Acoustic Neuroma: Advances in Treatment and Detection
Ashkan Monfared, Associate Professor of Surgery and Neurosurgery at the George Washington School of Medicine & Health Sciences, and Director of Otology and Neurotology at The George Washington Medical Faculty Associates discusses acoustic neuroma and the recent advances in treatment and detection.
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Learn more about Ashkan Monfared, MD
Ashkan Monfared, MD
Ashkan Monfared, MD is board-certified in Otolaryngology and was recruited from Stanford University to serve as the Director of Otology and Neurotology. Dr. Monfared is also an associate professor of surgery and neurosurgery at the GW School of Medicine & Health Sciences. He completed his medical training, residency and fellowship at Stanford University Medical Center. Previously he has served as staff surgeon in Otolaryngology at Stanford University Hospital and Santa Clara Valley Medical Center. He has had the distinct honor of serving at Veteran Administration Hospital and Walter Reed National Medical Center.Learn more about Ashkan Monfared, MD
Transcription:
Dr. Mike Smith (Host): Hearing loss, ringing in the ear, and unsteadiness can all be caused by acoustic neuroma. Welcome to The GW Hospital HealthCast. I'm Dr. Mike Smith, and today's topic, acoustic neuroma; advances in treatment and detection. My guest is Dr. Ashkan Monfared. Dr. Monfared is Associate Professor of Surgery and Neurosurgery at the George Washington School of Medicine and Health Sciences. Dr. Monfared, welcome to the show.
Dr. Ashkan Monfared, MD (Guest): Glad to be here.
Host: So acoustic neuroma. I have a feeling there's a few audience members who probably have never heard of that, so how about give us a nice overview of what is an acoustic neuroma?
Dr. Monfared: Certainly. So acoustic neuromas are very rare tumors. They're benign, as in they're not cancerous, they don't travel to anywhere else in the body, and they're a growth that happens to the nerves of hearing and balance. They usually cause progressive slow hearing loss in one ear, they may cause tinnitus, which is hearing any external sounds in the ear, and they can cause balance problems over time. They're extremely rare, they happen to about 1 in 100,000 people.
Host: And so some of those symptoms you mentioned though could be lots of different things, right? So could you run through some of those symptoms again? And when should somebody go seek help or go see their doctor if they're having some of those symptoms?
Dr. Monfared: Certainly. The majority of the time when you have these symptoms, they are caused by other conditions. For example, if you have hearing loss in only one ear, the great majority of the time that is something as simple as earwax, for example, or fluid in the middle ear. Same goes for having ringing in the ear. A very, very small fraction of patients who have ringing in one ear may have an acoustic neuroma. Now if a person has constellation of progressive hearing loss only in one ear, ringing sounds in one ear, balance issues, or vertigo attack, which is a sensation of movement that the patient may have, facial numbness, as in they touch their face and they can't feel it as well as the other side, or facial paralysis. So they're no longer able to move the face. These are all worrisome symptoms if they come in as a group together. The best thing always is to seek help. If you suddenly lose hearing, it's always an emergency because it can be from a nerve loss rather than a conduction problem such as having wax or fluid in the ear. But if there's progression of symptoms, you can always seek help from a regular doctor and they will lead you to see an ear, nose, and throat doctor, a hearing specialist, and we'll take on the diagnosis and management from there.
Host: With some of these symptoms, for instance the hearing loss, is it normally something that develops slowly over time? Or can it be acute?
Dr. Monfared: So in rare circumstances, the hearing loss from acoustic neuromas can be sudden, but that's a minority of the cases. However, in every patient with loss of hearing suddenly from what we call a nerve loss, as in it's not from the conduction mechanism of the ear, we do obtain an MRI to look for one of these acoustic neuromas. But in the great majority of the time, it's a progression of hearing loss only in one ear, unlike for example age-related or noise-related hearing loss, which more often than not happens to both ears. These acoustic neuromas cause hearing loss in one ear.
