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Pro Otology
Balkan Journal of Otology & Neuro-Otology, Vol. 2, No 2:60-65 © 2002
All rights reserved. Published by Pro Otology Association

Quality of Life of the Patients after
Vestibular Schwannoma Surgery

V. Gerganov, K. Romanski, V. Bussarsky, Il. Iliev

Department of Neurosurgery, University Hospital "Alexandrovska",
Medical University, Sofia, Bulgaria

ABSTRACT

Objective: Assesses how the operation affected the quality of life of patients with large vestibular schwannomas and investigates the possible predictors of the outcome.
Study design: Analysis of quality of life results obtained by sending a questionnaire, designed for that purpose.
Setting: The Department of Neurosurgery, University Alexander Hospital, Sofia.
Patients: 69 patients with vestibular schwannomas consecutively operated during a five year period .
Results: The response rate is 66%. The average total score is in the group of intermediate quality of life score- 542 of 900 points (60%). No statistically significant relationships were found when we compared quality of life and any of the included issues.
Conclusion: The overall quality of life of the patients after vestibular schwannoma surgery is reduced. The lower quality of life is a consequence of the impact of a large number of issues that should always be taken into account by the surgeon. Patients' expectations should be considered when predicting postoperative quality of life and the patients should be properly informed.
Key words: Quality of life, Vestibular schwannoma, Operative treatment.
Pro Otology 2: 60-65, 2002

INTRODUCTION

In addition to traditional focus on disease outcome measuerements, there is a growing appreciation of the importance of how the patients feel and how satisfied they are with treatment. One of the reasons for the widespread use of quality of life (QOL) measurements is the appreciation of the importance of the impact of the intervention on the life of the patient as a whole, not only on his body. This is especially true for patients with severe, life- treatening or disabling diseases such as those with vestibular schwannomas. The goal of treatment of vestibular schwannomas several decades ago was prolongation of life and avoidance of major complications. Due to the earlier diagnosis and the progress in microsurgery, electrophysiology and neuroanaesthesia (3,17,19,24) functional preservation of facial nerve function and of useful hearing became the goal. The assessment of QOL has supplemented the criteria for successful treatment in recent years (1,8,12). Controversy exists regarding the recommended treatment for patients with small vestibular schwannomas. Immediate operative intervention, using one of several possible operative approaches, stereotactic radiosurgery and initial conservative treatment have all been advocated. Proper evaluation of these options should include not only patient` survival and complication rates but also the impact on overall QOL (21).

The goal of our study is to assess how the operation affected the QOL of the pateints with large vestibular schwannomas and to investigate the possible predictors of the outcome.

MATERIAL AND METHODS

Clinical features of the patients

During the period 1996-2000 69 patients with vestibular schwannomas have been operated at the Department of Neurosurgery, University Alexander Hospital. 98% of them had grade IV tumor (11). The preferred operative approach was the suboccipital retrosigmoid - in 96%. Six of the operated died in the early postoperative period. The minimal follow- up period was 18 months and the maximal - 68 months (average- 48 months). The patients with bilateral vestibular schwannomas (4 patients) were excluded from the study group. 59 questionnaires were sent by post mail.

Methods

A QOL assessment questionnaire, developed by Schwartz MS, et al. (21) was used. The questionnaire conisists of nine domains, concerning functional issues, as well as the psychological and social functioning- headaghe, facial nerve function, hearing, tinnitus, vertigo or dizziness, activity level, employment, enjoyment of life and emotional well - being. Every question has 5 possible answers, ranging from 0 (worst) to 100 (best). Global score, as well as domain scores were calculated and analysed. Good QOL had the patients with 675 - 900 points, moderate - those with 450 - 675 points, bad- 225 - 450 and very bad - below 225 points.

FIG. 1. QOL scores in the particular domains.

FIG. 2. QOL in the different age groups.

The facial nerve function was assessed by sending to the patients a facial nerve function questionnaire. The questionnaire was developed by Brackmann and Barrs (2) in 1984 in an attempt to obtain objective measures of facial function. It consists of a series of questions, both qualitative and quantitative. The results are graded in percents - 100% (normal function), 75%, 50%, 25% and 0% (no facial motion).

An open question gave the patients the opportunity to describe the most serious problems according to their point of view.

