Vestibulopathy Following Microsurgical Resection of Vestibular Schwannoma—The Forgotten Symptom

Introduction: While roughly half of patients presenting with vestibular schwannoma (VS) experience some form of vestibular dysfunction, it is rarely the most prominent symptom. For patients undergoing microsurgery (MS), immediate postoperative vestibulopathy is common but has received less attention than facial nerve and hearing outcomes. Thus, the effect of VS resection on preexisting vestibulopathy remains poorly understood. We aimed to elucidate the effects and role of MS on vestibulopathy related to VS by examining the existing literature. Doing so is critical to shared decision-making with patients under consideration for MS relative to other potential treatments.

Methods: Studies addressing vestibulopathy in VS were identified using the PubMed Database based on MeSH and tiab terms from May 2023 to June 2023. Papers were restricted to the following inclusion criteria: published in years 2000–2023 (to reflect modern-era MS practice), English language, peer-reviewed. Additional studies were identified from a secondary review of reference lists. Data from the included sources of evidence was charted independently using Microsoft Excel.

Results: A total of 28 papers that met the criteria were included in this scoping review of the literature. The incidence of long-term postoperative vestibulopathy was reported in six studies, with all but one study reporting persistent vestibulopathy in the majority of patients undergoing MS (ranging 72–86%). Most papers also concluded that vertigo is a strong influencer of negative quality of life following surgery, including depression and lower social functioning. These papers did not compare the quality of postoperative vestibulopathy to a preoperative baseline to assess for improvement, but rather addressed vertigo on a binary scale. Predictors of postoperative vestibulopathy included the magnitude of preoperative canal paresis, caloric preservation, and sex. Four studies uniformly concluded that female sex is associated with worse compensation postoperatively. Other predictors such as patient age, tumor size, severity of symptoms, and headaches had conflicting evidence on the impact of these variables on vestibulopathy long term. Five papers found that postoperative vestibular rehabilitation has the potential to improve symptoms of vestibulopathy. For patients with vestibulopathy preoperatively, six studies report that a majority of patients were stable or experienced improved vestibulopathy compared with baseline. In the long term, 5–30% of patients report feeling better, and 21–32% report feeling worse. Of patients presenting with severe or disabling vertigo, 88–93% report resolution of symptoms. Three papers investigated whether dizziness should direct treatment modality and found no significant difference across groups, suggesting that dizziness should not be used to direct MS versus radiosurgery versus observation.

Conclusion: Vestibulopathy is a common symptom post-MS for VS. There is a relative paucity of evidence on the ability to improve pre-existing vestibulopathy with MS, other than potentially for patients that present with disabling vertigo where there is evidence to support the use of MS for alleviation of symptoms. Postoperative vestibular rehabilitation may play a role in improving the quality of vestibular function. Few articles evaluated the severity of preoperative and postoperative vestibulopathy to determine evolution of symptoms, but rather most draw conclusions based on the binary presence of vertigo.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024