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.
To investigate the factors associated with unilateral hearing loss (UHL) and its impact on communication in US adults.
Cross-sectional study.
Nationally representative sample of US adults.
We ...analyzed data from the 2011-2012 and 2015-2016 National Health and Nutritional Examination Survey, in which participants aged 20 to 69 years completed an audiometric evaluation (n = 8138). UHL was defined as a speech frequency pure-tone average ≥25 dB in the worse hearing ear and <25 dB in the better hearing ear. Logistic regression was used to examine the association between UHL and relevant factors.
The prevalence of UHL was 8.1% (95% CI, 7.3%-9.0%) in US adults. Factors associated with UHL included older age, male sex, white race, lower level of education, diabetes, cardiovascular disease, and off-work noise exposure. Among adults with UHL, 40% (95% CI, 32%-48%) reported subjective trouble with hearing, a rate higher than the 12% (95% CI, 11%-14%) among normal-hearing adults. After adjusting for relevant factors, adults with UHL were more likely to report difficulties with following conversations with noise (odds ratio OR, 1.7; 95% CI, 1.2-2.5) and frustration when talking to family and friends (OR, 3.0; 95% CI, 1.9-4.6). Higher levels of communication difficulties were observed with worsening level of UHL.
Adults with UHL report significant communication difficulties in comparison to normal-hearing adults. Further research is needed to understand the psychosocial impact of UHL on adults and ways to improve communication support for adults with UHL.
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.
Retrospective review.
Private practice tertiary neurotology referral center.
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.
Primary middle cranial fossa approach for removal of vestibular schwannoma.
Fundal fluid status (presence or absence), preoperative and postoperative pure-tone average, and speech discrimination scores and tumor nerve of origin.
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 <or= 0.014). Tumors arising from the superior vestibular nerve also were associated with a higher rate of preserved, serviceable, and measurable hearing, whereas the combination of the presence of fundal fluid and superior nerve tumor had a significantly better chance of hearing preservation than either factor alone.
The presence of fundal fluid on preoperative MRI is predictive of hearing outcomes and should be used in counseling patients who are considering hearing preservation surgery via a middle cranial fossa approach for the treatment of isolated vestibular schwannoma.
Abstract
Objective
Vestibular schwannoma (VS) are benign, often slow growing neoplasms. Some institutions opt for radiosurgery in symptomatic patients of advanced age versus surgical resection. The ...aim of the study is to analyze surgical outcomes of VS in patients over the age of 65 who were either not candidates for or refused radiosurgery.
Methods
This includes retrospective analysis of VS patients between 1988 and 2020. Demographics, tumor characteristics, surgical records, and clinical outcomes were recorded. Patient preference for surgery over radiosurgery was recorded in the event that patients were offered both. Facial nerve outcomes were quantified using House-Brackmann (HB) scores. Tumor growth was defined by increase in size of >2 mm.
Results
In total, 64 patients were included of average age 72.4 years (65–84 years). Average maximum tumor diameter was 29 mm (13–55 mm). Forty-five patients were offered surgery or GKRS, and chose surgery commonly due to radiation aversion (48.4%). Gross total resection was achieved in 39.1% (
n
= 25), near total 32.8% (
n
= 21), and subtotal 28.1% (
n
= 18). Average hospitalization was 5 days 2–17 with 75% (
n
= 48) discharged home. Postoperative HB scores were good (HB1–2) in 43.8%, moderate (HB3–4) in 32.8%, and poor (HB5–6) in 23.4%. HB scores improved to good in 51.6%, moderate in 31.3%, and remained poor in 17.1%, marking a rate of facial nerve improvement of 10.9%. Tumor control was achieved in 95.3% of cases at an average follow-up time of 37.8 months.
Conclusion
VS resection can be safely performed in patients over the age of 65. Advanced age should not preclude a symptomatic VS patient from being considered for surgical resection.
Objective:
To design a treatment algorithm based on experience with facial nerve schwannomas (FNS) over a 30‐year period.
Study Design:
Retrospective chart review.
Method:
Seventy‐nine patients with ...facial nerve schwannomas seen from 1979 through 2009 at a tertiary referral private otologic practice were categorized by treatment modality. Interventions included surgical resection with grafting, bony decompression, observation, or stereotactic radiation. Outcome measures included House‐Brackmann facial nerve grade before and after intervention as well as change in facial nerve grade, tumor size, involved segments of nerve, time to intervention.
Results:
Thirty‐seven patients (46.8%) ultimately underwent surgical excision with grafting or primary anastomosis, 21 (26.6%) underwent bony decompression alone, 15 (19.0%) were managed with observation only, and 6 (7.6%) had stereotactic radiation. Through 1995, 85% of cases had surgical resection and none had observation only. Of the 52 patients seen after 1995, 27% had surgical resection and grafting, 33% had bony decompression, 29% were managed with observation alone, and 11% had radiotherapy. Facial nerve grade was maintained or improved over the follow‐up period (mean time = 3.9 years) in 78.9% of the decompression group and 100% of the observation and radiation groups compared to 54.8% of the resection group (P ≤ .012).
