Melanie Cole, MS (Host): Welcome. We have a Northwestern Medicine Physician Roundtable for you today to highlight advancements in acoustic neuroma management, multidisciplinary insights. Today on Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And in this roundtable, we have neuro-otologist, Dr. Mark Wiet; neuro-otologist, Dr. Kevin Zhan; otoneurologist, Dr. Nicholas Hać; and neurosurgeon, Dr. Stephen Magill. Dr. Wiet, I turn it over to you.

Mark Wiet, MD: Thanks for having us today, Melanie. So, let's get started talking about acoustic neuromas. This is really actually probably more common than has previously been thought. You know, previously, I think we thought the incidence of these tumors was about one in 100,000. But it's appearing through a body of literature that the incidence is probably much more common than that, especially as we age. So, Steve, why don't you go ahead and just give us a little overview of acoustic neuroma and then discuss sporadic tumors and NF2.

Stephen Magill, MD: Yeah. So, acoustic neuroma is the third most common non-malignant tumor in the brain. The most common is meningioma followed by pituitary tumors and then schwannomas. And of all schwannomas in the brain, about 95% happen on the eighth nerve. And those are vestibular schwannoma, acoustic neuroma, which are used interchangeably.

In vestibular schwannoma, there's two ways they present. One is sporadic. So usually, that's a unilateral lesion on one hearing nerve. And I know, Kevin, you'll dive into the symptoms a little bit here, but that's by far the vast majority. But an important subset of vestibular schwannomas happen in patients with a disorder called neurofibromatosis type 2. And really, it's the diagnostic feature of neurofibromatosis type 2. And these patients have acoustic neuromas on both sides, which presents a whole lot of challenges, both for the patients from a hearing standpoint and from a management standpoint, because the risk of these tumors is obviously hearing loss. And if you can lose that on both sides, then you're talking about deafness. And that can be very disabling to people's quality of life. So, the management of NF2 is kind of a next level when it comes to vestibular schwannoma and making sure you're doing the right thing for the patient at the right time and really trying to optimize their quality of life as long as possible.

Mark Wiet, MD: Yeah, I know the decision-making can be extremely difficult with that. Kevin, next up, let's talk about some presenting symptoms for these patients. I mean, really, that's one of the key things we want to make sure that the audience understands.

Kevin Zhan, MD: Yeah. Just like Dr. Magill said, you know, this is a tumor that grows on the eighth nerve, which is the hearing and balance nerve. And so, oftentimes, most often, patients will present with hearing and balance problems, right? So, a lot of times, they come to our clinics and ENT clinic just with hearing complaints. They say that their ear is full, or they feel like they've had a sudden or a progressive hearing loss over a period of time, you know, in that they have some ringing or buzzing sounds in their ear, we call that tinnitus. And so, we will perform an audiogram, which is you know, a hearing test, and we look for any kind of asymmetry or imbalance to that. And then, we work that further up with an MRI, and sometimes we do discover these tumors.

And then, of course, the balance symptoms as well, so dizziness, imbalance, vertigo, like the sensation that the room is moving or that you're moving in some way. Those are also presenting symptoms of vestibular schwannoma. And then, of course, when tumors are really large and they're pushing up against the brainstem, you know, patients might experience some, you know, headaches and facial numbness, as well as vision changes, all these kind of things when the tumors are really, really big.

Mark Wiet, MD: Yeah, those are definitely bad signs if they have an acoustic neuroma, they have those sorts of symptoms. So, just kind of like a little caveat, what do you think about ABR and the diagnosis of of acoustic neuroma? I mean, what are your thoughts on that?

Kevin Zhan, MD: Yeah. So, ABR is a special type of hearing test called an auditory brainstem response. You know, in the past, we used to use that more often when we look for an asymmetry to their hearing. But I think today, I would say that the vast majority of physicians would favor just using an MRI to kind of definitively diagnose for vestibular schwannoma, ABR. There are some things that you can see on this specific type of hearing test. But at this point, it's fairly antiquated.

