Management of acoustic neuromas in the elderly: retrospective study.AbstractThe wide availability of gadolinium-enhanced magnetic resonance imaging magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures. (MRI-Gd) has led to the discovery of an increasing number of small and less symptomatic acoustic neuromas in elderly patients. We conducted a retrospective study retrospective study, a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. in order to obtain data on outcomes and complications associated with different management strategies that would be useful in establishing a management guideline. We identified 44 patients aged 65 to 77 years with acoustic neuromas who had been managed with either surgery or simple observation with MRI-Gd imaging. Of the entire group, 36 patients had tumors larger than 1 cm, and they underwent surgery (most via the translabyrinthine approach The translabyrinthine approach is a surgical approach to the cerebellopontine angle, or CPA. It is used in the surgical extirpation of lesions of the cerebellopontine angle, including acoustic neuroma. The translabyrinthine approach was developed by Dr. ). Complete removal of the tumor was achieved in 34 of these patients (94.4%). At the 1-year follow-up, grade VI facial nerve paralysis Facial nerve paralysis is a common problem that involves the paralysis of any structures innervated by the facial nerve. The pathway of the facial nerve is long and relatively convoluted, and so there are a number of causes that may result in facial nerve paralysis. was evident in only two of 35 evaluable patients (5.7%). Postsurgical complications occurred in five patients (13.9%), including one death. The remaining eight patients had tumors 1 cm or smaller, and they wer e managed with periodic MRI-Gd scanning. At the S-year follow-up, no tumor growth was seen in six of these patients. The other two patients exhibited a tumor growth rate of less than 2 mm per year. No patient in the observation group required surgical intervention. Introduction In 1992, Tos et al published the results of their epidemiologic study epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect in which they found that the incidence of small acoustic neuromas was increasing. (1) Since then, a number of factors has contributed to the discovery of a corresponding increase in the number of small and less symptomatic acoustic neuromas in elderly patients (age: 65 yr). (2,3) Among these factors are the wide availability of gadolinium-enhanced magnetic resonance imaging (MRI-Gd), a higher index of suspicion index of suspicion Medtalk A phrase broadly used to indicate how seriously a particular disease is being entertained as a diagnosis; as an example, there is a high IOS that rapid and unexplained weight loss in an elderly Pt is due to pancreas CA, and a low IOS that among physicians, the increasing interest in geriatric medicine, and a better informed patient population. (23) Even so, data specific to older patients are sparse because few epidemiologic studies limit their populations to this age group. Several recent developments have markedly reduced the rate of complications of neurotologic surgery for small acoustic neuromas, including progress in microsurgical and neuroanesthesiologic techniques and the greater availability of monitoring equipment. (4,5) Because the incidence of mortality and morbidity is higher in patients with large tumors--especially in the elderly and infirm- surgical removal of an acoustic neuroma is not always the management option of choice at the point of diagnosis. (6-8) Indeed, some acoustic neuromas remain stable over the expected lifespan of the patient. (9) Therefore, in selected patients, it is reasonable to simply monitor acoustic neuromas with MRI-Gd ("watch and scan"). (10) The primary factors that affect the management of acoustic neuromas in elderly patients are (1) the tumor's size, (2) the tumor's growth rate, (3) the patient's age, (4) the patient's general health, (5) the pretreatment pretreatment, n the protocols required before beginning therapy, usually of a diagnostic nature; before treatment. pretreatment estimate, n See predetermination. status of the patient's hearing in the affected and contralateral contralateral /con·tra·lat·er·al/ (-lat´er-al) pertaining to, situated on, or affecting the opposite side. con·tra·lat·er·al adj. ears, and (6) the patient's preference. (11,12) In this article, we describe our retrospective study of the management of elderly patients with acoustic neuromas, and we discuss our findings with respect to outcomes and complications associated with different