Details: Published: May 18, 2017

Acoustic Neuroma Treatment Side Effects

Acoustic neuroma patients may experience symptoms and/or side effects of treatment.

Each heading slides to reveal information.

Balance and dizziness issues are very common with acoustic neuroma, both pre- and post-treatment and can be long or short-term. Some patients experience vertigo, nausea, or what many describe as ‘wonky headedness’. These symptoms can be mild to severe, may be noticeable only during certain activities, or may impact ability to work or drive. The location of the tumor and its blood supply affect balance more than the tumor size itself.

Acoustic neuromas are also called vestibular schwannomas because they arise from the sheath of the eighth cranial nerve which plays an important role in the body's balance system. With surgery or radiation the balance nerve may be compromised and will take time to heal. If the nerve was severed, the balance nerve on the other side of the brain can take over, but this does not happen immediately. Balance or vestibular therapy can be quite effective for many acoustic neuroma patients. Refer to the ANA patient information booklet - Improving Balance Associated with Acoustic Neuroma.

Cognitive and Emotional Issues

The symptoms, diagnosis, and treatment options for acoustic neuroma can significantly challenge patients’ cognitive and emotional states. Fatigue, depression, relationship challenges, difficulty concentrating, and memory issues are potential side effects. There are therapies available specifically to brain tumor patients, and a neuropsychologist may be able to help. Neuropsychologists have expertise in assessing and treating problems with cognitive skills, psychological functions, and behavior as they relate to the brain and central nervous system. You may want to have an evaluation to determine which course of therapy and rehabilitation will work best for you. Your neurologist or neurosurgeon can help you find a Board Certified neuropsychologist, or you can contact The American Academy of Clinical Neuropsychology (AACN),https://www.theaacn.org/ to search for providers in your area.

Mindfulness and meditation courses, ANA Support Groups, yoga, spirituality or religious belief, improvement in diet, and getting enough sleep can also be helpful. Patients should seek local and online resources. The ANA has several webinars, videos, and articles available, as well as our information booklet Understanding Emotional, Cognitive, and Behavioral Changes.

CSF leaks

Cerebrospinal fluid, or CSF, is a watery fluid that flows in the ventricles (cavities) within the brain and around the surface of the brain and spinal cord. It is continuously produced and absorbed. On occasion, CSF leaks can happen after the microsurgical removal of an acoustic neuroma tumor. They can occur either through the nose or from the incision. Such leaks appear as a clear, watery discharge and can leave a salty taste in your mouth or a dripping feeling from your nose or from the incision. If left untreated, an infection that could lead to meningitis may follow, therefore these symptoms should be reported to your doctor immediately.

Eye Issues

Because of its proximity to multiple cranial nerves associated with eye function, removal of an acoustic neuroma may affect the eye of the patient. These nerves affect facial function, such as blinking and eyelid closure, sensation, tears, eye muscles and movement, and healing abilities.

Acoustic neuroma patients may experience difficulty blinking, excess moisture or dryness, double vision, or eye sensitivity. It is very important that the eye be protected and it may be necessary to apply artificial tears or to tape the eye shut to allow for healing. There are also several surgical options for improving eye issues. The ANA has a patient information booklet that covers eye issues in more depth– Eye Care after Acoustic Neuroma Surgery.

Facial Issues

Acoustic neuroma patients can experience facial pain, weakness, or paralysis, either before or after treatment. Post-surgery facial paralysis is less common than it used to be because of changes in the way surgeons attend to facial nerve concerns.

The 7th cranial nerve, or facial nerve, is often affected in the treatment of an acoustic neuroma. The nerve may be damaged with either surgery or radiation, however it is usually possible to preserve some degree of facial function, even in cases where the nerve is extensively involved. Temporary weakness of the face due to nerve swelling is common; although in some cases there may be permanent facial weakness.

If the facial nerve is damaged, it is possible for it to regenerate slowly. It is also possible to reconnect the facial nerve during or after surgery. When it is not possible to repair the facial nerve, additional surgeries may be necessary to substitute other nerves, allowing partial voluntary movement to return. There are also many non-surgical options including exercises for patients with facial issues. Refer to the ANA patient information booklet – Facial Nerve and Acoustic Neuroma – Possible Damage and Rehabilitation.