RESULTS

The questionnaire was completed correctly and returned by 37 of the patients - response rate 66%. All patients answered to the questions in both the questionnaires. Answers to the open question gave only 27%. Therefore these data were not further analysed.

The average age of the patients was 50 years, ranging from 23 to 74. 59% were female and 41 - male. Right sided tumors had 43% and left sided - 57% of the patients. 3 of the patients died 1 to 3 years after the operation. Total tumor removal was achieved in 16 cases (43%), subtotal - in 13 (35%) and partial - in 8 (22%). The removal was accomplished in one stage in 22 of the cases (60%) and in several stages - in 15 (40%). The age distribution of the patients is shown on Table 1.

The average QOL global score is 542 points (60%). The distribution in the particular domains is shown on Figure 1. Maximal results are obtained in the domains headache, activity level, tinnitus, vertigo and enjoyment of life.

The QOL scores in the different age groups are presented on Figure 2.

The QOL distribution in the particular domains in relation to the age is presented on Table 2.

Facial nerve function is presented on figure 3. In 11% of the cases the facial function restored completely. In 43% total palsy was the end result.

The patients with complete lesion had the worst QOL score - 437 points. The patients with partially preserved function are in the group of moderate QOL - 550 - 682 points. The relationship QOL: facial nerve function is presented on Table 3.

The analysis of the relation between the facial function and the particular domains showed lower scores in the domains hearing, vertigo, activity level and emotional well - being.

The relation between the surgical aggressiveness and QOL was also analysed. The results are presented on Figure 4.

The analysis in the particular domains showed no significant differences in relation to surgical aggressiveness. The percentage of preserved facial nerve function as a consequence of surgical aggressiveness is presented on Figure 5. In the group of total removal the percentage is 23%, in the group with subtotal - 38% and in that with partial - 23%.

The global QOL score after one- stage tumor removal (525 points) is almost identical to that in cases of staged removal (565 points). There is no difference in the particular QOL domains either. The percentage of facial nerve preservation is higher in the cases operated in one stage - 38%, than in those requiring reoperations - 23% (Fig. 6). Normal facial function (100%) is achieved in 14% of the cases, operated in one stage and only in 6,6% in the reoperations.

DISCUSSION

Despite the great improvements in the treatment of vestibular schwannomas (3,17,19,24) they still remain a challenge to the neurosurgeons. Their treatment exposes the patients at the risk of acquiring serious neurological deficits. The objective measures of outcome, such as the Glasgow Outcome Scale or the Karnofsky Performance Scale are physician-oriented global assessment tools. They measure the biological consequences of the treatment. Frequently the assessment of the physician, regarding some kind of deficit, does not match the assessment of the patient. The patients` perspective on the various aspects of recovery are not well accounted for. QOL measurements are increasingly used to supplement objective clinical and biological measures of disease outcome. They are used to measure the quality of the service, the need for health care, the effectiveness of different kinds of interventions and for cost utility analysis (4,7). Fifteen years ago there were almost no articles devoted to the problem QOL. Now more than 1500 new articles are published annually (15).

In order to provide significant information QOL tools must possess the following features (7):

-validity - does the instrument measure what it is intended to measure?

-appropriateness and acceptability - is the instrument suitable for its intended use?

-reliability - does it produce the same results when repeated in the same population?

-sensitivity to change - does the measure detect clinical meaningful changes?

-interpretability - can results from the measure be interpreted clinically and are they relevant?

FIG. 3. Facial nerve function. FIG. 5. Percentage of facial nerve function preservation in relation to surgical aggressiveness.

FIG. 4. QOL in relation to surgical aggressiveness. FIG. 6. Relation facial nerve function - tumor removal in one or several stages.

For a measure to have a clinical usefulness it should not only fulfill the above mentioned criteria. It must be simple, quick to complete, easy to score and provide useful data (7,20). It should be patient - oriented, self- assessment questionnaire. The assessment tool should include questions concerning not only the physical functioning, but also the social and psychological aspects of the daily activities.

Two types of assessment tools are used - general measurement tools and condition - specific studies. General measurement tools measure features that are important to all patients not only for those with a particular disorder. They are applied to a lot of healthy people and a reference series of population norms is available (5). Their disadvantage is that they cannot measure the different consequences on QOL, caused by a specific disorder.