management strategies. Patients and methods Between July 23, 1975, and May 21, 1996, the ENT ENT ears, nose, and throat (otorhinolaryngology). ENT abbr. ear, nose, and throat ENT ear, nose and throat. ENT Ears, nose & throat; formally, otorhinolaryngology department at the University of Parma History The school was founded during XI century [1]as a center for study of the general liberal arts curriculum of the medieval period. The faculties of law and medicine were added in thirteenth century. admitted 416 patients who had an acoustic neuroma. Of this group, we identified 44 elderly patients--23 women and 21 men, aged 65 to 77 years (mean: 70)--who had not undergone any previous treatment for their tumors. According to the University of Parma's policy for treating acoustic neuromas in the elderly, surgery is indicated for tumors that protrude pro·trude v. 1. To push or thrust outward. 2. To jut out; project. more than 1 cm into the cerebellopontine angle, while simple observation is indicated for tumors that are 1 cm or smaller. Tumor size is determined by measuring the largest diameter observed on MRI-Gd. In accordance with these criteria, 34 patients were initially scheduled for surgery and 10 for conservative management. However, two patients in the latter group exhibited a progression of symptoms and radiologic signs of tumor growth (>2 mm) at the 1-year follow-up, and they were then switched to the surgical group. Among the 36 patients in the surgical group, the translabyrinthine approach was used to treat 32 (88.9%), the retrosigmoid approach was used in three (8.3%), and a combined approach was used in one (2.8%). Follow-up MRI-Gd scans were recommended at 1 and 5 years for patients who underwent a complete excision of their tumor and at 1, 3, and 5 years for those who underwent an incomplete removal, In the nonsurgical group, MRI-Gd was performed every 6 months during the first year and yearly thereafter. Results Surgical results. Complete excision was achieved in 34 of the 36 surgical patients (94.4%); in the remaining two patients (5.6%), a near-total removal was achieved. Facial paralysis. Immediately following surgery, 13 patients (36.1%) exhibited grade VI facial nerve paralysis according to the House-Brackmann grading system (table). (13) Grade VI paralysis was seen in 17 of 35 evaluable patients (48.6%) at the 10-day follow-up (one patient died 3 days following surgery), but in only 2 of the 35 evaluable patients (5.7%) at the 1-year follow-up. Hearing preservation. Hearing preservation was attempted in three surgical patients, but was successful in only one. Preoperatively, the successful patient's pretreatment pure-tone average was 45 dB and his speech discrimination score was 50% (hearing class B, according to guidelines published by the American Academy of Otolaryngology--Head and Neck Surgery [AAO-HNS AAO-HNS American Academy of Otolaryngology - Head and Neck Surgery (Alexandria, VA) ] (14)); the corresponding postoperative values in this patient were 45 dB and 46% (hearing class D). Complications. Postoperative complications postoperative complications, n.pl unexpected problems that arise following surgery. The most frequent are bleeding, infection, and protracted pain. occurred in five of the 36 patients (13.9%), including the one death, which had been caused by acute pulmonary edema Pulmonary Edema Definition Pulmonary edema is a condition in which fluid accumulates in the lungs, usually because the heart's left ventricle does not pump adequately. and renal hemorrhagic Hemorrhagic A condition resulting in massive, difficult-to-control bleeding. Mentioned in: Hantavirus Infections hemorrhagic pertaining to or characterized by hemorrhage. infarction. Another patient was rushed back to surgery for treatment of postoperative hemorrhage postoperative hemorrhage, n unexpected and abnormal (excessive) bleeding following surgery. into the cerebellopontine angle, and her subsequent postoperative course was uneventful. Cerebrospinal fluid leak cerebrospinal fluid leak CSF leak Neurology The inappropriate loss of fluid from the otherwise sealed CSF space Etiology Trauma to head–eg CSF rhinorrhea, CSF otorrhea, cranial base surgery Diagnosis Suspicious post-op nasal or ear drainage, occurred in three patients, two of whom developed associated meningitis. Recurrence. At the 5-year follow-up, MRI-Gd detected no sign of recurrence in any of the 34 surgical patients whose tumors were removed completely. In the two patients whose acoustic neuromas had been incompletely removed, no growth of residual tumor was seen at the 5-year follow-up. Nonsurgical results. At the 5-year