Experts sit on a Triological Society panel at COSM 2015.
Explore This Issue
June 2015BOSTON—Otolaryngologists gathered in Boston at the Hynes Convention Center for the Combined Otolaryngology Spring Meetings, a conference of the annual meetings of nine head and neck societies, held April 22-27.
In session rooms, attendees learned about the latest research and technology, debated current issues in the field of otolaryngology, and listened to advice from veteran leaders. In the hallways and in the exhibit hall, attendees caught up with colleagues from faraway institutions and made new connections.
Ohad Hilly, MD, an otolaryngologist with Sunnybrook Health Sciences Centre in Toronto, Ontario, said his main interest was learning the newest information. “What is the new research?” he said. “What are the new things being done? It gives new ideas.” Networking is also an important part of the meeting, he said.
What attendees learn at COSM can alter what they do in their clinics back home. “I’m in pediatrics, so I’m looking at pediatric outcomes specifically to see what other institutions are doing compared to what my institution is doing,” said Terri Giordano, DNP, clinical outcomes research director at Children’s Hospital of Philadelphia. “You definitely can come away with information that can change your practice, because there might be places that are doing things better than the way you’re doing things.”
Triological Society Presidential Address
In his address during the annual meeting of the Triological Society, Derald Brackmann, MD, the society’s president, clinical professor of otolaryngology at the University of Southern California, and neurotologist at the House Clinic in Los Angeles, recalled an era when treatment of vestibular schwannomas differed from today.
Uttam Sinha, MD, delivers the Joseph H. Ogura Lecture to the audience on opening day of the
Triological Society’s annual meeting.
When he first began working as a neurotologist in 1970, the approach was straightforward. “Life was wonderful and simple back in those days,” he said. “When you diagnosed an acoustic neuroma, it was almost—bam—you just took it out. You had a tumor; you had no idea what the natural history was going to be, so it was removed.”
As technology and diagnostics have advanced, that’s no longer the case.
A review of cases from the House Clinic published in 2014 and covering 114 patients with an average follow-up of 6.4 years and up to 18.5 years, shows the benefits of a conservative approach (Otol Neurotol. 2014;35:1258-1265). A total of 38% of the tumors grew more than 2 mm, with only 31% receiving further treatment. Of patients with Class A hearing at the time of diagnosis, 85.7% retained serviceable hearing.
Dr. Brackmann said those kinds of figures bolster the case against rushing in and removing tumors. “If you had good hearing at diagnosis, the majority of them maintained good hearing,” he said. “So if you have a tumor, the first thing to do is to not—like we did in the old days, jerk reaction—take it out. That’s not reasonable anymore.”
He noted, however, that hearing did decline even among those whose tumors didn’t grow. “If tumors grow or not for reasons that are not understood, hearing does decline,” he said. “So that’s something to consider when you’re making recommendations for treatment.”
In a study out of Denmark, a country in which all tumors are treated at the same center, allowing for a large cohort of more than 2,000 patients, there is further evidence in favor of observation, he said (Otol Neurotol. 2010;31:271-275). At the center, tumors larger than 2 cm are treated immediately. If they’re smaller than 2 cm, they’re observed. “And only 20% of their tumors grew that required treatment,” Dr. Brackmann said. “They did have deterioration of hearing, but, like our study, those who had normal hearing at diagnosis had hearing preservation over the long term.”
At the House Clinic, observation is the course taken in elderly patients with small or medium-sized tumors, and for small and medium tumors with poor hearing at any age. Treatment is given if the tumors exhibit growth, Dr. Brackmann said. Exceptions are made for large tumors and in cases of small tumors in young patients, he added.
Indications for stereotactic radiation are patients with a poor surgical risk due to age or medical condition who have a growing tumor of smaller than 3 cm, tumors smaller than 3 cm with little doubt of the diagnosis after imaging, and younger patients who refuse to undergo surgery.
Attendees gather outside the exhibit hall at COSM 2015.
Dr. Brackmann noted that much of the push for gamma knife surgery performed upon diagnosis of vestibular schwannomas stems from a study out of France led by Jean Regis, MD, professor of neurosurgery at Aix Marseille University (J Neurosurg. 2013;119 Suppl:105-111). In the study, 47 patients treated with a “wait and see” approach had an average follow-up of 43.8 months. Tumor growth or hearing deterioration constituted a failure, according to the study’s parameters. Another 34 patients underwent gamma knife surgery. A total of 35 of the 47 (74%) wait-and-see patients experienced tumor growth and required treatment. Only one of the 34 patients (3%) in the surgery group had an outcome considered a failure.
“He [Dr. Regis] points out that [patients] in the wait-and-see category had poorer hearing preservation than those who received gamma knife and, based upon that, he says you ought to treat them at diagnosis—and neurosurgeons worldwide feel that the minute a tumor is diagnosed you should treat them,” Dr. Brackmann said. “I disagree with that.”
Part of the problem is the strict definition of failure in the study, he said. Additionally, other results show that there is reason to use a more conservative approach. “There’s a lot of inconsistency,” Dr. Brackmann said.
A study out of the Mayo Clinic reviewed long-term hearing preservation, with 44 patients followed up to nine years after undergoing radiosurgery—82% of the patients lost hearing over the follow-up period. “It’s becoming more and more apparent,” Dr. Brackmann said, “that radiosurgery is not a hearing conservation procedure.”
Thomas Collins is a freelance medical writer based in Florida.