Mark Wiet, MD: Yeah, I mean, there's definitely still uses for ABR in general across, you know, the population that we take care of, but it's not the first test we typically go to when we're considering a tumor in this cerebral pontine angle. So, the most common scenario when these patients are referred to us is typically there's hearing loss or tinnitus. They either present to ourselves or to an outside physician, primary care doctor, and then are referred to otolaryngologist. And otolaryngologsist are Ear, Nose, and Throat physicians. Typically, they undergo an audiogram, get the MRI, as you mentioned, and then are referred to us. But there can be sometimes these tumors, we'll find them incidentally. So, neurologists will find them incidentally in the workup for a variety of symptoms, and they'll get referred to us, because the tumor was identified. Typically, they're small in that case. And we'll work them up and talk to them about a variety of options that they have in the management of the tumor. But like you mentioned, headache can be a symptom of acoustic neuroma, although we don't want to overemphasize that, really, the main symptoms that these patients have are hearing loss and tinnitus, that's how they present.

 There's a few interesting cases, you know, that I've seen recently. One of them was a patient of mine that actually has a cholesteatoma. And I noticed that on his audiogram there was some sensory dysfunction of his inner ear. And I thought it would be a good idea to check an MRI and he happened to have an acoustic neuroma on the same side of his cholesteatoma, which, you know, it's very unusual that something like that can happen, but occasionally it does. It's not the first time I've seen that.

Furthermore, occasionally, we actually have these patients that will present to the emergency department because a headache and, like you mentioned, vision changes and that sort of thing. You know, Stephen, can you just talk about that?

Stephen Magill, MD: Yeah, I was going to say, it's interesting because I think that when I think about presentation, by far the most common, unilateral hearing loss for ENT or neuro-otologist like you guys are. On the neurosurgery side, we see a lot of them that come when they get large. And when they get large, it's interesting, sometimes the large ones don't have hearing loss. So, they don't actually have that symptom, but the tumor grows to a size where it obstructs the flow of cerebrospinal fluid. You develop hydrocephalus, and then the symptoms of hydrocephalus can be gait problems, blurry vision, headaches, and brainstem dysfunction. So, that's where we see on the Neurosurgery side actually a fair amount, but those typically come through the ER where they'll find out about that.

I had a recent patient who was actually pregnant and then she was an optometrist. And she was like, "I'm getting blurry vision." And her husband, who was also an optometrist, looked in her eyes and he sees papilledema or swelling at the back of the eye and says, "Hey, we need to get a scan." They get a scan and she's got like a four centimeter acoustic with normal hearing. So, you know, these things can happen. But in the subset of things, I think the most common unilateral hearing loss followed by incidental scans for headaches, other reasons get found. And then, you know, the smaller portion where they get so large and then present with neurosurgical complaints, hydrocephalus.

Mark Wiet, MD: Okay, Dr. Hać, can you help us understand the role of the otoneurologist in these patients? Because that's, you know, you have a very unique role in the care of these patients and we are so pleased to have you with us and I just would like you to expand on that.

Nicholas Hac, MD: Yeah, happy to. So, you know, it's very common beyond, of course, the hearing loss and the tinnitus as being presentations for this diagnosis, you know, people can have headaches, they can have dizziness, and they get an MRI, and then you find this. Then, the next question is, you know, is the dizziness actually related to the schwannoma itself?

Because of how common this condition actually is, as you had previously mentioned, it's possible that we're finding this incidentally quite a bit of the time, and that their symptoms cannot necessarily be attributed to that, in particular when it comes to vertigo, dizziness, imbalance, disequilibrium, unsteadiness, et cetera.

So, a lot of what I do is I'm just very meticulous about gathering the history of the dizziness, imbalance, unsteadiness itself, about doing a physical exam to look for objective evidence of vestibular weakness on the one side that has the schwannoma and trying to piece together whether or not these symptoms actually can be attributed to the schwannoma itself.

I think it's very easy to, you know, have somebody come in, they say, "Oh, I'm dizzy. I've been dizzy for so and so much time," get an MRI, see a schwannoma, "Oh, that's clearly why you're dizzy." That's not always the case. And so, I spend this time trying to piece out in retrospect, is your dizziness actually from something more common, like BPPV or a vestibular migraine? Or is your imbalance from some other neurological condition, you know, very common things like peripheral polyneuropathy or other things like Parkinsonism, cerebellar ataxia, myelopathy, et cetera?

