Quality of Life With Cochlear Implantation Using the CIQOL-35 at a Tertiary Urban Medical Center: Our Experience.

OBJECTIVE: Assessment of quality-of-life (QOL) outcomes after cochlear implantation (CI) using the Cochlear Implant Quality of Life-35 questionnaire (CIQOL-35). STUDY DESIGN: Retrospective cohort. SETTING: Single-institution tertiary care center. PATIENTS: Patients 18 years and older who have undergone CI and CIQOL-35 survey. INTERVENTIONS: Implementing CIQOL-35 from 2019 to 2022 to measure change in QOL after CI. Statistical analysis included nonparametric, univariate, and multivariate analyses. Significance was set at 0.05. MAIN OUTCOME MEASURES: Differences in QOL among CI patients in each of the CIQOL-35 domains. RESULTS: Ninety-three patients (40 female, 53 male) aged 20 to 93 years (median 70 years) turned in 164 QOL surveys (68 preactivation, 96 postactivation). Postactivation median QOL was 5 to 15 points higher across all domains (p < 0.001). QOL score distributions among unilateral CI only, bilateral CI, and unilateral CI with contralateral hearing aid users were not statistically different (p > 0.05). Multivariate analysis identified that male sex (ß = -2.0; 95% confidence interval, -3.9 to -0.1) was a negative predictor for environment scores and not being married (ß = 2.0; 95% confidence interval, 0.02 to 4.0) was a positive predictor for entertainment scores. Median follow-up time was 13 months post-CI (interquartile range [IQR], 7.1-21.5 months). CONCLUSIONS: CI patients experienced improved QOL postactivation among all QOL domains, whereas specific CI use pattern in regard to unilateral, bilateral, or bimodal did not affect QOL. Multivariate analysis identified marital status and sex as possible QOL predictors.

Natural History of Hearing Loss in Sporadic Vestibular Schwannoma.

Hearing loss is the most common and earliest symptom of sporadic vestibular schwannoma (VS). The most common pattern of hearing loss is asymmetric sensorineural hearing loss. Throughout its natural history, patients with serviceable hearing (SH) maintain SH at 94% to 95% after 1 year, 73% to 77% after 2 years, 56% to 66% after 5 years, and 32% to 44% after 10 years. For patients newly diagnosed with VS, it is likely their hearing will worsen despite small initial tumor size or lack of tumor growth.

Thermal Analysis of an Ultrasonic Aspirator Micro Claw Tool Compared With Standard High-Speed Drilling During Internal Auditory Canal Opening in a Cadaveric Model.

BACKGROUND: The ultrasonic aspirator micro claw tool (UAmCT) can be used to remove the bone of the internal auditory canal (IAC) during vestibular schwannoma resection via the retrosigmoid approach (RSA) without the risk of a spinning drill shaft. However, the thermal profile of the UAmCT during IAC removal has not been reported. OBJECTIVE: To compare the thermal profile of the UAmCT during access of the IAC to that of a conventional high-speed drill (HSD) and to present an illustrative case of this application. METHODS: IAC opening via RSA was performed in 5 embalmed cadaveric specimens using the UAmCT with 3, 8, and 15 mL/min irrigation on the left and the HSD at 75 000 revolutions per minute and 0%, 14%, and 22% irrigation on the right. Peak bone surface temperatures were measured 4 times in 20-second intervals, and statistical analyses were performed using SPSS software. An illustrative case of a vestibular schwannoma resected via an RSA using the UAmCT to access the IAC is presented. RESULTS: The IAC was opened in all 5 specimens using both the UAmCT and HSD without complication. The mean peak bone surface temperatures were significantly lower with the UAmCT compared with the HSD ( P < .001). The UAmCT did not meaningfully prolong the operating time in the illustrative case, and the IAC was accessed without complication. CONCLUSION: The UAmCT may be a safe and effective alternative to HSD for IAC opening during vestibular schwannoma resection via the RSA. Larger studies under clinical conditions are required to further validate these findings.

Retrosigmoid Vestibular Neurectomy for Meniere Disease: A Technical Note.

