Disparities in Sporadic Vestibular Schwannoma Initial Presentation Between a Public Safety Net Hospital and Tertiary Academic Medical Center at the Same Zip Code 2010 to 2020.

INTRODUCTION: Treatment of vestibular schwannoma (VS) has been extensively studied, but a gap in knowledge exists demonstrating how racial and socioeconomic status influence VS presentation. Our institution has a unique setting with a public safety net hospital (PSNH) and tertiary academic medical center (TAMC) in the same zip code, which we study to evaluate initial VS presentation disparities in patient populations presenting to these hospital settings. METHODS: Retrospective chart review was performed of all adult patients (n = 531) presenting 2010 to 2020 for initial VS evaluation at TAMC (n = 462) and PSNH (n = 69). Ethnicity, insurance, maximum tumor size, audiometry, initial treatment recommendation, treatment received, and follow up were recorded and statistical analysis performed to determine differences. RESULTS: Average age at diagnosis (51.7 ± 13.6 TAMC vs 52.3 ± 12.4 PSNH) and gender (58.4% TAMC vs 52.2% PSNH female) were similar. Patients' insurance (TAMC 75.9% privately insured vs PSNH 82% Medicaid) and racial/ethnic profiles (TAMC 67.7% White and 10.0% Hispanic/Latinx, vs PSNH 4.8% White but 59.7% Hispanic/Latinx) were significantly different. Tumor size was larger at PSNH (20.2 ± 13.3 mm) than TAMC (16.6 ± 10.0 mm). Hearing was more impaired at PSNH than TAMC (mean pure tone average 58.3 dB vs 43.9 dB, word recognition scores 52.3% vs 68.2%, respectively). Initial treatment recommendations and treatment received may include more than 1 modality. TAMC patients were offered 66.7% surgery, 31.2% observation, and 5.2% radiation, while PSNH patients offered 50.7% observation, 49.3% surgery, and 8.7% radiation. TAMC patients received 62.9% surgery, 32.5% observation, and 5.3% radiation, while PSNH patients received 36.2% surgery, 59.4% observation, and 14.5% radiation. Follow up and treatment at the same facility was not significantly different between hospitals. CONCLUSIONS: Hearing was worse and tumor size larger in patients presenting to PSNH. Despite worse hearing status and larger tumor size, the majority of PSNH patients were initially offered observation, compared to TAMC where most patients were initially offered surgery.

Socioeconomic determinants impact quality of life at vestibular schwannoma diagnosis.

BACKGROUND: Socioeconomic variables including race, education, and income have been shown to affect vestibular schwannoma incidence, treatment, and outcomes. We sought to determine the impact of socioeconomic factors on quality of life at the time of vestibular schwannoma diagnosis. METHODS: Retrospective cohort study conducted at a tertiary academic center. All patients evaluated for vestibular schwannoma from March 1, 2010 to December 31, 2021 who completed at least one Penn Acoustic Neuroma Quality of Life (PANQOL) questionnaire at presentation or prior to any intervention were included. PANQOL scores were compared across income quintiles, racial groups, and health insurance categories. RESULTS: Two-hundred and ninety-six patients who had non-missing information on variables of interest were included. Compared to White/Caucasian patients (84.5 %), Black/African American patients (4.7 %) had significantly lower PANQOL total scores (b = -12.8[-21.7, -4.0], p = 0.005). Compared to patients with Commercial insurance (53 %), patients who were Uninsured/ Self-pay (1.7 %) had significantly lower PANQOL total scores (b = -16.7[-31.4, -1.9], p = 0.027). Patients in higher income quintiles had significantly higher PANQOL total scores (b = 11.7[3.9, 19.5], p = 0.004 comparing highest income quintile to lowest). After controlling for potential confounders, income quintile (b = 9.6[1.3, 17.9], p = 0.023 comparing highest quintile to lowest) and insurance (b = -17.0[-31.9, -21], p = 0.025 comparing Uninsured/Self-pay to Commercial insurance) remained predictors of total PANQOL score. CONCLUSIONS: Socioeconomic factors including race, health insurance, and income appear to contribute to quality of life at the time of vestibular schwannoma diagnosis. These variables are interrelated and the effects of race may be mediated in part by differences in income and health insurance coverage.

An Update on Epidemiology and Management Trends of Vestibular Schwannomas.