Host: Okay, so hearing loss over time in one ear, maybe some facial numbness, the ringing in the ear, and maybe some unsteadiness, some vertigo type symptoms, and that constellation probably is a good sign that we need to go see our doctor, correct?
Dr. Monfared: Absolutely. Now unfortunately, these tumors can present with very subtle symptoms, but thankfully they are extremely rare. So I don't want to alarm patients that every time they feel ringing in one year, that means they may have an acoustic neuroma. It's not true.
Host: Right, right. Gotcha, gotcha. Okay, so when somebody finally decides to go see a specialist like yourself, how is this worked up? What's involved? How do we diagnose this? And then eventually, what is the treatment for it? But let's start with just kind of like the workup for it.
Dr. Monfared: Certainly. So the good news is we have MRI scans, and MRI scans with and without contrast can detect these tumors as small as about one millimeter, which is about 1/16 of an inch. So our detection of these tumors have dramatically increased over the past thirty years when we had to use imaging like CT scans with contrast which could see them down to about a centimeter, but now we can see them a tenth of that size. So if a patient presents with worrisome symptoms, for example one-sided hearing loss that's nerve related, or facial numbness, facial paralysis, we obtain an MRI, which is a magnetic wave imaging system. There's no radiation involved, and we administer contrast usually, and we can see the tumors and we go from there.
Host: Yeah, and all of that can be done, is that usually- I like for my listeners to get an idea of what the experience is like. So by the time they come see a specialist like you, does it take time to get that MRI? What's usually the timeframe?
Dr. Monfared: So the good news of acoustic neuromas is that one, they are benign, as in they're not cancerous, and two, they're very slow growing. They grow by about one to two millimeters per year. So they rarely are an urgent matter. The only time they become an emergency is when they have grown to such a large size that they're compressing the brain and causing issues with the out-flow of the fluid from around the brain. Now when they're smaller, usually by the time they see an audiologist - these are doctors that specialize in hearing - they obtain a hearing test, they see a specialist, we usually order an MRI which can be done within one to two weeks. The MRI is not always pleasant, because as your listeners may know, it's a fairly narrow tube. For patients who are claustrophobic, we may have to provide them with some medication either by mouth or through the vein to calm them down while they're going through the MRI scan. It is a fairly lengthy MRI scan, can take about thirty to forty minutes, so for someone who is severely claustrophobic and they can't be in confined spaces, it can be difficult.
Host: Yes. Yes, but you can help them out with some medication, make the experience a little bit better to get through that.
Dr. Monfared: Of course. We have different levels of help we can provide.
Host: Right. So let's say you do find an acoustic neuroma, you're making that diagnosis, what's the treatment plan at that point? I would assume it's kind of based on the severity of symptoms, how big it is. Kind of run us through how you approach this when it comes time for treatment.
Dr. Monfared: Absolutely. So acoustic neuroma’s treatment is fairly specialized, and it has to be custom tailored to that particular patient. Because thankfully they're a benign tumor and very slow growing, there's no urgency in most cases to provide treatment. For a large group of these patients upon diagnosis, we recommend watchful waiting. That means the patient will see us back again sometimes between six and twelve months later with a new MRI. We compare the two MRIs to see if the tumor has shown any signs of growth. About a third of the patients' tumors do not grow from the time of diagnosis, and these are the patients we will just monitor for years to come, and spread their MRIs farther and farther apart. The other two thirds that either are symptomatic or the tumors are growing over time, we offer them treatment. The treatment comes in two forms. We can offer micro surgery. These are delicate operations that my neurosurgeon and myself, we would make an incision, go into the skull, and remove the tumor. Or stereotactic radiation, and these are radiation that provides a very small dose rays of radiation from different angles around the body, usually done with a cyber knife, which is a robotic arm, or with a gamma knife, which is a dome that the patient goes inside. And these rays of radiation all have very small amounts of energy, and as they're going through the skull and the brain to get to the tumor, they cause very minimal effects on the normal healthy tissue. But because they're all triangulated into the tumor, the tumor sees the summation of all these rays and receives a massive dose of radiation. It is not the same type of radiation we use to provide treatment for many cancers. It's a much lower dose radiation to the surrounding tissue.
