Vestibular schwannoma and vestibular function

Vestibular schwannoma and vestibular function

The difference between vertigo, dizziness and balance problems.

Vertigo, dizziness, and balance problems may seem similar, but they are distinct sensations with different causes. Vertigo is a false sensation of spinning or movement, often associated with inner ear issues. Dizziness is a feeling of lightheadedness or unsteadiness, which can be caused by factors such as low blood pressure or dehydration. Balance problems refer to difficulty maintaining stability and can be related to the inner ear, nervous system, or musculoskeletal system issues. Patients may struggle to differentiate these sensations, as they can overlap and be challenging to describe accurately in medical terms.

Vertigo, dizziness, and balance issues often overlap, leading to symptoms such as the inability to stabilize vision while moving the head, spatial disorientation, and difficulty maintaining an upright stance when standing or walking. These symptoms can be debilitating and impact daily activities.


Vertigo, dizziness and balance problems in vestibular schwannoma

Vestibular problems leading to vertigo, dizziness and balance problems are underestimated in VS. Dizziness occurs in 49 to 66% of patients with VS (1,2). Vertigo is the presenting symptom in 10-19% of patients with VS (3,4,5).

Vestibular schwannoma and the vestibular nerve.

Vestibular schwannoma originates mainly from the vestibular nerve, which is involved in balance, eye movement, control during head motion and spatial orientation. Therefore, it is not surprising that patients with this condition commonly present with vertigo, dizziness, and imbalance. What is interesting, though, is that hearing loss and not vestibular loss is the most common complaint.

Hearing loss is more evident than vertigo

Hearing loss may be more noticeable to patients because no other sensory organs can fully compensate for the decline in hearing ability. Patients with hearing loss are more aware of the problem because hearing is their primary sensory organ for communication and awareness of the environment. They may struggle with communication, understanding conversations, and overall awareness of their surroundings without the ability to hear. The deficit is more noticeable when the hearing loss occurs suddenly.

On the other hand, patients with slow-onset vestibular deficits may not be as aware of the problem initially because the brain and other sensory modalities like vision and touch can compensate for the loss of vestibular function. Slow-growing tumours like vestibular schwannoma may gradually affect the vestibular system, allowing the brain to adapt and minimize symptoms such as vertigo, dizziness, and balance problems.

Only in cases where there is a sudden decline in vestibular function do patients experience more severe symptoms. These symptoms may improve over time as the brain compensates for the loss of vestibular function. In these cases, rehabilitation and therapy may be necessary to help the patient recover and regain their balance.

The mechanism of vestibular loss

As the tumour grows slowly, it destroys the vestibular nerve, causing a gradual loss of function in the affected ear. However, the brain can compensate for this loss by relying more heavily on input from the unaffected ear and other sensory systems.

In rare cases where the tumour grows rapidly, bleeds on the inside or forms a cyst, sudden and severe vestibular loss may follow. This sudden loss of function can result in symptoms such as vertigo, dizziness, and balance problems. The sudden nature of these symptoms can be particularly challenging for the brain to compensate for, leading to more pronounced difficulties with balance and spatial orientation.

Vestibular schwannoma can block a blood vessel in the inner ear, resulting in sudden vestibular or hearing loss. Additionally, the tumour may secrete harmful proteins that damage the cochlea and vestibular organs, leading to gradual loss of hearing and balance function over time.

Larger vestibular schwannoma is pressed directly on the brainstem and cerebellum, causing balance and other neurological problems.

What is the practical implication

 Acute vestibular loss due to a vestibular schwannoma is a sudden and often unexpected event that can lead to vertigo, dizziness, disorientation, and loss of balance. This can significantly impair a person’s ability to function normally and perform everyday tasks, making them prone to injuries.

For instance, a sudden bout of vertigo while driving a vehicle can lead to a car accident, endangering the patient and others on the road. Similarly, experiencing dizziness while piloting an aircraft or operating dangerous machinery can have severe consequences and potentially result in catastrophic accidents.

Patients with vestibular schwannomas must know the potential risks associated with acute vestibular loss and take necessary precautions to prevent injuries. This may include avoiding activities that require coordination and balance until the symptoms subside, seeking medical attention promptly, and informing healthcare providers of their condition to receive appropriate treatment and guidance. In South Africa, the traffic department requires that a patient report the diagnosis of a vestibular schwannoma when applying or renewal of a driver’s license. (6).

Vestibular loss and quality of life

A quality of life (QOL) questionnaire, such as the Penn Acoustic Neuroma Quality of Life Questionnaire, is a standardized tool used to assess various aspects of an individual’s well-being and how they are affected by a specific medical condition or treatment (7).

The Dizziness Handicap Inventory is a self-assessment tool used to measure the impact of dizziness on daily life (8).

These questionnaires typically include questions about physical, emotional, social, and cognitive functioning and overall satisfaction with life. The results can help healthcare professionals better understand the impact of a disease on a patient’s quality of life and tailor treatment plans accordingly.

Several studies have shown that vestibular symptoms are one of the most important negative influencers of QoL in patients with VS (9,10).


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2. Humphriss RL, Baguley DM, Axon PR, Moffat DA. Preoperative audiovestibular handicap in patients with vestibular schwannoma. Skull Base. 2006 Nov;16(4):193-9. doi: 10.1055/s-2006-950388. PMID: 17471318; PMCID: PMC1766462.

3. Sahyouni R, Moshtaghi O, Haidar YM, Mahboubi H, Moshtaghi A, Lin HW, Djalilian HR. Vertigo in Vestibular Schwannoma Patients Due to Other Pathologies. Otol Neurotol. 2017 Dec;38(10):e457-e459. doi: 10.1097/MAO.0000000000001567. PMID: 28891872; PMCID: PMC6082136.

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5. Moffat DA, Baguley DM, Beynon GJ, Da Cruz M. Clinical acumen and vestibular schwannoma. Am J Otol. 1998 Jan;19(1):82-7. PMID: 9455955.

6. Renewal of drivers licence in South Africa.

7. Shaffer BT, Cohen MS, Bigelow DC, Ruckenstein MJ. Validation of a disease-specific quality-of-life instrument for acoustic neuroma: the Penn Acoustic Neuroma Quality-of-Life Scale. Laryngoscope. 2010 Aug;120(8):1646-54. doi: 10.1002/lary.20988. PMID: 20641085.

8. Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990 Apr;116(4):424-7. doi: 10.1001/archotol.19’90.01870040046011. PMID: 2317323.

9. Jufas N, Flanagan S, Biggs N, Chang P, Fagan P. Quality of Life in Vestibular Schwannoma Patients Managed by Surgical or Conservative Approaches. Otol Neurotol. 2015 Aug;36(7):1245-54. doi: 10.1097/MAO.0000000000000789. PMID: 26075673.

10. Myrseth E, Møller P, Wentzel-Larsen T, Goplen F, Lund-Johansen M. Untreated vestibular schwannomas: vertigo is a powerful predictor for health-related quality of life. Neurosurgery. 2006 Jul;59(1):67-76; discussion 67-76. doi: 10.1227/01.NEU.0000219838.80931.6B. PMID: 16823302.