BACKGROUND: Meniere disease (MD) is an idiopathic peripheral pathology involving the acoustic apparatus. One of the most critical challenges in managing MD is intractable vertigo. In this context, retrosigmoid vestibular neurectomy has been described as a safe and effective technique to manage this symptom when it is resistant to first- and second-line treatments. This article analyzed the alternative treatment options, specific surgical anatomy, and relevant details of vestibular neurectomies performed for intractable MD. METHODS: Relevant neurovascular landmarks, critical surgical steps, adequate indications, and potential pitfalls of retrosigmoid vestibular neurectomy were analyzed based on an illustrative clinical case of intractable MD. RESULTS: The illustrative case demonstrated how early recognition of the facial nerve and the vestibulocochlear plane is fundamental to performing retrosigmoid vestibular neurectomy. This procedure is indicated in cases of resistant MD with preoperative hearing integrity. Potential pitfalls of this technique are incomplete neurotomy, nerve regeneration, comorbidities in the contralateral ear, adverse anatomy, the possibility of nonotologic vertigo, and incomplete vestibular compensation. CONCLUSIONS: Vestibular neurectomy represents a safe and effective technique to manage MD that is resistant to medical treatment, allowing symptom control and hearing preservation. Nevertheless, detailed knowledge of surgical anatomy and possible pitfalls is of paramount importance to achieve a good outcome.

Racial Disparities in Adult Cochlear Implantation.

OBJECTIVE: To compare rates of cochlear implant referral and cochlear implantation across different races and to compare audiometric profiles of these patients. STUDY DESIGN: Retrospective study. SETTING: Academic tertiary care institution. METHODS: Demographic and audiometric data were collected for patients who underwent cochlear implant evaluation or cochlear implantation from 2010 to 2020. RESULTS: A total of 504 patients underwent cochlear implant evaluation; 388 met cochlear implant candidacy criteria, and 258 underwent implantation. Of the patients referred for cochlear implant evaluation, 68.5% were White, 18.5% were Black, and 12.3% were Asian, while the institution's primary service area is 46.9% White, 42.3% Black, and 7.7% Asian (P < .001). Black patients referred for cochlear implant evaluation had significantly worse hearing (mean pure-tone average [PTA] 84.5 dB, 26.1% word recognition) than White patients (mean PTA 78.2 dB, P = .005; 35.7% word recognition, P = .015) and Asians patients (mean PTA 77.9 dB, P = .04; 36.5% word recognition, P = .04). Black patients who underwent cochlear implant evaluation also had significantly worse AzBio scores than White patients: 24.5% versus 36.7% (P = .003). There was no significant difference in cochlear implantation rates between Black and White candidates (P = .06). CONCLUSION: Black patients undergo cochlear implant evaluation and cochlear implantation at rates disproportionately lower than expected based on local demographics. In addition, Black patients have significantly worse hearing at the time of cochlear implant referral than White and Asian patients. Identifying and increasing awareness of these disparities are essential steps to improving cochlear implant access for potentially disadvantaged populations.

Current and Emerging Medical Therapies for Dizziness.

Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.

Cognitive Screening of Adults With Postlingual Hearing Loss: A Systematic Review.

OBJECTIVE: To systematically review the evidence for the use of cognitive screening tools for adults with postlingual hearing loss. DATA SOURCES: PubMed, Embase, Scopus, PsycINFO (EBSCO), CINAHL (EBSCO), and CENTRAL (Cochrane Library) electronic databases were searched from inception until October 4, 2018. REVIEW METHODS: Articles were reviewed for inclusion by 2 independent reviewers. The references of included articles were hand-searched for additional relevant articles. Data were extracted by 2 independent extractors. RESULTS: Of 2092 articles imported from the search, 81 were included for the review. Nearly a third (31%, n = 25) included patients with profound hearing loss. In total, 23 unique tools were used for 105 unique applications. The Mini Mental Status Exam (MMSE) was the most commonly used (54%, n = 55), followed by the Montreal Cognitive Assessment (MoCA) (19%, n = 10). Nearly half of the tools were used to define patient inclusion or exclusion in a study (48%, n = 50), followed by examination of a change after an intervention (26%, n = 27). Two articles attempted to study the validity of the MMSE and MoCA for screening patients with mild to moderate hearing loss and found mixed effects of the auditory components. There were no validation studies identified from the search. CONCLUSION: Many different cognitive screening tools have been used to study patients with postlingual hearing loss. The effects of the auditory components of these tools may be deleterious but ultimately remain unclear from the available evidence. To date, there has been no validation of any cognitive screening tool to be used for adults with postlingual hearing loss.

Spontaneous Skull Base Cerebrospinal Fluid Leaks and Their Relationship to Idiopathic Intracranial Hypertension.

