The Neurotologist as Gamma Knife Radiosurgeon

P. Ashley Wackym, MD, is the John C. Koss Professor and Chairman, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin in Milwaukee.

There are three management options for patients with acoustic neuromas: microsurgical removal, stereotactic radiosurgery, and expectant management. Since there are relative advantages and disadvantages of each and every patient and his or her tumor requires special consideration, it is important that physicians caring for these individuals factor these issues into their counseling. In my practice, I have a strong experience in all three of these management options; the direct experience in performing both microsurgical removal and Gamma Knife® radiosurgery has helped me become much better at both of these techniques. My having this direct experience enables each patient and his or her family to participate in a balanced discussion of these options, which is essential for a true informed consent to proceed with one of the three management options.

Why Should a Neurotologist or an Otolaryngologist Perform Gamma Knife Radiosurgery?

The core group of participants in the radiosurgery team includes a radiation oncologist, a radiation physicist, and a surgeon. While traditionally the surgeon has been a neurosurgeon, because most of the applications are for the treatment of brain metastases and arteriovenous malformations, there is no reason that other surgical disciplines focused on the care of patients with diseases of the head and neck could not use this technology. I first became interested in Gamma Knife radiosurgery because of the treatment of patients with acoustic neuromas. After receiving numerous patient referrals from neurosurgeons, it became clear that they were in no position to manage the complications of treating small to medium-sized acoustic neuromas, including hearing loss, vestibular dysfunction, and facial and trigeminal nerve dysfunction.

In addition, based on my colleagues’ experience and training, and being able to generalize these observations after review of the world’s literature, it was clear that a neurotologist as Gamma Knife radiosurgeon was in a far better place to treat and manage the complications of treatment of acoustic neuromas than a neurosurgeon. As of January 2007, there are 42 neurotologists who have been trained to perform Gamma Knife radiosurgery, according to the International Radiosurgery Association. There is no question that our involvement will change the way patients with skull base diseases are treated.

The next generation of the Gamma Knife technology, termed the Perfexion™, will allow single-day treatment of benign or malignant lesions of the skull base, head and neck and structures down to the clavicles. Consequently, all otolaryngologists should be considering training and performance of Gamma Knife radiosurgery. In addition, there are other forms of stereotactic radiosurgery or radiotherapy that are available and there many neurotologists have been trained and use these systems.