David A. Moffat

Postoperative Quality of Life in Vestibular Schwannoma Patients Measured by the SF36 Health Questionnaire

Objective: To quantify the postoperative quality of life in patients following surgical treatment for vestibular schwannoma.Objective: To quantify the postoperative quality of life in patients following surgical treatment for vestibular schwannoma. Study Design: Patient self-assessment using the short form 36 (SF36) multidimensional quality of life health questionnaire. Sex- and age-matched normalized scores were calculated using a standardized process and accepted normative data. Setting: Tertiary referral skull base unit. Results: An 80% response rate (90 patients) was achieved. The postoperative quality of life in vestibular schwannoma patients, as quantified by seven of the eight SF36 health scales was less than the appropriate matched healthy standard. Comparison of a variety of preoperative patients and tumor factors-different operative approaches (translabyrinthine and retrosigmoid), tumor size (group cut of points of tumor diameter 1.5 mm and 2.5 mm), patient sex, and ranking of patient age-showed no statistically significant difference in measured quality of life outcomes for each of these traditional predictors. Conclusion: Reduced quality of life in patients after surgical treatment for vestibular schwannoma, coupled with the low tumor growth rates and minimal preoperative symptoms, supports a conservative approach to patient management. The advantages and disadvantages of a variety of approaches used to measure the quality of life after surgical treatment of vestibular schwannoma and their impact on clinical decision making for patients, are discussed.

The outcome of radical surgery and postoperative radiotherapy for squamous carcinoma of the temporal bone.

Objectives/Hypothesis: The objective was to analyze the clinical data and outcome of all the patients treated surgically for squamous carcinoma of the temporal bone in a tertiary referral department of skull base surgery over a 20‐year period.

Cranial Nerve Involvement in Malignant External Otitis: Implications for Clinical Outcome

Background: Malignant external otitis is an uncommon, potentially lethal infection of the temporal bone primarily affecting elderly diabetic patients.

Strategy and benefits of acoustic neuroma searching

Advances in audiological, radiological and microsurgical techniques have enabled otologists to diagnose and excise very small acoustic tumours with a low morbidity and mortality. Is this cost effective? In an attempt to answer this question, an analysis of 66 cases of surgically treated acoustic neuromas is presented. This represents part of a series of skull base procedures carried out at Addenbrookes Hospital over the last five years. As a result of this work an investigative protocol is suggested. By studying the relative morbidity of early and late surgical intervention in these cases, and by costing the exercise, the justification for early diagnosis and treatment is presented both in financial and human terms.

Unusual cerebello-pontine angle tumours

Fifty-nine unusual cerebello-pontine angle tumours have been studied. These lesions represent 19.3 per cent or 1 in 5 of a series of 305 cerebello-pontine angle tumours of which the rest, 246 (80.7 per cent), were acoustic neuromas. An analysis of the relative incidence, histology and presenting clinical features has been carried out. The various radiographical features and imaging techniques used to diagnose these fascinating tumours have been described and also the otoneurosurgical procedures necessary to excise them.

Change in dizziness handicap after vestibular schwannoma excision.

Objective To evaluate the change in dizziness handicap after translabyrinthine vestibular schwannoma excision. Study Design Prospective administration of the Dizziness Handicap Inventory preoperatively and at 3 and 12 months postoperatively; retrospective review of case notes. Setting A tertiary referral neuro-otology clinic. Patients A total of 100 consecutive patients who had vestibular schwannomas excised between June 1998 and November 2001 and who had completed Dizziness Handicap Inventories preoperatively and at 3 and 12 months postoperatively. Interventions Translabyrinthine excision of a unilateral sporadic vestibular schwannoma; preoperative and postoperative generic vestibular rehabilitation exercises. Main Outcome Measures Dizziness Handicap Inventory scores. Results For most patients, dizziness handicap does not worsen postoperatively. However, for those in whom it does, dizziness handicap becomes significantly worse between preoperative and 3-month postoperative time points but then does not continue to decline. Tumor size, sex, and magnitude of preoperative canal paresis significantly affect the degree of change in handicap. Age, the presence of central vestibular system abnormalities, and the nature of the patients principal presenting symptom have no effect on this handicap change. Conclusions These findings help the clinician in counseling the patient preoperatively about dizziness handicap to be expected postoperatively. In particular, the clinician is now able to take an informed and positive stance in the event of a severe canal paresis preoperatively.

