Vestibular Schwannoma, Three Decades of Evolution in Management Strategy

Introduction: The management of acoustic neuroma has changed over the years. Early diagnosis together with improved imaging facilities and the availability of different management options have raised patients’ treatment expectations. There is, in addition, an abundance of information on the Internet. Three main therapeutic options are available: Surgery, radiotherapy, and conservative management or “watch (scan) and wait.” We report our experience in the multidisciplinary management of acoustic neuroma at our skull base clinic over the past 22 years.

Methods: From 1990 to 2011, we have maintained a database of patients presenting to our multidisciplinary skull base clinic. This comprises 728 patients. For analysis we have divided these into four distinct groups, with each comprising 5 years—groups I (1990-1994) II (1995-1999), III (2000-2004), and IV (2005-2011).

Results: Group I comprised 91 cases: The retrosigmoid approach (RS) was used in 49 patients (53.8%), the translabyrinthine approach (TL) in 23 patients (25.3%), stereotactic radiosurgery (SRS) in 1 case (1.1%), and surveillance (W+S) in 8 cases (8.8%). Group II had 191 patients treated as follows: RS 97 cases (57%), TL 46 cases (27%), SRS 13 cases (7.7%), and W+S in 14 cases (8.3%). Group III had 144 patients: RS 78 cases (54%), TL 8 cases (5.5%), SRS 31 cases (21.5%), and W+S 27 cases (19%). Group IV had 302 cases: RS in 53 cases (17.5%), TL 17 cases (6%), SRS 27 cases (9%) and W+S 205 cases (67.5%). Overall tumor control, maximum neurological function preservation, and patient satisfaction have improved from one group to another. Many variants have been studied, but the introduction of SRS and W+S with the reduction of the middle fossa approach was statistically significant. There was a linear increase with time in the proportion of preoperative patients with serviceable hearing. This trend is statistically significant. Tumor size became significantly smaller year after year. This may correspond to observed change in the clinical presentation of acoustic neuroma.

Conclusion: Early in our experience (1990-1994), more than 75% of patients with VS were managed surgically (RS or TL). Twenty years later, this has completely reversed with 77% of cases in the current group (2005-2011) being managed with SRS or W+S. Microsurgical emphasis has shifted to facial nerve and hearing preservation where possible in selected cases.