Objective Observation is a well-accepted management for small- to medium-sized vestibular schwannomas (VSs). Although there are good data on the natural history of this disease within adults, no studies have looked specifically at those aged over 70 years. Thus, there is a need for a surveillance protocol to determine if and when we can stop imaging safely patients aged 70 years and over with a new diagnosis of VSs when managed with observation.
Design Over a 13-year period, we retrospectively analyzed all skull base unit patients with a sporadic unilateral VSs managed with an imaging surveillance protocol. All data were collected prospectively with a minimum follow-up of 5 years.
Setting Tertiary referral skull base unit
Participants Patients aged 70 years and over with sporadic VSs at diagnosis
Main Outcome Measures Main outcome measures
Results A total of 112 patients met inclusion criteria. The median age at diagnosis was 74 years (range: 70–87 years). The mean follow-up was 82 months (range: 60–144). The size of the VSs at diagnosis was intracanalicular (IC) in 46%, small in 41%, medium in 12%, and large in 2%.Growth was more likely where tumors were extracanalicular (EC) rather than IC at presentation (p = 0.036) and within the first 18 months after diagnosis (p < 0.001). Twenty-nine percent of VSs displayed growth (6% continued surveillance, 23% received active treatment). Good hearing at diagnosis did not predict tumor stability for IC or EC tumors (p = 0.162 and p = 0.536).
Conclusions Since no VSs grew after 42 months from diagnosis, our data support an initial magnetic resonance imaging (MRI) at 6 months after diagnosis followed by an annual MRI for 3 years. At this point, consideration could be given to discussing discontinuation or further imaging with patients.
Only four early years postgraduate surgical training posts in the UK meet nationally approved minimum quality standards. Specific recommendations are made to improve training in this cohort and to bolster recruitment and retention into Higher Surgical Training.
The possible role of frequency-shift detectors (FSDs) was assessed for a task measuring the ability to hear out individual "inner" partials in a chord with seven partials uniformly spaced on the ERBN-number (Cam) scale. In each of the two intervals in a trial, a pure-tone probe was followed by a chord. In one randomly selected interval, the frequency of the probe was the same as that of a partial in the chord. In the other interval, the probe was mistuned upwards or downwards from the "target" partial. The task was to indicate the interval in which the probe coincided with the target. In the "symmetric" condition, the frequency of the mistuned probe was midway in Cams between that of two partials in the chord. This should have led to approximately symmetric activation of the up-FSDs and down-FSDs, such that differential activation provided a minimal cue. In the "asymmetric" condition, the mistuned probe was much closer in frequency to one partial in the chord than to the next closest partial. This should have led to differential activation of the up-FSDs and down-FSDs, providing a strong discrimination cue. Performance was predicted to be better in the asymmetric than in the symmetric condition. The results were consistent with this prediction except when the probe was mistuned above the sixth (second highest) partial in the chord. To explain this, it is argued that activation of FSDs depends both on the size of the frequency shift between successive components and on the pitch strength of each component.
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