Host: So one third of the patients pretty much is just for maybe the rest of their life, you're just watching and following up with a few MRIs. And then it was the two thirds that either there's worsening symptoms and/or growth of the tumor. So that's kind of how we're putting these patients into two broad groups. When it comes to the two thirds where treatment has to be done, what's the outcome? If it's the surgical way versus the radiation way, what can they expect down the line following that treatment?
Dr. Monfared: Certainly. It is an extremely complex algorithm because radiation and surgery have very different effects and very different outcomes in certain words. For example, the down time of a patient with radiation is close to zero. The risk of the patient developing any weakness in their face or facial paralysis is very close to zero. But there's a very small real risk of developing cancers from the radiation. The risk is extremely small, but it is a real risk. Whereas with surgery, patients usually require about a month of down time. They're only in the hospital for about an average of three to five days, but they can't exert themselves too much or take on heavy activity for sometimes around four to six weeks after surgery. There's also risk of facial paralysis and other risks associated with surgery for the surgical group. So what we have to do is go through the algorithm with the patient, and see based on their age, based on the size of the tumor, based on other symptoms that they're having, which one of these two modalities are the better treatment, and then take them through it.
Host: Dr. Monfared, why don't you, just to kind of summarize all this, just tell us what would you like people to know about acoustic neuroma?
Dr. Monfared: Sure. I would like them to know that they're not cancers, they're not brain tumors, they're tumors that grow outside of the brain in the inner ear. I would like them to not forego if they're having the constellation symptoms of one-sided hearing loss, one-sided tinnitus, if their balance is getting affected more and more, and particularly if they're having progressive headaches, facial numbness and facial paralysis to seek care from their primary care at least, and then they would refer them out to experts such as myself, and we can take them through the treatment. I would like them to know that there is a variety of treatment options available to them, and a diagnosis of acoustic neuroma is not a death sentence. It's something that they have a variety of options that they can pursue.
Host: Dr. Monfared, I want to thank you for the work that you're doing, and also thank you for coming on the show today. You're listening to The GW Hospital HealthCast. For more information, go to www.GWDocs.com. That's www.GWDocs.com. I'm Dr. Mike Smith, thanks for listening.
Dr. Mike Smith (Host): Hearing loss, ringing in the ear, and unsteadiness can all be caused by acoustic neuroma. Welcome to The GW Hospital HealthCast. I'm Dr. Mike Smith, and today's topic, acoustic neuroma; advances in treatment and detection. My guest is Dr. Ashkan Monfared. Dr. Monfared is Associate Professor of Surgery and Neurosurgery at the George Washington School of Medicine and Health Sciences. Dr. Monfared, welcome to the show.
Dr. Ashkan Monfared, MD (Guest): Glad to be here.
Host: So acoustic neuroma. I have a feeling there's a few audience members who probably have never heard of that, so how about give us a nice overview of what is an acoustic neuroma?
Dr. Monfared: Certainly. So acoustic neuromas are very rare tumors. They're benign, as in they're not cancerous, they don't travel to anywhere else in the body, and they're a growth that happens to the nerves of hearing and balance. They usually cause progressive slow hearing loss in one ear, they may cause tinnitus, which is hearing any external sounds in the ear, and they can cause balance problems over time. They're extremely rare, they happen to about 1 in 100,000 people.
Host: And so some of those symptoms you mentioned though could be lots of different things, right? So could you run through some of those symptoms again? And when should somebody go seek help or go see their doctor if they're having some of those symptoms?