Conclusions:
Surgical resection and grafting, once widely accepted and practiced, has in many cases given way to observation, bony decompression, or stereotactic radiation. A wide armamentarium of options is available to the neurotologist treating facial nerve schwannomas with the ability to preserve facial function for a longer period of time.
The mammalian inner ear consists of the cochlea and the vestibular labyrinth (utricle, saccule, and semicircular canals), which participate in both hearing and balance. Proper development and ...life-long function of these structures involves a highly complex coordinated system of spatial and temporal gene expression. The characterization of the inner ear transcriptome is likely important for the functional study of auditory and vestibular components, yet, primarily due to tissue unavailability, detailed expression catalogues of the human inner ear remain largely incomplete.
We report here, for the first time, comprehensive transcriptome characterization of the adult human cochlea, ampulla, saccule and utricle of the vestibule obtained from patients without hearing abnormalities. Using RNA-Seq, we measured the expression of >50,000 predicted genes corresponding to approximately 200,000 transcripts, in the adult inner ear and compared it to 32 other human tissues. First, we identified genes preferentially expressed in the inner ear, and unique either to the vestibule or cochlea. Next, we examined expression levels of specific groups of potentially interesting RNAs, such as genes implicated in hearing loss, long non-coding RNAs, pseudogenes and transcripts subject to nonsense mediated decay (NMD). We uncover the spatial specificity of expression of these RNAs in the hearing/balance system, and reveal evidence of tissue specific NMD. Lastly, we investigated the non-syndromic deafness loci to which no gene has been mapped, and narrow the list of potential candidates for each locus.
These data represent the first high-resolution transcriptome catalogue of the adult human inner ear. A comprehensive identification of coding and non-coding RNAs in the inner ear will enable pathways of auditory and vestibular function to be further defined in the study of hearing and balance. Expression data are freely accessible at https://www.tgen.org/home/research/research-divisions/neurogenomics/supplementary-data/inner-ear-transcriptome.aspx.
•We performed RNA-Seq of the human cochlea, ampulla, saccule and utricle.•We have built a comprehensive database of transcripts of the adult human inner ear.•We describe a first detailed inventory of long non-coding RNA's in the inner ear.•Our data supports potential tissue specificity of NMD in the inner ear.•The expression of genes in deafness loci without gene identification is described.
Analyze delayed facial nerve palsy (DFNP) following resection of vestibular schwannoma (VS) to describe distinct characteristics and facial nerve (FN) functional course.
Prospective cohort with ...retrospective review.
Academic medical center.
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.
VS resection with intraoperative electromyographic monitoring.
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.
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).
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.
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.
Retrospective cohort study.
Two tertiary skull base referral centers.
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.
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).
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.
Abstract
Objectives
To analyze the relationship between preoperative and intraoperative auditory brain stem response (ABR) characteristics and hearing outcomes in patients with vestibular ...schwannomas (VS) undergoing hearing preservation (HP) surgery via a middle cranial fossa (MCF) approach.
Design
Prospective study.
Setting
Academic tertiary skull base referral center.
Methods
Pre- and postoperative pure-tone average (PTA) and word recognition score (WRS) were examined. Intraoperative ABR wave III latency, wave V latency, and amplitude were recorded. HP was defined as postoperative WRS ≥50%.
Participants
Adult patients with VS and WRS ≥50% who underwent MCF tumor resection between November 2017 and September 2019.
Main Outcome Measures
Postoperative hearing outcomes.
Results
Sixty patients were included. Mean tumor size was 9.2 mm (range, 3–17). HP rates were 56.7% for the cohort and 69.7% for tumors <10 mm. A complete loss of wave V was associated with an 82.9% increase in postoperative PTA (
p
< 0.001) and 97.2% decrease in WRS (
p
< 0.001), whereas a diminished wave V was correlated with 62.7% increase in PTA (
p
< 0.001) and 55.7% decrease in WRS (
p
= 0.006). A diminished or absent wave V, but not increased wave III/V latency or decreased wave V amplitude, was correlated with a decline in postoperative hearing class (
r
= 0.735,
p
< 0.001). Receiver-operating characteristic analysis demonstrated that a stable wave V has the highest accuracy in predicting HP (sensitivity of 82.6%, specificity of 84.8%).
Conclusion
Of the examined preoperative and intraoperative ABR characteristics, a stable wave V intraoperatively was the strongest predictor of HP after MCF resection of VS.
Level of Evidence
Level III.
We performed a genome-wide association study (GWAS) to identify the genes responsible for age-related hearing impairment (ARHI), the most common form of hearing impairment in the elderly. Analysis of ...common variants, with and without adjustment for stratification and environmental covariates, rare variants and interactions, as well as gene-set enrichment analysis, showed no variants with genome-wide significance. No evidence for replication of any previously reported genes was found. A study of the genetic architecture indicates for the first time that ARHI is highly polygenic in nature, with probably no major genes involved. The phenotype depends on the aggregated effect of a large number of SNPs, of which the individual effects are undetectable in a modestly powered GWAS. We estimated that 22% of the variance in our data set can be explained by the collective effect of all genotyped SNPs. A score analysis showed a modest enrichment in causative SNPs among the SNPs with a P-value below 0.01.
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