Residential traffic noise exposure and vestibular schwannoma - a Danish case-control study.

BACKGROUND: Few risk factors for sporadic vestibular schwannoma (VS) are known. Several studies have proposed an increased risk with occupational noise exposure, whereas no studies have investigated residential traffic noise exposure as a risk factor. The present study investigated if residential traffic noise was associated with vestibular schwannoma in a large, population-based Danish case-control study. MATERIAL AND METHODS: We identified 1454 VS cases, age above 30 years at diagnosis, between 1990 and 2007. For each case, we selected two random population controls, matched on sex and year of birth. Road and railway traffic noise at the residence was calculated for all present and historical addresses between 1987 and index date. Associations between traffic noise and risk for VS were estimated using conditional logistic regression, adjusted for education, disposable personal income, cohabitation status, railway noise exposure, municipal population density, and municipal income. RESULTS: A two-year time-weighted mean road traffic noise exposure was associated with an adjusted odds ratio of 0.92 (0.82-1.03) for developing VS, per 10 dB increment. There was no clear trend in categorical analyses. Similarly, linear and categorical analyses of residential railway noise did not suggest an association. We found no interaction with demographics, year of diagnosis, individual and municipal socioeconomic variables, and railway noise exposure. The results did not differ by tumor side, spread or size. CONCLUSIONS: The present study does not suggest an association between residential traffic noise and VS.

Life Expectancy After Diagnosis of a Vestibular Schwannoma in Patients 70 Years and Older.

Importance: Over the past decades, the number of patients, especially in the older adult patient group, diagnosed with vestibular schwannoma (VS) has increased. Assuming that older adult patients have more comorbidities, a longer recovery period after surgery, a higher rate of surgical complications, and a higher mortality rate after VS surgery, a treatment strategy for this group of patients is warranted, based on clinical evidence on postsurgical survival. Objective: To evaluate the survival after diagnosis of a VS in patients 70 years and older, treated with either observation or surgery, and to compare these findings with the life span of an age-matched background population in Denmark. Design, Setting, and Participants: This was a retrospective cohort study of 624 patients 70 years and older diagnosed with VS in Denmark from 1976 to 2016. Since 1976, all patients with a VS have been registered in a national database, which contains 3637 patients. Of the included patients in this study, 477 were treated conservatively with the "wait-and-scan" strategy, and 147 were treated surgically with removal of the tumor. The survival of the patients was compared with a matched background population in Denmark. Data analysis was performed from January 1976 to January 2017. Exposures: Surgery, radiotherapy, or none. Main Outcomes and Measures: The main outcome was survival among the patients and compared with the matched background population. Results: A total of 624 patients were included (317 female patients [50.8%] and 307 male patients [49.2%]). The mean (SD) survival in the observed patients was 9.2 (4.7) years after diagnosis, whereas for the background population, the expected survival was 11 years from the mean age at diagnosis. For the surgically treated patients, the mean (SD) survival was 11.8 (6.6) years, and expected survival was 11 years for the matched background population. The mean (SD) survival was 10.7 (5.5) years in female patients and 8.9 (5.0) years in male patients. There was no significant difference in survival between treatment modalities, irrespective of tumor size. Conclusions and Relevance: In this cohort study, survival after diagnosis of a VS in patients 70 years and older was similar in the surgical group compared with the age-matched background population. In the wait-and-scan group, the survival after diagnosis was marginally shorter, which may be associated with increased comorbidity.

Long-term mobile phone use and the risk of vestibular schwannoma: a Danish nationwide cohort study.

