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Systematic Review and Meta-Analysis
Incidence of Vestibular Schwannoma in Patients with Unilateral
Tinnitus: A Systematic Review and Meta-Analysis
*Azfar Javed, *Magnus Okoh, †Zahir Mughal, *Faisal Javed, and †Keshav Gupta
∗Department of Otolaryngology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birming-
ham, UK; and †Department of Otolaryngology, Russells Hall Hospital, Dudley, UK
Objectives: Vestibular schwannoma (VS) is a tumor of the
vestibulocochlear nerve. Current literature indicates that 1.6% of
patients undergoing magnetic resonance imaging of the internal
auditory meatus (MRI IAM) for audiovestibular symptoms are di-
agnosed with a VS. However, there is limited research reporting
on patients who present with unilateral tinnitus without asymmet-
rical hearing loss. This study is a systematic review and
meta-analysis evaluating how many of those patients had a VS di-
agnosed on MRI IAM.
Databases Used: Online searches of PubMed, Medline, and
Embase databases were performed up to October 2022.
Methods: This meta-analysis was undertaken aligning with
PRISMA guidelines. Articles reporting on patients having MRI
IAM for unilateral tinnitus without asymmetrical hearing loss were in-
cluded. Outcomes measures were patient demographics, VS cases, in-
cidental findings, size, and management of tumor. A meta-analysis of
proportions was performed using a random-effects model with the re-
stricted maximum likelihood method. Quality assessment was per-
formed using the Joanna Briggs Institute critical appraisal checklist.
Results: Seven case series were included in the review: a total of
1,394 patients. Seven patients had a VS, with a median size of
4 mm. The pooled detection rate for VS was 0.08% (95% confi-
dence interval = 0.00–0.45). Subsequent management was re-
ported in six cases of which four were actively monitored and
two surgically excised. The most common incidental finding
was sinus disease (49 patients).
Conclusion: Our findings indicate that MRI IAM has a low diag-
nostic yield for VS detection in patients presenting with unilateral
tinnitus without asymmetrical hearing loss, with mostly small tu-
mors that are conservatively managed.
Key Words: MRI IAM—Unilateral tinnitus—Vestibular schwannoma.
Otol Neurotol 00:00–00, 2023.
INTRODUCTION
Vestibular Schwannoma (VS), also known as acoustic
neuroma, is a tumor of the vestibulocochlear nerve repre-
senting 8% of all intracranial tumors and 85% of
cerebellopontine angle tumors (1). The lifetime incidence
of VS is 1 in 1000 (2). This has been gradually increasing
in recent years as increased referrals and better diagnostic
capability are catching these tumors earlier (3).
Hearing loss and tinnitus are two of the most common
symptoms, affecting 95% and 63% of patients with VS, re-
spectively (4). If these tumors continue to grow, they can
damage surrounding intracranial structures because of
mass effect, causing neurological symptoms such as tri-
geminal and facial nerve impairment and, in extreme cases,
hydrocephalus or brain stem compression (5). Despite this,
the rate of growth of these tumors is very low, on average
1–2 mm per year, with 75% of diagnosed tumors not grow-
ing at all (6). Therefore, most patients with VS do not have
any significant morbidity or mortality.
Management options include conservative management
with active monitoring, radiotherapy, or surgical resection
(7). Small- or medium-sized tumors (less than 3 cm) that
are not causing mass effect can be treated with stereotactic
radiosurgery (SRS), fractionated stereotactic radiosurgery
(FSRS), or proton beam therapy as an alternative to active
monitoring (8).
The current gold standard for diagnosis is magnetic res-
onance imaging of the internal auditory meatus (MRI IAM)
(9). A gadolinium enhanced T1 scan provides better imag-
ing, but because of its cost and minimal differences in sen-
sitivity and specificity, the noncontrast T2-weighted scan is
preferred in clinical practice (9).
Current clinical practice guidelines in the UK recom-
mend investigating via MRI IAM if the patient has hearing
loss with localizing neurological symptoms or objective
asymmetrical sensorineural hearing loss in the absence of
localizing signs (10). MRI IAM is also carried out if a pa-
tient has non pulsatile unilateral tinnitus (11). A study of
a hospital trust in the UK revealed 1,300 MRI IAMs
Address correspondence and reprint requests to Azfar Javed, MBBS,
Birmingham Heartlands Hospital, 172 Devon House, Birmingham B9 5SS,
UK; E-mail: azfar.javed1@nhs.net
Conflict of interest statement: The authors disclose no conflicts of
interest.