BACKGROUND: The association between spontaneous skull base cerebrospinal fluid (CSF) leaks and idiopathic intracranial hypertension (IIH) has been suggested, but its significance remains unclear. OBJECTIVE: To estimate the prevalence of IIH in spontaneous skull base CSF leak patients. METHODS: Systematic collection of demographics, neuro-ophthalmic and magnetic resonance imaging evaluation of spontaneous skull base CSF leak patients seen pre- and post-leak repair in one neuro-ophthalmology service. Patients with preexisting IIH were diagnosed with definite IIH if adequate documentation was provided; otherwise, they were categorized with presumed IIH. Classic radiographic signs of intracranial hypertension and bilateral transverse venous sinus stenosis were recorded. RESULTS: Thirty six patients were included (age [interquartile range]: 50 [45;54] years; 94% women; body mass index: 36.8 [30.5;39.9] kg/m2), among whom six (16.7%, [95% confidence interval, CI]: [6.4;32.8]) had a preexisting diagnosis of definite or presumed IIH. Of the remaining 30 patients, four (13.3%, 95%CI: [3.8;30.7]) had optic nerve head changes suggesting previously undiagnosed IIH, while one was newly diagnosed with definite IIH at initial consultation. One out of 29 patients with normal findings of the optic nerve head at presentation developed new onset papilledema following surgery (3.4%, 95%CI: [0.1;17.8]) and was ultimately diagnosed with definite IIH. Overall, the prevalence of definite IIH was 19.4% (95%CI: [8.2;36.0]). CONCLUSION: Striking demographic overlap exists between IIH patients and those with spontaneous CSF leak. Definite IIH was present in approximately 20% of our patients. However, its true prevalence is likely higher than identified by using classic criteria. We therefore hypothesize that an active CSF leak serves as an auto-diversion for CSF, thereby "treating" the intracranial hypertension and eliminating characteristic signs and symptoms at initial presentation.

Coronavirus Disease-19 and Otology/Neurotology.

The severe acute respiratory syndrome corona virus 2, responsible for the worldwide COVID-19 pandemic, has caused unprecedented changes to society as we know it. The effects have been particularly palpable in the practice of medicine. The field of otolaryngology has not been spared. We have had to significantly alter the way we provide care to patients, changes that are likely to become a new norm for the foreseeable future. This article highlights some of the changes as they apply to otology/neurotology. Although this is written from the perspective of an academic physician, it is also applicable to private practice colleagues.

Practices and perceptions of cognitive assessment for adults with age-related hearing loss.

OBJECTIVES: To investigate the landscape of cognitive impairment (CI) screening for adults with age-related hearing loss (ARHL) among otolaryngologists and audiologists. To identify provider factors and patient characteristics that impact rates of CI screening and referral. METHODS: A 15 question online survey was sent to members of the Georgia Society of Otolaryngology (GSO), Georgia Academy of Audiology (GAA), American Otological Society and American Neurotology Society (AOS/ANS), and posted on the web forum for two hearing disorders special interest groups within the American-Speech-Language-Hearing Association (ASHA). Responses were collected anonymously. Chi-square tests were used to compare responses. RESULTS: Of the 66 included respondents, 61% (n = 40) were otolaryngologists and 35% (n = 23) were audiologists. Respondents were significantly more likely to refer patients for CI assessment than to screen (64% vs 21%, respectively, P < .001). The complaint of a neurological symptom, such as memory loss, would prompt screening or referral for only 27.3% (n = 18) and 51.52% (n = 34) of respondents, respectively. Forty-two percent (n = 28) of respondents suggested CI screening with the MMSE vs 20% (n = 13) with the Montreal Cognitive Assessment. CONCLUSIONS: Despite recommendations for cognitive assessment in high-risk populations, such as older adults with ARHL, the practice of CI screening and referral is not yet commonplace among otolaryngologists and audiologists. These providers have a unique opportunity to assess adults with ARHL for CI and ensure appropriate referral. LEVEL OF EVIDENCE: 5.

Postoperative Healthcare Utilization of Elderly Adults After Cochlear Implantation.

