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Vestibular Schwannomas: Surgical and Nonsurgical Management

  • Ear Surgery (C Limb, Section Editor)
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Abstract

Management options of vestibular schwannomas continue to evolve as surgical, radiation, and radiologic imaging techniques and technology change and improve over time. Currently, three options for these tumors exist and include primary surgical extirpation, stereotactic radiation, and observation with serial imaging. Skull base surgeons are charged with providing the patient with a comprehensive discussion of each option based on the inherit risks and benefits of each option to craft a management plan based on numerous factors that include age, tumor location, and size, hearing level at presentation and any medical comorbidities that may influence functional outcomes and quality of life. The purpose of this article was to review the surgical and non-surgical approaches to tumor management highlighting the risks and benefits and ongoing controversies between modalities regarding optimal functional outcomes. A particular emphasis is placed on hearing preservation and facial nerve function after treatment.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Quesnel A, McKenna M. Current strategies in management of intracanicular vestibular schwannoma. Curr Opin Otolaryngol Head Neck Surg. 2011;19:335–40.

    Article  PubMed  Google Scholar 

  2. Arriaga M, Lin J. Translabyrinthine approach: indications, techniques, and results. Otolaryngol Clin N Am. 2012;45:399–415.

    Article  Google Scholar 

  3. DeMonte F, Gidley P. Hearing preservation for vestibular schwannoma: experience with the middle fossa appraoch. Neurosurg Focus. 2012;33:1–6.

    Article  Google Scholar 

  4. Wang AC, Chinn SB, Than KD, Arts HA, Telian SA, El-Kashlan HK, Thompson BG. Durability of hearing preservation after microsurgical treatment of vestibular schwannoma using the middle cranial fossa approach. J Neurosurg. 2013;119:131–8.

    Article  PubMed  Google Scholar 

  5. Brackmann DE, Owens RM, Friedman RA, et al. Prognostic factors for hearing preservation in vestibular schwannoma surgery. Am J Otol. 2000;21:417–24.

    Article  CAS  PubMed  Google Scholar 

  6. Satar B, Jackler RK, Oghalai J, et al. Risk-benefit analysis of using the middle fossa approach for acoustic neuromas with >10 mm cerebellopontine angle component. Laryngoscope. 2002;112:1500–6.

    Article  PubMed  Google Scholar 

  7. Friedman RA, Kesser B, Brackmann DE, Fisher LM, Slattery WH, Hitselberger WE. Long-term hearing preservation after middle fossa removal of vestibular schwannoma. Otolaryngol Head Neck Surg. 2003;129:660–5.

    Article  PubMed  Google Scholar 

  8. • Hillman T, Chen DA, Arriaga MA, Quigley M: Facial nerve function and hearing preservation acoustic tumor surgery: does the approach matter? Otolaryngol Head Neck Surg. 2010;142:115–9. This large, single institution study provides a comparison of the middle fossa and retrosigmoid approaches for hearing preservation with small tumors.

  9. Woodson EA, Dempewolf RD, Gubbels SP, Porter AT, Oleson JJ, Hansen MR, et al. Long-term hearing preservation after microsurgical excision of vestibular schwannoma. Otol Neurotol. 2010;31:1144–52.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Staecker H, Nadol JB Jr, Ojeman R, et al. Hearing preservation in acoustic neuroma surgery: middle fossa versus retrosigmoid approach. Am J Otol. 2000;21:399–404.

    Article  CAS  PubMed  Google Scholar 

  11. Noudel R, Gomis P, Duntze J, et al. Hearing preservation and facial nerve function after microsurgery for intracanalicular vestibular schwannomas: comparison of middle fossa and retrosigmoid approaches. Acta Neurochir (Wien). 2009;151:935–44.

    Article  CAS  Google Scholar 

  12. Sameshima T, Fukushima T, McElveen JT Jr, et al. Critical assessment of operative approaches for hearing preservation in small acoustic neuroma surgery: retrosigmoid vs middle fossa approach. Neurosurgery. 2010;67:640–4.

    Article  PubMed  Google Scholar 

  13. Arriaga M, Laxford W, Berliner K. Facial nerve function following middle fossa and translabyrinthine acoustic tumor surgery: a comparison. Am J Otol. 1994;15:620–4.