Funding statement: There was no funder for this study.
Supplemental digital content is available in the text.
DOI: 10.1097/MAO.0000000000003987
© 2023, Otology & Neurotology, Inc.
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requested between July 2017 and June 2019, of which only
16 patients (1.23%) were later diagnosed with VS (12).
The utility of carrying out an MRI IAM to exclude a VS
in patients presenting with unilateral tinnitus only has been
called into question as studies have indicated that a very
low proportion of these patients have the disease (13,14).
Furthermore, most patients with a diagnosed VS undergo
conservative management with serial MRI IAM to monitor
growth. There is often no further treatment required (1).
The purpose of this systematic review and meta-analysis
is to synthesize all the available evidence regarding patients
presenting with unilateral tinnitus in isolation to see the
proportion of VS diagnosed with MRI IAM.
MATERIALS AND METHODS
Search Strategy and Selection Criteria
This systematic review and meta-analysis were under-
taken in accordance with the Preferred Reporting Items for
Systematic reviews and Meta-Analyses (PRISMA) guide-
lines (15) following a preregistered, publicly available proto-
col (PROSPERO: CRD42023399050). Online searches via
the Ovid® platform were performed in October 2022.
PubMed, MEDLINE, and EMBASE were searched with no
restrictions imposed using the search strategy outlined in Sup-
plement 1, http://links.lww.com/MAO/B721. Searches for
gray literature were undertaken by means of Google
Scholar® using the same keywords. Reference screening
of all included articles was performed to further identify el-
igible articles.
Eligibility Criteria
All studies that reported on MRI IAMs carried out for
patients with tinnitus were reviewed. Articles reporting on
patients with unilateral or clearly asymmetrical tinnitus as
the presenting symptom were included.
Patients who presented with unilateral or asymmetrical
hearing loss or localized neurological symptoms were ex-
cluded from the study. Articles that did not report on the
number of patients diagnosed with VS were excluded. Ar-
ticles that did not specify whether the tinnitus was unilateral
or bilateral were excluded. Articles reporting on patients
with previously diagnosed VS or a diagnosis of neurofibro-
matosis were excluded. Studies that were not original
FIG. 1. Flow diagram detailing study selection process.
2 A. JAVED ET AL.
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research and did not have full text available in English or
conference abstracts were excluded.
Identified articles were screened against the inclusion
criteria by two reviewers (A.J. and M.O.) independently.
The mediation of articles to be included was carried out in-
dependently by a third reviewer (K.G.).
Data Analysis
Study level data from included articles were extracted
using a standardized template in Microsoft Excel® (Red-
mond, WA) by two reviewers (A.J. and M.O.) indepen-
dently. Discrepancies in extracted data were mediated by a
third reviewer (K.G.). Data extracted included the follow-
ing: author, title, year, location, study design, inclusion
criteria, participant number, participant characteristics, tin-
nitus characteristics, duration of symptoms, and diagnosis.
Further details, including size of tumor and treatment, were
also included if available.
A meta-analysis of proportions was performed using a
random-effects model with the restricted maximum likeli-
hood method (REML). The primary outcome was the pro-
portion of MRI IAMs performed for unilateral tinnitus
alone that demonstrated a VS. The Freeman–Tukey double
arcsine transformation was applied to the observed propor-
tions. The variance between studies was measured using τ
2
.
The presence of study heterogeneity was examined using
the Qtest, and this was quantified using the I
2
statistic. Sta-
tistical analyses were performed in R (R Project for Statis-
tical Computing version 4.1.3; Lucent Technologies, Mur-
ray Hill, NJ) using meta and metafor packages.
The Joanna Briggs Institute (JBI) critical appraisal
checklist for case series (16) was used by two reviewers
(A.J. and M.O.) independently to assess the quality of evi-
dence of the included studies. Any discrepancies were re-
solved by the senior author (K.G.).
Role of Funding Source
There was no funder for this study.
RESULTS
Study Selection
The study selection process is detailed in the PRISMA
flow diagram (Fig. 1).