Vestibular schwannomas grow in the region within the brain where most of the energy by radiofrequency electromagnetic fields from using mobile phones is absorbed. The authors used 2 Danish nationwide cohort studies, one a study of all adult Danes subscribing for a mobile phone in 1995 or earlier and one on sociodemographic factors and cancer risk, and followed subjects included in both cohorts for occurrence of vestibular schwannoma up to 2006 inclusively. In this study including 2.9 million subjects, a long-term mobile phone subscription of ≥11 years was not related to an increased vestibular schwannoma risk in men (relative risk estimate = 0.87, 95% confidence interval: 0.52, 1.46), and no vestibular schwannoma cases among long-term subscribers occurred in women versus 1.6 expected. Vestibular schwannomas did not occur more often on the right side of the head, although the majority of Danes reported holding their mobile phone to the right ear. Vestibular schwannomas in long-term male subscribers were not of larger size than expected. Overall, no evidence was found that mobile phone use is related to the risk of vestibular schwannoma. Because of the usually slow growth of vestibular schwannoma and possible diagnostic delay, further surveillance is indicated.

The natural history of vestibular schwannoma growth-prospective 40-year data from an unselected national cohort.

BACKGROUND: Optimal management of vestibular schwannoma (VS) is still debated and thus international consensus has not been achieved. Treatment options are observation, radiotherapy, and surgery. Knowledge on the natural history of tumor growth is essential for choice of treatment modality. The aim is to present intra-/extrameatal tumor growth and management data from a prospective, unselected national cohort of patients diagnosed with VS during the period 1976-2015. METHODS: Since 1976, all data from patients diagnosed with sporadic VS in Denmark have been referred to our national treatment center, where they have been entered prospectively into the national database. Data on tumor localization, growth, and treatment were retrieved. Growth definition: >2 mm by linear measurement, in accordance with the Tokyo 2001 consensus-meeting recommendations. RESULTS: 3637 cases of VS were diagnosed, in which 1304 patients had surgery and 21 received radiotherapy post diagnosis. 2312 patients were observed with mean follow-up of 7.33 years. Of these, 434(19%; 102 intra-and 332 extrameatal tumors) changed to active treatment during the observation period due to tumor growth. 5 years after diagnosis, 21% of the intrameatal tumors exhibited growth during observation, whereas 37% of extrameatal tumors had grown, increasing to 25% intrameatal and 42% extrameatal after 10 years. Following growth, the intrameatal tumors were mostly observed further and the extrameatal mostly underwent surgery. Tumor growth occurred mainly within the first 5 years post diagnosis. CONCLUSION: This natural history study documents the growth occurrence of both intra-and extrameatal VS during the first 12 years after diagnosis and should be used in patient counseling, management, and treatment decision making.

Natural History of Growing Sporadic Vestibular Schwannomas During Observation: An International Multi-Institutional Study.

OBJECTIVE: Active treatment of small- or medium-sized vestibular schwannoma during wait-and-scan management is currently recommended at most centers globally once growth is detected. The primary aim of the current study was to characterize the natural history of growing sporadic vestibular schwannoma during observation. STUDY DESIGN: Cohort study. SETTING: Four tertiary referral centers across the United States and Denmark. PATIENTS: Patients with two prior MRI scans demonstrating ≥2 mm of linear growth who continued observational management. INTERVENTION: Observation with serial imaging. MAIN OUTCOME MEASURE: Subsequent linear growth-free survival (i.e., an additional ≥2 mm of growth) following initial growth of ≥2 mm from tumor size at diagnosis. RESULTS: Among 3,402 patients undergoing observation, 592 met inclusion criteria. Median age at initial growth was 66 years (IQR 59-73) for intracanalicular tumors (N = 65) and 62 years (IQR 54-70) for tumors with cerebellopontine angle extension (N = 527). The median duration of MRI surveillance following initial detection of tumor growth was 5.2 years (IQR 2.4-6.9) for intracanalicular tumors and 1.0 year (IQR 1.0-3.3) for cerebellopontine angle tumors. For intracanalicular tumors, subsequent growth-free survival rates (95% CI; number still at risk) at 1, 2, 3, 4, and 5 years following the initial MRI that demonstrated growth were 77% (67-88; 49), 53% (42-67; 31), 46% (35-60; 23), 34% (24-49; 17), and 32% (22-47; 13), respectively. For cerebellopontine angle tumors, subsequent growth-free survival rates were 72% (68-76; 450), 47% (42-52; 258), 32% (28-38; 139), 26% (21-31; 82), and 22% (18-28; 57), respectively. For every 1 mm increase in magnitude of growth from diagnosis to tumor size at detection of initial growth, the HRs associated with subsequent growth were 1.64 (95% CI 1.25-2.15; p < 0.001) for intracanalicular tumors and 1.08 (95% CI 1.01-1.15; p = 0.02) for cerebellopontine angle tumors. CONCLUSIONS: Growth detected during observation does not necessarily portend future growth, especially for slowly growing tumors. Because early treatment does not confer improved long-term quality of life outcomes, toleration of some growth during observation is justifiable in appropriately selected cases.