Dr. Monfared: Certainly. The majority of the time when you have these symptoms, they are caused by other conditions. For example, if you have hearing loss in only one ear, the great majority of the time that is something as simple as earwax, for example, or fluid in the middle ear. Same goes for having ringing in the ear. A very, very small fraction of patients who have ringing in one ear may have an acoustic neuroma. Now if a person has constellation of progressive hearing loss only in one ear, ringing sounds in one ear, balance issues, or vertigo attack, which is a sensation of movement that the patient may have, facial numbness, as in they touch their face and they can't feel it as well as the other side, or facial paralysis. So they're no longer able to move the face. These are all worrisome symptoms if they come in as a group together. The best thing always is to seek help. If you suddenly lose hearing, it's always an emergency because it can be from a nerve loss rather than a conduction problem such as having wax or fluid in the ear. But if there's progression of symptoms, you can always seek help from a regular doctor and they will lead you to see an ear, nose, and throat doctor, a hearing specialist, and we'll take on the diagnosis and management from there.
Host: With some of these symptoms, for instance the hearing loss, is it normally something that develops slowly over time? Or can it be acute?
Dr. Monfared: So in rare circumstances, the hearing loss from acoustic neuromas can be sudden, but that's a minority of the cases. However, in every patient with loss of hearing suddenly from what we call a nerve loss, as in it's not from the conduction mechanism of the ear, we do obtain an MRI to look for one of these acoustic neuromas. But in the great majority of the time, it's a progression of hearing loss only in one ear, unlike for example age-related or noise-related hearing loss, which more often than not happens to both ears. These acoustic neuromas cause hearing loss in one ear.
Host: Okay, so hearing loss over time in one ear, maybe some facial numbness, the ringing in the ear, and maybe some unsteadiness, some vertigo type symptoms, and that constellation probably is a good sign that we need to go see our doctor, correct?
Dr. Monfared: Absolutely. Now unfortunately, these tumors can present with very subtle symptoms, but thankfully they are extremely rare. So I don't want to alarm patients that every time they feel ringing in one year, that means they may have an acoustic neuroma. It's not true.
Host: Right, right. Gotcha, gotcha. Okay, so when somebody finally decides to go see a specialist like yourself, how is this worked up? What's involved? How do we diagnose this? And then eventually, what is the treatment for it? But let's start with just kind of like the workup for it.
Dr. Monfared: Certainly. So the good news is we have MRI scans, and MRI scans with and without contrast can detect these tumors as small as about one millimeter, which is about 1/16 of an inch. So our detection of these tumors have dramatically increased over the past thirty years when we had to use imaging like CT scans with contrast which could see them down to about a centimeter, but now we can see them a tenth of that size. So if a patient presents with worrisome symptoms, for example one-sided hearing loss that's nerve related, or facial numbness, facial paralysis, we obtain an MRI, which is a magnetic wave imaging system. There's no radiation involved, and we administer contrast usually, and we can see the tumors and we go from there.
Host: Yeah, and all of that can be done, is that usually- I like for my listeners to get an idea of what the experience is like. So by the time they come see a specialist like you, does it take time to get that MRI? What's usually the timeframe?
Dr. Monfared: So the good news of acoustic neuromas is that one, they are benign, as in they're not cancerous, and two, they're very slow growing. They grow by about one to two millimeters per year. So they rarely are an urgent matter. The only time they become an emergency is when they have grown to such a large size that they're compressing the brain and causing issues with the out-flow of the fluid from around the brain. Now when they're smaller, usually by the time they see an audiologist - these are doctors that specialize in hearing - they obtain a hearing test, they see a specialist, we usually order an MRI which can be done within one to two weeks. The MRI is not always pleasant, because as your listeners may know, it's a fairly narrow tube. For patients who are claustrophobic, we may have to provide them with some medication either by mouth or through the vein to calm them down while they're going through the MRI scan. It is a fairly lengthy MRI scan, can take about thirty to forty minutes, so for someone who is severely claustrophobic and they can't be in confined spaces, it can be difficult.
Host: Yes. Yes, but you can help them out with some medication, make the experience a little bit better to get through that.