    CAS  PubMed  Google Scholar 

  14. Fayad JN, Brackmann DE. Treatment of small acoustic tumors (vestibular schwannomas). Neurosurg Q. 2005;15:127–37.

    Article  Google Scholar 

  15. Elhammady MS, Telischi FF, Morcos JJ. Retrosigmoid approach: indications, techniques and results. Otolaryngol Clin N Am. 2012;45:375–97.

    Article  Google Scholar 

  16. Hecht CS, Honrubia VF, Wiet RJ, Sims HS. Hearing preservation after acoustic neuroma resection with tumor size used as a clinical prognosticator. Laryngoscope. 1997;107:1122–6.

    Article  CAS  PubMed  Google Scholar 

  17. Irving RM, Jackler RK, Pitts LH. Hearing preservation in patients undergoing vestibular schwannoma surgery: comparison of middle fossa and retrosigmoid approaches. J Neurosurg. 1998;88:840–5.

    Article  CAS  PubMed  Google Scholar 

  18. • Phillips DJ, Kobylarz EJ, De Peralta ET, et al. Predictive factors of hearing preservation after surgical resection of small vestibular schwannomas. Otol Neurotol. 2010; 31:1463–8. In this retrospective evaluation of patients with small tumors, the authors did not find that preoperative hearing or filling of the entire auditory canal were statistically significant predictors of postoperative hearing preservation.

  19. Sughrue ME, Yang I, Rutkowski MJ, et al. Preservation of facial nerve function after resection of vestibular schwannoma. Br J Neurosurg. 2010;24:666–761.

    Article  PubMed  Google Scholar 

  20. Cardoso AC, Fernandes YB, Ramina R, et al. Acoustic neuroma (vestibular schwannoma): surgical results on 240 patients operated on dorsal decubitus position. Arq Neuropsiquiatr. 2007;65:605–9.

    Article  PubMed  Google Scholar 

  21. Zhao X, Wang Z, Ji Y, et al. Long-term facial nerve function evaluation following surgery for large acoustic neuromas via retrosigmoid transmeatal approach. Acta Neurochir (Wien). 2010;152:1647–52.

    Article  Google Scholar 

  22. Jacob A, Robinson LL, Bortman JS, et al. Nerve of origin, tumor size, hearing preservation, and facial nerve outcomes in 359 vestibular schwannoma resections at a tertiary care academic center. Laryngoscope. 2007;117:2087–92.

    Article  PubMed  Google Scholar 

  23. Anderson DE, Leonetti J, Wind JJ, et al. Resection of large vestibular schwannomas: facial nerve preservation in the context of surgical approach and patient- assessed outcome. J Neurosurg. 2005;102:643–9.

    Article  PubMed  Google Scholar 

  24. Patel J, Vasan R, van Loveren H, Downes K, Agazzie S. The changing face of acoustic neuroma management in the USA: analysis of the 1998 and 2008 patient surveys from the acoustic neuroma association. Br J Neurosurg. 2014;28:20–4.

    Article  PubMed  Google Scholar 

  25. Stangerup SE, Caye-Thomasen P, Tos M, Thomsen J. The natural history of vestibular schwannoma. Otol Neurotol. 2006;27:547–52.

    Article  PubMed  Google Scholar 

  26. Theodosopoulos PV, Pensak ML. Contemporary management of acoustic neuromas. Laryngoscope. 2011;121:1133–7.

    Article  PubMed  Google Scholar 

  27. • Stangerup SE, Thomsen J, Tos M, Caye-Thomasen P. Long-term hearing preservation in vestibular schwannoma. Otol Neurotol. 2010;31:271–5. All patients in Denmark with VS diagnosed since 1976 are referred to a single national referral center and entered prospectively in a national database, thereby eliminating referral or retrospective review biases. This is the largest study looking at long term hearing outcomes in those with vestibular schwannomas who are observed, and in those who presented with a word recognition score of 100 % in the affected ear, the hearing preservation rate was 69 % at 10 years. The hearing preservation rate fell drastically to 38 % at 10 years in those with good word recognition scores less than 100 % at presentation.

  28. Kondziolka D. Hearing after gamma knife surgery. J Neurosurg. 2012;117:874–5.

    Article  PubMed  Google Scholar 

  29. Maniakas A, Saliba I. Conservative management versus stereotactic radiation for vestibular schwannomas: a meta analysis of patients with more than 5 years’ follow-up. Otol Neurotol. 2012;33:230–8.

    Article  PubMed  Google Scholar 

  30. Pennings RJ, Morris DP, Clarke L, Allen S, Walling S, Bance ML. Natural history of hearing deterioration in intracanalicular vestibular schwannoma. Neurosurgery. 2011;68:68–77.