OBJECTIVE: To determine the current epidemiology and management trends for patients with vestibular schwannomas (VS). STUDY DESIGN: Retrospective cohort study. SETTING: The Surveillance, Epidemiology, and End Results (SEER) tumor registry. PATIENTS: The SEER database was queried to identify patients diagnosed with VS from 1973 to 2015. Demographics, patient and tumor characteristics, and treatment methods were analyzed. RESULTS: A total of 14,507 patients with VS were identified. The mean age at diagnosis was 55 ±â€Š14.9 years. Age-adjusted incidence from 2006 to 2015 was 1.4 per 100,000 per year and remained relatively stable. Incidence across age varied with sex, as younger women and older men had increased incidences comparatively. A higher percentage of patients underwent surgery alone (43%), followed by observation (32%), radiation alone (23%), and combined radiation and surgery (2%). Age 65 and older was associated with observation (odds ratio [OR] 1.417; p = 0.029) whereas age 20 to 39 and 40 to 49 were associated with surgery (OR 2.013 and 1.935; p < 0.001). Older age was associated with radiation. Larger tumor size was associated with surgery and combined treatment. African American patients and American Indian or Alaskan Native patients were more likely to undergo observation than surgery. CONCLUSIONS: The overall incidence of VS is 1.4 per 100,000 per year and has remained relatively stable. There is a trend toward more conservative management with observation, which may be secondary to earlier diagnosis given widespread use of magnetic resonance imaging. Further studies are necessary to investigate differences in disease patterns and disparities in management.

Patient Demographics Influencing Vestibular Schwannoma Size and Initial Management Plans.

OBJECTIVE: To explore patient demographics as to predicting vestibular schwannoma (VS) size and treatment plan within a single institution. METHODS: Using a large tertiary referral skull base center database, all patients with sporadic VS who presented to the center between 2009 and 2018 were reviewed. RESULTS: A total of 816 patients with VS over 18 years of age were included. The median age was 56.8 years (range: 18.6-90.9 years). The median tumor diameter at diagnosis was 11.9 mm (range: 0.6-51.1 mm). With multivariate analysis, older age was associated with decreased tumor size (0.23 mm, 95% confidence interval [CI]: 0.17-0.29), whereas married patients had larger tumors (2.5 mm, 95% CI: 0.92-4.09). When comparing observation, radiation, or surgery, older patients are more likely to pursue observation as compared with surgery and radiation (odds ratio [OR]: 1.08, 95% CI: 1.06-1.10 and OR: 1.20, 95% CI: 1.08-1.33), respectively. Married patients were less likely to pursue observation as compared with surgery (OR: 0.49, 95% CI: 0.29-0.82). Each additional mile a patient lives farther from the center increases his or her odds of pursuing treatment (OR: 1.002, 95% CI: 1.001-1.003). CONCLUSIONS: Older age is associated with smaller tumors, whereas married patients have larger tumors at diagnosis as compared with nonmarried patients. Furthermore, married patients are more likely to pursue treatment, specifically surgery, as compared with nonmarried patients, whereas patients who live farther from the center are more likely to pursue treatment.

Changing trends in management of vestibular schwannoma: A National Cancer Database study.

OBJECTIVE: To describe changes in management trends of vestibular schwannoma (VS) and the effects of median income, education level, insurance status, and tumor size on receipt of treatment. METHODS: Cross-sectional analysis using the National Cancer Database from 2004 to 2014. All patients with a diagnosis of VS were identified between 2004 and 2014. Trends in treatment modality over time were analyzed. Correlation between demographics, institution type, median income, education level, and insurance status were assessed using univariate and multivariate logistic regressions. RESULTS: Of the 22,290 VS patients identified, 16,011 (71.8%) received treatment, whereas 6,279 (28.2%) received observation. Management trend analysis over the 11-year period revealed patients with tumor size < 1 cm are more frequently observed (34.6% of cases in 2004 vs. 60.8% of cases in 2014) and less frequently received surgery (34.6% vs. 16.8%). Multivariate analysis showed observation was more frequently used in patients ≥ 65 years; black patients; and those on Medicaid, Medicare, and noninsured (P < 0.0001). All tumors > 2 cm were more likely to be treated with surgery, specifically subtotal resections (P < 0.0001). Patients treated at nonacademic centers were more likely to receive linear accelerator, or LINAC (Accuray Incorporated, Sunnyvale, CA) therapy than Gamma Knife (Elekta, Stockholm, Sweden) (P < 0.0001). CONCLUSION: Management of VS is shifting toward increased observation, most significantly in tumors size < 1 cm. Insurance provider plays a significant role on receipt of treatment and modality, whereas income and education do not. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1197-1205, 2019.