Questionnaire techniques exhibit several methodological shortcomings and limitations (8,16). The issue of overall QOL measurement following acoustic neuroma surgery was first explored by Weigand and Fickel (23) in 1989 in an open-ended-question study, that was sent to the members of the American Acoustic Neuroma Association. The authors found that patients were bothered not only by cranial nerve dysfunction but also by a variety of physical, psychological, and social problems, including depression, anxiety, headache, sleep disturbance, fatigue, dental problems, and speech or swallowing difficulties. The methodological disadvantage of that study was that the data were significantly skewed by the selection of a patient group, in which the patients were involved with a self-help organization. They used an open-ended questions that complicated the accurate statistical analysis. An adaptation of the questionnaire of Wiegand was used to study outcomes of a more complete patient series in Denmark (18). Irving, et al. (9), used a questionnaire adapted from the European Organization for Research into the Treatment of Cancer core questionnaire. It is based on an instrument designed to assess QOL after cancer treatment and is not sufficiently sensitive to the symptoms after vestibular schwannoma treatment. Nikopoulos, et al. (16) used the Glasgow Benefit Inventory, which is a patient- oriented tool, designed to measure QOL after otorhinolaryngological interventions. Da Cruz MJ, et al. (5) applied the Short Form 36- a patient - oriented self-assessment general measurement tool. They assessed life issues important to all patients, not just for those with vestibular schwannomas. Latter on Martin HC, et al. (14) and Kelleher MO, et al. (10) used the same tool and stated that general QOL measures should be used to assess outcome and to draw comparisons between different populations.

The questionnaire that we used in our study was developed as a condition - specific tool for measurement of QOL after vestibular schwannoma surgery by Schwartz, Riddle, et al. (21). It is based more directly on an instrument developed by Hassan and Weymuller (6, 22) to evaluate QOL after treatment for head and neck cancer. This questionnaire is designed to determine not the presence of various symptoms or life issues. It evaluates the effects that these symptoms or life issues have on the patient's ability to continue functioning normally. By directly asking patients about the perceived effects of operative consequences on QOL, the examiner is released from the need to infer QOL from the presence of symptoms reported by patients. Because the questionnaire was specifically developed to measure QOL in patients with vestibular schwannomas, the majority of questions concerned problems specific to this pathological process. The remainder of the questions concerned more general issues that affect QOL.

A limitation inherent to all QOL measures is that they will never capture all aspects of life that are important to an individual (7). The perception of QOL varies between individuals and is dynamic within them. People with different expectations will report of having different QOL even when they have the same clinical condition. People whose health has changed may report the same QOL when measured repeatedly (4). The QOL depends among other things upon the cultural features and financial status of the patients. Another shortcoming is the risk that the patient population may be skewed. It may be speculated that the patients that replied to our questionnaire are not a representative sample, eg. that the patients with worst outcome did not have the ability to reply.

In an attempt to overcome the last problem we compared the features - epidemiological and clinical, of the studied group with the corresponding features in the group of patients operated for vestibular schwannomas in our department during the period 1991 - 2000. We did not found any significant differences in both groups -neither between the age or sex distribution, side or size of the tumor, nor between the issues concerning their treatment. We included in the studied group only the patients with a minimal follow-up of 18 months in order to exclude the early complications of treatment, such as CSF leakage, infections, meningitis etc.

The response rate in our group (66%), is in the same range as that reported by different authors - 65 - 93% (1,5,8,9,23).

The average total score in our group is in the group of moderate QOL score - 542 of 900 points (60%). It is lower than the rate reported by other authors, which is not difficult to explain taking into account that all tumors were grade IV (according to Koos grading scale (11). Although, it is higher than could be anticipated in view of the rate of morbidity among thes e patients. In the patients with large tumors surgery is a life-saving treatment. The survivors tend to accept and adjust to their disabilities.

The average total score in the group of Schwartz, et al. (21) - 645 points (71%), placed the patients in the range of mild, but definite limitations on QOL. Nikopoulos, et al. (16) reported QOL of their patients worse or the same after surgery. Reduced was the QOL also in the group of patients studied by da Cruz MJ, et al. (5). Van Leeuwen, et al. (12) found that the overall state of health was lower for acoustic neuroma patients than for the general population. They concluded that in patients with smaller tumors (< 2.5 cm), the translabyrinthine approach yielded better outcomes than did the suboccipital approach. The results of Martin HC, et al. (14) showed that the QOL of their patients was significantly below published norms and their work capacity was reduced. Contrary to that, Irving, et al. (9) found that, despite a wide range of problems, most of their patients continued to function at a high level following acoustic neuroma surgery. They found a significant difference in functioning between patients with small tumors (< 1.5 cm) and large tumors and, based on this, recommended surgery rather than observation in those patients with small tumors.