Headache

Headache post-treatment can be caused by a variety of reasons. The acute phase refers to headache experienced for the first several weeks post-treatment, due to the incision, variations in cerebrospinal fluid pressure, muscle pain, or even meningitic pain. Depending on the type of treatment, the reported incidence of headache ranges from 23% to 33% of patients. Frequent and severe post-operative headaches have been more often associated with the retrosigmoid/sub-occipital surgery approach than the translabyrinthine or middle fossa approaches. Chronic headache following acoustic neuroma surgery has been noted to be higher than after craniotomy for other causes.

Chronic headaches can persist for months or even years, and many times the exact prevalence and causes are elusive. Younger age, greater anxiety and depression, pre-existing diagnosis of migraine, and presence of headaches prior to treatment are the primary predictors of severe long-term headache disability, while tumor size and treatment modality had little influence. Preventative medications, local therapy to neck muscles, antidepressants, stress reduction, acupuncture, and lifestyle changes are all potential avenues for patients to explore. In the most resistant cases, it may be necessary to treat headaches in a multidisciplinary pain center. Refer to the ANA patient information booklet – Headache Associated with Acoustic Neuroma Treatment.

Migraine - More than a Headache (pdf)

Hearing Loss

Hearing loss in acoustic neuroma patients can vary from no or mild hearing loss to complete deafness (also known as profound hearing loss or single-sided deafness – SSD). Hearing loss on one side (asymmetrical) is the most common first symptom of acoustic neuroma. Approximately 90% of participants report single-sided hearing loss or deafness. Most patients present with a slowly progressive hearing loss; however, some patients experience a sudden loss of hearing on the side of the tumor. Tinnitus on the tumor side is also common. An audiologist will look for asymmetrical hearing loss, particularly high-frequency sensorineural hearing loss.

Hearing loss may occur whether one chooses observation, radiation therapy, or surgery. Patients and their doctors should discuss the possibility of hearing preservation with each treatment option. There are many options for hearing aids, each with pros and cons. As the degree of hearing loss varies among patients, the type of hearing aid best-suited for each depends on many factors.

Hearing loss can disrupt one’s social and work life; it can contribute to depression and a sense of isolation. Hearing rehabilitation, using hearing aids, and assistive listening devices, can be quite useful and improve quality of life.

Refer to the ANA patient information booklet – Hearing Loss – Rehabilitation for Acoustic Neuroma Patients

Hydrocephalus

Meningitis

CSF leaks and infection following surgery are rare occurrences which can lead to meningitis if left untreated. Meningitis is inflammation or irritation of the meninges (fluid and tissue surrounding the brain). One causal factor that is particular to acoustic neuroma surgery is the drilling of bone from within the intradural space for further exposure of the tumor in the internal auditory canal. This process is nearly exclusive to the retrosigmoid approach and is much less common in the translabyrinthine or middle fossa approaches. The drilling often results in bone dust distributed around the meninges in the posterior fossa, which can be difficult to remove completely. Two studies have highlighted the importance of bone dust in inducing meningitis following AN surgery. If this condition occurs, it would require an extended hospital stay.

Mouth Issues

It is not uncommon to experience dry mouth and taste disturbance for a few weeks following surgery or radiation treatment. In some cases the duration is prolonged. Dentists may recommend mouth rinses or other medications. If swallowing becomes a problem, a speech pathologist, nurse, or occupational therapist can provide exercises to help. Facial weakness or paralysis, numbness, or facial pain may impact chewing and drinking, tooth, and oral health. For patients experiencing these side effects, a dentist can help with these issues.

Regrowth of the Tumor

Recurrence of acoustic neuromas can be caused by several factors and usually only occur in a small percentage of patients. There is unfortunately no good way to predict which tumors will recur after treatment. Sometimes a small part of the tumor is left along the facial nerve at the time of initial surgery in an effort to preserve its function. Management options for the recurrence or re-growth of the tumor can include another surgery or oftentimes radiation. Each patient should be counseled on a case-by-case basis by doctors with expertise and experience with treating acoustic neuromas.