follow-up, no tumor growth was seen in six of the eight patients in the observation group. The other two patients exhibited a tumor growth rate of less than 2 mm per year, and their tumors still protruded less than 1 cm into the cerebellopontine angle. Therefore, neither of these patients required surgical intervention. Discussion Current management options for acoustic neuroma in the geriatric population include surgery, radiosurgery radiosurgery /ra·dio·sur·gery/ (-ser´jer-e) surgery in which tissue destruction is performed by means of ionizing radiation rather than by surgical incision. , and observation (figure) (9,15,16) Patient preference is a major consideration in selecting a strategy, but surgical intervention is clearly indicated for patients who exhibit ataxia ataxia (ətăk`sēə), lack of coordination of the voluntary muscles resulting in irregular movements of the body. Ataxia can be brought on by an injury, infection, or degenerative disease of the central nervous system, e.g. , cranial nerve cranial nerve n. Any of 12 pairs of nerves that emerge from or enter the brain, comprising the olfactory (I), optic (II), oculomotor (III), trochlear (IV), trigeminal (V), abducent (VI), facial (VII), vestibulocochlear (VIII), glossopharyngeal (IX), dysfunction, or hydrocephalus hydrocephalus (hī'drəsĕf`ələs), also known as water on the brain, developmental (congenital) or acquired condition in which there is an abnormal accumulation of body fluids within the skull. . The ideal treatment for an elderly patient with a large acoustic neuroma is total excision of the tumor with a minimum of morbidity. (17-21) Total excision via the translabyrinthine approach is appropriate for most patients, and in our series, this approach was used in almost 90% of cases. However, it is not always easy to completely remove large tumors without complications. According to Glasscock et al, surgery in a geriatric population is associated with a 5% mortality and a 15% risk of hydrocephalus. (6) Therefore, a near- or subtotal subtotal /sub·to·tal/ (sub-to´t'l) less than, but often almost, complete. removal has been proposed for older patients with large tumors. (22) The decision to perform a near-total removal can be made intraoperatively after the surgeon has assessed the relationships between the tumor and the brainstem or the facial nerve facial nerve n. Either of a pair of nerves that originate in the pons, traverse the facial canal of the temporal bone, and pass through the parotid gland, reach the facial muscles through various branches, control facial muscles, and relay sensation . Also, an incomplete resection can be undertaken if intraoperative changes in a patient's vital signs indicate that the patient's condition has deteriorated and might become life-threatening. In cases of incomplete removal, MRI-Gd scans should be obtained 1,3, and 5 years postoperatively, as we did in our study. If growth of the residual tumor is noted, more frequent MRI-Gd evaluations are necessary. The introduction of MRI-Gd has enabled physicians to offer conservative management to patients who have small tumors that protrude 1 cm or less into the cerebellopontine angle and whose symptoms are minimal. Conservative management helps preserve--or at least does not diminish--quality of life in these patients during their expected lifespan. (12) For patients whose acoustic neuromas remain stable, we advocate repeat MRI-Gd scanning every 6 months during the first postoperative year and once a year thereafter. For those whose acoustic neuromas continue to grow, surgery might or might not be necessary, depending on the rate of growth. A growth rate of more than 2 mm per year is an indication for surgery. (10) Hearing is rarely preserved in patients whose tumors protrude more than 1.5 cm into the cerebellopontine angle. In our series, no patient's postoperative hearing was in AAO-HNS class A or B. (14) In the case of an acoustic neuroma in an only hearing ear, we prefer to monitor the patient with serial MRI-Gd evaluations. Depending on the tumor's size, its growth rate, and the patient's preference, radiosurgery might be a good option. Radiosurgery can also be offered to candidates for traditional surgery whose poor general health puts them at risk during prolonged general anesthesia Anesthesia, General Definition General anesthesia is the induction of a state of unconsciousness with the absence of pain sensation over the entire body, through the administration of anesthetic drugs. and to patients who are simply unwilling to undergo traditional surgery. (19, 23-25) In our series, no patient underwent radiosurgery.