I think that this helps the patients in whom it's actually the chief complaint that they got the MRI in the first place, because it helps them to better understand where their symptoms are coming from, and then how do we kind of diagnose and manage what could be the cause of these symptoms. If it turns out to be the schwannoma, great. And I kind of defer to my, you know, neurosurgical colleagues such as Dr. Magill and my ENT colleagues such as Dr. Zhan here.

Kevin Zhan, MD: Yeah. I think, just to chime in on that, I think this is why our multidisciplinary approach is so important, you know, because Dr. Hać's assessment really informs us when we're thinking about treatment decisions and making sure that we are treating the symptoms that are related to the tumor itself. And we are making decisions on that, whereas, you know, if someone is having a lot of dizziness symptoms, just like he said, that are unrelated to the tumor, then we want to make sure those are treated in the ways that he would help with and that we are not treating those symptoms with what we're able to do.

Stephen Magill, MD: I think that's one of the biggest challenges in vestibular schwannoma, and the patients that come to my clinic, you know, unless it's an emergency with hydrocephalus or something, which is pretty rare, they've often seen multiple people and trying to figure out what is the right thing, and often we spend a fair amount of time talking about what are your treatment options, how do you decide which one, because if you come in dogmatically like, "Oh, I'm a surgeon, we've got to take this out," or "I'm a radiation oncologist, we're just going to treat this with Gamma Knife," or "We just watch it." Like, the patients are left and they don't really know, and we're having our team and having Dr. Hać here to help both set expectations and make sure we're doing the right thing because if dizziness is the primary complaint and it's related to the vestibular dysfunction on that side, then maybe we want to be more aggressive in our treatment.

If it's unrelated, they have BPPV, they just need some Epley maneuvers, they're totally asymptomatic from a small vestibular schwannoma, maybe we can just watch that. And teasing this out is really important to know that you're doing the right thing because without that diagnostic information that you add to the team about the etiology of the vestibular function, the detailed analysis of it, oftentimes our decision-making can just be you know, "Well, we'll do surgery" or, you know, we come in with different biases. But the more data we can have helps us make the right decision for the patient. And oftentimes the patients, when they see me, are super scared. They're like, "Oh, my goodness, I have a brain tumor. What's going to happen?" they've heard of somebody who's died from a brain tumor. And there's a lot of anxiety that goes along with this, not to mention the anxiety anyone would feel when they're dizzy, when they're imbalanced, they're struggling to walk. It's really difficult. So, I think the more we can have really data-driven approaches with that individual patient's data, really empowers us to help guide the patient to the best thing for them.

Kevin Zhan, MD: Yeah. And I think we've all shared a few patients now where we have some smaller tumors that were sort of incidentally discovered and have come to our clinics and, you know, Dr. Hać was able to evaluate them and found that the vast majority of their dizziness symptoms were actually from migraine, right? And he was able to intervene and help with their migraine symptoms and they're significantly better symptomatically. And, again, once that's been treated, that's a totally different picture on how we counsel these patients about what to do for their vestibular schwannoma itself.

Stephen Magill, MD: And what to expect after surgery because if the problem is from the tumor, we treat the tumor, that's good. But if the problem is not from the tumor, we treat the tumor, the problem is still going to be there.

Kevin Zhan, MD: Absolutely. Absolutely.

Mark Wiet, MD: Absolutely. Yeah. You definitely don't want to be in that situation where the dizziness is persistent post-op with the expectation pre-op that the disease is going to resolve. So, it's really key to kind of have that discussion with your patients ahead of time. Personally, I actually even have had patients with problems in the contralateral ear that, you know, I like to check a Dix-Hallpike maneuver on people. You know, that's pretty easy to pick up a case of BPPV. I've definitely seen that on patients. And then, obviously, with a small tumor, you're not going to intervene on that right away.

Well, Kevin, let's get into the treatment options. What are the options? You know, when somebody comes in, you sit down with them, new patient, newly diagnosed acoustic neuroma-- I guess probably a better question is, what are the top three patient and tumor characteristics you take into consideration when you're talking to a patient with acoustic neuroma, okay? So, patient and tumor characteristics. And then, you know, run through the options real quick.