Epidemiology and Diagnostic Characteristics of Vestibular Schwannomas-Does Gender Matter?

INTRODUCTION: A number of epidemiological studies have reported data on, e.g., tumor size and hearing at diagnosis for patients with a vestibular schwannoma (VS), whereas only a few have touched upon the potential significance of sex. The aim of this report is thus to present gender-specific data on incidence and age, tumor localization, tumor size, and hearing loss at diagnosis. MATERIAL AND METHODS: Since 1976, various data for all patients diagnosed with a sporadic VS in Denmark have been entered prospectively into a national database. Data on sex, incidence, age, tumor localization, tumor size, and hearing (discrimination) were extracted for the period 1976 to 2015. RESULTS: Over the 40 years, 3,637 cases were diagnosed, of which 1,804 were women (50%) and 1,833 men (50%). For both sexes, an increasing incidence of tumors with a steadily decreasing size was found. Age was increasing and hearing at diagnosis was increasingly better.Previously, women had more extrameatal and thus larger tumors. During the most recent decade, more tumors were found in men and hearing at diagnosis was better for women, whereas age and tumor size were comparable. CONCLUSION: The data on gender-specific epidemiology and diagnostic characteristics show varying trends over the 40-year-period spanned. For both sexes, an increasing incidence of tumors with a steadily decreasing size was found. Age is increasing and hearing at diagnosis is increasingly better. More extrameatal and thus larger tumors were previously found in women. Contemporarily, more vestibular schwannomas are found in men and diagnostic hearing is better in women.

Epidemiology Of Vestibular Schwannomas - Prospective 40-Year Data From An Unselected National Cohort.

OBJECTIVE: Reports on the epidemiology of vestibular schwannoma (VS) indicate an increase in diagnosed cases, often based on selected materials over a limited period of time. This report presents prospective 40-year epidemiological data from an unselected national cohort of all patients diagnosed with a VS in Denmark since 1976. STUDY-DESIGN: Data on gender, age, tumor localization and size registered during the period 1976-2015 were retrieved. RESULTS: 3637 new cases of VS were diagnosed during the 40-year period. The annual number of diagnosed VS increased from 14 in 1976 to 193 in 2015. Mean extrameatal tumor size decreased from 26mm in 1976 to 13.4mm in 2015. Large and giant tumors were more frequent during the first decades, whereas predominantly smaller tumors were diagnosed during the recent years. Median age at diagnosis increased gradually from 49.2 years in 1976 to 60 years in 2015. CONCLUSION: Over the past 40 years, the incidence rate of vestibular schwannomas has increased steadily from 3 VS/million/year to 34 VS/million/year, primarily due to easier access to improved diagnostics and the finding of more tumors in older people. Concurrently, the diagnostic tumor size has decreased from 26mm to 7mm, and the age at diagnosis has increased from 49 to 60 years.

Ten-Year Follow-up on Tumor Growth and Hearing in Patients Observed With an Intracanalicular Vestibular Schwannoma.

