Aspects of Life Quality After Surgery for Acoustic Neuroma
Some
Agnete Parving, MD; Mirko Tos, MD; Jens Thomsen, MD; Henrik M\l=o/\ller,MD; Christian Buchwald, \s=b\
This
investigation
was
performed
to describe
some as-
pects of the quality of life in subjects after translabyrinthine
removal of an acoustic neuroma, resulting in unilateral total deafness. Two hundred ninety-three subjects who had been operated on during 1976 through 1990 and who were living outside the Copenhagen (Denmark) City and County received a postal questionnaire, to which 93% (n=273) responded: 118 men and 155 women with a median age of 58 years (range, 18 to 81 years). The median observation period from surgery to the questionnaire was 6 years (range, 6 months to 14 years), and the median age at operation was 52 years (range, 15 to 76 years). Among the subjects, 22% had received postoperative hearing rehabilitation with various types of hearing aids in the ear not operated on. In 62%, tinnitus was experienced in the ear with tumor before surgery, and at the time of the questionnaire, 49% experienced tinnitus in the ear operated on. Half a year after surgery, 56% still experienced dizziness. Sixty-four percent reported damage to the facial nerve in relationship to the operation. At the time of the questionnaire, 12% indicated a total loss of facial nerve function. No vocational consequences were found in 74% after surgery. Information concerning different symptoms related to surgery was insufficient in 29%, while the quality of information in relation to surgery was more satisfying. In conclusion, the study demonstrates that deafness, dysequilibrium, and reduced facial nerve function caused the most severe problems. Improved information to patients before surgery may reduce the frequency of negative experiences. (Arch Otolaryngol Head Neck Surg. 1992;118:1061-1064) of surgery for has been evaluated extensively by surgeons throughout The the world. the evaluations of outcome
an
acoustic
neuroma
Although concerning aspects surgical techniques and practices are highly important to assure the quality of surgery,1"5 the outcome reflecting the patient's viewpoint is also important and may lead to adAccepted
for
publication
December 30, 1991.
Department of Audiology, Bispebjerg Hospital, Copenhagen (Dr Parving), and the Ear-Nose-Throat Department, University Hospital, Gentofte (Drs Tos, Thomsen, M\l=o/\ller,and Buchwald), Denmark. From
Presented in part
the First International Conference on Acoustic Neuroma, Copenhagen, Denmark, August 29, 1991. Reprint requests to Department of Audiology, Bispebjerg Hospital, DK 2400 Copenhagen, Denmark (Dr Parving). at
MD
ditional therapeutic improvements. Recently, an American survey based on a comprehensive questionnaire evaluated the patients' experiences in relation to symptoms, diagno¬ sis, treatment, and postsurgical consequences of an acous¬ tic neuroma.6 The questionnaire was mailed to 832 subjects,
operated on during a 10-year period. However, as pointed out by the authors, only 65% responded to the question¬ naire, and doubts were raised concerning the sample pop¬ ulation being selected among members of the American Acoustic Neuroma Association. In addition, the operations had been performed at many different centers by various surgical teams, resulting in predictable variances in the surgical techniques and outcome and thus in the responses to the questionnaire.6 To obtain data from a representative sample, and thus further validate the previously described results, this examination
was
undertaken.
DESIGN OF EXAMINATION
nearly all subjects with an acoustic neuroma are operated on by the same surgical team (M.T. and J.T.), perform¬ ing a translabyrinthine tumor removal.'1-4 During 1976 through 1990 this team operated on a total of 507 patients. (Fifty-nine pa¬ tients [10%] were operated on by neurosurgeons through the suboccipital approach during the same period, and these patients are excluded from this investigation.) Among the 507 patients operated on, 60 (12%) died, eight (1.6%) of causes related to the surgery, while 52 patients died of causes unrelated to the acous¬ tic neuroma surgery. The remaining 447 patients were subdivided into two groups, based exclusively on a geographical criterion: group A, comprising 303 subjects (68% of the sample), lived out¬ side Copenhagen City and County and received a postal ques¬ tionnaire; group B, comprising 144 subjects (32% of the total sam¬ ple), were invited to an interview, based on the questionnaire in combination with an objective examination at the E^r-NoseThroat Department in Gentofte (Fig 1). No significant differences In Denmark,
in age and sex between the two groups could be demonstrated. Thus, group constitutes a reference group in relation to those who only received a questionnaire. Group also allows an eval¬ uation of the interindividual observer bias between the operating surgeons on one side, and other otolaryngologists on the other side, as well as correlations between the professional evaluation and the experiences indicated by the patients. In the present con¬ text, descriptive data concerning only group A will be included.
SUBJECTS AND METHODS A
sample of 293 subjects received a questionnaire by mail (10
could not be traced), and 273 (93%), 118 (43%) men and 155 (57%) women, responded. The median age at operation was 52 years (range, 15 to 76 years) (Figs 2 and 3), and the median observation
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Operated
On
(n=507) Died (n=60)
Remaining (n=447)
Group A
Group (Personal Interview)
(n=303)
(n=144)
Questionnaire
Not Found
(n=293)
Responders (n=273)
(n=10)
Nonresponders
Fig 2.—Age at surgery (shaded bars)
(n=20)
Males
Females
(n=118)
(n=155)
bars) bars).
and age
at
questionnaire (black
Fig 1.—Study design.
period
from performance of surgery to questionnaire response 6 years (range, 6 months to 14 years). The questionnaire in¬ cluded 36 questions concentrating on the presurgical and postsurgical experience and information concerning the following items: (1) hearing ability and rehabilitation; (2) characteristics of tinnitus; (3) dizziness; (4) facial nerve function (estimated by the patient); (5) general condition; (6) social situation and conse¬ was
quences; (7) present activities; (8) presurgical information con¬ cerning procedures and possible preoperative and postoperative complications; and (9) the patient's social network. The question¬ naire is fairly similar to the questionnaire used by Wiegand and Fickel6 and includes open and closed sets of questions with a cer¬ tain inner consistency. The closed questions were tabulated, while the open questions were interpreted (by A.P.) and categorized before tabulation. For comparative analysis of the different indi¬ cated frequencies, we used confidence intervals with a signifi¬ cance level of .057
gree of annoyance before surgery, after surgery (in retro¬ spect), and at the time of this study showed no significant differences by cross-correlations.8
Dysequilibrium
RESULTS
Postsurgical Hearing and Audiological
Fig 3.—Year of surgery.
Rehabilitation
Ear With Tumor.—In all patients, the acoustic neuroma had been removed by a translabyrinthine approach, re¬ sulting in a totally deaf ear. Ninety-six percent responded that they experienced deafness in the ear operated on, while 4% did not respond to this question. Contralateral Ear.—Seventy-four patients (27%) indi¬ cated that they had been provided with a hearing aid in the ear not operated on; in 14 patients, the aid was fitted be¬ fore surgery. In the 60 subjects who had a hearing aid fit¬ ted after surgery, 39 subjects were fitted within 1 year af¬ ter surgery, which may be considered as a "consequence" of surgery. The remaining 21 subjects had been provided with various types of hearing aids in the ear not operated on (n=10) or with a monocross or bicross arrangement (n=ll), 2 to 8 years after surgery. Thus, in total, 22% had received hearing rehabilitation, but only 14% as a conse¬ quence of surgery.
Tinnitus the Among respondents, 170 (62%) suffered from tinni¬ tus before surgery, while 135 (49%) indicated tinnitus at the time of the questionnaire. The 13% reduction in the frequency of tinnitus may be the result of both an im¬ provement or worsening, as indicated in Table 1. The de-
Before and after surgery,
patients may experience dys¬ patients (57%) had experienced dizziness before the operation, and among these, changes
equilibrium. Thus,
156
experienced as indicated in Table 1. Six months after surgery, 152 patients (56%) still had experienced dizziness, which indicates that a period of more than 6 months is re¬ quired before a reduction in the frequency of the dizziness occurs. No information concerning dysequilibrium at the time of the questionnaire is available, however, as only nine patients had received antivertiginous drugs within
were
the 3 months before receiving the questionnaire, so an im¬ provement in dysequilibrium during the observation pe¬ riod is likely.
Facial Nerve Ninety-seven patients (36%) indicated that their facial nerve was undamaged in relation to the operation, whereas 169 patients (64%) indicated damage (seven
patients
function
did not
are
respond). However, improvements in occur during the immediate post¬
known to
operative period (Table 1) and thereafter. Thus, the degree of facial nerve function at the time of the questionnaire is given in Table 1. Table 1 also gives the surgical procedures some of the patients went through to relieve problems from the reduced facial
nerve
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function.
Table 1.—Questionnaire Results*
Table 3.—Patients' Evaluation of Information Before Surgery Related to Symptoms
No. (%)
No. (%) satisfied with information
Tinnitus (n=170) Better Worse
80 (47)
73 (47)
Better Worse
33(21) 50 (32)
Unchanged Facial 1
79 (29)* No. (%) dissatisfied with information No. concerned with information (multiple responses) 21 Pain 57 Facial paralysis Tinnitus 30 Dizziness 33 Various 13
29(17) 49 (29)
Unchanged Dysequilibrium (n=156)
function after surgery (n=262t) Normal facial mobility Partial facial mobility No facial mobility
*Data not available for four
nerve
(71)*
190
patients.