Kevin Zhan, MD: So, I think, you know, obviously, we want to do a very comprehensive, you know, big picture reception, right? We want to make sure we understand their hearing levels, we do a hearing test. We understand, you know, the size of the tumor, where the tumor is located, because that often does inform what our management options are. We want to get a really good sense of what their vestibular imbalance symptoms are, right? And a lot of, like you said, because these tumors are a lot more common than we think, we are actually picking them up quite a bit earlier, right? When tumor sizes are a lot smaller, and these quality of life decisions are so important, and we need to make sure that us as providers and physicians that we are treating the symptoms that actually are bothering that patient, right?

So, you know, when it comes to patients with a significant amount of hearing, that certainly influences how we counsel those patients. But you know, there's very rare circumstances where we need to jump to surgery right away, right? Those are the very large tumors that are presenting with, you know, brain stem compression, hydrocephalus, those kind of things. So, we take a step back, get the full picture, make sure that this tumor is growing. You know, observe it or make sure that this tumor is growing or it is doing something in the first place, right? A lot of times when these tumors are diagnosed, this is one snapshot in time. We don't know if the tumor's been there for a very long time beforehand, so we need to understand is the tumor actually growing before we, you know, particularly counsel on the management.

So, this is a very, very nuanced and very nuanced discussion. I think that's why our multidisciplinary team, we have to have these conversations and really get a full picture of the patient's symptoms before we, you know, recommend one option versus the other.

Mark Wiet, MD: So, you know, basically, just to summarize, the options are observation, surgery, radiation and, you know, there's intricacies of each. You know, each patient is different. And we always have to involve the patients in their treatment decision and so on and so forth. Really, the only ones that are straightforward are the large tumors. We all know that, you know, those patients, they generally need surgery. And then, you know, that's where the decision-making gets simple.

So, next up, Dr. Magill, I'd like you to just talk about, you know, the multidisciplinary team and discuss, you know, maybe some cases that you recently took care of and that sort of thing. That'd be great.

Stephen Magill, MD: Yeah. It was interesting, you're talking about treatment options. You know, it's pretty simple. It's three. Do we watch it and just get a serial scan? Is this growing or not? Once it's growing, let's say it's small, they're mildly symptomatic or asymptomatic, then our treatment options are either radiosurgery. So, a single session like Gamma Knife. Other forms of radiosurgery are out there, but by far, the longest track record is with the Gamma Knife or microsurgical resection. Once you choose resection, there's different surgical approaches.

So, I was thinking of a lady who I saw, she had actually seen a partner of mine years ago, had a small acoustic. She was asymptomatic. She watched it. It grew a little bit over, I think it was two or three years. And then once it had grown, he had recommended radiosurgery. Unfortunately, due to life circumstances, she was lost to followup. She wasn't able to get MRIs. And then, that tumor just completely exploded about four years later. It went from maybe a centimeter, centimeter and a half, up to 4.5 cm.

So, I think the first thing, if we're going to watch it, we have to make sure the patients can follow up and that you have good options there. When we decide where does the multidisciplinary team comes? That's when we say, "Okay, you have a small acoustic. I can think of a case where we had an intracanalicular acoustic just in the internal auditory canal, about eight millimeters." We watched it for a year. It actually grew to 12 millimeters, still all in the IAC. So, no brainstem compression, mild hearing loss. No significant balance symptoms. What do we do for that patient? Well, that's when I say, "Hey, you need to see Dr.  Hać, let's evaluate your vestibular function. Let's see Dr. Zhan. Let's evaluate your hearing, get the audiogram tested. You've lost some hearing. What sort of hearing recovery options do you have?" You bring an expertise in that with hearing options that I don't have. You can help us understand the vestibular function. And then, we can decide, "Do we keep watching it?" No, it's growing, so we need to treat it. Do we take it out or treat with Gamma Knife? And a small intracanalicular acoustic, perfect case for Gamma Knife. Patient comes in for one day, they get an MRI, they're in the machine for 45 minutes or an hour, hour and a half, depending on the complexity of the shots and the plan, and goes home. No skin incision, no postop recovery, and they generally do very well, 93% control at 10 years for growth.

Mark Wiet, MD: Just to, you know, kind of reflect on some of the things, some of the points you just made there, though, I think it's important for the audience to just talk about the average growth rate for these tumors. In general, it's about one to two millimeters a year, but you can definitely have fast-growing tumors. That's a separate subset. It's probably genetically different in these tumors, and I've seen patients like that as well. But, yeah, that's really amazing. Could you repeat that, it went from-- over four years?