BACKGROUND: Reports on the natural history of tumor growth and hearing in patients with a vestibular schwannoma (VS) are almost exclusively short-term data. Long-term data are needed for comparison with results of surgery and radiotherapy. OBJECTIVE: To report the long-term occurrence of tumor growth and hearing loss in 156 patients diagnosed with an intracanalicular VS and managed conservatively. METHODS: In this longitudinal cohort study, diagnostic and follow-up magnetic resonance imaging and audiometry were compared. RESULTS: After a follow-up of 9.5 years, tumor growth had occurred in 37% and growth into the cerebellopontine angle had occurred in 23% of patients. Conservative treatment failed in 15%. The pure tone average had increased from 51- to 72-dB hearing level, and the speech discrimination score (SDS) had decreased from 60% to 34%. The number of patients with good hearing (SDS > 70%) was reduced from 52% to 22%, and the number of patients with American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A hearing was reduced from 19% to 3%. Hearing was preserved better in patients with 100% SDS at diagnosis than in patients with even a small loss of SDS. Serviceable hearing was preserved in 34% according to AAO-HNS (class A-B) and in 58% according to the word recognition score (class I-II). Rate of hearing loss was higher in patients with growing tumors. CONCLUSION: Tumor growth occurred in only a minority of patients diagnosed with an intracanalicular VS during 10 years of observation. The risk of hearing loss is small in patients with normal discrimination at diagnosis. Serviceable hearing is preserved spontaneously in 34% according to AAO-HNS and in 58% according to the word recognition score.

Sublocalization and volumetric growth pattern of intracanalicular vestibular schwannomas.

OBJECTIVE: None of several previous reports on the growth pattern of vestibular schwannomas (VS) have dealt with the sublocalization and volumetric growth pattern of intracanalicular tumors. This paper reports such data from 196 patients. STUDY DESIGN: All VS patients have been registered prospectively at one center in Denmark since 1975. Data on intracanalicular tumors were drawn from the database, yielding 196 patients with a diagnostic and at least one control magnetic resonance imaging scan. All images were retrieved and the tumor sublocalization, size, and growth rate determined. RESULTS: The majority (50%) of the tumors was located centrally in the internal auditory canal (IAC), whereas 31% were porus-near and 19% fundus-near. Of the 196 tumors, 88 (45%) displayed growth, 20 (10%) shrinkage, and 88 (45%) remained unchanged. Thirty-eight (19%) tumors grew to extrameatal extension. Growth occurred only within 5 years after diagnosis. In the 88 growing tumors, the mean absolute growth rate was 111mm/year and the relative rate 114%/volume/year. The occurrence of IAC expansion at diagnosis was higher for tumors displaying subsequent shrinkage. Growth occurrence and rate, IAC expansion, and progression to extrameatal extension were not related to tumor sublocalization. CONCLUSION: Most intracanalicular VS are located centrally in a nonexpanded IAC at diagnosis. Growth occurs within 5 years after diagnosis in up to 45% of the tumors, although only 19% extend into the cerebellopontine angle. IAC expansion, growth occurrence, and rate are not related to tumor sublocalization. These findings justify primary observation of all purely intracanalicular tumors, unless realistic hearing preservation is intended.

The natural history of vestibular schwannoma.