    Article  PubMed  Google Scholar 

  31. Vivas EX, Wegner R, Conley G, Torok J, Heron DE, Kabolizadeh P, Burton S, Ozhasoglu C, Quinn A, Hirsch BE. Treatment outcomes in patients treated with cyberknife radiosurgery for vestibular schwannoma. Otol Neurotol. 2014;35:162–70.

    Article  PubMed  Google Scholar 

  32. Lau T, Olivera R, Miller T, Downes K, Danner C, van Loveren HR, Agazzi S. Paradoxical trends in the management of vestibular schwannoma in the United States: Clinical article. J Neurosurg. 2012;117:514–9.

    Article  PubMed  Google Scholar 

  33. Combs SE, Welzel T, Kessel K, Habermehl D, Rieken S, Schramm O, Debus J. Hearing preservation after radiotherapy for vestibular schwannoma is comparable to hearing deterioration in healthy adults and is accompanied by local tumor control and a highly preserved quality of life (QOL) as patients’ self-reported outcomes. Radiother Oncol. 2013;106:175–80.

    Article  PubMed  Google Scholar 

  34. Park SS, Grills IS, Bojrab D, Pieper D, Kartush J, Martin A, Perez E, Hahn Y, Ye H, Martinez A, Chen P. Longitudinal assessment of quality of life and audiometric test outcomes in vestibular schwannoma patients treated with gamma knife surgery. Otol Neurotol. 2011;32:676–9.

    Article  PubMed  Google Scholar 

  35. Varughese JK, Wentzel-Larsen T, Pedersen PH, Mahesparan R, Lund-Johansen M. Gamma knife treatment of growing vestibular schwannoma in Norway: a prospective study. Int J Radiat Oncol Biol Phys. 2012;84:161–6.

    Article  Google Scholar 

  36. Fong BM, Pezeshkian P, Nagasawa DT, De Salles A, Gopen Q, Yang I. Hearing preservation after LINAC radiosurgery and LINAC radiotherapy for vestibular schwannoma. J Clin Neurosci. 2012;19:1065–70.

    Article  PubMed  Google Scholar 

  37. Litre F, Rousseaux P, Jovenin N, Bazin A, Peruzzi P, Wdowczyk D, Colin P. Fractionated stereotactic radiotherapy for acoustic neuromas: a prospective monocenter study of about 158 cases. Radiother Oncol. 2013;106:169–74.

    Article  PubMed  Google Scholar 

  38. Puataweepong P, Dhanachai M, Dangprasert S, Narkwong L, Sitathanee C, Sawangsilpa T, Janwityanujit T, Yongvithisatid P. Linac-based sterotactic radiosurgery and fractionated stereotactic radiotherapy for vestibular schwannomas: comparative observations of 139 patients treated at a single institution. J Radiat Res. 2014;55:351–8.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Rasmussen R, Claesson M, Stangerup SE, Roed H, Christensen IJ, Caye-Thomasen P, Juhier M. Fractionated stereotactic radiotherapy of vestibular schwannomas accelerates hearing loss. Int J Radiat Oncol Biol Phys. 2012;83:e607–11.

  40. Woolf DK, Williams M, Goh CL, Henderson DR, Menashy RV, Simpson N, Mastroianni B, Collis CH. Fractionated stereotactic radiotherapy for acoustic neuromas: long-term outcomes. Clin Oncol. 2013;25:734–8.

    Article  CAS  Google Scholar 

  41. Link MJ, Driscoll CL, Foote RL, Pollock BE. Radiation therapy and radiosurgery for vestibular schwannomas: indications, techniques, and results. Otolaryngol Clin North Am. 2012;45:353–66.

    Article  PubMed  Google Scholar 

  42. Chung WY, Pan DH, Lee CC, Wu HM, Liu KD, Yen YS, Guo WY, Shiau CY, Shih YH. Large vestibular schwannomas treated by gamma knife surgery: long-term outcomes. J Neurosurg. 2010;113:112–21.

    PubMed  Google Scholar 

  43. Milligan BD, Pollock BE, Foote RL, Link MJ. Long-term tumor control and cranial nerve outcomes following gamma knife surgery for larger-volume vestibular schwannomas. J Neurosurg. 2012;116:598–604.

    Article  PubMed  Google Scholar 

  44. Ganz JC. Complications of gamma knife neurosurgery and their appropriate management. Acta Neurochir Suppl. 2013;116:137–46.

    PubMed  Google Scholar 

  45. Husseini ST, Piccirillo E, Sanna M. On, malignant transformation of acoustic neuroma/vestibular schwannoma 10 years after gamma knife stereotactic radiosurgery. Skull Base. 2011;21:135–8.

    Article  PubMed Central  PubMed  Google Scholar 

  46. Baschnagel AM, Chen PY, Bojrab D, Pieper D, Kartush J, Didyuk O, Naumann IC, Maitz A, Grills IS. Hearing preservation in patients with vestibular schwannoma treated with gamma knife surgery. J Neurosurg. 2013;118:571–8.

    Article  PubMed  Google Scholar 

  47. Hasegawa T, Kida Y, Kato T, Lizuka H, Yamamoto T. Factors associated with hearing preservation after gamma knife surgery for vestibular schwannomas in patients who retain serviceable hearing. J Neurosurg. 2011;115:1078–86.

    Article  PubMed  Google Scholar 

  48. Hayden Gephart MG, Hansasuta A, Balise RR, Choi C, Sakamoto GT, Venteicher AS, Soltys SG, Gibbs IC, Harsh GR, Adler JR, Chang SD. Cochlea radiation dose correlates with hearing loss after stereotactic radiosurgery for vestibular schwannoma. World Neurosurg. 2013;80:359–63.

  49. Karam SD, Tai A, Strohl A, Steehler MK, Rashid A, Gagnon G, Harter KW, Jay AK, Collins SP, Kim JH, Jean W. Frameless fractionated stereotactic radiosurgery for vestibular schwannomas: a single-institution experience. Front Oncol. 2013;17:121.

    Google Scholar 

  50. Sager O, Beyzadeoglu M, Dincoglan F, Demirai S, Uysal B, Gamsiz H, Oysul K, Dirican B, Sirin S. Management of vestibular schwannomas with linear accelerator-based stereotactic radiosurgery: a single center experience. Tumori. 2013;99:617–22.

    PubMed  Google Scholar 

  51. Tsai JT, Lin JW, Lin CW, Chen YH, Ma HI, Jen YM, Chen YH, Ju DT. Clinical evaluation of cyberknife in the treatment of vestibular schwannomas. Biomed Res Int. 2013. doi:10.1155/2013/297093

  52. Hasegawa T, Kida Y, Kobayashi T, Yoshimoto M, Mori Y, Yoshida J. Long-term outcomes in patients with vestibular schwannomas treated using gamma knife surgery: a 10-year follow-up. J Neurosurg. 2013;119:10–6.

    PubMed  Google Scholar 

  53. Roos DE, Potter AE, Brophy BP. Stereotactic radiosurgery for acoustic neuromas: what happens long term? Int J Radiat Oncol Biol Phys. 2012;82:1352–5.

    Article  PubMed  Google Scholar 

  54. Roche PH, Noudel R, Regis J. Management of radiation/radiosurgical complications and failures. Otolaryngol Clin North Am. 2012;45:367–74.

    Article  PubMed  Google Scholar 

  55. • Carlson ML, Jacob JT, Pollock BE, Neff BA, Tombers NM, Driscoll CL, Link MJ. Long-term hearing outcomes following stereotactic radiosurgery for vestibular schwannoma: patterns of hearing loss and variables influencing audiometric decline. J Neurosurg. 2013;118:579–87. Evaluated serviceable hearing preservation rates over time, with a median follow up of 9.3 years (range 5–14 years), and used the contra-lateral, non-radiated ear to control for age related hearing loss over time. Found an 80 % hearing preservation rate at 1 year, which decreased to 23 % at 10 years.

  56. Kim YH, Kim DG, Han JH, Chung HT, Kim IK, Song SW, Park JH, Kim JW, Kim YH, Park CK, Kim CY, Paek SH, Jung HW. Hearing outcomes after stereotactic radiosurgery for unilateral intracanalicular vestibular schwannomas: implication of transient volume expansion. Int J Radiat Oncol Bil Phys. 2013;85:61–7.

    Article  Google Scholar 

  57. Badakhshi H, Graf R, Bohmer D, Synowitz M, Wiener E, Budach V. Results for local control and functional outcome after linac-based image-guided stereotactic radiosurgery in 190 patients with vestibular schwannoma. J Radiat Res. 2014;55:288–92.

    Article  PubMed Central  PubMed  Google Scholar 

  58. Friedman RA, Berliner KI, Bassim M, Ursick J, Slattery WH, Schwartz MS, Brackmann DE. A paradigm shift in salvage surgery for radiated vestibular schwannoma. Otol Neurotol. 2011;32:1322–8.

    Article  PubMed  Google Scholar 

  59. Park SH, Lee KY, Hwang SK. Nervus intermediate dysfunction following gamma knife surgery for vestibular schwannoma. J Neurosurg. 2013;118:566–70.

    Article  PubMed  Google Scholar 

  60. Lee SH, Seol HJ, Kong DS, Nam DH, Park K, Kim JH, Lee JL. Risk factors and tumor response associated with hydrocephalus after gamma knife radiosurgery for vestibular schwannoma. Acta Neurochir. 2012;154:1679–84.

    Article  PubMed  Google Scholar 

  61. Aoyama H, Onodera S, Takeichi N, Onimaru R, Terasaka S, Sawamura Y, Shirato H. Symptomatic outcomes in relation to tumor expansion after fractionated stereotactic radiation therapy for vestibular schwannomas: single-institutional long-term experience. Int J Radiat Oncol Biol Phys. 2013;85:329–34.

    Article  PubMed  Google Scholar 

  62. Hayhurst C, Zadeh G. Tumor pseudoprogression following radiosurgery for vestibular schwannoma. Neuro Oncol. 2012;14:87–92.

    Article  PubMed Central  PubMed  Google Scholar 

  63. Ujifuku K, Matsuo T, Toyoda K, Baba S, Okunaga T, Hayashi Y, Kamada K, Morikawa M, Suyama K, Nagata I, Hayashi N. Repeated delayed onset cerebellar radiation injuries after linear accelerator-based stereotactic radiosurgery for vestibular schwannoma: case report. Neurol Med Chir. 2012;52:933–6.

    Article  Google Scholar 

  64. Akamatsu Y, Murakami K, Watanabe M, Jokura H, Tominaga T. Malignant peripheral nerve sheath tumor arising from benign vestibular schwannoma treated by gamma knife radiosurgery after two previous surgeries: a case report with surgical and pathological observations. World Neurosurg. 2010;73:751–4.

    Article  PubMed  Google Scholar 

  65. Lee SH, Rhee BA, Choi SK, Koh JS, Lim YJ. Cerebellopontine angle tumors causing hemifacial spasm: types, incidence, and mechanism in nine reported cases and literature review. Acta Neurochir. 2010;152:1901–8.

    Article  PubMed  Google Scholar 

  66. Markou K, Elmer S, Perret C, Huchet A, Goudakos J, Liguoro D, Franco-Vidal V, Maire JP, Darrouzet V. Unique case of malignant transformation of a vestibular schwannoma after fractionated radiotherapy. Am J Otolaryngol. 2012;33:168–73.

    Article  PubMed  Google Scholar 

  67. Puataweepong P, Janwityanujit T, Larbcharoensub N, Dhanachai M. Radiation-induced peripheral malignant nerve sheath tumor arising from vestibular schwannoma after linac-based stereotactic radiation therapy: a case report and review of literatures. Case Rep Med. 2012;2012:648191.

    PubMed Central  PubMed  Google Scholar 

  68. Schmitt WR, Carlson ML, Giannini C, Driscoll CL, Link MJ. Radiation-induced sarcoma in a large vestibular schwannoma following stereotactic radiosurgery: case report. Neurosurgery. 2011;68:840–6.

    Article  Google Scholar 

  69. Yang T, Rockhill J, Born DE, Sekhar LN. A case of high-grade undifferentiated sarcoma after surgical resection and stereotactic radiosurgery of a vestibular schwannoma. Skull Base. 2010;20:179–83.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Otology/Neurotology-Skull Base Surgery, Department of Otolaryngology/Head and Neck Surgery, The University of Michigan, 1500 East Medical Center Drive, Taubman Center-1904, Ann Arbor, MI, 48109, USA

    Gregory J. Basura, Cameron Budenz & H. Alexander Arts

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  1. Gregory J. Basura
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  2. Cameron Budenz
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Correspondence to Gregory J. Basura.

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This article is part of the Topical Collection on Ear Surgery.

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Basura, G.J., Budenz, C. & Arts, H.A. Vestibular Schwannomas: Surgical and Nonsurgical Management. Curr Surg Rep 3, 5 (2015). https://doi.org/10.1007/s40137-015-0082-5

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