A standardised pathway for the surveillance of stable vestibular schwannoma.

Introduction Conservative management of patients with a stable vestibular schwannoma (VS) places a significant burden on National Health Service (NHS) resources and yet patients' surveillance management is often inconsistent. Our unit has developed a standardised pathway to guide surveillance imaging of patients with stable VS. In this article, we provide the basis for our imaging protocol by reviewing the measurement, natural history and growth patterns of VS, and we present a cost analysis of implementing the pathway both regionally and nationally. Methods Patients with an extrameatal VS measuring ≤20mm in maximal diameter receive magnetic resonance imaging (MRI) six months after their index imaging, followed by three annual MRI scans, two two-year interval MRI scans, a single three-year interval MRI scan and then five-yearly MRI scans to be continued lifelong. Patients with purely intrameatal tumours follow the same protocol but the initial six-month imaging is omitted. A cost analysis of the new pathway was modelled on our unit's retrospective data for 2015 and extrapolated to reflect the cost of VS surveillance nationally. Results Based on an estimation that imaging surveillance would last approximately 25 years (+/- 10 years), the cost of implementing our regional surveillance programme would be £151,011 per year (for 99 new referrals per year) and it would cost the NHS £1,982,968 per year if implemented nationally. Conclusions A standardised surveillance pathway promotes safe practice in the conservative management of VS. The estimated cost of a national surveillance programme compares favourably with other tumour surveillance initiatives, and would enable the NHS to provide a safe and economical service to patients with VS.

Impact of insurance status and race on receipt of treatment for acoustic neuroma: A national cancer database analysis.

Acoustic neuroma (AN) management involves surgery, radiation, or observation. Previous studies have demonstrated that patient race and insurance status impact in-hospital morbidity/mortality following surgery; however the nationwide impact of these demographics on the receipt of each treatment modality has not been examined. The National Cancer Data Base (NCDB) from 2004 to 2013 identified AN patients. Multivariate analysis adjusted for several variables within each treatment modality, including patient age, race, sex, income, primary payer for care, tumor size, and medical comorbidities. Patients who were African-American (OR=0.7; 95%CI=0.5-0.9; p=0.01), elderly (minimum age 65) (OR=0.4; 95%CI=0.4-0.6; p<0.0001), on Medicare (OR=0.6; 95% CI=0.4-0.7; p=0.0005), or treated at a community hospital (OR=0.4; 95%CI=0.2-0.7; p=0.007) were less likely to receive surgery. Patients on Medicaid (OR=1.2; 95%CI=0.8-1.8; p=0.04) or treated at an integrated network (OR=1.2; 95%CI=0.9-1.6; p=0.0004) were more likely to receive surgery. Patients who were elderly (OR=2.2; 95%CI=1.7-2.9; p<0.0001) or treated in a comprehensive cancer center (OR=1.5; 95%CI=1.3-1.9; p=0.02) were more likely and Medicaid patients (OR=0.8; 95%CI=0.5-1.2; p=0.04) were less likely to receive radiation. Patients who were elderly (OR=2.2; 95%CI=1.7-2.7; p<0.0001), African-American (OR=1.5; 95%CI=1.1-2.0; p=0.01), on Medicare (OR=1.8; 95%CI=1.4-2.3; p=0.0003), or treated in a community hospital (OR=3.0; 95%CI=1.6-5.6; p=0.0007) were more likely to receive observation. Patients on Medicaid (OR=0.8; 95%CI=0.5-1.2; p=0.04) or treated in an integrated network (OR=0.8; 95%CI=0.6-1.0; p=0.0001) were less likely to receive observation. African-American race, elderly age, and community hospital treatment triaged towards observation/away from surgery; age also triaged towards radiation. Conversely, integrated networks triaged towards surgery/away from observation; comprehensive cancer centers triaged towards radiation. Medicaid insurance triaged towards surgery/away from radiation/observation; this may be detrimental since lack of private insurance is a known risk factor for increased in-hospital postoperative morbidity.

A United Kingdom survey of concerns, needs, and priorities reported by patients diagnosed with acoustic neuroma.

