OBJECTIVES: Hearing preservation after vestibular schwannoma (VS) surgery remains a surgical challenge. In some patients with preserved inner ear function, hearing improvement is achievable. As it is currently impossible to determine which patients will present this outcome, predictions must rely on previously published reports. Our case report describes a patient who experienced hearing improvement from an unuseful level to a useful one after vestibular schwannoma surgery. METHODS: Surgery was performed via suboccipital retrosigmoid approach. The patient underwent a basic audiovestibular protocol before and after the surgery - pure tone and speech audiometry, otoacoustic emissions, auditory brainstem responses, electronystagmography - together with a detailed questionnaire study. Usefulness of hearing was evaluated using the AAO-HNS guidelines, supplemented by a frequency of 4 kHz. RESULTS: Hearing was preserved and even improved from an unuseful level to a useful one. Based on the available literature, the most informative predictive factors for such a result seem to be: sudden sensorineural hearing loss prior to surgery, elicitable otoacoustic emissions and the origin from the superior vestibular nerve. CONCLUSION: There are a limited number of studies on this topic and it is still impossible to regularly improve hearing in properly selected patients. Furthermore, the importance of postoperative hearing quality compared to other symptoms and complications remains debatable.
- MeSH
- audiometrie čistými tóny MeSH
- lidé MeSH
- retrospektivní studie MeSH
- sluch fyziologie MeSH
- vestibulární schwannom * komplikace chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- kazuistiky MeSH
- přehledy MeSH
AIMS: Preoperative chemical vestibular ablation can reduce vestibular symptoms in patients who have gone through vestibular schwannoma resection. The goal of this study was to determine whether chemical vestibular prehabituation influences the patients' post-operative perception of visual stimulation, mental status and quality of life. We also tried to find out whether increases of optokinetic nystagmus, measured by routine electronystagmography, correlate with subjective symptoms. METHODS: We preoperatively administered (2 months prior to surgery) 0.5 - 1.0 mL of 40 mg/mL nonbuffered gentamicin in three intratympanic instillations in 11 patients. Head impulse and caloric tests confirmed reduction of vestibular function in all patients. The control group consisted of 21 patients. Quality of life in both groups was evaluated using the Glasgow Benefit Inventory, the Glasgow Health Status Inventory and the Dizziness Handicap Inventory questionnaires. Visual symptoms and optokinetic sensation were evaluated using a specific questionnaire developed by our team and by measuring gains preoperatively and postoperatively in both groups using routine electronystagmography. The psychological profile was evaluated using the Zung Self-Rating Depression Scale and the Generalised Anxiety Disorder Assessment questionnaires. RESULTS: There were no statistically significant differences between both groups with regards to the results of the questionnaires. Patients who received preoperative gentamicin were less sensitive to visual stimulation (P<0.10) and many of them had a significantly higher gain in the optokinetic nystagmus than the control group in the preoperative stage. CONCLUSION: Pre-treatment with gentamicin helps to lower anxiety levels in patients and improves their general postoperative status. Pre-treated patients are also less sensitive to optokinetic stimulation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03638310.
- MeSH
- antibakteriální látky aplikace a dávkování MeSH
- čití, cítění fyziologie MeSH
- dospělí MeSH
- gentamiciny aplikace a dávkování MeSH
- kvalita života psychologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- pooperační období MeSH
- předoperační péče * MeSH
- průzkumy a dotazníky MeSH
- senioři MeSH
- vestibulární aparát chirurgie MeSH
- vestibulární schwannom chirurgie MeSH
- zraková ostrost fyziologie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
INTRODUCTION: Hearing loss is the most frequent sensory disorder and is genetically extremely heterogeneous. By far the most frequent cause of nonsyndromic autosomal recessive hearing loss (AR-NSHL) are biallelic pathogenic mutations in the GJB2 gene causing DFNB1. The worldwide search for the second most common type of AR-NSHL took almost two decades. Recently reported alterations (mostly deletions) of the STRC gene, also named DFNB16, seem to be the second most frequent cause of AR-NSHL. Genetic testing of STRC is very challenging due to the highly homologous pseudogene. Anecdotal evidence from single patients shows that STRC mutations have their typical audiological findings and patients usually have moderate hearing loss. The aim of this study is to discover if audiological findings in patients with biallelic pathogenic mutations affecting STRC have the characteristic features and shape of audiological curves and if there are genotype/phenotype correlations in relation to various types of STRC mutations. METHODS: Eleven hearing loss patients with pathogenic mutations on both alleles of the STRC gene were detected during routine genetic examination of AR-NSHL patients. Audiological examination consisted of pure tone audiometry, stapedial reflexes, tympanometry and otoacoustic emission tests. RESULTS: The threshold of pure tone average (PTA) was 46 dB and otoacoustic emissions were not detectable in these DFNB16 patients. All patients were without vestibular irritation or asymmetry. CONCLUSION: Moderate sensorineural hearing loss is typical for DFNB16-associated hearing loss and there are no significant differences in audiological phenotypes among different types of mutations affecting STRC.