Table
Pre- and postoperative incidence and type of facial nerve function
according to the House-Brackmann grading system (13)
Grade I Grade II Grade III Grade IV
n (%) n (%) n (%) n (%)
Preop (n = 36) 33 (91.7) 1 (2.8) 0 1 (2.8)
Immediate postop (n = 36) 13 (36.1) 4 (11.1) 2 (5.6) 3 (8.3)
10 days postop (n = 35 *) 9 (25.7) 3 (8.6) 2 (5.7) 3 (8.6)
1 year postop (n = 35 *) 13 (37.1) 4 (11.4) 11 (31.4) 5 (14.3)
Grade V Grade VI
n (%) n (%)
Preop (n = 36) 1 (2.8) 0
Immediate postop (n = 36) 1 (2.8) 13 (36.1)
10 days postop (n = 35 *) 1 (2.9) 17 (48.6)
1 year postop (n = 35 *) 0 2 (5.7)
* One patient died 3 days after surgery.
Acknowledgment We are grateful to Antonella Piazza for her substantial support and contribution to this work. References (1.) Tos M, Thomsen J, Charabi S. Incidence of acoustic neuromas. Ear Nose Throat J 1992;71:391-3. (2.) Piazza F, Gandolfi A, Vighi V, et al. Il neurinoma dell'acustico nell'anziano. In: Grande F, Leone CA, eds. La Patologia dell'Orecchio nell'Anziano. Ospedaletto: Pacini Editore, 1996: 487-92. (3.) Wayman JW, Dutcher PO, Jr., Manzione JV, et al. Gadolinium-DTPA-enhanced magnetic resonance magnetic resonance, in physics and chemistry, phenomenon produced by simultaneously applying a steady magnetic field and electromagnetic radiation (usually radio waves) to a sample of atoms and then adjusting the frequency of the radiation and the strength of the scanning in cerebellopontine angle tumors cerebellopontine angle tumor Acoustic neuroma, see there . Laryngoscope la·ryn·go·scope n. A tubular endoscope that is inserted through the mouth and into the larynx and that is used for examining the interior of the larynx. la·ryn 1989;99:1167-70. (4.) Glasscock ME III, Dickins JR. Complications of acoustic tumor acoustic tumor Acoustic neuroma, see there surgery. Otolaryngol Clin North Am 1982;15:883-95. (5.) Gormley WB. Sekhar LN, Wright DC, et al. Acoustic neuromas: Results of current surgical management. Neurosurgery neurosurgery /neu·ro·sur·gery/ (noor´o-sur?jer-e) surgery of the nervous system. neu·ro·sur·ger·y n. Surgery on any part of the nervous system. 1997;41:50-8; discussion 58-60. (6.) Glasscock ME III, Pappas DG, Jr., Manolidis S, et al. Management of acoustic neuroma in the elderly population. Am J Otol 1997;18:236-41; discussion 241-2. (7.) Wiet RJ, Teixido M, Liang JG. Complications in acoustic neuroma surgery. Otolaryngol Clin North Am 1992;25:389-412. (8.) Perry BP, Gantz BJ, Rubinstein JT. Acoustic neuromas in the elderly. Otol Neurotol 2001;22:389-91. (9.) Tschudi DC, Linder TE, Fisch U. Conservative management of unilateral acoustic neuromas. Am J Otol 2000;21:722-8. (10.) Nedzelski JM, Schessel DA, Pfleiderer A, et al. Conservative management of acoustic neuromas. Otolaryngol Clin North Am 1992;25:691-705. (11.) Kassel EE, Nedzelski JM, Canter RJ, et al. Radiologic assessment of acoustic neuroma in the elderly. Is no treatment good treatment? Acta Radiol Suppl 1986;369:182-5. (12.) Silverstein H, McDaniel A, Norrell H, Wazen J. Conservative management of acoustic neuroma in the elderly patient. Laryngoscope 1985;95(Pt 1):766-70. (13.) House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7. (14.) Committee on Hearing and Equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma (vestibular ves·tib·u·lar adj. Of, relating to, or serving as a vestibule, especially of the ear. Vestibular Pertaining to the vestibule; regarding the vestibular nerve of the ear which is linked to the ability to hear sounds. schwannoma). American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg 1995;113:179-80. (15.) Jackler RK. Acoustic neuroma (vestibular schwannoma). In: Jackler RK, Brackmann DE, eds. Neurotology. St. Louis: Mosby, 1994;729-85. (16.) Sekhar LN, Gormley WB, Wright DC. The best treatment for vestibular schwannoma (acoustic neuroma): Microsurgery microsurgery or micromanipulation Surgical technique for operating on minute structures, with specialized, tiny precision instruments under observation through a microscope, sometimes equipped with cameras to show the operation on a monitor. or radiosurgery? Am J Otol 1996;17:676-82. (17.) Charabi S, Thomsen J, Mantoni M, et al. Acoustic neuroma (vestibular schwannoma): Growth and surgical and nonsurgical consequences of the wait-and-see policy. Otolaryngol Head Neck Surg 1995;113:5-14. (18.) House JW, Nissen RL, Hitselberger WE. Acoustic tumor management in senior citizens. Laryngoscope 1987;97:129-30. (19.) Pulec JL, Gianotta SL. Acoustic neuroma surgery in patients over 65 years of age. Ear Nose Throat J 1995;74:21-7. (20.) Pulec JL. Acoustic neuroma surgery in geriatric patients. Ear Nose Throat J 1999;78:429-42. (21.) Selesnick SH, Johnson G. Radiologic surveillance of acoustic neuromas. Am J Otol 1998;19:846-9. (22.) Kemink JL, Langman AW, Niparko JK, Graham MD. Operative management of acoustic neuromas: The priority of neurologic function over complete resection. Otolaryngol Head Neck Surg 1991;104:96-9. (23.) Eldridge R, Parry D. Vestibular schwannoma (acoustic neuroma). Consensus development conference. Neurosurgery 1992;30:962-4. (24.) Noren G, Greitz D, Hirsch A, Lax I. Gamma knife Gamma Knife A trademark for a radiologic nonsurgical device used in stereotactic radiosurgery. Gamma knife A surgical tool that focuses beams of radiation at the head, which converge in the brain to form a lesion. surgery in acoustic tumours. Acta Neurochir Suppl (Wien) 1993;58:104-7. (25.) van Roijen L, Nijs HG, Avezaat CJ, et al. Costs and effects of microsurgery versus radiosurgery in treating acoustic neuroma. Acta Neurochir (Wien) 1997;139:942-8. From the Department of ENT, Otology otology /otol·o·gy/ (o-tol´ah-je) the branch of medicine dealing with the ear, its anatomy, physiology, and pathology.otolog´ic o·tol·o·gy n. The branch of medicine that deals with the ear. , Neurotology, and Skull Base Surgery, University of Parma, Italy (Dr. Piazza, Dr. Frisina, Dr. Gandolfi, and Dr. Zini), and the Otolaryngology Institute, Catholic University of the Sacred Heart The University of the Sacred Heart can refer to:
Reprint requests: Fabio Piazza, MD, ENT Department, University of Patina, viale Gramsci 14, 43100 Parma, Italy. Phone: 39-338-362-4049; fax: 39-0521-290-157; e-mail: piazzafabio@hotmail.com This study was supported by the Associazione Ricerca e Didattica in Otologia of Parma, Italy. |
|
||||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion