What is the best course of treatment for an adult patient with no significant medical history presenting with a tumor in the ear causing dizziness?

Treatment of Ear Tumors Causing Dizziness

For an adult patient with an ear tumor causing dizziness, surgical resection is the definitive treatment, with the specific approach determined by tumor type, size, and location—most commonly vestibular schwannoma (acoustic neuroma) requiring microsurgical removal or stereotactic radiosurgery for smaller lesions. 1

Initial Diagnostic Workup

The evaluation must establish the tumor type and extent:

• MRI with gadolinium contrast of the internal auditory canal and brain is the gold standard imaging modality to characterize the tumor, assess size, and identify any central nervous system extension 2
• Audiometry should be performed to document baseline hearing function, as this influences surgical approach and prognosis 1
• Otoscopic examination to evaluate for middle ear involvement, retraction pockets, or cholesteatoma 3
• CT temporal bone without contrast if cholesteatoma is suspected based on chronic ear discharge and otoscopic findings 3

Treatment Algorithm by Tumor Type

Vestibular Schwannoma (Most Common)

For symptomatic tumors causing dizziness, active treatment is indicated rather than observation. 1

Surgical Resection

• Large tumors (Koos grade IV) require surgery as primary treatment to address symptomatic mass effect 1
• Goal is gross total or near-total resection, as residual tumor volume correlates with recurrence rates (3.8% for GTR vs 27.6% for subtotal resection) 1
• Intraoperative monitoring is mandatory, including facial nerve monitoring with direct electrical stimulation and free-running electromyography, plus brainstem auditory evoked responses when hearing preservation is attempted 1
• Surgery should be performed at high-volume centers due to the significant impact of surgical team experience on outcomes 1
• Surgery-related mortality is 0.5% in large series 1

Stereotactic Radiosurgery (SRS)

• For intracanalicular tumors, SRS achieves equivalent tumor control to surgery with superior facial nerve preservation and similar hearing preservation rates 1
• SRS is particularly appropriate for smaller tumors in patients seeking to avoid surgical risks 1

Conservative Surveillance

• Reserved for older patients with no appreciable tumor growth, regardless of hearing status 1
• Approximately 50% of vestibular schwannomas grow over a 5-year period, with mean growth of 2.9 mm/year 1
• Not appropriate for symptomatic patients with dizziness, as this indicates active tumor effect requiring intervention 1

Other Temporal Bone Tumors

Meningiomas

• Surgical excision is the treatment of choice for primary ear and temporal bone meningiomas 4
• These tumors behave as slow-growing neoplasms with good overall prognosis (83% 5-year survival) 4
• Recurrence occurs in 28% of cases, making extent of surgical resection the most important prognostic factor 4

Leiomyomas/Angioleiomyomas

• Gross total resection should be achieved when possible, accomplished in 81.8% of skull base cases 1
• No cases of radiographic or clinical recurrence were reported in the literature review 1
• Radiation therapy is reserved for subtotal resections (3 of 6 patients with incomplete resection received adjuvant radiation) 1

Symptomatic Management During Workup

Meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases and can provide symptomatic relief while definitive diagnosis and treatment planning proceed 5

Critical Pitfalls to Avoid

• Do not delay imaging with MRI in patients with unilateral hearing loss and dizziness—vestibular schwannoma occurs in the majority of patients with unilateral tinnitus who undergo imaging 2
• Do not assume bilateral presentation—only 1.1% of acoustic neuromas are associated with neurofibromatosis type 2, and 15% of NF2 patients initially present with unilateral disease 2, 6
• Do not pursue conservative management in symptomatic young patients—larger tumors are significantly more prevalent among younger patients, suggesting more aggressive tumor biology 6
• Consider meningeal carcinomatosis in patients with cancer history—lumbar puncture with CSF cytology should be performed early if there is a history of malignancy, particularly gastric cancer 7

Prognostic Factors

Hearing preservation after surgery depends on:

• Tumor size <1 cm (better outcomes) 1
• Good preoperative hearing function 1
• Presence of distal internal auditory canal CSF fluid fundal cap 1

Facial nerve outcomes:

• Risk of persisting facial palsy ranges 3-46% depending on tumor size 1
• Intraoperative monitoring significantly improves functional outcomes 1