mo
Patient-estimated degree of facial nerve function ( =268 ) 100% (normal function) 75% 50% 25% 0% (abolished) Surgical procedures to relieve problems due to reduced facial nerve function (n=169)
83 (32) 81 (31) 98 (37)
104(39) 43 (1 6) 39 (1 5) 51 (19) 31 (12)
228
35
10
228
17
28
203
16
54
22
Sleep disturbance Dental problems Speech and swallowing
15
Sexual
17
18
13 6 19
dysfunction
6
Social Consequences
gives the consequences for social situation following surgery as indicated by the patients. Thus, 74% indicated that the surgery had no consequences for their social situation. Among those working (n=157) at the time of the questionnaire, 49% had returned to work within 2 months, 39% within 6 months, and 11% within 12 months after surgery. Among the responders, 14 indicated that they never resumed normal activities, and 28 that their Table 1
and Fickel, %
of Difference
96
94
NS
14
21
S
Bothersome tinnitus Total loss of facial nerve function
27
13
S
12
15
NS
Dysequilibrium
29
90
S
HA
*NS indicates not
29
Wiegand
Current Study, %
Postoperative
tData not available in 11 patients. iData not available in five patients.
Headache/pressure
No.
nurses
Total deafness
ponding.
Anxiety Depression
No
Table 5.—Frequency of Different Experiences Compared With Study by Wiegand and Fickel6*
194(74) 12 (5) Vocational change 23 (9) Ceased to work 3 (1) New education 18 (7) State pension 11 (4) Dismissal 'Values given in parentheses with category indicate number of patients with that problem before surgery or number of patients res¬
Table 2.—Frequency (%) of Additional Problems Experienced (Multiple Responses)
Yes
physician
Estimated social consequences of surgery (n=261) No consequences
Motor
Data Not
Available,
From
14(9)
Cardiovascular
No. Satisfied With Information
From
64 (39) 20 (12)
nerve
by Staff at Time
I-1
Additional staff
Eye Facial Face
Table 4.—Information Given Patient of Surgery
Significance
significant; HA, hearing aid; and S, significant.
was poor. The specific factors causing this impact on the quality of life are unknown in these subjects. Moreover, one must be cautious in accepting a direct
postsurgical adjustment
relationship between surgery and a reduced life quality, as additional physical or mental problems unre¬ lated to surgery can be expected in this sample operated on at a median age of 52 years (range, 15 to 76 years). The frequency of some additional problems experienced at the
causal
time of this
investigation is indicated in Table 2. Information Concerning the Surgery The patients' responses to the quality of the presurgery verbal information concerning different symptoms is indi¬ cated in Table 3. The information on facial paralysis and dizziness was most frequently found unsatisfactory among the 79 patients, indicating that the information had been insufficient. The quality of the information in relation to surgery, given by different staff members, was described
being fairly equal (Table 4). professional network before and at surgery represented by the local hospital staff and the staff at the operating hospital, the most important persons to help the patients were the spouses and family, with a fre¬ as
In addition to the
quency of 81%.
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Some Aspects Obtained From the Open Questions As mentioned previously, a series of open questions were included in the questionnaire to obtain as complete data as possible, considering the questionnaire technique. Thus, the patients had several possibilities to comment further on their experiences; among other things, they were asked to give information about their "most difficult experience" in relation to the surgery. Although 15% did not respond to this question, the most difficult problem experienced in relation to surgery was deafness, 9%; tinni¬ tus, 1%; dizziness, 12%; facial nerve paralysis, 17%; wait¬ ing for surgery, 8%; and anxiety about malignancy and outcome, 6%. In 22%, various problems were rated as the most difficult experience. In 9%, no most difficult problem was experienced. Thus, it seems that the most frequently indicated most difficult experience in relation to surgery was reduced facial nerve function. However, this was not significantly more frequent than, for example, the predict¬ able deafness. A question addressing the most positive experience dem¬ onstrated that most experienced relief for their concern about tumor malignancy and possible surgical complica¬ tions. Also, the service offered by the staff at the operating hospital was a most positive experience for many subjects. In combination with the most positive/difficult experi¬ ence at surgery, psychological consequences of the opera¬ tion were evaluated. Thus, 154 patients (57%) indicated that they had changed predominantly in a negative direc¬ tion, such as isolation, depression, reduced memory and concentration, insufficient self-confidence, nervousness, and feeling less attractive (reduced facial nerve function). However, a few indicated that they had achieved a better quality of life after the surgery. No relationship between the social and psychological consequences of the surgery could be established based on this investigation. COMMENT
Although postal questionnaire technique exhibits several methodological shortcomings and limitations,910 the high response rate of 93% and information rate of 90% (273/303), the inner consistency in the questionnaire, and the inclusion of open and closed questions support a fairly high validity of the data obtained. The minor inconsisten¬ cies, which can be derived from the number of patients re¬ sponding in a different way to nearly identical questions, are insignificant for the indicated frequencies. Although Wiegand and Fickel6 point to limitations and shrewdness in their sample selection, a comparison of the overall frequency of different experiences in the present and the previous studies shows that they are relatively similar (Table 5). In this study, only 14% of patients were fitted postoperatively with a hearing aid, in contrast to 21 % in the American study, where a cross hearing aid was used, resulting in a hearing benefit in two thirds of the subjects. The limited frequency of audiological rehabilitation in this study may be explained by a lack of information on the possibility of needing hearing rehabilitation, which is free of charge in Denmark,11 but it may also reflect a negative attitude toward audiological rehabilitation both in the general population and among physicians.12 These data concerning tinnitus demonstrate a reduced fre¬ quency of 13% in the ear with tumor at the time of the ques¬ tionnaire. This is significantly better than what was reported in the American survey, which indicated a 2% improvement the
worsening in tinnitus. However, as the data analysis per¬ by Wiegand and Fickel6 concerning the postopera¬ tively experienced tinnitus differs from the present data analysis, a direct comparison cannot be performed. The frequency of dysequilibrium 6 months postopera¬ tively in this investigation is significantly lower than that found by Wiegand and Fickel6 (Table 5), who found that only "10% had normal function, and 8% rated dysequilib¬ rium as a severe handicap." Although differences were present in the information concerning dysequilibrium, the 8% rating this experience as a severe handicap corresponds fairly well to those 12% experiencing dysequilibrium as the most difficult problem in this survey. The frequency of 12% having total loss of facial nerve function at the time of the questionnaire corresponds to the frequency found in the American study (Table 5). Only 39% experienced normal function at the time of the ques¬ or
formed
tionnaire, while 50% had more or less reduced facial nerve
function. Although 74% indicated that the operation had no consequences for their social situation, 9% never resumed normal activities, and 10% responded that they had been unable to adjust to the postsurgical situation. This may be related to the unilateral deafness, dysequilibrium, and reduced facial nerve function, alone or in combination, which is supported by 9%, 12%, and 17%, respectively, re¬ porting these postsurgical symptoms as the most difficult experience. However, other factors, as outlined in Table 2, may also be important. The verbal information concerning symptoms given be¬ fore surgery was thought to be satisfactory by only 71% (Table 3), while the information given by the different staff members concerning the surgery was thought to be satis¬ factory by 87% to 93% (Table 4). This might be improved by giving written material, by the professionals providing more thorough information concerning risks and compli¬ cations, and by including information from subjects who have been operated on for an acoustic neuroma previously. This investigation was supported by grants from Else and Mogens Wedell-Wedellsborg's Foundation, Copenhagen, Denmark, which we gratefully acknowledge. References
Transtemporal bone microsurgical removal of acoustic neuromas. Arch Otolaryngol Head Neck Surg. 1964;80:752-754. 2. Glassock ME, Heys JW. The translabyrinthine removal of acoustic and other cerebello-pontine angle tumours. Ann Otol Rhinol Laryngol. 1973;82: 1. House WF.
415-427. 3. Tos
M, Thomsen J, Harmsen
Is preservation of hearing in acoustic worthwhile? Acta Otolaryngol. 1988;452(suppl):57-68. 4. Thomsen J, Tos M. Management of acoustic tumors. Adv Otolaryngol Head Neck Surg. 1989;3:153-194. 5. Dutton JEM, Ramsden RT, Lye RH, Morris K, Keith AO, Page R, Vafadis J. Acoustic neuroma (schwannoma) surgery. 1979-90. J Laryngol Otol. neuroma
.
1991;105:165-173. 6. Wiegand DA, Fickel V. Acoustic neuroma\p=m-\thepatient's perspective: subjective assessment of symptoms, diagnosis, therapy, and outcome in 541 patients. Laryngoscope. 1989;99:179-187. 7. Scientific Tables. Basel, Switzerland: RJ Ciba-Geigy; 1970. 8. Parving A, Tos M, Thomsen J. Tinnitus before and after surgery for an acoustic neuroma. Presented at the First International Conference on Acoustic Neuroma; August 28, 1991; Copenhagen, Denmark.
9. Petrinowich L. Probabilistic functionalism: a conception of research method. Am Psychol. 1979;34:373-390. 10. Bradburn NM, Rips LJ, shevall SK. Answering autobiographical questions: the impact of memory and inference on surveys. Science. 1987;236: 157-161. 11. Ewertsen HW.
History of Danish medical audiology. In: Ewertsen HW, Jordan O, Salomon G, eds. Danish Audiology:1951-76. Copenhagen, Denmark: Nyt Nordisk Forlag/Arnold Busck; 1976:1-16. 12. Parving A, Boisen G. Hreproblemer\p=m-\hvadved man om det. Ugeskr Laeger. 1989;151:633-635.
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Some
Agnete Parving, MD; Mirko Tos, MD; Jens Thomsen, MD; Henrik M\l=o/\ller,MD; Christian Buchwald, \s=b\
This
investigation
was
performed
to describe
some as-
pects of the quality of life in subjects after translabyrinthine
removal of an acoustic neuroma, resulting in unilateral total deafness. Two hundred ninety-three subjects who had been operated on during 1976 through 1990 and who were living outside the Copenhagen (Denmark) City and County received a postal questionnaire, to which 93% (n=273) responded: 118 men and 155 women with a median age of 58 years (range, 18 to 81 years). The median observation period from surgery to the questionnaire was 6 years (range, 6 months to 14 years), and the median age at operation was 52 years (range, 15 to 76 years). Among the subjects, 22% had received postoperative hearing rehabilitation with various types of hearing aids in the ear not operated on. In 62%, tinnitus was experienced in the ear with tumor before surgery, and at the time of the questionnaire, 49% experienced tinnitus in the ear operated on. Half a year after surgery, 56% still experienced dizziness. Sixty-four percent reported damage to the facial nerve in relationship to the operation. At the time of the questionnaire, 12% indicated a total loss of facial nerve function. No vocational consequences were found in 74% after surgery. Information concerning different symptoms related to surgery was insufficient in 29%, while the quality of information in relation to surgery was more satisfying. In conclusion, the study demonstrates that deafness, dysequilibrium, and reduced facial nerve function caused the most severe problems. Improved information to patients before surgery may reduce the frequency of negative experiences. (Arch Otolaryngol Head Neck Surg. 1992;118:1061-1064) of surgery for has been evaluated extensively by surgeons throughout The the world. the evaluations of outcome
an
acoustic
neuroma
Although concerning aspects surgical techniques and practices are highly important to assure the quality of surgery,1"5 the outcome reflecting the patient's viewpoint is also important and may lead to adAccepted
for
publication
December 30, 1991.
Department of Audiology, Bispebjerg Hospital, Copenhagen (Dr Parving), and the Ear-Nose-Throat Department, University Hospital, Gentofte (Drs Tos, Thomsen, M\l=o/\ller,and Buchwald), Denmark. From
Presented in part
the First International Conference on Acoustic Neuroma, Copenhagen, Denmark, August 29, 1991. Reprint requests to Department of Audiology, Bispebjerg Hospital, DK 2400 Copenhagen, Denmark (Dr Parving). at
MD
ditional therapeutic improvements. Recently, an American survey based on a comprehensive questionnaire evaluated the patients' experiences in relation to symptoms, diagno¬ sis, treatment, and postsurgical consequences of an acous¬ tic neuroma.6 The questionnaire was mailed to 832 subjects,
operated on during a 10-year period. However, as pointed out by the authors, only 65% responded to the question¬ naire, and doubts were raised concerning the sample pop¬ ulation being selected among members of the American Acoustic Neuroma Association. In addition, the operations had been performed at many different centers by various surgical teams, resulting in predictable variances in the surgical techniques and outcome and thus in the responses to the questionnaire.6 To obtain data from a representative sample, and thus further validate the previously described results, this examination
was
undertaken.
DESIGN OF EXAMINATION
nearly all subjects with an acoustic neuroma are operated on by the same surgical team (M.T. and J.T.), perform¬ ing a translabyrinthine tumor removal.'1-4 During 1976 through 1990 this team operated on a total of 507 patients. (Fifty-nine pa¬ tients [10%] were operated on by neurosurgeons through the suboccipital approach during the same period, and these patients are excluded from this investigation.) Among the 507 patients operated on, 60 (12%) died, eight (1.6%) of causes related to the surgery, while 52 patients died of causes unrelated to the acous¬ tic neuroma surgery. The remaining 447 patients were subdivided into two groups, based exclusively on a geographical criterion: group A, comprising 303 subjects (68% of the sample), lived out¬ side Copenhagen City and County and received a postal ques¬ tionnaire; group B, comprising 144 subjects (32% of the total sam¬ ple), were invited to an interview, based on the questionnaire in combination with an objective examination at the E^r-NoseThroat Department in Gentofte (Fig 1). No significant differences In Denmark,
in age and sex between the two groups could be demonstrated. Thus, group constitutes a reference group in relation to those who only received a questionnaire. Group also allows an eval¬ uation of the interindividual observer bias between the operating surgeons on one side, and other otolaryngologists on the other side, as well as correlations between the professional evaluation and the experiences indicated by the patients. In the present con¬ text, descriptive data concerning only group A will be included.