OBJECTIVE: The incidence of vestibular schwannomas (VSs) approaches 20 per million/yr. As treatment may depend on tumor growth, there is a demand of a treatment strategy based on hard data on the growth pattern of these tumors. This article reports growth data registered prospectively in 552 patients. STUDY DESIGN: Of the 1,818 consecutive patients, diagnosed with VS during the period from 1975 to 2005, 729 patients were allocated to observation by repetitive magnetic resonance imaging. At least two scans had been performed in 552 patients at the time of data analysis. Two hundred thirty patients had a tumor confined to the internal acoustic meatus, whereas 322 patients had a tumor with an extrameatal extension. Growth to extrameatal extension was the definition for growth in intrameatal tumors, whereas a largest diameter change of more than 2 mm was the criteria for growth/shrinkage of extrameatal tumors. The mean observation time was 3.6 years (range, 1-15 yr). RESULTS: Seventeen percent of the intrameatal tumors grew, whereas significantly more of the extrameatal tumors displayed growth during the period (28.9%). Growth occurred within the first 5 years after diagnosis. No correlation could be demonstrated between tumor growth rate, sex, or age. CONCLUSION: VS growth occurs within the first 5 years after diagnosis in a limited number of tumors, primarily in tumors with an extrameatal extension. We found no relation between tumor growth and sex or age. These findings justify primary observation of small tumors. A treatment strategy is proposed for this disease, focusing on the patient group allocated to observation.

VEGF and VEGF receptor-1 concentration in vestibular schwannoma homogenates correlates to tumor growth rate.

OBJECTIVE: Vascular endothelial growth factor (VEGF) is one of the most potent mediators of angiogenesis, which is a mandatory process during tumor growth. Immunohistochemical studies have demonstrated VEGF expression in vestibular schwannomas (VS), and a semi-quantitation of staining intensity indicated a correlation between tumor growth rate and VEGF expression. The present objectives were to determine the concentration of VEGF and the high-affinity receptor VEGFR-1 in VS homogenates and to examine a possible correlation with symptom duration, tumor size, or growth rate. STUDY DESIGN, PATIENTS, AND METHODS: Prospective selection of 27 patients with VS growth determined by repeated magnetic resonance imaging. Patient files were reviewed for symptom duration and all magnetic resonance images reviewed for determination of tumor size and growth rate. ELISA was used for determination of the VEGF and VEGFR-1 concentration in tumor homogenates. SETTING: Tertiary University Hospital Clinic. RESULTS: All tumor homogenates contained VEGF and VEGFR-1. A significant correlation existed between the concentration of both VEGF and VEGFR-1 and tumor growth rate but not symptom duration or tumor size. CONCLUSION: The concentration of VEGF and VEGFR-1 in VS homogenates correlates with tumor growth rate but not with tumor size or symptom duration. We conclude that VEGF and VEGFR-1 appear to be directly involved in the growth pattern of VS.

Immunohistochemical demonstration of vascular endothelial growth factor in vestibular schwannomas correlates to tumor growth rate.

OBJECTIVE: Vascular endothelial growth factor (VEGF) is one of the most potent mediators of angiogenesis, which is a mandatory process during tumor growth. The present objectives were to determine expression of VEGF in vestibular schwannomas by immunohistochemistry and to examine a possible correlation with symptom duration, tumor size, or growth rate. STUDY DESIGN: Retrospective patient file review; immunohistochemistry and light microscopy of vestibular schwannomas removed by surgery. METHODS: Vestibular schwannomas from 18 patients were immunolabelled using a polyclonal antibody against VEGF, followed by light microscopy and blinded semiquantitation of VEGF expression. Fifteen patients had a well-defined tumor growth rate defined by repeated preoperative magnetic resonance imaging scans. RESULTS: All tumors showed expression of VEGF in the Schwann cell cytoplasm, with a more intense staining of the perinuclear region of some cells. The staining intensity varied from tumor to tumor, and semiquantitation revealed a significant correlation between VEGF expression and tumor growth rate, but not symptom duration or tumor size. CONCLUSION: VEGF is expressed in vestibular schwannomas and the level of expression correlates positively with tumor growth rate, but not with tumor size and symptom duration. We conclude that VEGF seems to be a factor involved in the growth of vestibular schwannomas.

What is the real incidence of vestibular schwannoma?