Stephen Magill, MD: Yeah. And we'll cut in and show a picture here, but you know, between over four years, it went from about a centimeter and a half to a huge tumor compressing the brainstem, 4.5 cm, something totally changed. So typically, it's very safe to watch them. Usually, if it's a new diagnosis, we'll get a six-month scan, something like that. So, you have some ideas, is this a fast or slow growing, but the most are right, one to two millimeters. But then, there will be some that will grow fast and it's not something you go, "Oh, it didn't grow fast. We'll just get a scan in four years." Usually, we watch at least every year.

Mark Wiet, MD: So, you know, we know that the options are observation, radiation and surgery as a surgeon. You know, you guys had a great case recently you were telling me about, you had a really successful operation at your trans lab. Just go through that day, tell me about the day so that people have an idea what that's like.

Stephen Magill, MD: So once the patient decides for surgery, the two approaches would be a retrosigmoid or a trans lab. This patient had already lost hearing. That's kind of the biggest differentiator. If you've lost hearing, then a trans lab is okay because you can't recover hearing after that. The trans lab approach really, it highlights our team-based work because at the start of the day, Dr. Zhan comes in, we put the patient to sleep. Patient goes, I can go take care of stuff in the morning. Dr. Zhan sits down, drills for two, three hours, prepares that exposure. And a trans lab approach comes through the bone as opposed to having to go between the brain and the temporal bone. The trans lab approach comes through the bone. And so Dr. Zhan will develop that approach. After maybe two hours, I come in 11:00, 11:30, I'm right at the tumor. And really, the advantage for the patients that we chose the other day, his tumor was perfectly aligned for this approach. So, we could see the tumor from stem to stern right at the beginning. It was all the way up, compressing the brainstem against the facial nerve. And with that exposure, then I come in and under the microscope, all this is microsurgery. I come in and then start debulking that tumor internally, resect the internal portion of the tumor, so then we can start to look around because these are balls that will obstruct your view. Once you can get around it, then I go to the brainstem. And I'm looking for those cranial nerves, and this is really where preserving function becomes so important. We find the lower nerves, the nerves for swallowing, cranial nerves IX, X, XI for the shoulder.

Then, I get to the brainstem, and that's really where we start to look for the eighth nerve root entry zone, where the facial nerve is coming off. And then, with a trans lab, what was beautiful is once I found the facial nerve at the brainstem, we could then start to peel it. And this is really where the tumor starts to dictate the outcome with a good surgeon. Sometimes we can have a nice plane and peel that tumor right off the nerve, even if the nerve is fanned out. And I can develop from the brainstem side coming in. And then, Dr. Zhan, we go back and forth and you can talk a little bit about that. But really, I think, one of the values of this is the surgery is so delicate when you're dissecting right off the facial nerve to get a good outcome. I love having that second set of eyes. So, Dr. Zhan's watching while I'm operating. Then, you can come in and do the part in the internal auditory canal. You want to talk a little bit about that, maybe?

Kevin Zhan, MD: Yeah. So, that's one of the great benefits, I think, of the trans laboratory approach is that, you know, you can really handle tumors of any size and out laterally. You know, you're always able to find that facial nerve at an anatomically normal location, right? And so, that's one of the really great advantages of it. And so, you know, once the tumor has been significantly debulked by Dr. Magill, you know, we can come out laterally in the IAC and start peeling the tumor off, find the facial nerve at a normal location, protect it, obviously, and then peel the tumor and connect the dots between the two and then, you know, finish the tumor dissection.

Mark Wiet, MD: Yeah, it's a great approach. Thanks to Bill House who, you know, developed it many years ago. But the beauty of that approach is when you're, you know, in the internal auditory canal, you find the Bill's bar, transverse crest, and you can flip the superior vestibular nerve off the facial nerve and just get things going. But you know, we have to keep in mind that, you know, it really goes beyond the surgeons. It's the support staff, you know, the nurses, anesthesiologists, the physical therapists, the caseworkers, they really find a place like Northwestern that make it a special place. And that's the sort of place where these sorts of tumors need to be taken care of.