INTRODUCTION: The Patient Concerns Inventory-Acoustic Neuroma (PCI-AN) was developed to explore specifically the concerns that patients would like to discuss during their clinic consultation. The PCI covers a range of issues including hearing, intimacy, fatigue, financial/benefits, relationships, regret, and support for family. It also lists multidisciplinary team (MDT) members that patients would like to see or be referred on to. METHOD: The PCI-AN was emailed to members of the British Acoustic Neuroma Association. RESULTS: A total of 465 complete (54.5%) responses were received. There were 284 female and 181 male subjects. Overall, the most common treatment modality was surgical excision (47%). A quarter of the study cohort had stereotactic radiosurgery, whereas 23% were conservatively managed with interval MRI scanning. The remaining 5% had both surgery and stereotactic radiosurgery. From the 55-item PCI-AN, the most commonly selected issues that patients wanted to talk about were related to the physical and functional well-being and treatment received. Tinnitus was the most frequently selected issue (46%), followed by fatigue/tiredness (43%), dizziness (33%), further investigation (39%), acoustic neuroma treatment (38%), and energy levels (32%). More than a quarter of the respondents had fears of their acoustic neuroma recurring (29%), had concerns about their facial appearance/ palsy (29%), or suffered pain in the head and neck region (26%). The 3 health-care professionals patients most wanted to talk with either in clinic or by referral were as follows: ENT/neurosurgeon (39%), vestibular (balance) physiotherapist (39%), and audiologist (39%). Although it was unknown how many respondents had facial palsy, 21% wanted to see a facial palsy physiotherapist, and another 10% sought referral to a plastic surgeon. CONCLUSION: The PCI-AN has shed light on an interesting array of issues, which may be overlooked by clinicians in busy skull base clinic. The PCI-AN allows for patient-directed consultation and ultimately empowers them to be actively involved in the management of their health.

Conservative management, surgery and radiosurgery for treatment of vestibular schwannomas: a model-based approach to cost-effectiveness.

OBJECTIVE: To undertake a cost-effectiveness analysis comparing conservative management, surgery and radiosurgery for treating small-to-medium (1-20 mm)-sized vestibular schwannomas. DESIGN: Model-based economic evaluation using individual-level data from a Birmingham-based longitudinal patient database and from published sources. Both a decision tree and state-transition (Markov) model were developed, from an National Health Service (NHS) perspective. Sensitivity analyses were also carried out. SETTING: Secondary care treatment for patients with small-to-medium-sized vestibular schwannomas. PARTICIPANTS: Three hypothetical cohorts of adult patients receiving conservative management, radiosurgery or surgery treatment, aged 58 years as starting age within model. MAIN OUTCOME MEASURES: Cost-effectiveness based on cost per quality-adjusted life year (QALY). RESULTS: Conservative management is the preferred strategy for the treatment of small-to-medium-sized vestibular schwannomas. Conservative management is both cheaper (-£ 722 and -£ 2764) and more effective (0.136 and 0.554 quality-adjusted life years) than both radiosurgery and surgery, respectively. A conservative strategy can therefore be considered as highly cost-effective. This result is sensitive to the assumed quality-of-life parameters in the model. Sensitivity analysis suggests that the probability of a conservative strategy being the most cost-effective approach compared with surgery and radiosurgery at a willingness to pay of £ 20 000/quality-adjusted life year gained is 80% and 55%, respectively. CONCLUSIONS: A conservative approach is the preferred strategy for treatment of small-to-medium vestibular schwannomas. This result is sensitive to quality-of-life values used in the analysis. More research is required to assess the impact of treatment upon patients' health-related quality of life over time.

Incidental vestibular schwannomas: a review of prevalence, growth rate, and management challenges.