OBJECTIVES: To present the incidence of vestibular schwannoma (VS) in Denmark, compare the incidence with that of previous periods, and discuss the real incidence of VS. DESIGN, SETTING, AND PATIENTS: Prospective registration of all diagnosed VS in Denmark, with a population of 5.1 to 5.2 million, during the 6 years from January 1996 through December 2001. Incidence in this period was compared with that of 3 previous periods (July 1976 through June 1983 [first period], July 1983 through June 1990 [second period], and July 1990 through December 1995 [third period]). RESULTS: In the 1996-2001 period, 542 cases of VS were diagnosed, representing a mean incidence of 17.4 VS/1 million inhabitants per year. Of these, 227 tumors underwent operation, 14 underwent irradiation, and 301 were allocated to observation (wait-and-scan policy). One hundred sixty-six tumors were intrameatal. Size of extrameatal tumors was small in 104; medium in 194; large in 68; and giant (>40 mm) in 10. Compared with incidences of 7.8 VS/1 million inhabitants per year in the first, 9.4 VS/1 million inhabitants in the second, and 12.4 VS/1 million inhabitants in the third periods, the incidence for the 1996-2001 period represents an increase to 17.4 VS/1 million inhabitants per year. The mean incidence for the entire 25.5-year period was 11.5 VS/1 million inhabitants per year. CONCLUSIONS: An estimate of a realistic mean incidence of VS depends on the observation period. Our 25.5-year registration of an entire population showed a mean incidence of 11.5 VS/1 million inhabitants per year. However, the latest period registered represents an incidence of 17.4 VS/1 million inhabitants per year, which, combined with a probable further increase of diagnosed tumors in forthcoming years, suggests a realistic incidence of approximately 13 VS/1 million inhabitants per year.

Point prevalence of barotitis and its prevention and treatment with nasal balloon inflation: a prospective, controlled study.

INTRODUCTION: The most common cause of barotitis is pressure changes induced during descent in aviation. The incidence after air flight has been reported to vary from 8% to 17%. OBJECTIVES: We conducted this study to estimate the incidence of barotitis after flight, to evaluate whether the incidence of barotitis can be reduced by nasal balloon inflation during descent, and, finally, to estimate the effect of nasal balloon inflation in case of negative middle ear pressure after landing. STUDY DESIGN: Aircraft passengers were examined by otoscopy and tympanometry before and after flying and filled in a questionnaire inquiring about ear problems. On half of the flights, the passengers were asked to inflate a nasal balloon during descent, whereas the other half were control flights. RESULTS: A total of 188 passengers filled in the questionnaire. Of these, 134 were examined before and after the flight. Otoscopic signs of barotitis were found in 15% of the ears in the control group compared with 6% in the balloon inflation group. In ears with a negative pressure after flying, the pressure could be equalized by Valsalva's maneuver in 46%. Passengers who were unable to equalize the pressure in this way inflated a nasal balloon, and in 69%, this maneuver cleared the middle ear pressure. CONCLUSION: The incidence of barotitis in this study of aircraft passengers was 14%. This figure could be reduced to 6% in passengers who performed nasal balloon inflation during descent. We recommend nasal balloon autoinflation in aircraft passengers who have difficulty clearing their ears during and after flying.

Patients' fears, expectations and satisfaction in relation to management of vestibular schwannoma: a comparison of surgery and observation.