Seizures and Strokes

A rare complication of acoustic neuroma surgery is the possibility of a stroke due to damage to major blood vessels in the brain. Fortunately, current microsurgical techniques take great care to preserve all major blood vessels encountered during the removal of the tumor, making a stroke quite rare. However, any significant changes in thought processes or neurological functioning should be immediately reported to physicians.

Tinnitus

Tinnitus is the perception of sound when no actual external noise is present. While it is commonly referred to as “ringing in the ears,” tinnitus can manifest in many different perceptions of sound, including buzzing, hissing, whistling, swooshing, and clicking. In some rare cases, tinnitus patients report hearing music. Tinnitus can be both an acute (temporary) condition or a chronic (ongoing) health malady. – American Tinnitus Association

Tinnitus is a common presenting symptom of acoustic neuroma, and can impact quality of life. Although there is no cure for tinnitus, there are several treatment options that can lessen the impact on the patient. Some hearing aids and devices have features that mitigate tinnitus.

Details: Published: May 18, 2017

Keywords

ACOUSTIC
pertaining to hearing

ACOUSTIC NEUROMA (AN)
benign tumor of the eighth cranial nerve

ACOUSTIC NEUROMA ASSOCIATION OF CANADA (ANAC)
a registered non-profit organization in Canada with similar purposes to ANA

AUDIOGRAM
a chart of hearing acuity recorded during hearing tests

AUDIOLOGIST
a medical professional who assesses and manages hearing and balance-related disorders

AUDIOVESTIBULAR SPECIALIST
a medical professional specializing in the diagnosis and treatment of hearing, balance, and communication problems, including tinnitus

AUDITORY BRAINSTEM IMPLANT (ABI)
a type of hearing device that bypasses the cochlea in the middle ear and the auditory nerve and is implanted in the brainstem

BENIGN
not malignant, non-cancerous: does not invade surrounding tissue or spread to other parts of the body

BILATERAL
pertaining to both sides of the body

BONE ANCHORED HEARING AID
a hearing device that works through bone conduction with a sound processor attached to a small titanium implant

The sound processor is placed on the deaf side, behind the ear and sound is transferred through the bone of the skull, stimulating the cochlea in the hearing ear. The brain is then able to distinguish between the sounds that it receives from the deaf side, via this system, from the sound that it receives directly from the hearing ear. This ultimately results in the sensation of hearing from the deaf side.

BRAINSTEM
connects the upper brain to the spinal cord; is less than three inches long

BRITISH ACOUSTIC NEUROMA ASSOCIATION (BANA)
a registered charity organization in the United Kingdom that is dedicated to promoting the exchange of mutual support and information among individuals affected by acoustic neuromas, with similiar purposes to ANA

CENTIMETER (cm)
.394 inch (2.54 cm equals one inch) - ten millimeters equal one centimeter

CEREBELLOPONTINE ANGLE
space bounded by the petrous bone, brainstem, and cerebellum, and through which cranial nerves 6-11 pass

CEREBELLUM
located behind the brainstem, extending from the brainstem out toward each mastoid bone; carries 11% of the brain's weight and controls muscular coordination

COCHLEAR IMPLANT (CI)
CI is a small, electronic device that is implanted within the inner ear to increase hearing capabilities. Cochlear implants may be helpful when the patient has significant hearing loss in both ears. The cochlear nerve and blood supply must be intact on the CI side - often not the case for post-treatment AN patients. CIs compensate for damaged or non-working parts of the inner ear, finds useful sounds and sends them to the brain.

CRANIAL NERVES
control the sensory and muscle functions around the eyes, face and throat- There are two sets each of twelve cranial nerves, one set for each side of the body.

CROS HEARING AID
Contralateral Routing of Sound - used with single-sided deafness. It receives sound on the deaf side, amplifies it, and carries it to the good ear.

