Collaborative Care and Innovation in Lateral Skull Base Tumors

Podcast Transcript

Paul C. Bryson, MD, MBA:

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology. Today I'm joined by Dr. Nguyen-Huynh, an otolaryngologist specializing in neurotology. Welcome to the podcast, Dr. Nguyen-Huynh.

Anh Nguyen-Huynh, MD:

Hello. Thank you very much for having me here.

Paul C. Bryson, MD, MBA:

And Dr. Pranay Soni, a neurosurgeon specializing in skull base, brain tumor and spine tumor surgeries. Welcome to the podcast, Pranay.

Pranay Soni, MD:

Hi, thank you so much for having me.

Paul C. Bryson, MD, MBA:

Well, before we dive in, can you each briefly share your training background and how your specialties intersect in the management of lateral skull-based pathology?

Anh Nguyen-Huynh, MD:

Well, I began my training in ENT Otolaryngology at Massachusetts INE and Infirmary at Harvard Medical School. And then I finished with fellowship in neurotology and skull-based surgery at Stanford. Throughout my training, I have been educated in the necessity for teamwork when you operate in the complex anatomy of the skull base close to many vital structures. So I've been used to working with my colleague in neurosurgery throughout my training and also my practice. So that's been a pleasure associating with Fred A ever since I came to the Cleveland Clinic.

Pranay Soni, MD:

Thank you so much. And so as you mentioned, I'm a skull-based neurosurgeon, which means I did a neurosurgery residency. I was actually here at Cleveland Clinic. And then I did a skull-based tumor fellowship, which involved learning the intricacies and complexities of the lateral skull base and skull-based pathologies. And then I stayed on a staff. And as Dr. Nguyen-Huynh mentioned, I've been working very closely with our neurotologist for many of our complex lateral skull-based tumor cases.

Paul C. Bryson, MD, MBA:

Yeah. I mean, as you both alluded to, I mean, it's a pretty high-end piece of real estate and lots of structures to preserve as you try to tackle some of these things. But what are the most common types of tumors or pathologies that you guys see in your practice and how do patients find you?

Pranay Soni, MD:

Yeah. So the interesting thing is that patients can sometimes present to Dr. Nguyen-Huynh in ENT, or they can present to me in neurosurgery. And oftentimes it's the symptoms that dictate that, whether it's more the hearing or balance type symptoms or more the neurologic symptoms. But by and far, the most common pathology we see would be a vestibular schwannoma, sometimes called an acoustic neuroma. That's a benign tumor and probably about 80% of cerebellopontine angle tumors that we see and work on. Some of the other ones that I see in practice would be meningiomas, paragangliomas. And then there's a whole host that involve more ear pathology that Dr. Nguyen-Huynh would see primarily as well.

Anh Nguyen-Huynh, MD:

Most common presenting symptoms for me is either sudden hearing loss or hearing loss that's progressive but significantly worse on one side. These patient often comes to the ENT to have evaluation. And as part of that evaluation, we often include an MRI to look at the inner ear and the auditory nerves and that's how we pick up these tumors that I would say far and away the most common reason for patient to show up on our door and got diagnosed with these things.

Paul C. Bryson, MD, MBA:

Yeah, thanks for that. For our listeners or for our physicians, it sounds like an MRI is really helpful and it sounds like an audiogram if there's asymmetry or sudden hearing loss. Any other diagnostic workup that referring physicians might consider? Or is it once they get here you have sort of a protocol of imaging modalities that you like to further characterize some of this pathology?

Pranay Soni, MD:

Yeah. So I would say, yeah, definitely MRI is the most important test. Every patient with a lateral skull-based tumor will get an MRI. Oftentimes they'll also get a CAT scan or CT because we want to look at the bony structures, see is there destruction of the bone or expansion of bony canals, an audiogram also for almost every patient. But then there are some ancillary tests that we may include as well, an angiogram sometimes to assess the vascularity of tumors or other CTAs or MRVs to look at the blood vessels. Sometimes patients will get vestibular batteries. That's a test to look at the vestibular function, which Dr. Nguyen-Huynh can certainly explain better than I can, but sometimes we want to know are there symptoms coming from the vestibular nerve? Are they coming from somewhere else? And so that can also help in the diagnosis.