- MeSH
- alely MeSH
- audiometrie MeSH
- dítě MeSH
- dospělí MeSH
- genetické asociační studie MeSH
- hluchota genetika MeSH
- jednonukleotidový polymorfismus genetika MeSH
- konexiny genetika MeSH
- lidé MeSH
- membránové proteiny genetika MeSH
- mezibuněčné signální peptidy a proteiny genetika MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mutace genetika MeSH
- percepční nedoslýchavost diagnóza genetika MeSH
- polymerázová řetězová reakce MeSH
- sekvenční delece genetika MeSH
- sluchové testy MeSH
- Check Tag
- dítě MeSH
- dospělí MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE: Vestibular schwannoma removal causes unilateral vestibular deafferentation, which results in dizziness and postural unsteadiness. Vertigo and balance problems together are among the most important aspects affecting quality of life. Intensive vestibular rehabilitation, which starts before surgery, with following postsurgical supervised rehabilitation, using visual biofeedback propose an instrument to accelerate a recovery process. Another option how to accelerate the vestibular compensation, is employment of presurgical gentamicin ablation together with vestibular rehabilitation (prehabilitation) of vestibular function. Purpose of present study was to examine the dynamics of vestibular compensation process using supervised intensive vestibular rehabilitation with visual biofeedback in the short-term postsurgical period. The second aim was to compare both studied groups mainly to evaluate if prehabilitation has potential to accelerate the compensation process in the early postoperative course. METHODS: The study included 52 patients who underwent the retrosigmoid vestibular schwannoma removal. They were divided into two groups. The first group was prehabilitated with intratympanic application of gentamicin before surgery to cause unilateral vestibular loss (14 patients), the second group (38 patients) was treated in standard protocol without prehabilitation. All patients underwent at home vestibular training before surgery to learn new movement patterns. Following the surgery supervised intensive vestibular rehabilitation including visual biofeedback was employed daily in both groups between the 5th and 14th postoperative day. Outcome measurements included an evaluation of subjective visual vertical (SVV), posturography and the Activities-Specific Balance Confidence Scale (ABC). ANOVA for repeated measurements was used for statistical analysis. RESULTS: We observed significant improvement in SVV (p < 0.05), posturography parameters (p < 0.05) and ABC scores (p < 0.05) with postoperative rehabilitation program following surgery in both groups. There was no statistically significant difference between group treated by prehabilitation and group without prehabilitation. CONCLUSIONS: Results of this study showed that intensive postsurgical rehabilitation represents key factor in compensation process following retrosigmoid vestibular schwannoma surgery. Prehabilitation did not speed up recovery process.
- MeSH
- kvalita života * MeSH
- lidé středního věku MeSH
- lidé MeSH
- neurorehabilitace metody MeSH
- otologické chirurgické výkony škodlivé účinky metody rehabilitace MeSH
- pooperační komplikace * psychologie rehabilitace MeSH
- premedikace metody MeSH
- vertigo * etiologie rehabilitace MeSH
- vestibulární schwannom chirurgie MeSH
- výsledek terapie MeSH
- závrať * etiologie rehabilitace MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Cílem práce je podat přehled o studiu prediktivních faktorů centrální kompenzace u pacientů po operaci vestibulárního schwannomu. Operace vede u většiny pacientů ke vzniku jednostranné akutní periferní či kombinované vestibulární léze v důsledku chirurgického přerušení obou větví vestibulárního nervu a v některých případech i k poškození mozečku. Pooperačně se stav projevuje poruchami posturální stability, závratí, oscilopsií a někdy i vegetativním doprovodem. Faktory ovlivňující kompenzaci lze rozdělit do několika skupin: jsou to faktory dané stavem pacienta a velikostí tumoru, dále je to stav funkce vestibulárního systému, a v neposlední řadě jsou to faktory navozené terapeutem. Trvání vestibulárních symptomů je závislé především na centrální kompenzaci, při které hraje dominantní roli mozeček. Terapeutickou snahou je rychlé navození kompenzačních mechanismů a zkrácení doby kompenzace. Základním postupem v současné době je časně zahájená řízená vestibulární rehabilitace, která u většiny pacientů vede k rychlejší rekonvalescenci. Nicméně u některých pacientů se i přes veškerou snahu fyzioterapeuta nedaří této kompenzace dosáhnout, což vede k trvalému funkčnímu deficitu projevujícím se nejčastěji posturální instabilitou. Jednou z možností jak urychlit pooperační kompenzaci je provedení předoperační chemické vestibulární ablace, tzv. "prehabituace". Při chemické prehabituaci je aplikováno ototoxické antibiotikum intratympanálně, což vede k funkčnímu výpadku labyrintu, a tím k nastartování kompenzačních mechanismů již v předoperačním období. Prehabituace by hypoteticky měla vést ke snížení intenzity závrati po operaci a ke zkrácení doby centrální kompenzace.
