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Sporadic Vestibular Schwannomas
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
7 sections · 99 slides
Overview
- Scope of this presentation
Background and historical development
- Definition and cell of origin
- Early clinical reports
- Cushing's described stages of symptom progression
- Dandy and the unilateral cerebellar approach
- William House and the modern approaches
- Origins of stereotactic radiosurgery
- Recognition that not all tumours grow
Evolution in epidemiology and its implications
- Era before cross-sectional imaging
- Imaging and the change in detection
- Incidence of sporadic vestibular schwannoma
- Age and tumour size at diagnosis today
- Heightened detection as the explanation for rising incidence
- Environmental exposures and risk
- Incidence and prevalence distinguished
- Lifetime risk and rare disease status
- Chronic disease management as the new model
Patient presentation
- Common presenting symptoms
- Symptom pattern and diagnostic delay
- Less common presentations
- Referral bias in reported symptom frequencies
- Other cranial nerve involvement
- Headache, cerebellar signs and hydrocephalus
Diagnosis
- Indications for MRI in asymmetrical hearing loss
- Discordance between tumour size and hearing
- Retrocochlear findings on audiological testing
- Definition of serviceable hearing
- Role of vestibular testing
- MRI protocol and diagnostic yield
- Characteristic MRI signal features
- Distinguishing vestibular schwannoma from meningioma
- Tumour size categories by CPA extension
- How tumour size is measured
- Variation in tumour size at diagnosis
Management
- Principles of modern management
- Determinants of treatment choice
- Expectations from treatment of small tumours
- Geographic variation in initial management across the United States
- Quality of life across management modalities
- Penn Acoustic Neuroma Quality of Life scores by treatment group
- Observation as first-line management
- Rationale for observation
- A representative surveillance imaging schedule
- Definition of growth and its consequence
- Patients in whom observation is not advised
- Stereotactic radiation techniques
- Aims and radiobiology of radiosurgery
- Central necrosis after radiosurgery
- Tumour control rates and size limits
- Hearing outcomes after radiosurgery
- Cranial neuropathy risk and marginal dose
- Malignant transformation and secondary tumours
- Role of microsurgical resection
- Trade-offs of microsurgery against other options
- Microsurgical approaches to vestibular schwannoma
- Translabyrinthine approach
- Translabyrinthine approach: advantages and drawbacks
- Retrosigmoid craniotomy
- Limitations of the retrosigmoid approach
- Middle fossa craniotomy
- Facial nerve position in the middle fossa approach
- Facial nerve and hearing risk after microsurgery
- Other postoperative complications
- Postoperative care pathway
- Principles of surgical approach selection
- Approach selection by hearing status and tumour position
- Anatomical factors limiting approach choice
- Comparative outcomes between approaches
- Trends in extent of microsurgical resection
- Recurrence risk after incomplete resection
Current controversies and challenges
- Evidence for potential overtreatment
- The overtreatment paradox
- Debate over management of small tumours
- Quality-adjusted life years and initial observation
- Saltatory growth in sporadic vestibular schwannoma
- Internal contradiction of the growth-triggers-treatment rule
- Candidates for continued observation despite growth
- Key points
- Key points continued
- References
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- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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