EXTENDED TEMPORAL BONE RESECTION FOR SQUAMOUS CELL CARCINOMA

OBJECTIVE: The aim of this study was to assess the surgical results of a series of patients from this unit who underwent extended temporal bone resection for recurrent squamous cell carcinoma as a salvage procedure. DESIGN: The surgical records of 15 patients were analyzed in detail. Each patient had salvage surgery in the form of an extended temporal bone resection with supraomohyoid block dissection, dural grafting, and free microvascular forearm or scalp rotation flap repair for recurrent squamous cell carcinoma in a radical mastoid cavity. RESULTS: Radical surgery yielded a 47% 5-year survival. Twenty-nine percent of the survivors had temporal lobe involvement that necessitated a partial excision of the temporal lobe of the brain. Histologic evidence of local lymph node involvement in the supraomohyoid neck dissection was present in 13% of cases. Those who died did so in the first postoperative year. All those with poorly differentiated tumors died. The survivors had well or moderately differentiated tumors. CONCLUSIONS: Radiotherapy alone or partial temporal bone resection, most commonly a radical mastoidectomy with or without preoperative or postoperative radiotherapy is used by the majority of otolaryngologists in treating squamous cell carcinoma of the temporal bone. The 5-year survival rate after this treatment remains depressingly low and the prognosis gloomy, particularly for advanced tumors. The findings in this series of extended temporal bone resections as salvage surgery in recurrent disease is encouraging, and radical surgery combined with radiotherapy from the outset may give much better 5-year survival figures in the future than the conventional partial temporal bone resection and radiotherapy. (Otolaryngol Head Neck Surg 1997;116:617–23.)

What is the effect of translabyrinthine acoustic schwannoma removal upon tinnitus

A series of 129 patients who had undergone translabyrinthine removal of a unilateral acoustic schwannoma completed a postal questionnaire about pre- and post-operative tinnitus. A simple grading system was devised from which it was possible to determine the likely outcome of translabyrinthine acoustic schwannoma surgery upon tinnitus. The results have been analyzed in detail, and as a result it is possible to advise a patient undergoing this form of surgery that if they have no tinnitus pre-operatively they are unlikely to develop it, and if they do it will not be severe enough to significantly affect their quality of life. If they have mild or moderate tinnitus it is most likely to stay the same, or become less intense. If a patient has severe tinnitus it is very likely to improve and not affect their future quality of life.

Reliability of the House and Brackmann grading system for facial palsy

The House and Brackmann grading system has been recommended as a universal standard for assessing the degree of facial palsy. This study examined the inter-observer reliability of this system. Three observers assigned a grade to each patient, examined independently, on the same day. Forty patients with a unilateral facial palsy of varying aetiology and severity were assessed. Of the 120 judgements, eight were in dispute, by a maximum of one grade, giving an inter-observer reliability of 93 per cent. We conclude that the House and Brackmann grading system is a simple and robust method of assessing facial function.

Clinical correlates of acoustic neuroma morphology

Thirty-eight patients with vestibular schwannomas were reviewed. A correlation was found between tumour morphology and clinical presentation. Based on our knowledge of the variability in the neurilemmal-neurologlial junction and therefore the site of origin of these tumours in relation to the internal auditory canal, a classification into three different appearances on magnetic resonance imaging was possible. Dumbbell shaped tumours (21 per cent) represented laterally arising schwannomas, lollipop shaped tumours (18 per cent) were medially arising and cone shaped tumours (61 per cent) were the more common intermediate form. Patients with laterally arising dumb-bell shaped tumours were more likely to present early with hearing loss and had smaller tumours than patients with medially arising lollipop shaped ones. The relatively well preserved hearing in patients with medially arising tumours made them more likely to present at a later stage with signs of trigeminal compression, cerebellar dysfunction and raised intracranial pressure.