OBJECTIVE: To determine the association between geriatric age and postoperative healthcare utilization after cochlear implantation. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Older adults (>59 yr) who underwent unilateral cochlear implantation from 2009 until 2016. INTERVENTION(S): Standard electrode length cochlear implantation. MAIN OUTCOME MEASURE(S): Postoperative surgical and audiological visit rate after cochlear implantation for those aged 60 to 69, 70 to 79, and 80+ years. RESULTS: Fifty-nine older adult patients were included in the study with a mean age of 71.5 ±â€Š6.9 years (range, 60-88 yr), mean duration of hearing loss of 25.4 ±â€Š19.6 years (range, 0.25-67 yr), and mean length of follow up of 37 ±â€Š24.6 months (range, 6-107 mo). There was no significant difference in the mean number of surgical and audiological visits over both the first and second postoperative years between those aged 60 to 69, 70 to 79, and 80+ years. Additionally, on one-way multivariate analysis of covariance (MANCOVA), there was no significant difference in cumulative postoperative healthcare utilization measures between each age group, when controlling for postoperative AzBio scores, estimated household income, and driving distance to the hospital. CONCLUSIONS: Older geriatric adults do not have higher rates of postoperative healthcare utilization after cochlear implantation than their younger, geriatric hearing impaired counterparts, despite presumed higher rates of frailty and comorbidity.

The Role of Sex on Early Cochlear Implant Outcomes.

OBJECTIVE: To determine the presence of sex differences in cochlear implant outcomes. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Adult patients having undergone cochlear implantation from 2009 to 2017. INTERVENTION(S): Standard electrode length cochlear implantation. MAIN OUTCOME MEASURE(S): AzBio scores in quiet of the implanted ear at the 1 to 3 months and 6 to 9 months postoperative time points. RESULTS: Of 55 patients with complete demographic and speech recognition testing, 36.4% (n = 20) were men. The mean age at time of surgery was 59.81 ±â€Š16.54 years and the mean duration of hearing loss was 26.33 ±â€Š18.54 years; there was no significant difference between men and women. The mean preoperative AzBio score was 11 ±â€Š15.86% and there was no difference between men and women. Through 2 (sex) × 3 (time point) analysis of covariance (ANCOVA), there was no main effect of sex (F[1, 48] = 0.74, p = 0.39, η = 0.02) on postoperative AzBio scores, but there was a significant sex by time point interaction, (F[1.77, 85.03] = 4.23, p = 0.02, η = 0.08). At the 1 to 3 months postoperative time point, women exhibited higher relative improvement in AzBio scores than men (67 ±â€Š27% versus 55 ±â€Š31%). Further, this relative improvement increased and remained significant at the 6 to 9 months postoperative time point (women: 71 ±â€Š22% versus 58 ±â€Š30%). CONCLUSIONS: Sex may play a role in early speech recognition outcomes after adult cochlear implantation.

The Prevalence of Superior Semicircular Canal Dehiscence in Patients With Mastoid Encephalocele or Cerebrospinal Fluid Otorrhea.

OBJECTIVE: To evaluate the association between mastoid encephalocele or cerebrospinal fluid (CSF) otorrhea and concurrent superior semicircular canal dehiscence (SSCD). STUDY DESIGN: Retrospective case-control study with chart and imaging review. SETTING: University-affiliated tertiary referral center. PATIENTS: A chart review was conducted of all patients greater than 18 years of age who had primary surgery for CSF otorrhea or encephalocele at our university-affiliated tertiary center from 2000 to 2016. Eighty-three patients matched inclusion criteria for case subjects, and 100 patients without CSF otorrhea or encephalocele were included for controls. MAIN OUTCOME MEASURE: High-resolution computed tomography (CT) scans were reviewed to assess superior semicircular canal roof integrity. Student's t test was used to determine significance of continuous variables. Odds ratio (OR) and χ test was used to determine the association between SSCD and concurrent mastoid encephalocele or CSF otorrhea compared with the control population. RESULTS: The mean age of the 83 case subjects was 54 years, and 73% were women. In patients with confirmed encephalocele and CSF otorrhea, the prevalence of SSCD was 35%, which was significantly greater than controls (2%) (OR = 26.1, p < 0.001). In patients with only CSF otorrhea, 21% had concurrent SSCD (OR = 10.3, p = 0.001). In patients with SSCD, 46% had bilateral canal dehiscence. CONCLUSIONS: This is the largest study to evaluate the prevalence of SSCD in patients with concurrent mastoid encephalocele. This study showed a significant association between SSCD and the presence of both mastoid encephalocele and CSF otorrhea. This data suggests that surgeons should have a high suspicion for SSCD in patients presenting with encephalocele or CSF otorrhea.

When Preoperative Imaging and Audiometry Conflict: A Case of Cochlear Implantation in a Prelingually Deafened Adult.

