assessed using the PANQOL, whereas men declined more with treatment and observation. The largest difference in PANQOL change between sexes occurred after microsurgery, with men experiencing greater losses in facial function, balance, energy, and total scores.

ABSTRACT Objectives To characterize the structure, resources, and educational practices of temporal bone laboratory training across ACGME‐accredited U.S. otolaryngology residency programs. Methods A national cross‐sectional survey was distributed to program directors and faculty responsible for temporal bone education. Survey domains included curriculum structure, training frequency, faculty involvement, assessment practices, and access to laboratory resources. Descriptive statistics and univariable regression analyses were performed to explore associations between program characteristics and neurotology fellowship pursuit. Results Thirty‐seven programs responded (28.2%). Laboratory structure varied widely, including longitudinal (monthly or weekly) and condensed (annual or 2–3 courses/year) formats. Programs with longitudinal sessions reported more annual lab hours than condensed formats (median 42 vs. 16 h/year, p = 0.003). All programs had access to cadaveric temporal bones (mean 2.25 ± 1.13 bones per resident/year), though five reported fewer bones than residents. The mean drill‐to‐resident ratio was 0.59, with 10.8% reporting a 1:1 ratio. Formal performance evaluation was used by 43.2% of programs. On exploratory univariable analysis, longer otology rotation duration was associated with having at least one neurotology fellow within five years ( p = 0.025). Larger resident cohort size ( p = 0.048) and older laboratory instruments ( p = 0.043) were associated with producing more than one fellow. Conclusion There is substantial variability in temporal bone education across U.S. otolaryngology training programs. Programs differ in curricula, resources, and access to cadaveric and simulation‐based training. Standardization of core components may improve educational equity and training consistency. Level of Evidence N/A.

Objective: To examine the benefit of cochlear implantation (CI) in pediatric patients with a history of temporal bone fracture resulting in single-sided deafness (SSD). Study design: Retrospective chart review. Setting: Two tertiary academic centers. Patients: Pediatric patients less than 18 years of age with SSD secondary to temporal bone fracture who underwent CI from 2012 to 2022. Intervention(s): CI. Main outcome measure(s): Postoperative audiometric testing. Results: Seven subjects were identified (median age: 10 years (y); Q1 to Q3: 5 to 16 y). Median time from temporal bone trauma to CI was 7 months (mo) (Q1 to Q3: 3 to 7 mo) and 85% had otic capsule involvement. Subjects were followed for a median length of 12 months (Q1 to Q3: 6 to 24 mo) after CI. All patients achieved full electrode insertion, though 2 required scala vestibuli insertion due to ossification of the scala tympani (one of whom had a history of meningitis after temporal bone fracture). Postoperative audiometric testing revealed variable speech perception outcomes with 4 of 7 obtaining open or closed set speech perception and 3 of 7 obtaining only sound awareness. No postoperative complications occurred. Conclusions: CI is a feasible intervention for SSD following pediatric temporal bone fractures, but outcomes are variable. Early evaluation and timely CI, ideally within 6 months of temporal bone fracture, may optimize outcomes. Cochlear ossification, either as a result of otic capsule fracture or subsequent meningitis, may lead to suboptimal outcomes.