Analyzing the QOL results in the different age groups we found that the lowest average total score had the patients in their fifth decade - 464 points (51%). The difference is greatest in the topics tinnitus, vertigo, enjoyment of life and emotional well-being, but is not statistically significant. It is difficult to explain this observation but it might be related to the different expectations from life and from surgery in this most active age group.

Da Cruz et al. (5) similarly found no significant differences in the particular domains of QOL regardless of tumor size, operative approach or patient age. Schwartz, et al. (21) also found very few differences in overall QOL among subsets of the patients included in their study. Patient age and operative approach had no statistical effect on overall QOL. Irving et al. (9) reported that age at operation did not affect the overall postoperative QOL. This is in contrast to the findings of Nikopoulos, et al. (16) that older patients had better QOL. As the authors use different assessment tools, it is impossible to compare their results.

Besides the well known negative influence upon facial nerve function and hearing, vestibular schwannoma surgery influenced most severely the topics employment - 53 points (59%) and emotional well-being - 49 points (54%). The low percentage of normal facial nerve functioning - 11 %, is a consequence of the large size of the schwannomas. Not surprisingly, the patients with total facial palsy had worse QOL score - 434 (48%), but the difference was not statistically significant. Despite the severe problems that might be expected with poor facial nerve function, no significant difference in overall QOL was found between patients with fair or poor facial nerve function compared to those with excellent or good function. Schwartz, et al. (21) and Kelleher et al. (10) reported similar findings. Their explanation is the difference in the expectations of patients with small and large tumors. Because most patients with fair or poor facial nerve function had larger tumors, they may have been more able to reconcile their facial weakness, without perceiving it as a major QOL problem. The patients with large tumors were not so sensitive to any nonideal results.

We did not find correlation between QOL and surgical aggressiveness, as well as between QOL and tumor removal in one or several stages. Total removal led to a lower degree of functioning of the facial nerve - 23%, opposed to the 40% in the cases of incomplete removal. If the patient with less than total removal required a second operation, the degree of preserving of the facial nerve was 23%. In case of one stage removal the degree of preserving of the facial nerve was 38%. The best chances of preserving the nerve are in those cases when it is possible to remove the tumor totally in one stage.

According to Schwartz, et al. (21) the operative approach had no statistical significant effect on overall QOL, although patients who underwent operation via suboccipital approach were more likely to have headache. They found no difference between patients with intracanalicular tumors and those with larger vestibular schwannomas- the overall QOL was worse (although not significantly) for patients with intracanalicular tumors than for those with small (< 2 cm) CPA tumors. The explanations offered by the authors to these findings are insufficient preoperative study of various symptoms or different patient expectations.

Nikopoulos, et al. (16) and Van Leewen, et al. (12) also noted that tumor size does not significantly affect the overall QOL. This is in contrast to the results of Irving et al., who found that tumor size affected the QOL postoperatively. Besides the methodological shortage of the last study, the authors labeled arbitrarily as large tumors all schwannomas greater than 1,5. Nikopoulos et al. (16) and Kelleher et al. (10) in view of the fact that with small tumors the postoperative QOL may be significantly affected and that the tumor size may not have a direct relationship on long-term outcome, suggest a conservative approach with interval MRI for such schwannomas. Although there are not enough evidence for assuming such approach, we accept that management decisions considering the treatment of small tumors should always take into account patient`s personal, social and psychological demands.

CONCLUSIONS

The overall QOL of the patients after vestibular schwannoma surgery is reduced. The lower QOL is not a consequence of one or two serious deficits such as facial nerve palsy or hearing loss. Rather it is the result of interaction of a large number of issues that should always be taken into account by the surgeon. Patients' expectations should be considered when predicting postoperative QOL and the patients should be informed precisely. If the different modes of treatment of schwannomas are to be compared, prospective condition - specific QOL studies in addition to global outcome studies should be designed and cinducted.

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