Study Characteristics
Seven studies were included in the systematic review, all
case series, reporting on a total of 1,394 patients. The study
characteristics can be found in Table 1. Two studies exclu-
sively reported on patients with unilateral tinnitus with no
asymmetrical hearing loss (13,17). The other five studies
reviewed all MRI IAM requests for audiovestibular com-
plaints and reported on patients presenting with unilateral
tinnitus without hearing loss in their results section. Six
of the studies recorded the audiogram results of the pa-
tients. The largest study (13) reported on 566 patients with
unilateral tinnitus alone, whereas the smallest study (14) in-
cluded had 23 such patients. Three of the studies did not
mention the type of tinnitus of their patients and whether
TAB LE 1. Study characteristics of included studies in analysis
Author Year Country
Study
Type Setting Inclusion Criteria
Total Patient
Number
Mean Age
(yr)
Male
(%)
Audiometry
Performed
Saxby et al.
(13)
2021 UK Case
series
Four hospitals All MRI IAM scans for unilateral nonpulsatile tinnitus without asymmetrical
hearing loss from January 2014 to January 2019
566 54 41 Yes
Perera et al.
(12)
2021 UK Case
series
Single-center
hospital
All MRI IAM scans to exclude retrocochlear pathology from July 2017 to June 2019 1,300 56 56 Yes
Dawes and
Basiouny
(17)
1999 UK Case
series
Three hospitals All MRI IAMs performed for patients with unilateral tinnitus without asymmetrical
hearing loss from April 1994 to April 1997
174 50 (median) 46 Yes
Vand er v el de
and
Connor (18)
2009 UK Case
series
Three hospitals All patients with first time MRI IAM for audiovestibular symptoms from October
2005 to March 2007
881 NR NR Yes
Robinette et al.
(19)
2018 USA Case
series
Tertiary neurotology
center
All MRI IAMs for adult patients with neurotologic complaints from March 2012 to
October 2013
1,537 59 41 Yes
Choi et al. (20) 2015 USA Case
series
Single-center
hospital
All MRIs performed for adults with nonpulsatile tinnitus with or without hearing
loss from March 2008 to February 2014
218 59 53 Yes
Sajid and Frost
(14)
2022 UK Case
series
22 Primary care
facilities
All MRI IAM scans between January 2017 and December 2018 200 49 (median) 44 No
INCIDENCE OF VS IN PATIENTS WITH UNILATERAL TINNITUS 3
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it was pulsatile or not. One study (14) made reference to the
lack of documentation of tinnitus type in clinical records.
Three studies (13,18,20) documented and reported exclu-
sively on patients with nonpulsatile tinnitus only. Only
one of the studies documented symptom duration (14) at
the time of investigation.
Incidence of VS
Out of 1,394 patients, seven patients had a VS diagnosed
(Table 2). The pooled detection rate for VS was 0.08%
(95% confidence interval [CI] = 0–0.45), as shown in
Figure 2. The τ
2
= 0 (95% CI = 0–0.0026), and the Qtest
(df = 6) = 3.2417, p= 0.7780, failed to detect heterogeneity
between studies. The I
2
was0%(95%CI=0–63.3707),
suggesting that the differences between studies could be at-
tributed to sampling error rather than differences in the
characteristics of the studies.
VS Characteristics
Table 3 provides details of the patients diagnosed with
VS. Details on tumor size were reported in five patients,
with four being between 3.0 and 5.1 mm. Of note, one of
these patients had a diagnosed VS on the contralateral side
of her symptoms. All of these tumors were managed with
active monitoring. Two of these patients had symmetrical
sensorineural hearing loss on audiogram. The tumor size
of the fifth patient was 24 mm, and surgery was planned.
Of note, although this patient’s presenting complaint was
tinnitus and not hearing loss, they were found to have se-
vere unilateral SNHL on audiogram. The VS patient in
the study of Dawes and Basiouny (17) was a 49-year-old fe-
male who was managed surgically, and the size of the tumor
was not reported. For the remaining patient, there were no
details on the size or the management of the VS.
Incidental Findings
Five of the studies reported on incidental findings, a total
of 152 out of 948 patients (13,17–20). Sinus disease (5.2%)
and small vessel disease (4.5%) were the most common in-
cidental findings discovered in the MRI scan. Table 4 pro-
vides a breakdown of the incidental findings.
Risk of bias
The JBI critical appraisal checklist for case series (16)
was used to perform the risk of bias assessment (Table 5).