With the relatively recent increase in the use of MRI techniques, there has been a concurrent rise in the number of vestibular schwannomas (VSs) detected as incidental findings. These incidental VSs may be prevalent in up to 0.02%-0.07% of individuals undergoing MRI and represent a significant portion of all diagnosed VSs. The management of these lesions poses a significant challenge for practitioners. Most incidental VSs tend to be small and associated with minimal symptoms, permitting them to be managed conservatively at the time of diagnosis. However, relatively few indicators consistently predict tumor growth and patient outcomes. Furthermore, growth rates have been shown to vary significantly over time with a large variety of long-term growth patterns. Thus, early MRI screening for continued tumor growth followed by repeated MRI studies and clinical assessments throughout the patient's life is an essential component in a conservative management strategy. Note that tumor growth is typically associated with a worsening of symptoms in patients who undergo conservative management, and many of these symptoms have been shown to significantly impact the patient's quality of life. Specific indications for the termination of conservative management vary across studies, but secondary intervention has been shown to be a relatively safe option in most patients with progressive disease. Patients with incidental VSs will probably qualify for a course of conservative management at diagnosis, and regular imaging combined with the expectation that the tumor and symptoms may change at any interval is crucial to ensuring positive long-term outcomes in these patients. In this report, the authors discuss the current literature pertaining to the prevalence of incidental VSs and various considerations in the management of these lesions. It is hoped that by incorporating an understanding of tumor growth, patient outcomes, and management strategies, practitioners will be able to effectively address this challenging disease entity.

Decision analysis of treatment options for vestibular schwannoma.

OBJECT: Widespread use of MR imaging has contributed to the more frequent diagnosis of vestibular schwannomas (VSs). These tumors represent 10% of primary adult intracranial neoplasms, and if they are symptomatic, they usually present with hearing loss and tinnitus. Currently, there are 3 treatment options for quality of life (QOL): wait and scan, microsurgery, and radiosurgery. In this paper, the authors' purpose is to determine which treatment modality yields the highest QOL at 5- and 10-year follow-up, considering the likelihood of recurrence and various complications. METHODS: The MEDLINE, Embase, and Cochrane online databases were searched for English-language articles published between 1990 and June 2008, containing key words relating to VS. Data were pooled to calculate the prevalence of treatment complications, tumor recurrence, and QOL with various complications. For parameters in which incidence varied with time of follow-up, the authors used meta-regression to determine the mean prevalence rates at a specified length of follow-up. A decision-analytical model was constructed to compare 5- and 10-year outcomes for a patient with a unilateral tumor and partially intact hearing. The 3 treatment options, wait and scan, microsurgery, and radiosurgery, were compared. RESULTS: After screening more than 2500 abstracts, the authors ultimately included 113 articles in this analysis. Recurrence, complication rates, and onset of complication varied with the treatment chosen. The relative QOL at the 5-year follow-up was 0.898 of normal for wait and scan, 0.953 for microsurgery, and 0.97 for radiosurgery. These differences are significant (p < 0.0052). Data were too scarce at the 10-year follow-up to calculate significant differences between the microsurgery and radiosurgery strategies. CONCLUSIONS: At 5 years, patients treated with radiosurgery have an overall better QOL than those treated with either microsurgery or those investigated further with serial imaging. The authors found that the complications associated with wait-and-scan and microsurgery treatment strategies negatively impacted patient lives more than the complications from radiosurgery. One limitation of this study is that the 10-year follow-up data were too limited to analyze, and more studies are needed to determine if the authors' results are still consistent at 10 years.

Current epidemiology and management trends in acoustic neuroma.

OBJECTIVE: The objective of this study was to assess the epidemiology of acoustic neuroma and determine current trends in therapy using tumor registry techniques. STUDY DESIGN: Analysis of a national database. SUBJECTS AND METHODS: The Surveillance Epidemiology and End Results (SEER) database is a national tumor registry that began to identify and abstract benign and borderline tumors of the brain and central nervous system in the year 2004. Coding for International Classification of Diseases for Oncology (ICD-O-3) codes for schwannoma (9560/0) with collaborative staging (CS) coding for acoustic nerve (72.4) was used to identify acoustic neuromas. Demographic data, tumor size, and treatment data were analyzed. RESULTS: A total of 1621 patients with acoustic neuroma were identified, for an incidence rate of 1.1/100,000. Mean age was 53.1 years. Tumors were equally distributed across gender and tumor laterality, with the majority (84%) occurring in Caucasians. Nine hundred sixty-four patients (59.5%) were treated with surgery, whereas 341 (21.0%) were treated with radiation. A total of 1.6 percent received combined therapy over the study period, with the remaining patients receiving either no treatment or unknown therapy. Of tumors less than 2 cm, 27.2 percent were treated with radiotherapy. Statistically significant associations were observed with the increased use of radiotherapy for small (< 2 cm) tumors (P = 0.0001). CONCLUSION: Unlike data from single series, which usually represent individual treatment preferences and techniques, use of SEER data allows for the assessment of demographics and treatment trends at the national level. The results and potential applications are discussed.