OBJECTIVE: To describe a unique case of excellent audiometric outcomes for a prelingually deafened adult after cochlear implantation and to caution on the limits of magnetic resonance imaging for a diagnosis of cochlear nerve aplasia. PATIENT: Adult man with congenital bilateral profound sensorineural hearing loss. INTERVENTION (S): Cochlear implantation. MAIN OUTCOME MEASURE(S): Audiometric testing and subjective hearing improvement. RESULTS: Improved subjective and objective hearing after cochlear implantation. CONCLUSIONS: Consideration of cochlear implantation is reasonable for adults with long-standing hearing loss when preoperative audiometric testing is discordant with magnetic resonance imaging findings of radiographic cochlear nerve aplasia.

Idiopathic, Infectious and Reactive Lesions of the Ear and Temporal Bone.

A number of infectious, inflammatory and idiopathic lesions develop within otologic tissues that may share similar clinical and/or microscopic features. This review first provides a working classification for otitis externa, and then otitis media and includes two recently described entities, eosinophilic otitis media and otitis media with ANCA-associated vasculitis. Next, the microscopic findings of a spectrum of otopathologic conditions are described, including post-inflammatory conditions such as tympanosclerosis and aural polyps, an overview of animate aural foreign body as well as iatrogenic aural foreign body reactions. Finally, a review of fungal disease affecting the ear with a brief synopsis of Candida auris, a recently described and virulent organism, is presented.

Spontaneous Labyrinthine Hemorrhage: A Case Series.

OBJECTIVES: To describe patient characteristics, audiometric outcomes, and magnetic resonance imaging (MRI) signal patterns in patients with suspected labyrinthine hemorrhage. STUDY DESIGN: Retrospective review. SETTING: Tertiary medical center. SUBJECTS AND METHODS: Radiology database was queried for terms related to labyrinth hemorrhage or labyrinthitis and then selected for patients in which labyrinthine hemorrhage was suspected in the report. Eleven patients were identified and all treated at our institution. Blinded assessment of temporal bone MRI by 2 experienced neuroradiologists was performed and interrater reliability assessed. Patient demographics, medical comorbidities, and audiometric outcomes are described. RESULTS: Of the 11 patients identified, the median patient age was 60 years; 7 were female and 4 male. Ten of 11 patients presented with unilateral sudden sensorineural hearing loss (SNHL), and 8 of 11 had associated vertigo. One patient experienced vertigo without hearing loss. Of those presenting with sudden SNHL, 82% were left with nonserviceable American Academy of Otolaryngology-Head and Neck Surgery class D hearing. Interrater reliability for detecting T1 signal abnormalities was moderate but very good for detecting fluid attenuation inversion recovery (FLAIR) signal abnormalities. Most patients had existing hypertension. Average follow-up was 13.3 months. CONCLUSION: We present the largest cohort of patients with radiographic diagnosis of labyrinthine hemorrhage using T1 and FLAIR signal abnormalities on MRI. Most patients presented with a profound unilateral sudden SNHL that did not recover. Our findings are consistent with prior reports that abnormal FLAIR signal on MRI is a reliable marker for detecting inner ear injury and can potentially be used as a marker for poor prognosis.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Intraoperative Cranial Nerve Monitoring in Vestibular Schwannoma Surgery.

Question 1: Does intraoperative facial nerve monitoring during vestibular schwannoma surgery lead to better long-term facial nerve function? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery regardless of tumor characteristics. Recommendation: Level 3: It is recommended that intraoperative facial nerve monitoring be routinely utilized during vestibular schwannoma surgery to improve long-term facial nerve function. Question 2: Can intraoperative facial nerve monitoring be used to accurately predict favorable long-term facial nerve function after vestibular schwannoma surgery? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery. Recommendation: Level 3: Intraoperative facial nerve can be used to accurately predict favorable long-term facial nerve function after vestibular schwannoma surgery. Specifically, the presence of favorable testing reliably portends a good long-term facial nerve outcome. However, the absence of favorable testing in the setting of an anatomically intact facial nerve does not reliably predict poor long-term function and therefore cannot be used to direct decision-making regarding the need for early reinnervation procedures. Question 3: Does an anatomically intact facial nerve with poor electromyogram (EMG) electrical responses during intraoperative testing reliably predict poor long-term facial nerve function? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery. Recommendation: Level 3: Poor intraoperative EMG electrical response of the facial nerve should not be used as a reliable predictor of poor long-term facial nerve function. Question 4: Should intraoperative eighth cranial nerve monitoring be used during vestibular schwannoma surgery? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery with measurable preoperative hearing levels and tumors smaller than 1.5 cm. Recommendation: Level 3: Intraoperative eighth cranial nerve monitoring should be used during vestibular schwannoma surgery when hearing preservation is attempted. Question 5: Is direct monitoring of the eighth cranial nerve superior to the use of far-field auditory brain stem responses? Target Population: This recommendation applies to adult patients undergoing vestibular schwannoma surgery with measurable preoperative hearing levels and tumors smaller than 1.5 cm. Recommendation: Level 3: There is insufficient evidence to make a definitive recommendation. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-manage-ment-patients-vestibular-schwannoma/chapter_4.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Hearing Preservation Outcomes in Patients With Sporadic Vestibular Schwannomas.