All the studies apart from Vandervelde and Connor (18) re-
ported on the demographics of their patients. However,
most studies did not focus solely on tinnitus patients and re-
ported on the demographics of the entire group rather than
just the tinnitus patients. Hence, only Saxby et al. (13) and
Dawes and Basiouny (17) reported on the demographics of
our target population. The study of Perera et al. (12) did not
report on the clinical information or outcomes of the pa-
tients diagnosed with a VS. This is understandable given
the purpose of their study was to ascertain if MRI scans
were being requested according to national guidelines.
For the purpose of our meta-analysis, all the included stud-
ies were at a low risk of bias.
DISCUSSION
According tothe findings of this meta-analysis, 1,394 in-
dividuals investigated by MRI IAM for unilateral tinnitus
alone had a pooled detection rate for VS of 0.08%. This
outcome is comparable with a 2018 review (21) that looked
at 720 patients with asymmetric tinnitus but no asymmetric
hearing loss and discovered a VS detection rate of less than
1%. This percentage is considerably lower than the esti-
mated 1.6% VS detection rate for all patients investigated
with an MRI IAM (22).
FIG. 2. Forest plot demonstrating meta-analysis of proportion of patients presenting with unilateral tinnitus alone diagnosed with VS.
TABLE 2. Outcome measures reported by each included study
Study Tinnitus-Only Patients, n Positive VS Diagnosis on MRI, n (%) Incidental Findings, n (%)
Saxby et al. (13) 566 3 (0.53) 134 (24)
Perera et al. (12) 423 1 (0.24) NR
Dawes and Basiouny (17) 163 1 (0.61) 11 (6.7)
Vandervelde and Connor (18) 115 2 (1.7) 1 (0.87)
Robinette et al. (19) 80 0 5 (6.3)
Choi et al. (20) 24 0 1 (4.2)
Sajid and Frost (14) 23 0 NR
Total 1,394 7 (0.50) 152 (16)
NR indicates not reported.
4 A. JAVED ET AL.
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Our research indicates that over 200 patients would
need to be imaged to detect one VS patient. This low diag-
nostic yield raises concerns about overtesting and the cost-
effectiveness of this investigation in our target population.
An MRI IAM typically costs around £200 per test (22,23).
A study in Portsmouth (24) calculated that MRI IAMs
accounted for 3 weeks’full use of the MRI scanner per
annum, at a rate of three scans per hour. In addition, these
investigations typically need a specialist radiologist to re-
port, a further resource constraint. According to a 2019
study (25), if 100 people needed to be scanned to diagnose
one case of VS, the cost per diagnosis would be £11,000.
Based on the results of our investigation, we may anticipate
that a single positive diagnosis will cost £22,000 for our tar-
get population.
The change in management of VS patients over the last
two decades should also be taken into account when con-
sidering the utility of this costly investigation in our target
population. An American study reported that 47% of pa-
tients with VS underwent surgical excision between 2007
and 2017, compared with 66% before 2006 (26). This dif-
ference was significant even when accounting for tumor
size. A British Skull Base audit showed 69% of patients be-
ing managed with observation, with only 19% undergoing
surgical excision (27).
It is also known that smaller tumors are less likely to
grow when compared with tumors greater than 2 cm
(6). Our analysis revealed a median tumor size of
4 mm, with only two tumors requiring surgical excision.
One tumor requiring surgery was 24 mm, but this was
notably associated with severe asymmetrical sensorineu-
ral hearing loss. The other studies that reported on tumor
size were all managed conservatively with the largest VS
measuring 5.1 mm. A similar study not included in this
analysis has echoed this by showing individuals who
underwent surgery had a mean tumor size of 24 mm as
opposed to 11 mm for those actively monitored (26).
SRS or FSRS can be used to target smaller tumors, but
typically a conservative approach with active monitoring
is adopted for tumors less than 15 mm (5).
Our results also suggest that patients without asymmetri-
cal symptoms usually have smaller tumors. This follows
because of the mass effect of larger tumors. Of the five pa-
tients where tumor size was reported, all four <5.1 mm had
symmetrical SNHL, otalgia, or no additional symptoms
and were managed conservatively. Otalgia isrelatively non-
specific for VS, and bilateral SNHL has multiple other
causes, the most common being presbycusis. However,
the patient with a tumor size of 24 mm had severe unilateral
SNHL and required surgery. This is consistent with other
studies (4,28), which revealed that at the time of diagnosis,
VS patients without hearing loss had, on average, smaller
tumor sizes. The increased use of conservative manage-
ment, together with the small tumor sizes in our patient
sample, raises additional concerns about the value of fur-
ther investigation in this group.