SUBJECTS AND METHODS A
sample of 293 subjects received a questionnaire by mail (10
could not be traced), and 273 (93%), 118 (43%) men and 155 (57%) women, responded. The median age at operation was 52 years (range, 15 to 76 years) (Figs 2 and 3), and the median observation
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Operated
On
(n=507) Died (n=60)
Remaining (n=447)
Group A
Group (Personal Interview)
(n=303)
(n=144)
Questionnaire
Not Found
(n=293)
Responders (n=273)
(n=10)
Nonresponders
Fig 2.—Age at surgery (shaded bars)
(n=20)
Males
Females
(n=118)
(n=155)
bars) bars).
and age
at
questionnaire (black
Fig 1.—Study design.
period
from performance of surgery to questionnaire response 6 years (range, 6 months to 14 years). The questionnaire in¬ cluded 36 questions concentrating on the presurgical and postsurgical experience and information concerning the following items: (1) hearing ability and rehabilitation; (2) characteristics of tinnitus; (3) dizziness; (4) facial nerve function (estimated by the patient); (5) general condition; (6) social situation and conse¬ was
quences; (7) present activities; (8) presurgical information con¬ cerning procedures and possible preoperative and postoperative complications; and (9) the patient's social network. The question¬ naire is fairly similar to the questionnaire used by Wiegand and Fickel6 and includes open and closed sets of questions with a cer¬ tain inner consistency. The closed questions were tabulated, while the open questions were interpreted (by A.P.) and categorized before tabulation. For comparative analysis of the different indi¬ cated frequencies, we used confidence intervals with a signifi¬ cance level of .057
gree of annoyance before surgery, after surgery (in retro¬ spect), and at the time of this study showed no significant differences by cross-correlations.8
Dysequilibrium
RESULTS
Postsurgical Hearing and Audiological
Fig 3.—Year of surgery.
Rehabilitation
Ear With Tumor.—In all patients, the acoustic neuroma had been removed by a translabyrinthine approach, re¬ sulting in a totally deaf ear. Ninety-six percent responded that they experienced deafness in the ear operated on, while 4% did not respond to this question. Contralateral Ear.—Seventy-four patients (27%) indi¬ cated that they had been provided with a hearing aid in the ear not operated on; in 14 patients, the aid was fitted be¬ fore surgery. In the 60 subjects who had a hearing aid fit¬ ted after surgery, 39 subjects were fitted within 1 year af¬ ter surgery, which may be considered as a "consequence" of surgery. The remaining 21 subjects had been provided with various types of hearing aids in the ear not operated on (n=10) or with a monocross or bicross arrangement (n=ll), 2 to 8 years after surgery. Thus, in total, 22% had received hearing rehabilitation, but only 14% as a conse¬ quence of surgery.
Tinnitus the Among respondents, 170 (62%) suffered from tinni¬ tus before surgery, while 135 (49%) indicated tinnitus at the time of the questionnaire. The 13% reduction in the frequency of tinnitus may be the result of both an im¬ provement or worsening, as indicated in Table 1. The de-
Before and after surgery,
patients may experience dys¬ patients (57%) had experienced dizziness before the operation, and among these, changes
equilibrium. Thus,
156
experienced as indicated in Table 1. Six months after surgery, 152 patients (56%) still had experienced dizziness, which indicates that a period of more than 6 months is re¬ quired before a reduction in the frequency of the dizziness occurs. No information concerning dysequilibrium at the time of the questionnaire is available, however, as only nine patients had received antivertiginous drugs within
were
the 3 months before receiving the questionnaire, so an im¬ provement in dysequilibrium during the observation pe¬ riod is likely.
Facial Nerve Ninety-seven patients (36%) indicated that their facial nerve was undamaged in relation to the operation, whereas 169 patients (64%) indicated damage (seven
patients
function
did not
are
respond). However, improvements in occur during the immediate post¬
known to
operative period (Table 1) and thereafter. Thus, the degree of facial nerve function at the time of the questionnaire is given in Table 1. Table 1 also gives the surgical procedures some of the patients went through to relieve problems from the reduced facial
nerve
Downloaded From: http://archotol.jamanetwork.com/ by a University of Edinburgh Library User on 06/21/2015
function.
Table 1.—Questionnaire Results*
Table 3.—Patients' Evaluation of Information Before Surgery Related to Symptoms
No. (%)
No. (%) satisfied with information
Tinnitus (n=170) Better Worse
80 (47)
73 (47)
Better Worse
33(21) 50 (32)
Unchanged Facial 1
79 (29)* No. (%) dissatisfied with information No. concerned with information (multiple responses) 21 Pain 57 Facial paralysis Tinnitus 30 Dizziness 33 Various 13
29(17) 49 (29)
Unchanged Dysequilibrium (n=156)
function after surgery (n=262t) Normal facial mobility Partial facial mobility No facial mobility
*Data not available for four
nerve
(71)*
190
patients.
