Dartmouth Atlas Takes Aim at Excess Utilization of Medical Resources

Over a 25-year span, the investigative team treated 464 patients with VS. All were informed of the various treatment options, including their risks and possible complications. Of these patients, 336 (72.4%) patients were treated surgically, 125 (27.1%) with a wait and scan policy, and two (0.4%) with radiotherapy. The authors noted that over the years there was a progressive increase in the number of primarily observed patients compared with the number of surgically treated patients.

Tumor size at presentation ranged from 2 to 28 mm; almost half were intracanalicular tumors. Each radiologically observed patient received a second MRI scan after six months; tumor growth was defined as a dimensional increase of 2 mm or more in comparison to the previous scan, and a decrease of 2 mm or more defined tumor shrinkage. Audiometric assessment was conducted during the entire period of observation. The mean follow-up period was 57.4 months.

Among the patients for whom the wait and scan approach was used, no evidence of tumor growth was recorded during the entire period of observation for 59.7% of the cases. Tumors shrank in 4.8% of cases, and grew in 35.5%. Of the tumors that grew, enlargement was detected during the first year of observation in 45.4% of cases, whereas in 22.7% of cases, the growth was observed at least three years after diagnosis. No tumor growth was discovered after six or more years of observation. The average growth rate of the growing tumors was 1.2 mm/year. Sixteen (36.3%) patients with growing tumors had them treated surgically; all had favorable outcomes, indicating that surgical delay does not affect postoperative outcome.

The investigators conclude that conservative management of VS appears to be a safe and effective option because most tumors do not grow over the course of time, and surgical outcomes are not affected by delaying surgery. Furthermore, almost three-fourths of patients in the study maintained useful hearing during the observation period, and no differences were recorded in relation to tumor growth rate. Future research should look for predictive factors for the growth of tumors.

(Laryngoscope 2008;118:951-7)

Contact the Editor

ENToday welcomes your feedback about our publication! Contact us using the information below: ENToday@lwwny.com

Laryngoscope Highlights

Video Presentation: Endoscopic Removal of Juvenile Nasopharyngeal Angiofibromas

Juvenile nasopharyngeal angiofibroma (JNA) is a relatively rare, benign neoplasm characterized by nasal airway obstruction, recurrent unilateral epistaxis, headache, and facial swelling. JNAs arise in close proximity to the posterior attachment of the middle turbinate, near the superior border of the sphenopalatine foramen, and can extend into the nasal cavity, sphenoid sinus, and pterygopalatine fossa. In the past, surgical management of JNA included lateral rhinotomy, transpalatal and transmaxillary routes, and mid-face degloving. However, endoscopic sinus surgery for resection of JNA is a relatively new phenomenon that has recently become the standard approach for tumors that are limited to the nasal cavity and nasopharynx. Studies have shown that patients who underwent endoscopic JNA resection had less intraoperative blood loss, shorter hospital stays, lower complication rates, and fewer recurrences. In this video presentation, available online, Daekeun Joo, MD, Dinesh K. Chhetri, MD, and Marilene B. Wang, MD, demonstrate the procedure.