CEREBROSPINAL FLUID (CSF)
a watery fluid, continuously being produced and absorbed, which flows in the ventricles (cavities) within the brain and around the surface of the brain and spinal cord

COMPUTERIZED TOMOGRAPHY (CT SCAN)
X-ray test which creates a cross-sectional picture of any part of the body - can distinguish among tissue, fluid, fat and bone

CYBERKNIFE (CK)
a robotic radiosurgery system that delivers multiple beams of radiation, used to treat benign tumors and cancers and other medical conditions located anywhere in the body in multiple sessions

EAR, NOSE AND THROAT (ENT) PHYSICIAN
also called an otolaryngologist, a physician specializing in the diagnosis and treatment of diseases of the head and neck, especially those involving the ears, nose, and throat

ELECTRONYSTAGMOGRAM (ENG)
a recording of the eye movements, usually done to confirm the presence of involuntary eye movements; can also be done in cases of vertigo to determine if there is damage to the vestibular portion of the acoustic nerve or in cases of possible acoustic neuroma

FACIAL PLASTIC SURGEON
a medical professional who specializes in the reconstruction, restoration, and enhancement of the face, head, and neck

FRACTIONATED STEREOTACTIC RADIATION (FSR)
any focused radiation treatment that requires more than one treatment delivery session

GADOLINIUM
a contrast material given at the time of MRI which concentrates in the tumor and makes it more visible

GAMMA KNIFE (GK)
a radiosurgical machine that contains 201 separate radioactive cobalt sources; gamma rays from each source are focused together at the tumor

INTENSITY MODULATED RADIATION THERAPY (IMRT)
an advanced mode of high-precision radiotherapy that utilizes computer-controlled linear accelerators to deliver precise radiation doses to a tumor or specific areas within the tumor

INTERNAL AUDITORY CANAL (IAC)
a short auditory canal in the petrous portion of the temporal bone, part of the base of the skull that extends from the ear towards the center of the head, through which pass the vestibulocochlear and facial neves

LINAC
a radiosurgical machine that produces x-rays electronically

MAGNETIC RESONANCE IMAGING (MRI)
a technique that uses a magnetic field and radio waves to create detailed images of the organs and tissues within the body

MIDDLE FOSSA
surgical approach to an acoustic neuroma primarily used for the purpose of hearing preservation

MILLIMETER (MM)
a metric unit of measure; 10mm=1cm

NEUROFIBROMATOSIS (NF)
a familial condition characterized by developmental changes in the nervous system, muscles, bones, and skin - the central form (Neurofibromatosis 2 - NF2) may produce bilateral acoustic neuromas

NEUROMA
benign growth originating on a nerve

NEURO-OPHTHALMOLOGIST
a medical professional who specializes in visual issues related to the nervous system

NEUROPSYCHOLOGIST
a psychologist who specializes in the relationship between the brain and behavior

NEUROTOLOGIST
a physician specializing in the neurological aspects of the auditory and vestibular apparatus

NEUROSURGEON
a physician with a surgical specialty concerned with the treatment of diseases and disorders of the brain, spinal cord and peripheral and sympathetic nervous system

OCCUPATIONAL THERAPY (OT)
a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life

OPHTHALMOLOGIST
a medical doctor who specializes in diagnosing and treating eye conditions and injuries

OTOLARYNGOLOGIST (OTO)
a physician specializing in the diagnosis and treatment (including surgery) of head and neck disorders, especially those involving the ear, nose and throat (ENT)

OTOLOGIST
a physician specializing in the diagnosis and treatment of ear disorders only

PATIENT NAVIGATOR
a person who helps patients navigate the health care system by connecting them with the right services and providers

PHYSICAL THERAPY (PT)
treatment that helps you improve how your body performs physical movements

PONS
located at the base of the brain in front of the cerebellum, this section of the cranium is a mass of nerve tissue which coordinates the activities of the various lobes of the brain

POSTERIOR FOSSA
the cavity in the back part of the skull which contains the cerebellum, brainstem and cranial nerves 5-12

PROTON RADIATION
a therapy using protons, a positively charged particle, to treat AN

RADIOSURGERY (STEREOTACTIC RADIOSURGERY - SRS)
a treatment consisting of a single session of radiation treatment

RADIOTHERAPY (RT)
a treatment consisting of multiple sessions of radiation treatment

RETROSIGMOID/SUB-OCCIPITAL
a surgical approach for AN where an opening in the cranium behind the mastoid, close to the back of the head is used for access

SENSORINEURAL HEARING LOSS (SNHL)
deafness caused by failure of the acoustic nerve

SPEECH-LANGUAGE PATHOLOGIST (SLP)
a communication expert who assesses, diagnoses, treats, and prevents speech, language, voice, and swallowing disorders

SUDDEN SENSORINEURAL HEARING LOSS (SSHL)
a rapid loss of hearing that requires medical attention

SHUNT
a tube implanted in the cranium to balance the flow of cerebrospinal fluid and used in the treatment of hydrocephalus

TINNITUS
a common symptom of AN patients, a noise produced in the inner ear, such as ringing, buzzing, roaring, clicking, etc.