Stephen Magill, MD: That's just one other person that's really important and part of this resection and just going from where you were at is the neuromonitoring. So, understanding the function of that seventh nerve. So, many times we can develop that plane. In the case we shared last week, where we were able to get a gross total resection of the tumor, we were able to keep that plane going and really connect the dots, completely remove the tumor, separate it from the facial nerve and have a great facial outcome. We can do that because we're continuously monitoring the nerve, we're stimulating as we go, making sure that we have good stimulation at the brainstem. So, I know the nerve is still intact. The patient's going to wake up with a symmetric face. Sometimes you can't. And so, sometimes then it gets a little more difficult and the tumor is very sticky. And that's when we have to make decisions about how much tumor do we leave? And you choose to leave just a small amount of tumor on the facial nerve and that can preserve that facial function.

We published a study just recently here at Northwestern, looking at our outcomes at how much tumor do we need to take out? And we found a threshold where if you get beyond that, that tumor is unlikely to grow. So, we can use that kind of data that we're generating here because of our team working together, because of the experience we have as a group, as an institution, my partners to really make sure that we're providing that care as best as possible, really maximizing what we can do.

Mark Wiet, MD: And you have the resources to do that kind of work really, which is key. Kevin, you know, something that's kind of relatively new to the field and, you know, before we have to get in the discussion here is can you just talk about cochlear implants? And cochlear implants in the area of, you know, just acoustic neuroma in general, we have three phases or three options. Observation, stereotactic radiosurgery, surgery, without getting too extensive, I mean, you could probably give an hour long talk on this, but just try to kind of summarize this for the audience.

Kevin Zhan, MD: Yeah. Well, I think the first thing that we have to recognize is just how much of a disability it is. And certainly, hearing loss in one ear, being deaf in one ear, is it is a significant disability for patients, right? You know, if you can't hear in one ear, you're going to have a lot of difficulty hearing in noisy situations, even in quiet situations. There are some significant safety considerations, not being able to hear from one side. You can't hear when cars are coming in, you know, from one area. If you sleep on your good side, you can't hear an alarm or a fire alarm or those kind of things.

Mark Wiet, MD: Yeah, it's been shown in hearing and noise and localization that they're far superior to the other options that are available to patients.

Kevin Zhan, MD: And, you know, patients have so much anxiety about their one remaining ear, right? Like, what if something happens to my good ear, you know? And that provides a lot of, you know, anxiety and stress. And with hearing loss in one ear, you can have a lot of difficulty with communicating with others, right? And at the workplace, job performance, your ability to socialize with others and connect with your family. So, you know, up until very recently in the United States, the FDA did approve cochlear implantation for one-sided deafness in adults.

Mark Wiet, MD: That was in 2019, right?

Kevin Zhan, MD: Right.

Stephen Magill, MD: And it's now, it's giving us this option where we can say, "Hey, you know what? In patients with vestibular schwannomas, this actually is a really good option for rehabilitation, improving their quality of life, right? So, you know, an ideal candidate would be someone who, for example, has had a vestibular schwannoma for a long time. We know it's not growing. It's been demonstrated over many years that it's not growing, but they have significant hearing loss. Those are patients that could be excellent candidates for cochlear implantation to try to restore that hearing. Ideally with a smaller tumor, right?

Mark Wiet, MD: Ideally with a smaller tumor.

Stephen Magill, MD: Absolutely. But, you know, if we know a tumor is not growing at all, right? Over many, many, many years, then we know to sort of understand that behavior. And you still can get an MRI, right? I mean, with a cochlear implant in place. And that's also new too, and now we have cochlear implants that have MRI-compatible magnets that we can still continue to monitor tumors. So, this is really kind of a breakthrough in terms of--

Mark Wiet, MD: What year was that? I forgot. Was it 2019 also that--

Stephen Magill, MD: Somewhere around there. But so prior to that, just for the audience, if you have a cochlear implant that was placed prior to 2019, MRI is contraindicated, and I don't want to get into it any beyond that, but after 2019, if it was implanted, all three companies have MRI-compatible cochlear implants. So, go ahead.