Evaluation of cost effectiveness for conservative and active management strategies for acoustic neuroma.

OBJECTIVE: To determine whether economic costs associated with a conservative management strategy for unilateral acoustic neuroma offer an economic advantage over active management options. DESIGN: Cost and sensitivity analysis on a prospective cohort. SETTING: Single centre study within a tertiary referral centre in Toronto, Canada. PARTICIPANTS: 72 patients (32 males, 40 females) aged 36 to 78 years with unilateral acoustic neuroma were assigned initially to a conservative management strategy. Entry criteria were small tumour size (less than 15 mm in the cerebellopontine angle), patient preference and/or significant co-morbidity. INTERVENTIONS: MRI scanning was performed every 6 months for the first year, annually subsequently and then every 2-3 years as required. Clinical review occurred every 6 months. Failure of conservative management led to active treatment. MAIN OUTCOME MEASURES: Cost analysis was performed to determine the mean total cost per patient for continued conservative management over the follow up period compared to the mean upfront total cost per patient undergoing active intervention. RESULTS: Cost analysis within the Canadian health care system determined the mean total cost per patient for microsurgical removal at CAD$22,402 (12,545 pounds; 14,561 euros), for gamma knife radiotherapy at CAD$27659 (15,489 pounds; 17,978 euros), for LINAC radiotherapy at CAD$9,003(5,041 pounds; 5,852 euros) and for conservative management at CAD$9,651 (5,405 pounds;6,273 euros) over the follow-up timeframe. CONCLUSION: An economic advantage can be demonstrated for the conservative management of acoustic neuromas compared to microsurgical removal and gamma knife radiotherapy on the proviso that no increase in active treatment complications arose from continued tumour growth during the period of observation.

Comparison of the surgical and follow-up costs associated with microsurgical resection and stereotactic radiosurgery for vestibular schwannoma.

OBJECT: The best approach to the management of vestibular schwannoma (VS) remains controversial. The aim of this study is to analyze the initial and follow-up costs of resection and stereotactic radiosurgery for patients with VS. METHODS: Initial and follow-up costs in 53 cases in which patients with unilateral, previously unoperated VSs > 3 cm underwent resection (21 cases) or radiosurgery (32 cases) at the Mayo Clinic from June 2000 until July 2002 were analyzed for 36 months. Follow-up treatment-specific utilization records were gathered prospectively for patients not returning to the Mayo Clinic after treatment. Six-month moving averages of incremental follow-up costs were calculated for the 2 patient groups. RESULTS: The mean cost of surgery in the microsurgery group was $23,788 (95% confidence interval $22,280-$24,842) compared with $16,143 (95% confidence interval $15,277-$17,545) for the radiosurgical group. Mean incremental follow-up costs per month for patients in the microsurgery group started just > $1,000 per month, decreased steadily, and remained < $70 per month by the 10th month of follow-up. Mean incremental follow-up costs per month for patients in the radiosurgery group were <$10 per month for the first few months and thereafter increased to as much as $200 per month. CONCLUSIONS: Although the total cost of microsurgery is higher due to the costs of hospitalization, follow-up costs for radiosurgery are greater in general. From a societal perspective, radiosurgery is less expensive than microsurgical resection provided that the rate of tumor progression after radiosurgery remains low with long-term follow-up.

Management of the patient and family with neurofibromatosis 2: a consensus conference statement.

A consensus conference on neurofibromatosis 2 (NF2) was held in 2002 at the request of the United Kingdom (UK) Neurofibromatosis Association, with particular emphasis on vestibular schwannoma (VS) surgery. NF2 patients should be managed at specialty treatment centres, whose staff has extensive experience with the disease. All NF2 patients and their families should have access to genetic testing because presymptomatic diagnosis improves the clinical management of the disease. Some clinical manifestations of NF2, such as ocular abnormalities, can be detected in infancy; therefore, clinical screening for at-risk members of NF2 families can start at birth, with the first magnetic resonance (MRI) scan at 10-12 years of age. Minimal interference, maintenance of quality of life, and conservation of function or auditory rehabilitation are the cornerstones of NF2 management, and the decision points to achieve these goals for patients with different clinical presentations are discussed.

Vestibular schwannoma management: What is the 'best' option?