Dr. Monfared: Of course. We have different levels of help we can provide.
Host: Right. So let's say you do find an acoustic neuroma, you're making that diagnosis, what's the treatment plan at that point? I would assume it's kind of based on the severity of symptoms, how big it is. Kind of run us through how you approach this when it comes time for treatment.
Dr. Monfared: Absolutely. So acoustic neuroma’s treatment is fairly specialized, and it has to be custom tailored to that particular patient. Because thankfully they're a benign tumor and very slow growing, there's no urgency in most cases to provide treatment. For a large group of these patients upon diagnosis, we recommend watchful waiting. That means the patient will see us back again sometimes between six and twelve months later with a new MRI. We compare the two MRIs to see if the tumor has shown any signs of growth. About a third of the patients' tumors do not grow from the time of diagnosis, and these are the patients we will just monitor for years to come, and spread their MRIs farther and farther apart. The other two thirds that either are symptomatic or the tumors are growing over time, we offer them treatment. The treatment comes in two forms. We can offer micro surgery. These are delicate operations that my neurosurgeon and myself, we would make an incision, go into the skull, and remove the tumor. Or stereotactic radiation, and these are radiation that provides a very small dose rays of radiation from different angles around the body, usually done with a cyber knife, which is a robotic arm, or with a gamma knife, which is a dome that the patient goes inside. And these rays of radiation all have very small amounts of energy, and as they're going through the skull and the brain to get to the tumor, they cause very minimal effects on the normal healthy tissue. But because they're all triangulated into the tumor, the tumor sees the summation of all these rays and receives a massive dose of radiation. It is not the same type of radiation we use to provide treatment for many cancers. It's a much lower dose radiation to the surrounding tissue.
Host: So one third of the patients pretty much is just for maybe the rest of their life, you're just watching and following up with a few MRIs. And then it was the two thirds that either there's worsening symptoms and/or growth of the tumor. So that's kind of how we're putting these patients into two broad groups. When it comes to the two thirds where treatment has to be done, what's the outcome? If it's the surgical way versus the radiation way, what can they expect down the line following that treatment?
Dr. Monfared: Certainly. It is an extremely complex algorithm because radiation and surgery have very different effects and very different outcomes in certain words. For example, the down time of a patient with radiation is close to zero. The risk of the patient developing any weakness in their face or facial paralysis is very close to zero. But there's a very small real risk of developing cancers from the radiation. The risk is extremely small, but it is a real risk. Whereas with surgery, patients usually require about a month of down time. They're only in the hospital for about an average of three to five days, but they can't exert themselves too much or take on heavy activity for sometimes around four to six weeks after surgery. There's also risk of facial paralysis and other risks associated with surgery for the surgical group. So what we have to do is go through the algorithm with the patient, and see based on their age, based on the size of the tumor, based on other symptoms that they're having, which one of these two modalities are the better treatment, and then take them through it.
Host: Dr. Monfared, why don't you, just to kind of summarize all this, just tell us what would you like people to know about acoustic neuroma?
Dr. Monfared: Sure. I would like them to know that they're not cancers, they're not brain tumors, they're tumors that grow outside of the brain in the inner ear. I would like them to not forego if they're having the constellation symptoms of one-sided hearing loss, one-sided tinnitus, if their balance is getting affected more and more, and particularly if they're having progressive headaches, facial numbness and facial paralysis to seek care from their primary care at least, and then they would refer them out to experts such as myself, and we can take them through the treatment. I would like them to know that there is a variety of treatment options available to them, and a diagnosis of acoustic neuroma is not a death sentence. It's something that they have a variety of options that they can pursue.
Host: Dr. Monfared, I want to thank you for the work that you're doing, and also thank you for coming on the show today. You're listening to The GW Hospital HealthCast. For more information, go to www.GWDocs.com. That's www.GWDocs.com. I'm Dr. Mike Smith, thanks for listening.