OBJECTIVE: To investigate patients' expectations, fears and satisfaction in relation to management of vestibular schwannoma in a comparison of observed and operated patients. MATERIAL AND METHODS: A total of 768 patients operated on for vestibular schwannoma and 247 patients diagnosed with and observed for the same condition answered a mailed questionnaire. Among several questions, the patients were asked to indicate the worst aspect of the management (surgery or observation) of their condition. Furthermore, the patients were asked if they regretted the choice of management and if the information provided by the medical staff was satisfactory. RESULTS: Of the operated patients, 37% reported loss of hearing (anacusis) on the operated side to be the worst aspect of the operation and 38% of the observed patients found decreased hearing on the affected side to be the worst aspect. Of the operated patients, 653 (85%) did not regret having the operation, whereas 62 (8%) did. In the observed series, 206 patients (83%) did not regret the choice of observation, 12 (5%) did regret it and 29 (12%) did not answer the question. Of the operated patients, 448 (58%) were satisfied with the information given, whereas 289 (38%) were not satisfied. Of the observed patients, 175 (71%) were satisfied with the information given and 59 (24%) were not. The ratio of satisfied to dissatisfied patients did not change during the period 1976-2000. CONCLUSION: Overall, the worst aspect of vestibular schwannoma is the associated hearing loss, regardless of the treatment modality. A majority of both the operated and observed patients did not regret their choice of treatment modality and were satisfied with the information given by the medical staff, although there may be scope for further improvement in terms of the latter aspect.

Long-term socio-economic impact of vestibular schwannoma for patients under observation and after surgery.

This study describes and compares the long-term socio-economic impact for patients diagnosed with a vestibular schwannoma and either operated on or observed. A consecutive sample of patients diagnosed with vestibular schwannoma in Denmark and either operated on (748 patients) or observed by the wait-and-re-scan policy (272 patients) during the period 1976-2000 were studied retrospectively. The consequences of operation/diagnosis (and observation) on vocational status, ability to handle daily chores and some psycho-social aspects were studied by means of a prospective postal questionnaire. Ninety-six per cent of the operated and 83 per cent of the observed patients answered the questionnaire. Overall, 34 per cent of operated patients resumed their daily activities within one to two months, and 76 per cent within four to six months. Patients operated on for a large tumour resumed their daily activities later than patients with a small tumour. Regardless of tumour size, employment was unchanged for the majority of observed and operated patients. The vocational consequences were significantly worse for operated patients with a large tumour, than for observed patients. However, no difference existed between the observed group and operated patients with a tumour below 20 mm in size. A change in vocational status was most frequent for assisting spouses, unskilled manual workers and the self-employed. The majority of both observed and operated patients experienced no change in their ability to handle daily chores. The changed ability of operated patients was worse than that of observed patients. Among various changes in their psycho-social well-being, decrease in social ability was the most frequent complaint in both groups, followed by increased fatigue, decreased concentration, increased irritability, depression and headache, decreased intellect and libido. Regardless of tumour size, the change in social ability, concentration and fatigue was worse for operated patients. Concerning headache, patients operated on for a large tumour were better off than observed patients and patients operated on for a small tumour. There was no difference between the operated and observed groups concerning irritability, intellect and libido. Deterioration of vocational status, ability to handle daily chores and several aspects of psycho-social well-being are reported both by patients operated on and observed for vestibular schwannoma. However, the negative changes were more frequent among the operated patients, although the differences were surprisingly modest, especially when comparing observed patients with patients operated on for a small tumour.

Increasing annual incidence of vestibular schwannoma and age at diagnosis.

During the last 26 years the annual number of diagnosed vestibular schwannomas (VS) has been increasing. The aim of this study is to describe and analyse this increase. Since 1976, 1446 new cases of VS have been diagnosed at the authors' centre. Special focus was on the age at diagnosis, the localization and the size of the tumour. The size of the tumour was registered as either intrameatal or with the largest extrameatal diameter. The annual number of diagnosed VS has increased from 26 in 1976 to 101 in 2001. The size of the diagnosed tumours has decreased from a median of 35 mm in 1979 to 10 mm in 2001. In the first years large and giant tumours dominated, in contrast to recent years in which intrameatal and small tumours dominated. The median age at the time of diagnosis has been almost unchanged through the period (median 55 years). If the decreasing size of the tumour and the increasing incidence of VS can be explained only by earlier diagnosis and easier access to magnetic resonance (MR) scanning it should be expected that the median age at the time of diagnosis would decrease simultaneously. In this study, the median age at the time of diagnosis has been almost unchanged throughout the 26-year period. This paradox can be explained by the fact that, with easier access to MR scanning, the examination has been offered also to elderly patients, in whom the small and intrameatal tumours dominate.