There is an abundance of medical literature describing the management options for vestibular schwannomas. However, the lack of high quality clinical trials means that, for any individual patient, the decision is often based on the clinician's personal biases. The management options that are available are conservative treatment, surgery, single-dose stereotactic radiosurgery and fractionated radiotherapy. In this review, we set out what the aims of managing a vestibular schwannoma should be and compare how these different treatment modalities perform. The particular objectives of tumour control, cranial nerve preservation, prevention of malignancy, quality of life and cost-effectiveness are discussed. It remains difficult to differentiate between these methods when more than one is suitable; the literature confirms that they are all safe and effective, but the decision must be the patient's, based on their individual priorities. This review should equip the clinician to provide an informed overview of the options.

Assessment of vestibular schwannoma growth: application of a new measuring protocol to the results of a longitudinal study.

This study pertains to a group of 44 patients with unilateral vestibular schwannoma who did not undergo surgery. Prospectively, the dimensions of the tumor were depicted at regular intervals by means of magnetic resonance imaging and then judged independently by an otolaryngologist and a neuroradiologist. Retrospectively, the size of the tumor was quantified by measuring the maximum surface of the lesion in the axial plane. The retrospective surface measurements confirmed the assessments made in the prospective part of the study: growth in 18% of the patients and shrinkage in 7%; 75% remained unchanged. This approach is a pragmatic means to determine whether the size of a tumor has changed over the course of time.

Management of the small acoustic neuroma: a decision analysis.

Imaging techniques such as magnetic resonance imaging (MRI) with gadolinium may detect small acoustic neuromas before significant symptoms have developed. In this situation, the patient and surgeon may question whether the tumor requires treatment, especially if the tumor was discovered incidentally. A computerized clinical decision analysis was undertaken to model the decision to observe such tumors or proceed to immediate surgery. The decision tree was constructed with flexibility to account for tumor size, hearing level, and other critical variables such as the individual's aversion to unilateral hearing loss and facial paralysis. Unless life expectancy is short, the analysis suggests that surgery at the time of diagnosis is appropriate, assuming that growth of the tumor is anticipated. Variations in surgical proficiency and patient risk aversion within expected ranges do not influence the decision to operate. The most critical variable appears to be the probability that the tumor will remain stable in size. This finding suggests that better data regarding the growth rate of small acoustic neuromas is needed.

Acoustic neuroma: clinical aspects, audiovestibular assessment, diagnostic delay, and growth rate.

The diagnostic findings in 300 patients with acoustic neuromas are reported. Because of a centralized treatment of acoustic neuromas, we have a uniform diagnostic work-up of all patients, which enables us to make a nonselected comparison of the diagnostic efficiency of the various tests. In patients with hearing better than 80 dB, a normal auditory brainstem response, the presence of recruitment, and normal caloric reaction, the presence of a tumor can be excluded. In patients with poor hearing, tomography is necessary if one does not prefer to perform CT directly. If CT, even with contrast enhancement, is negative, we continue to perform air CT. Only then do we know whether or not the patient has a tumor. Magnetic resonance imaging has not been available to us, but with this diagnostic modality even intrameatal tumors are visualized. However, with the present economy involved with magnetic resonance imaging it is not realistic at the present time to use this way of imaging as a screening procedure. In spite of an intensive campaign for making early diagnosis of acoustic neuromas, our attempts have not been successful, since we have even more tumors measuring over 40 mm in diameter among the latest 100 patients than among the first one hundred. Both patients and physicians (otologists) to some extent are still ignoring the possible significance of a unilateral, progressive, sensorineural hearing impairment. Guidelines for improving this situation are given. Twenty-one patients were followed for an average of 4 years, repeated CT scans were performed, and the tumor appeared to be progressing to a size requiring surgical intervention in only three of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiologic assessment of acoustic neuroma in the elderly. Is no treatment good treatment?

Twenty-three elderly patients with acoustic neuroma have been followed conservatively (no treatment) for a mean of 3.8 years. Five patients subsequently required ventricular shunting. Two patients required partial excision of their tumors (one previously treated by shunting). Eleven patients who have required no treatment have no significant complaints. There was significant variation in tumor growth rates making predictability for surgical intervention hazardous. A mean growth rate of 0.22 cm/year was noted. Our statistics suggest tumor removal in healthy patients with larger tumors at time of presentation; in other patients, conservative follow-up may be more appropriate.