mo
Patient-estimated degree of facial nerve function ( =268 ) 100% (normal function) 75% 50% 25% 0% (abolished) Surgical procedures to relieve problems due to reduced facial nerve function (n=169)
83 (32) 81 (31) 98 (37)
104(39) 43 (1 6) 39 (1 5) 51 (19) 31 (12)
228
35
10
228
17
28
203
16
54
22
Sleep disturbance Dental problems Speech and swallowing
15
Sexual
17
18
13 6 19
dysfunction
6
Social Consequences
gives the consequences for social situation following surgery as indicated by the patients. Thus, 74% indicated that the surgery had no consequences for their social situation. Among those working (n=157) at the time of the questionnaire, 49% had returned to work within 2 months, 39% within 6 months, and 11% within 12 months after surgery. Among the responders, 14 indicated that they never resumed normal activities, and 28 that their Table 1
and Fickel, %
of Difference
96
94
NS
14
21
S
Bothersome tinnitus Total loss of facial nerve function
27
13
S
12
15
NS
Dysequilibrium
29
90
S
HA
*NS indicates not
29
Wiegand
Current Study, %
Postoperative
tData not available in 11 patients. iData not available in five patients.
Headache/pressure
No.
nurses
Total deafness
ponding.
Anxiety Depression
No
Table 5.—Frequency of Different Experiences Compared With Study by Wiegand and Fickel6*
194(74) 12 (5) Vocational change 23 (9) Ceased to work 3 (1) New education 18 (7) State pension 11 (4) Dismissal 'Values given in parentheses with category indicate number of patients with that problem before surgery or number of patients res¬
Table 2.—Frequency (%) of Additional Problems Experienced (Multiple Responses)
Yes
physician
Estimated social consequences of surgery (n=261) No consequences
Motor
Data Not
Available,
From
14(9)
Cardiovascular
No. Satisfied With Information
From
64 (39) 20 (12)
nerve
by Staff at Time
I-1
Additional staff
Eye Facial Face
Table 4.—Information Given Patient of Surgery
Significance
significant; HA, hearing aid; and S, significant.
was poor. The specific factors causing this impact on the quality of life are unknown in these subjects. Moreover, one must be cautious in accepting a direct
postsurgical adjustment
relationship between surgery and a reduced life quality, as additional physical or mental problems unre¬ lated to surgery can be expected in this sample operated on at a median age of 52 years (range, 15 to 76 years). The frequency of some additional problems experienced at the
causal
time of this
investigation is indicated in Table 2. Information Concerning the Surgery The patients' responses to the quality of the presurgery verbal information concerning different symptoms is indi¬ cated in Table 3. The information on facial paralysis and dizziness was most frequently found unsatisfactory among the 79 patients, indicating that the information had been insufficient. The quality of the information in relation to surgery, given by different staff members, was described
being fairly equal (Table 4). professional network before and at surgery represented by the local hospital staff and the staff at the operating hospital, the most important persons to help the patients were the spouses and family, with a fre¬ as
In addition to the
quency of 81%.
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Some Aspects Obtained From the Open Questions As mentioned previously, a series of open questions were included in the questionnaire to obtain as complete data as possible, considering the questionnaire technique. Thus, the patients had several possibilities to comment further on their experiences; among other things, they were asked to give information about their "most difficult experience" in relation to the surgery. Although 15% did not respond to this question, the most difficult problem experienced in relation to surgery was deafness, 9%; tinni¬ tus, 1%; dizziness, 12%; facial nerve paralysis, 17%; wait¬ ing for surgery, 8%; and anxiety about malignancy and outcome, 6%. In 22%, various problems were rated as the most difficult experience. In 9%, no most difficult problem was experienced. Thus, it seems that the most frequently indicated most difficult experience in relation to surgery was reduced facial nerve function. However, this was not significantly more frequent than, for example, the predict¬ able deafness. A question addressing the most positive experience dem¬ onstrated that most experienced relief for their concern about tumor malignancy and possible surgical complica¬ tions. Also, the service offered by the staff at the operating hospital was a most positive experience for many subjects. In combination with the most positive/difficult experi¬ ence at surgery, psychological consequences of the opera¬ tion were evaluated. Thus, 154 patients (57%) indicated that they had changed predominantly in a negative direc¬ tion, such as isolation, depression, reduced memory and concentration, insufficient self-confidence, nervousness, and feeling less attractive (reduced facial nerve function). However, a few indicated that they had achieved a better quality of life after the surgery. No relationship between the social and psychological consequences of the surgery could be established based on this investigation. COMMENT