Need for facial reanimation after operations for vestibular schwannoma: patients perspective.

A total of 779 patients operated on for vestibular schwannoma mostly by the translabyrinthine approach in Denmark during the period 1976-2000 answered a questionnaire about various postoperative consequences. In this paper we describe the patients' facial function evaluated by professionals one year postoperatively and self-evaluated by each patient according to the House-Brackmann scale at the time of the questionnaire. The patients' self-evaluation was more pessimistic than that of the professionals with 26% reporting House-Brackmann grade IV-VI, compared with 20%. One hundred and seventeen (15%) of 779 patients considered their facial palsy to be a big problem and 125 patients (16%) were interested in surgical treatment for the sequelae of facial palsy. Seventy-eight (10%) had already had some kind of operation, usually the VII-XII coaptation. Thirty-three of 61 patients who had already been operated on for facial palsy were interested in further surgical treatment. One hundred and ninety-five patients (25%) had some kind of operation on the eye, mostly (88%) a tarsorrhaphy. Reanimation procedures such as a palpebral gold weight or a spring, apparently still have a small place in Denmark. In conclusion, there seem to be a considerable and unmet need for surgical reanimation of facial function in patients with facial palsy after operations for vestibular schwannoma in Denmark.

Socio-demographic distribution of vestibular schwannomas in Denmark.

CONCLUSION: Vestibular schwannomas (VSs) are diagnosed less frequently in the remote parts of Denmark, whereas the diagnostic age and tumor size is the same across the different socio-demographic areas of Denmark. OBJECTIVE: To determine whether VSs are diagnosed equally often in different socio-demographic areas of Denmark and whether a change has occurred during the period 1976-2012. In addition, differences in diagnostic age and tumor size between areas were explored. METHODS: Since 1976, all patients diagnosed with a VS in Denmark have been registered in a national database, in which information on, for example, the size of the tumor and the age and address of the patient has been registered. Up to 2012, 2739 patients were diagnosed with a VS. Patient distribution according to area of habitat was determined by subgrouping into urban, suburban, rural, and remote municipalities, using the definitions of socio-demographic areas elaborated by Demarks Statistic. RESULTS: The mean national incidence increased almost linearly over the time period from 6.1 per million per year in the first period from 1976 to 1984, to 22.1 per million per year in the last period from 2003 to 2012. There was a lower incidence at the end of the period in the remote areas compared with the other socio-demographic areas (1976-1984, p = 0.05 and 2003-2011, p = 0.001). The mean age at diagnosis increased during the period, from 52.6 years in the first period to 58.6 years in the last period. There was no significant difference in the age distribution between socio- demographic areas. The mean diagnostic tumor size decreased during the period, from 28.6 mm in the first period to about 10 mm in the last period. There was no significant difference in the size of the tumor between socio- demographic areas.

Distinct spontaneous shrinkage of a sporadic vestibular schwannoma.

We present a case with outspoken spontaneous vestibular schwannoma shrinkage and review the related literature. The patient was initially diagnosed with a left-sided, intrameatal vestibular schwannoma, which subsequently grew into the cerebello-pontine angle (CPA), followed by total shrinkage of the CPA component without any intervention over a 12-year observation period. The literature on spontaneous tumor shrinkage was retrieved by searching the subject terms "vestibular schwannoma, conservative management" in PubMed/MEDLINE database, without a time limit. Of the published data, the articles on "shrinkage" or "negative growth" or "regression" or "involution" of the tumor were selected, and the contents on the rate, extent and mechanism of spontaneous tumor shrinkage were extracted and reviewed. The reported rate of spontaneous shrinkage of vestibular schwannoma is 5-10% of patients managed conservatively. Extreme shrinkage of the tumor may occur spontaneously.