TRANSLABYRINTHINE
a surgical approach for AN where the mastoid bone and the bone in the inner ear (labyrinthine) are removed to access the tumor; this approach results in complete hearing loss on the tumor side

TRIGEMENAL NEURALGIA
a chronic pain disorder that causes episodes of severe facial pain

UNILATERAL
involving only one side

VERTIGO
a sensation of whirling or spinning, dizziness, and loss of balance, associated particularly with looking down from a great height, or caused by disease affecting the inner ear or the vestibular nerve

VESTIBULAR
associated with the balance system

VESTIBULAR THERAPY (VT)
type of physical therapy that uses exercise to help improve balance and reduce dizziness

Details: Published: May 18, 2017

Diagnosing

How are acoustic neuromas (vestibular schwannomas) diagnosed?
The diagnosis of an acoustic neuroma is often triggered by a patient’s symptoms. The most common presenting feature of acoustic neuromas, occurring in 90% of patients, is unilateral hearing loss. When "pure tone audiometry" is used, the most common finding is high frequency hearing loss. The hearing loss is progressive in most patients, but in approximately 12% of patients the hearing loss may occur suddenly. Other symptoms of the acoustic neuroma include asymmetric tinnitus (ringing in the ear, occurring in 80% of patients), dizziness, and disequilibrium (difficulty with balance). These symptoms will often prompt a doctor to order a hearing test, called an audiogram. If the hearing test confirms that one ear has more hearing loss than the other, then a magnetic resonance imaging (MRI) scan of the head is typically ordered. Early diagnosis offers the best opportunity for successful treatment.

Diagnosis involves:

Hearing test (audiometry): A test of hearing function, which measures how well the patient hears sounds and speech, is usually the first test performed to diagnose acoustic neuroma. The patient listens to sounds and speech while wearing earphones attached to a machine that records responses and measures hearing function. The audiogram may show increased "pure tone average" (PTA), increased "speech reception threshold" (SRT) and decreased "speech discrimination" (SD).
Brainstem auditory evoked response (BAER): Historically, this test was performed in some patients to provide information on brain wave activity as a response to clicks or tones. The patient listens to these sounds while wearing electrodes on the scalp and earlobes and earphones. The electrodes pick up and record the brain's response to these sounds, but these tests have been shown to be less accurate in diagnosing acoustic neuromas than MRI.
Scans of the head: If other tests show that the patient may have acoustic neuroma, magnetic resonance imaging (MRI) is used to confirm the diagnosis. MRI uses magnetic fields and radio waves, rather than x-rays, and computers to create detailed pictures of the brain. It shows visual “slices” of the brain that can be combined to create a three-dimensional picture of the tumor. A contrast dye is injected into the patient. If an acoustic neuroma is present, the tumor will soak up more dye than normal brain tissue and appear clearly on the scan. The MRI commonly shows a densely "enhancing" (bright) tumor in the internal auditory canal. If the patient is unable to get an MRI, a computed tomography (CT) scan may be ordered instead.
Because MRI and CT scans of the head are often ordered for many different conditions, in some cases, acoustic neuromas are discovered incidentally.

Details: Published: May 18, 2017

Symptoms of Acoustic Neuroma (Vestibular Schwannoma)

Each heading slides to reveal more information.

Early Symptoms

Early symptoms of acoustic neuroma (vestibular schwannoma) can be mistaken for other medical issues, and may be ignored or overlooked, thus making diagnosis a challenge. Approximately 90% of patients have single-sided hearing loss at the time of diagnosis. Hearing loss with acoustic neuroma is usually subtle and more pronounced in higher frequencies, although sudden hearing loss can occur. Sometimes the patient or doctor attributes hearing loss to aging, noise exposure, or allergies.