Anh Nguyen-Huynh, MD:

Our workup is usually dictated by the patient's symptoms and of course the size and involvement of structures related to the tumor. So some patient will also have endoscopy to look at the vocal core function or speech and swallow evaluation. That all depends on where the tumor is located and what we expect the possible involvement of the nerves.

Paul C. Bryson, MD, MBA:

Yeah. So as you get this data, what factors influence sort of treatment strategy? I'm aware of observing things. There's specialized radiation and then certainly some of the really complex surgery approaches that we'll talk about. But I guess maybe as we dive into the surgical management or even other management, what are some of the sort of factors that you both consider when you're guiding patients toward treatment?

Anh Nguyen-Huynh, MD:

Well, many of the tumors that we deal with are actually benign tumor. And so observation is a very reasonable option, especially since data have shown it gives the best short-term outcome in terms of preserving function the way they are in the patient at presentation. But as the tumor progress and we can see that through a serial imaging study, of course, other treatment modality will be discussed. And one of the nice things about working in the team here is that Alcali, Dr. Soni and other are well versed in all of them. So they are not all engaged in one modality of treatment but not others. And so they're able to present very balanced views of the pros and cons and I'll let Pranay takes over in discussing what goes through his mind when he advise patient on a different option.

Pranay Soni, MD:

Yeah, thanks. So I think whenever I meet with a patient with the lateral skull-based tumor, we want to get a sense of the symptoms because sometimes these patients may have symptoms, hearing loss, balance. We talked about some of those presenting symptoms, but sometimes they may be asymptomatic. It may be something that was picked up on an MRI that was done for another reason and we found this and it's incidental or asymptomatic. And so we want to get a sense of what are their symptoms, what is the tumor doing? Is this the first time we're seeing it or have we seen it before? Is it stable? Is it growing? And is it at a place, a location that could potentially cause significant issues down the road, or is it somewhere that's far away from those important neurologic structures? And then finally, and sometimes most importantly, it's the patient's preferences and goals because not every tumor needs to be treated right away or sometimes ever.

And a patient may have a preference to treat a tumor earlier because it causes significant anxiety or the risk that it poses down the road may be something that is important to them. Whereas some patients may have a preference not to treat it right away, whether that's for personal reasons because those risks don't matter as much to them. And so it's important to have that conversation and it's a combined collective decision that involves the multidisciplinary team, but also the patient, their family and what their preferences are. I think the important factors that go into that are the size, the symptoms and what the tumor's doing.

Paul C. Bryson, MD, MBA:

Yeah. I mean, it sounds like preserving function, hearing preservation, facial nerve function, quality of life are really important conversations. And then can you speak a little bit to the balance that you try to strike, but also some of the surgical approaches that you might entertain for those patients that might be surgical candidates?

Anh Nguyen-Huynh, MD:

We offer observation with serial imaging, stereotactic radiation therapy, as well as surgical resection. And when we go on the route of surgery, we pursue all possible venues depending on the location, tumor involved structures and a specific anatomical variation on any particular patient. One nice things about our working relationship here at the Cleveland Clinic, our teamwork here is that we are comfortable with many approaches and some fairly innovative ones as well as the traditional ones. And we will tailor our treatment to the patient's goals and the feasibility of complete resection or not, the risk to the various structures. So these conversations are taking place among our team with the patient foremost in mind and without any particular agenda as to whether we should be doing this one because that's the one I'm more comfortable with or whether we doing this one because it's going to benefit us in any way, but we do take care of our patient and put that front and foremost.

And we have these discussion and when we see the patient, if one of us see the patient for the first time, we always say we're going to make our decision based of treatment after consultation with our colleague and discussions. And we will communicate that clearly with the patient so they will understand our reasoning behind that and be part of the decision.

Paul C. Bryson, MD, MBA:

Is there a tumor board structure that like we see with some of our colleagues in head and neck oncology, is there a skull-based tumor board as well?

Pranay Soni, MD:

Yeah, actually we have a few tumor boards. We have a brain tumor board, which can discuss tumors such as schwannomas, meningiomas, paragangliomas, but we actually have dedicated tumor boards as well. We have a skull-based conference where we can discuss complex cases. And then we also have a neurofibromatosis and schwannomatosis tumor board that meets once a month and involves the multidisciplinary team members. So a lot of different avenues for that multidisciplinary discussion.

Paul C. Bryson, MD, MBA:

Yeah. I think it's one of the ... I mean, I know tumor boards aren't unique around the country, but I do feel like the spirit of collaboration here at Cleveland Clinic seems to happen pretty naturally between our specialties and some of the other specialties. I don't know, it's really a great thing. I think win-win you were alluding to this and it's just a really nice way for people to come together with the best interests of the patient in mind. I wanted to change gears a litle bit here as maybe we kind of wrap up a little, but it's such a dynamic, very complex space. You both alluded to a little bit of the innovation that may be happening in this area. Can both of you speak to emerging technologies or innovations and advances in the management of these pathologies?

Pranay Soni, MD:

Yeah, I can highlight a couple of those. In the operating room, one of the newest technologies that we use is called an exoscope, which is similar to a microscope that's been used for decades, but it allows better illumination, better visualization of structures and really allows us to work more efficiently in the operating room. So that's one of the newest technologies that we've been employing, but there have been improvements in navigation techniques in the operating room with better accuracy. We continue to use different monitoring techniques as well to help us monitor those nerves that we talked about to preserve things like hearing and facial nerve function and vocal cord function. So all of those are techniques and technologies that we use in the operating room. And then from the standpoint of other treatment modalities, we've continued to kind of modify the radiation strategies using GammaKnife, which is a type of stereotactic radiosurgery.

We've changed our dosing to help preserve things like hearing, minimize side effects from radiation and improve tumor control. So that's continuing to evolve as well.

Paul C. Bryson, MD, MBA:

Yeah. It seems like we just keep refining this stuff and it's pretty exciting. I mean, the exoscope as an observer to come into the room and be able to put on the glasses and kind of see what's happening without having to look under the traditional microscope is really amazing and the picture and the visualization is quite impressive.

Pranay Soni, MD:

Yeah. It's great for education, it's great for ergonomics, really a significant improvement over the microscope in my mind.

Paul C. Bryson, MD, MBA:

Well, as we wrap up, any final take-home messages for our listeners?

Anh Nguyen-Huynh, MD:

The thing that strike me the most when I come to the Cleveland Clinic is this ethos of teamwork and how we all come together, bring our own expertise or special training in the service of patients and to be able to handle the most complex cases with the best possible outcome.

Pranay Soni, MD:

Like Dr. Nguyen-Huynh said, these are very complex tumors and there are a handful of centers that can handle the complexity and also involve the multidisciplinary team that we have here. And so I think these tumors require that collaboration and as a referring provider, you want to be able to have a patient be seen at somewhere where they have the newest technologies, the newest techniques, and that multidisciplinary approach. And as a patient, one of the things I stress is that you want to be seen at a center where you're involved in that discussion, you're a part of the decision making and coming up with the best treatment strategy that fits each patient because every patient with a skull-based tumor is different and there's no one size fits all.

Paul C. Bryson, MD, MBA:

Yeah. Well, I really congratulate you both on the program that you're a part of and that you've built and continue to build. It's just so impressive as a surgeon in another specialty, coming to the room and seeing the collaboration and seeing the technology, it is just really impressive. I congratulate you both on the way that you provide this care, that your skills and innovations have evolved over your careers and will continue to involve. Really, really great to have you both on the podcast and for more information, please visit clevelandclinic.org/services/otolaryngology-care and to connect directly with a specialist or to submit a referral, call 216-444-8500, that's 216-444-8500. Dr. Nguyen-Huynh, Dr. Soni. Thank you both for joining us on Head and Neck Innovations.

Anh Nguyen-Huynh, MD:

Thank you so much. Well, thank you for having us.

Paul C. Bryson, MD, MBA:

Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access real time updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.