Question 1: What is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery utilizing modern dose planning, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 2: Among patients with AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery hearing classification) class A or GR (Gardner-Robertson hearing classification) grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery, utilizing modern dose planning, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 3: What patient- and tumor-related factors influence progression to nonserviceable hearing following stereotactic radiosurgery using ≤13 Gy to the tumor margin? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size, marginal tumor dose ≤12 Gy, and cochlear dose ≤4 Gy. Age and sex are not strong predictors of hearing preservation outcome. Question 4: What is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately low probability (>25%-50%) of hearing preservation immediately following surgery, moderately low probability (>25%-50%) of hearing preservation at 2 yr, moderately low probability (>25%-50%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 5: Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment? Recommendation: Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately high probability (>50%-75%) of hearing preservation immediately following surgery, moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 6: What patient- and tumor-related factors influence progression to nonserviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas? Recommendation: Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size commonly less than 1 cm, and presence of a distal internal auditory canal cerebrospinal fluid fundal cap. Age and sex are not strong predictors of hearing preservation outcome. Question 7: What is the overall probability of maintaining serviceable hearing with conservative observation of vestibular schwannomas at 2, 5, and 10 yr following diagnosis? Recommendation: Level 3: Individuals who meet these criteria and are considering observation should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 8: Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing with conservative observation at 2 and 5 yr following diagnosis? Recommendation: Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, and moderately high probability (>50%-75%) of hearing preservation at 5 yr. Insufficient data were available to determine the probability of hearing preservation at 10 yr for this population subset. Question 9: What patient and tumor-related factors influence progression to nonserviceable hearing during conservative observation? Recommendation: Level 3: Individuals who meet these criteria and are considering observation should be counseled regarding probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, as well as nongrowth of the tumor. Tumor size at the time of diagnosis, age, and sex do not predict future development of nonserviceable hearing during observation. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-manage-ment-patients-vestibular-schwannoma/chapter_3.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Otologic and Audiologic Screening for Patients With Vestibular Schwannomas.

QUESTION 1: What is the expected diagnostic yield for vestibular schwannomas when using a magnetic resonance imaging (MRI) to evaluate patients with previously published definitions of asymmetric sensorineural hearing loss? TARGET POPULATION: These recommendations apply to adults with an asymmetric sensorineural hearing loss on audiometric testing. RECOMMENDATION: Level 3: On the basis of an audiogram, it is recommended that MRI screening on patients with ≥10 decibels (dB) of interaural difference at 2 or more contiguous frequencies or ≥15 dB at 1 frequency be pursued to minimize the incidence of undiagnosed vestibular schwannomas. However, selectively screening patients with ≥15 dB of interaural difference at 3000 Hz alone may minimize the incidence of MRIs performed that do not diagnose a vestibular schwannoma. QUESTION 2: What is the expected diagnostic yield for vestibular schwannomas when using an MRI to evaluate patients with asymmetric tinnitus, as defined as either purely unilateral tinnitus or bilateral tinnitus with subjective asymmetry? TARGET POPULATION: These recommendations apply to adults with subjective complaints of asymmetric tinnitus. RECOMMENDATION: Level 3: It is recommended that MRI be used to evaluate patients with asymmetric tinnitus. However, this practice is low yielding in terms of vestibular schwannoma diagnosis (<1%). QUESTION 3: What is the expected diagnostic yield for vestibular schwannomas when using an MRI to evaluate patients with a sudden sensorineural hearing loss? TARGET POPULATION: These recommendations apply to adults with a verified sudden sensorineural hearing loss on an audiogram. RECOMMENDATION: Level 3: It is recommended that MRI be used to evaluate patients with a sudden sensorineural hearing loss. However, this practice is low yielding in terms of vestibular schwannoma diagnosis (<3%). The full guideline can be found at: https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_2.