Approximately 70% of patients report tinnitus (ringing or noise in the ear) at the time of diagnosis, and 55% report vertigo/dizziness or balance issues. Other presenting symptoms can include a feeling of fullness/plugging in the ear, headache, facial weakness/paralysis, fatigue, eye problems, cognitive changes, and oral/swallowing issues. Some people find that these acoustic neuroma symptoms may come and go or fluctuate over time.

Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness, vertigo, dizziness, or what many describe as ‘wonky-headedness’ may occur during the growth of the tumor. Acoustic neuroma patients often experience balance issues before diagnosis. The remainder of the balance system sometimes compensates for this loss, and, in some cases, no imbalance will be noticed.

Larger tumors can press on the trigeminal nerve, causing facial or tongue numbness and tingling, constantly or intermittently. Tumor-related increase of intracranial pressure may cause headaches, clumsy gait, and mental confusion. This can be a life-threatening complication requiring urgent treatment. Even though the facial nerve (the nerve that moves the face) may be compressed by the tumor, it is unusual for patients to experience weakness or paralysis of the face from acoustic neuroma, although this may occasionally occur, either short or long term.

Typical Symptoms Overview

Unilateral Hearing Loss (on one side only) - This can sometimes occur suddenly (sudden hearing loss), but it generally can be very gradual, over months or years. In most acoustic neuroma patients, the loss is more pronounced in the higher frequencies. Unilateral hearing loss is usually the first symptom that leads to discovery of this benign brain tumor.
Tinnitus (ringing or buzzing in the ears) - Most AN patients do have tinnitus both before and after treatment. Not all patients with tinnitus have a brain tumor.
Feeling of fullness in the ear - Acoustic neuroma patients sometimes complain of a feeling that their ear is plugged or "full.”
Balance problems, vertigo - Acoustic neuroma patients often experience balance issues before diagnosis. It can occur very gradually and may go unnoticed as the body has many compensating mechanisms.
Headaches - Acoustic neuroma patients sometimes recall, after diagnosis, that they had unexplained headaches.
Facial pain, numbness, paralysis - Acoustic neuromas are usually discovered before they cause facial symptoms. However, if they are large or impacting one of the facial nerves, they can cause numbness, tingling or even facial paralysis.

Details: Published: May 16, 2017

Caregiver Resources

Caregiver Information Sheet

AARP
Caregiving Link
Online discussion group, videos, articles, free online tools including care cost calculator.

American Brain Tumor Association
Care and Support Link/Caregiver Resources
Living and Coping e-newsletter, online support, and links to additional resources including organizations that provide financial assistance and transportation assistance. Orientation to Caregiving, download the pdf handbook for family caregivers.

Caregiver Action Network
Provides education, peer support, and resources for family caregivers. Family caregiving toolbox provides a great selection of links and resources to helpful organizations. A peer network provides access to volunteers across the U.S. who are current and former caregivers and can help provide information and support.

CaringBridge
Provides free websites to connect people experiencing a significant health challenge to family and friends. Websites are easy to create and use. Authors add health updates and photos to share their stories while friends and visitors can leave messages in the guestbook.

Family Caregiver Alliance
Caregiver discussion group, tips, FAQs, fact sheets, resource listing by state, information available in other languages, and detailed listing of practical tools and resources for caregivers.

Lotsa Helping Hands
Provides free tools, resources, an online community, webinars, a monthly newsletter, and a resource directory.

National Alliance for Caregiving
NAC is dedicated to improving the quality of life for friend and family caregivers and those in their care, by advancing research, advocacy, and innovation.

National Brain Tumor Society
Resources and Support Link
Caregiver training, support groups, workshops, interactive online community, Link Library, tip sheets, how-to-guides.

Today´s Caregiver
Today´s Caregiver magazine, local resources, e-newsletter, discussion forum, Caretips, Fearless Caregiver conferences.

WellSpouse Association
Respite weekends, support groups, online forum, quarterly newsletter, e-newsletter, resource directory.

The Acoustic Neuroma Association® does not endorse any of the organizations listed above or any commercial product, physician, surgeon, medical procedure, medical institution or its staff.

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