Kevin Zhan, MD: Yeah. And it really comes down to do you have a functioning cochlear nerve? And certainly, if it's never been manipulated, like let's say you had a Gamma Knife, radiosurgery, or just strict observation, we know for sure that the cochlear nerve is fine. You know, we can also do surgery as well, you know, for these tumors and preserve the cochlear nerve so that we can use a cochlear implant. So oftentimes, it can be an option in the correctly selected patient.

Mark Wiet, MD: Right. So in all three options, observation, radiation, or surgery, we can incorporate a cochlear implant. But it's unique and it doesn't work for everybody. So, you have to have an intact cochlear nerve, you know, in the surgical patient. So, small tumors that are growing, the patient has maybe symptoms from it, you want to remove it. You can actually simultaneously place a cochlear implant. You can stage the cochlear implant later. You can leave a dummy in the cochlea to preserve the cochlear lumen and then come back and put the cochlear implant in.

Kevin Zhan, MD: And then, of course, a lot of patients with significant hearing loss have really bad tinnitus and buzzing sounds in their ear that can really affect their quality of life and their sleep. And we know that a cochlear implantation in this population does help with that.

Nicholas Hac, MD: It ends up being relevant to brain health too, actually, because we know from studies that you lose a certain amount of hearing and you're predisposed to cognitive deficits years down the line. And so, having an early kind of like intervention even for that ends up being very helpful. Patients who also have hearing loss can develop all kinds of interesting neurological syndromes, this musical ear syndrome, you know, this kind of almost Charles Bonnet presentation, but of hearing rather than of sight, where they're hearing things that aren't there, and these things can be very debilitating. And by intervening on this earlier on, you're actually helping to prevent this stuff from developing later down the line too.

Mark Wiet, MD: Great point. Great point. I'd just like to emphasize the importance of a multidisciplinary team for our patients. It really goes beyond, you know, just the surgeons and you know, the neurologists are involved, nurses, anesthesiologists, physical therapists, case workers, so on and so forth. And if you guys have anything to add, feel free to speak up.

Kevin Zhan, MD: Yeah. We mentioned physical therapy, and I wish we could spend more time talking about that, but they are such a key and critical part of this, right? And helping our patients rehabilitate either before surgery or even after, or certainly after surgery. And you know, we just have tremendous physical therapists here and, you know, have the access to Shirley Ryan AbilityLab, just outstanding therapists that can help us with these patients. So, it's really such a joy to take care of these patients in this setting.

Stephen Magill, MD: Yeah. I really enjoy that. The one thing I kind of maybe bring full circle to our training, you know, I think all of us are fellowship-trained. And I think that's really important. What I gained and learned in fellowship, we have a skull-based surgery fellowship here where we teach people how to do this. And I think that's absolutely important when you're choosing a team. Not only do you have a full team with a vestibular neurologist, an otoneurologist and all of us, and radiation oncologists as well. But having people who are ready--

Mark Wiet, MD: It adds to the care.

Stephen Magill, MD: Yeah, I think it certainly broadened my horizons and helped me be a better doctor. So, you know, that's something that's important to look for.

Nicholas Hac, MD: I think the one thing I would emphasize is the culture of the multidisciplinary approach. I think it's very common for, you know, Stephen and I or Kevin and I to basically just call each other up, send text messages, send Epic messages, whatever it may be. And those barriers to communication are pretty much zero. You know, I'm glad you also mentioned our physical therapy colleagues because I think it's pretty much every single day that I talk to a physical therapist. But of course, I'm taking care of many, you know, dizzy patients in which our physical therapy colleagues are incredibly important to the care of these patients.

Mark Wiet, MD: You know, it's just great to see you guys, you know, interested in this and you're doing a great job. Especially Kevin with our cochlear implant program here is really taking off, so. I was just thinking about a couple of patients we had recently where it was exactly that. A couple of quick phone calls. Yes, I think, you know, look at the patient. We can treat with Gamma Knife, then put in a cochlear implant. That's really going to restore this patient's function, give them a step up, which was something that, you know, I hadn't really thought about or wouldn't have thought about if I was practicing solo or on my own, but working so closely together and it's really a pleasure and a fun environment to work in and to care for our patients.

Nicholas Hac, MD: Cosigned.

Melanie Cole, MS: Thank you so much, gentlemen. What a lively, enlightening discussion. Thank you so much for this roundtable today. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/neurosciences to get connected with one of our providers. That concludes today's episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.