Conservative management of acoustic neuroma in the elderly patient

Abstract

A subtotal resection through the translabyrinthine approach should be used in the treatment of large symptomatic acoustic neuromas in patients over the age of 65. This approach will consistently relieve the patient's symptoms of brain stem compression, reduce postoperative morbidity and complications, and preserve facial nerve function. In the elderly, after subtotal resection, the remaining tumor in 80% of cases appears to remain dormant during the average six year follow‐up (1‐16 year range). Eighty percent of acoustic neuromas not operated upon, appear to grow at a slow rate (0.2 cm/yr) while 20% grow at a fast rate (1 cm/yr). Patients over the age of 65 with small acoustic neuromas do not need surgical intervention. Yearly CT scanning is recommended to determine the growth rate of the acoustic neuroma. A conservative approach should be used in the treatment of all acoustic neuromas in the elderly.

Diagnostic Accuracy of the Constructive Interference in Steady State Sequence Alone for Follow-Up Imaging of Vestibular Schwannomas

“…1,22 Studies investigating the natural history of sporadic VS reported a growth rate of Ͻ2 mm/year. 6,23,24 Approximately 43%-80% of these lesions show no growth on follow-up, 25,26 as was the case in 13 (72.2%) of our patients. Spontaneous regression, with an overall incidence of 5%, has also been described.…”

“…29 However, with the development of imaging and radiation treatment technologies, radiologic observation with serial imaging studies or treatment with stereotactic radiation therapy (such as gamma knife surgery) has become an acceptable alternative. 5,6,[23][24][25]27,28,30 The radiologic surveillance is especially preferred in elderly patients, in patients with small tumor size or with minimal symptoms, and in patients who are poor surgical candidates. 5,23,24,27,28 Contrast-enhanced T1WI is the established standard technique for this follow-up imaging, and an increasing number of patients are being followed-up with this technique.…”

Predictive factors of acoustic neuroma growth

“…The "wait and scan" approach was initially introduced during the 1980's by Silverstein and consists of a serial MRI and audiometric assessment from diagnosis until either choice of another treatment policy or discharge. 18 Numerous studies, have confirmed the fact that a proportion of tumours ranging from 30% to 90% does not change size during observation. 19,20 Growth rate varies from 0.7 to 2 mm annually, there are plenty of long term follow up studies proposing that over 65% of ANs do not grow or even decrease in size, limiting the need for intervention between 20-35% of the cases.…”

“…[21][22][23][24] In a meta-analysis by Smouha et al 57% of ANs did not seem to grow after a mean follow up period of more than 3 years, whereas failure rate of conservative management was 20%. 18,21 Overall mean AN growth was 1.9 mm per year. These results are similar to the findings our study.…”

Malignant Vestibular Schwannoma

“…[5][6][7] Vestibular schwannomas (acoustic neuromas) are generally felt to be benign tumors, and under certain circumstances, some authors have suggested a conservative nonoperative approach. [8][9][10] We present the fourth case of a malignant vestibular schwannoma, in a patient where the initial presentation was sudden unilateral hearing loss. Previous cases of malignant acoustic neuroma are summarized, and an attempt is made to incorporate consideration of these rare tumors into the general management of sudden hearing loss and of acoustic neuromas.…”