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Clinical features of vestibular schwannomas in patients who experience hearing improvement after surgery

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Abstract

Postoperative improvements in hearing in patients with vestibular schwannoma are extremely rare. We reviewed nine cases retrospectively to investigate the clinical features of these cases. Hearing improvement was defined as an improvement in hearing class according to American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) criteria. The nine patients comprised five men and four women with a mean age of 40.4 years. Of the nine tumors, three were solid and six cystic; mean tumor size was 29.7 mm. Mean pure tone average (PTA) and mean speech discrimination scores (SDS) were 47.5 dB and 22.8 %, respectively, preoperatively and 29.6 dB and 83.9 %, respectively, postoperatively. AAO-HNS class distribution was class B:1 and D:8, preoperatively, and class A: 5 and B:4, postoperatively. A lateral suboccipital retrosigmoid approach with a lateral (park bench) position was used in all nine patients. Clinical features of these vestibular schwannomas included (1) large cystic tumors, (2) sudden onset hearing loss, (3) the presence of a valley shape in the middle-pitch area on preoperative audiograms, (4) almost intact preoperative inner ear function, (5) a low SDS relative to PTA preoperatively, (6) surgical treatment via a lateral suboccipital approach within 6 months of the most recent exacerbation of hearing loss, (7) observation of I waves in preoperative, intraoperative, and postoperative auditory brainstem response (ABR) recordings, and (8) postoperative improvement in mainly the middle-pitch range and SDS. For surgical treatment of vestibular schwannomas with the above clinical features, a translabyrinthine approach and cochlear nerve section (unless the I wave on the intraoperative ABR trace disappears) should be avoided, regardless of the patient’s preoperative hearing level, if a surgeon hopes to maximize the chances of preserving or improving hearing.

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Acknowledgments

We would like to thank our many colleagues, including medical doctors (neurosurgeons and otolaryngologists), nurses, medical engineers, and medical technologists, for their participation in managing these patients at Tokyo Metropolitan Police Hospital.

Conflict of interest

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

The protocol for this study was approved by the ethics committee of Tokyo Metropolitan Police Hospital, and all patients gave their informed consent for inclusion in this study.

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Authors and Affiliations

  1. Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan

    Michihiro Kohno, Shigeo Sora & Hiroaki Sato

  2. Department of Otolaryngology, Tokyo Metropolitan Police Hospital, Tokyo, Japan

    Masanobu Shinogami

  3. Department of Neurosurgery, Tokyo Medical University, 6-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan

    Michihiro Kohno

  4. Department of Otolaryngology, Yoneyama Clinic, Fujinomiya, Shizuoka Pref., Japan

    Hidehiko Yoneyama

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  1. Michihiro Kohno
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Correspondence to Michihiro Kohno.

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Comments

Rudolf Probst, Zurich, Switzerland

The dream of every surgeon operating on vestibular Schwannomas (VS) is to improve hearing. Unfortunately, we know that this is a very rare and unpredictable event. Surgeons are rightfully proud and happy if existing hearing does not deteriorate. The series of Michihiro Kohno et al. reporting 9 cases with postsurgical hearing improvement is quite remarkable against this background, even though the cases represent just 1 % of all VS treated surgically in 18 years by this surgeon, making the event appear on average once in two years.

Given the rarity of these events, means to identify possible candidates for postsurgical hearing improvement could be important. In fact, the reported cases have some common features possibly allowing such a positive risk profile, as pointed out nicely by the authors. These features include cystic tumors and sudden hearing loss, which was noted consistently in all cases. Sudden hearing loss as an early symptom of VS is usually followed by some degree of spontaneous recovery of hearing. The paper leaves some ambiguity in this aspect, because it does not report about spontaneous recovery of hearing before surgery, and audiograms were not consistently performed immediately before surgery. However, the appearance of ABR wave V during surgery indicates perioperative improvement of hearing.

But it does not come as a surprise that not all aspects of these rare and diverse cases are clear. Among the most puzzling aspects may be the reported changes of the DPOAEs. Timing of DPOAE measurements may have contributed to these findings, similarly to the above mentioned timing of audiograms, but evidence for a clear trend toward worsening of DPOAEs seems to be presented. Since improvement of hearing must go along with improved or at least stable cochlear function, the apparently systematic worsening of DPOAE remains puzzling. It may point to yet unrecognized factors related to changes of cochlear metabolism or efferent innervations induced by surgery. It will be important to follow further the hearing of these patients, because hearing may become slowly worse during the years to follow. We do not know the basis of these well-known postsurgical, slowly progressing hearing losses, but it could be related to the puzzling pattern of DPOAE findings in these cases.

Nevertheless, Kohno et al. are to be congratulated on their achievements. Their report may hopefully contribute to more success in the effort to identify possible candidates for hearing improvement with surgical treatment of VS, and to reach this top aim.

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Kohno, M., Sora, S., Sato, H. et al. Clinical features of vestibular schwannomas in patients who experience hearing improvement after surgery. Neurosurg Rev 38, 331–341 (2015). https://doi.org/10.1007/s10143-014-0599-6

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