Although postal questionnaire technique exhibits several methodological shortcomings and limitations,910 the high response rate of 93% and information rate of 90% (273/303), the inner consistency in the questionnaire, and the inclusion of open and closed questions support a fairly high validity of the data obtained. The minor inconsisten¬ cies, which can be derived from the number of patients re¬ sponding in a different way to nearly identical questions, are insignificant for the indicated frequencies. Although Wiegand and Fickel6 point to limitations and shrewdness in their sample selection, a comparison of the overall frequency of different experiences in the present and the previous studies shows that they are relatively similar (Table 5). In this study, only 14% of patients were fitted postoperatively with a hearing aid, in contrast to 21 % in the American study, where a cross hearing aid was used, resulting in a hearing benefit in two thirds of the subjects. The limited frequency of audiological rehabilitation in this study may be explained by a lack of information on the possibility of needing hearing rehabilitation, which is free of charge in Denmark,11 but it may also reflect a negative attitude toward audiological rehabilitation both in the general population and among physicians.12 These data concerning tinnitus demonstrate a reduced fre¬ quency of 13% in the ear with tumor at the time of the ques¬ tionnaire. This is significantly better than what was reported in the American survey, which indicated a 2% improvement the
worsening in tinnitus. However, as the data analysis per¬ by Wiegand and Fickel6 concerning the postopera¬ tively experienced tinnitus differs from the present data analysis, a direct comparison cannot be performed. The frequency of dysequilibrium 6 months postopera¬ tively in this investigation is significantly lower than that found by Wiegand and Fickel6 (Table 5), who found that only "10% had normal function, and 8% rated dysequilib¬ rium as a severe handicap." Although differences were present in the information concerning dysequilibrium, the 8% rating this experience as a severe handicap corresponds fairly well to those 12% experiencing dysequilibrium as the most difficult problem in this survey. The frequency of 12% having total loss of facial nerve function at the time of the questionnaire corresponds to the frequency found in the American study (Table 5). Only 39% experienced normal function at the time of the ques¬ or
formed
tionnaire, while 50% had more or less reduced facial nerve
function. Although 74% indicated that the operation had no consequences for their social situation, 9% never resumed normal activities, and 10% responded that they had been unable to adjust to the postsurgical situation. This may be related to the unilateral deafness, dysequilibrium, and reduced facial nerve function, alone or in combination, which is supported by 9%, 12%, and 17%, respectively, re¬ porting these postsurgical symptoms as the most difficult experience. However, other factors, as outlined in Table 2, may also be important. The verbal information concerning symptoms given be¬ fore surgery was thought to be satisfactory by only 71% (Table 3), while the information given by the different staff members concerning the surgery was thought to be satis¬ factory by 87% to 93% (Table 4). This might be improved by giving written material, by the professionals providing more thorough information concerning risks and compli¬ cations, and by including information from subjects who have been operated on for an acoustic neuroma previously. This investigation was supported by grants from Else and Mogens Wedell-Wedellsborg's Foundation, Copenhagen, Denmark, which we gratefully acknowledge. References
Transtemporal bone microsurgical removal of acoustic neuromas. Arch Otolaryngol Head Neck Surg. 1964;80:752-754. 2. Glassock ME, Heys JW. The translabyrinthine removal of acoustic and other cerebello-pontine angle tumours. Ann Otol Rhinol Laryngol. 1973;82: 1. House WF.
415-427. 3. Tos
M, Thomsen J, Harmsen
Is preservation of hearing in acoustic worthwhile? Acta Otolaryngol. 1988;452(suppl):57-68. 4. Thomsen J, Tos M. Management of acoustic tumors. Adv Otolaryngol Head Neck Surg. 1989;3:153-194. 5. Dutton JEM, Ramsden RT, Lye RH, Morris K, Keith AO, Page R, Vafadis J. Acoustic neuroma (schwannoma) surgery. 1979-90. J Laryngol Otol. neuroma
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1991;105:165-173. 6. Wiegand DA, Fickel V. Acoustic neuroma\p=m-\thepatient's perspective: subjective assessment of symptoms, diagnosis, therapy, and outcome in 541 patients. Laryngoscope. 1989;99:179-187. 7. Scientific Tables. Basel, Switzerland: RJ Ciba-Geigy; 1970. 8. Parving A, Tos M, Thomsen J. Tinnitus before and after surgery for an acoustic neuroma. Presented at the First International Conference on Acoustic Neuroma; August 28, 1991; Copenhagen, Denmark.
9. Petrinowich L. Probabilistic functionalism: a conception of research method. Am Psychol. 1979;34:373-390. 10. Bradburn NM, Rips LJ, shevall SK. Answering autobiographical questions: the impact of memory and inference on surveys. Science. 1987;236: 157-161. 11. Ewertsen HW.
History of Danish medical audiology. In: Ewertsen HW, Jordan O, Salomon G, eds. Danish Audiology:1951-76. Copenhagen, Denmark: Nyt Nordisk Forlag/Arnold Busck; 1976:1-16. 12. Parving A, Boisen G. Hreproblemer\p=m-\hvadved man om det. Ugeskr Laeger. 1989;151:633-635.
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