The aim of this study is to consider predictive factors influencing central vestibular compensation in patients who underwent surgery for vestibular schwannoma. Surgical removal of vestibular schwannoma causes acute peripheral vestibular loss due to surgical lesion to both branches of vestibular nerve and in some cases lesion of cerebellum. The postoperative symptoms are postural instability, vertigo, oscillopsia sometimes accompanied with vegetative symptoms. Factors affecting compensation may be divided into several groups. Firstly, general health status of a patient as well as the tumour itself affects the compensation, then actual state of function of vestibular system plays important role. Finally, compensation may be induced by therapist. Central compensation, in which cerebellum plays dominant role, influences duration of the symptoms. Therapeutic aim is to induce compensatory mechanisms as soon as possible and to reduce overall duration of the compensation. Early operated vestibular rehabilitation is currently the basic procedure. It leads to faster recovery in majority of patients. However, in some patients it is difficult to achieve full compensation despite maximum effort of physiotherapist and that results in permanent functional deficit manifesting with postural instability. Chemical prehabituation with gentamicin is one of the options how to achieve this goal. Ototoxic antibiotic is installed intratympanically which causes reduction of vestibular function and helps to start compensatory mechanisms already in preoperative period. Reduction of duration of the whole compensatory process and reduction of intensity of vertigo should be achieved.
- Klíčová slova
- vestibulární kompenzace, vestibulární rehabilitace, chemická labyrintektomie,
- MeSH
- lidé MeSH
- pooperační období MeSH
- pooperační péče metody MeSH
- premedikace metody MeSH
- rehabilitace * metody MeSH
- vestibulární schwannom * chirurgie rehabilitace MeSH
- vnitřní ucho účinky léků MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
- MeSH
- barotrauma diagnóza etiologie MeSH
- Bellova paréza * diagnóza prevence a kontrola MeSH
- cestování letadlem * MeSH
- diagnostické techniky neurologické využití MeSH
- dospělí MeSH
- lidé MeSH
- mozek diagnostické zobrazování MeSH
- nemoci lícního nervu patofyziologie patologie MeSH
- nervus facialis patofyziologie patologie MeSH
- paréza diagnóza MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
- práce podpořená grantem MeSH
Technický rozvoj mikrochirurgie ve 20. století vedl k výraznému snížení mortality a morbidity operační léčby vestibulárních schwannomů. Jedním z hlavních kritérií hodnocení úspěchu operace se stala pooperační funkce lícního nervu. Retrospektivně jsme analyzovali soubor 90 pacientů operovaných v letech 2010–2012 retrosigmoidním-transmeatálním přístupem. Cílem práce bylo zhodnotit faktory mající vliv na pooperační funkci lícního nervu. Kontinuita lícního nervu byla narušena v devíti případech (10 %). V těchto případech byla vždy provedena rekonstrukce. Jako statisticky významné parametry úspěšnosti zachování kontinuity lícního nervu byly stanoveny pozice nervu vůči tumoru, prodloužení a rozprostření nervu do plochy, dále pak cystický charakter nádoru a míra zasahování do vnitřního zvukovodu. Definitivní výborné až dobré funkce (1.–3. stupeň dle House-Brackmanna) dosáhlo 96 % pacientů, u kterých byl lícní nerv zachován. Ve skupině pacientů po rekonstrukci dosáhlo dobré funkce 67 % pacientů. Závěrečný stimulační práh determinoval časný pooperační výsledek. Neprokázali jsme však vztah mezi výsledkem a definitivní funkcí lícního nervu. V současné době se daří zachovat kontinuitu lícního nervu u většiny operovaných pacientů. Je potřeba definovat prognostické faktory, které jsou spojeny se zvýšeným rizikem poškození lícního nervu, a implementovat tyto faktory do rozhodování o vhodné léčebné strategii.
Technological development in microsurgery during the 20th century has led to a significant decline in mortality and morbidity of surgical management of vestibular schwannoma. Postoperative facial nerve function is among the main criteria of success. A retrospective analysis focused on 90 patients undergoing retrosigmoid-transmeatal surgery of vestibular schwannoma during 2010–2012. The aim of the study was to evaluate perioperative factors associated with postoperative facial nerve function. Facial nerve was discontinued in nine cases (10%) and was subsequently reconstructed. The position of the facial nerve to the tumor, morphological changes (e.g. elongation and splaying), cystic component of a tumor and an extent of tumor growth into the fundus of the internal acoustic meatus were among the parameters affecting facial nerve preservation. Definitive excellent to good function (House-Brackmann grade 1–3) was achieved in 96% of patients in the group with preserved facial nerve continuity. There was 67% of patients with good definitive postoperative function in the facial nerve reconstruction group. Stimulation threshold at the end of the surgery brought no significant information about definitive function of the facial nerve but it predicted early postoperative outcome. At present, the facial nerve continuity can be preserved in the vast majority of surgically managed vestibular schwannomas cases. It is crucial to define prognostic factors influencing the facial nerve injury outcome and include them into a decision-making protocol. Equally, it is necessary to define factors leading to unfavorable outcomes of the facial nerve function despite its anatomical preservation.