Objective: To survey critical areas of variation in published research methodology with a primary aim of highlighting fundamental aspects that contribute to ongoing controversy surrounding optimal management of patients with sporadic vestibular schwannoma. Interventions: Observation, stereotactic radiosurgery (SRS), and microsurgery. Main outcome measures: Variation in reported outcomes surrounding facial function, useful hearing, tumor pseudoprogression following SRS, and tumor growth/natural history. Results: Published research defines “good” post-treatment facial function as anything ranging from HB I, ≤HB II, to ≤HB III. While most studies define serviceable hearing as AAO Class A/B, others include Class C in published post-treatment hearing preservation results; meanwhile, patients report their greatest decrement in quality-of-life at a threshold around 75% in word recognition scores. Heterogeneously defined as post-SRS tumor growth 6 months after SRS to 5 years after SRS, the reported incidence of tumor pseudoprogression ranges from 7% to 77% within the published literature. Natural history studies that employ linear tumor measurements consistently suggest most tumors do not grow following diagnosis, whereas volumetric studies of natural history suggest the exact opposite is true. Limited follow-up and absent time-to-event analyses undermine many outcomes surrounding vestibular schwannoma that are inherently time-dependent. Conclusions: Disparate definitions used in vestibular schwannoma research beget variable outcome reporting and confuse interpretation of optimal management, particularly for the increasingly common scenario of a small tumor in a minimally symptomatic patient. Progress towards optimizing management requires re-evaluation and alignment on key outcome measures to improve consistency in reporting with renewed emphasis on clinically significant, patient-driven outcomes that often exceed the thresholds most frequently studied to date.

Objective: To examine microsurgical outcomes of medial sporadic vestibular schwannoma (VS), defined as a spherical tumor within the cerebellopontine angle (CPA) without tubular internal auditory canal (IAC) extension, compared with a referent cohort of “typical” VS with IAC extension. Study design: Historical matched cohort study. Setting: Tertiary referral center. Patients: Forty patients with medial sporadic VS who met the inclusion criteria were each matched to 3 referent patients by age, CPA tumor size, preoperative hearing class, and surgical approach. Interventions: Microsurgical resection. Main outcome measures: Extent of resection, immediate and long-term postoperative facial nerve weakness (House-Brackmann grade >I), and long-term hearing preservation were compared between patients with medial VS and the referent cohort using conditional logistic regression. Results: Medial VS and matched patients with IAC extension were not statistically significantly different in nongross total extent of resection (OR: 1.04, 95% CI: 0.47-2.31), immediate (OR: 0.82, 95% CI: 0.40-1.67) or long-term (OR: 0.59, 95% CI: 0.23-1.48) postoperative facial nerve weakness, or long-term nonserviceable hearing (OR: 0.84, 95% CI: 0.17-4.22). Conclusions: In this matched cohort study of medial VS, we found no statistically significant differences in the extent of resection, facial nerve function, or hearing preservation between tumors with and without IAC extension.

Objective: To explore the existing evidence on novel imaging modalities that may aid in prognostication of vestibular schwannoma (VS) clinical outcomes across various management approaches. Study design: Scoping review. Setting: Not applicable. Patients: Individuals diagnosed with VS. Interventions: Novel imaging techniques. Main outcome measures: Tumor growth and response to medical therapy. Results: A total of 18 articles were included in this review. Of these, 7 focused on pretreatment prognosis, 6 evaluated radiosurgery outcomes, 4 examined microsurgery outcomes, and 1 assessed response to bevacizumab. The imaging modalities investigated included radiomics (n = 10), positron emission tomography (PET; n = 2), dynamic contrast-enhanced MRI (DCE-MRI; n = 2), both PET and DCE-MRI (n = 1), magnetic resonance elastography (MRE; n = 1), contrast-enhanced CT (CE-CT; n = 1), and slip interface imaging (SII; n = 1). Radiomic studies yielded encouraging results in predicting tumor growth after wait-and-scan and radiosurgery, with reported accuracies ranging from 52% to 88%, sensitivities from 13% to 95%, specificities from 50% to 94%, and area under the curves from 0.65 to 0.99. PET studies identified several promising ligands associated with tumor growth during wait-and-scan, suggesting a potential role in prognostication. DCE-MRI also demonstrated associations with tumor growth and treatment response to bevacizumab. Studies on MRE, CE-CT, and SII identified novel imaging parameters associated with tumor stiffness and adhesion. Conclusions: Several emerging imaging modalities hold potential for improving clinical outcome prognostication in VS. Techniques such as radiomics, PET, and DCE-MRI have shown promising results; however, the supporting evidence is still limited and heterogeneous. Further research is necessary to validate and refine these approaches to enhance their clinical utility.