There were a high number of incidental findings with
MRI IAM, as shown in Table 4. The largest study included
in our review (13) had 566 patients, and 24% had incidental
findings on MRI IAM. Another study (14) reported that
these incidental findings led to unnecessary onward refer-
rals and patient distress without any resultant significant di-
agnosis or change in care. This representsa significant con-
cern given the unnecessary distress and adverse effect on
patients’well-being it can cause.
Our studies had several limitations. There were a limited
number of studies because the subject remains insuffi-
ciently studied. Only two of these were exclusively de-
signed to study our research topic, the rest were reporting
on all patients with audiovestibular complaints who
underwent MRI IAM. The sample size was under 100 pa-
tients for three of the studies, with all three studies reporting
no VS diagnosis. This may have skewed the overall pooled
analysis toward 0%. There was overall poor reporting in in-
cluded studies on tumor demographics. Only five out of the
seven patients’VS sizes and management could be deter-
mined. Where reported, they were done inconsistently and
did not focus on outcomes in terms of tumors growth rate,
survival, and complications after surgery.
The authors of this article suggest that more extensive re-
search on MRI IAM scans for patients who present with
TABLE 4. Incidental findings
Incidental Finding Number
Sinus disease 49
Small vessel disease 43
Mastoid opacification 18
Demyelination 10
Ischemic changes/infarct 8
Arachnoid cyst 5
Empty sella 3
Aneurysm 3
Va s c ul a r lo o p s 2
Other 11
TABL E 3. Details of VS
Study
VS
Size,
mm
Patient
Demographic
Symptoms in
Addition to
Unilateral Tinnitus Management
Saxby et al.
(13)
3.0 73-year-old
male
Otalgia, bilateral
high-frequency
SNHL
Monitoring
Saxby et al.
(13)
a
4.0 61-year-old
female
None Monitoring—
static size
Vandervelde
and Connor
(18)
4.0 NR Symmetrical
SNHL
Monitoring—
static size
Saxby et al.
(13)
5.1 45-year-old
female
Otalgia Monitoring
Vandervelde
and Connor
(18)
24.0 NR Severe right sided
SNHL
Surgery
Dawes and
Basiouny
(17)
NR 49-year-old
female
Slight change in
hearing, no
asymmetric
hearing loss
Surgery
Perera et al.
(12)
NR NR NR NR
a
VS diagnosed on contralateral side of tinnitus.
NR indicates not reported.
INCIDENCE OF VS IN PATIENTS WITH UNILATERAL TINNITUS 5
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unilateral tinnitus is required. Future studies should focus
on a robust trial design to include information on VS size,
cost-effectiveness, incidental findings, subsequent manage-
ment, outcomes, and complications. This will allow a more
valid consensus to be made regarding how patients with
suspected VS should be investigated as this review suggests
that the current method has a low diagnostic yield.
CONCLUSION
Our results demonstrated the pooled detection rate for
VS with MRI IAM in patients presenting with isolated uni-
lateral tinnitus was 0.08%. This effect size is clearly small.
Further examination of patients diagnosed with VS in this
cohort revealed most were small (<5.1 mm) and conserva-
tively managed. The tumors requiring surgery were often
associated with larger sizes and additional asymmetrical
symptoms. MRI IAM is also associated with high cost
and resources as well as incidental findings (16%), which
were higher than the detection rate (0.08%). Given the
above, the authors conclude that MRI IAM has a low diag-
nostic yield for VS detection in patients presenting with
unilateral tinnitus. Further research is required with trials
focusing on more specifics regarding patient demographics,
tumor size, treatment, and follow-up to allow a more robust
screening and diagnostic criteria to be established to best
manage patients suspected with VS.
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TAB LE 5. Risk of bias assessment
Question
Perera et al.
(12)
Saxby et al.
(13)
Dawes and Basiouny
(17)
Vandervelde and Connor
(18)
Robinette et al.
(19)
Choi et al.
(20)
Sajid and Frost
(14)
Clear criteria for inclusion Y Y Y Y Y Y Y
Condition measured in standard, reliable way for all participants Y Y Y Y Y Y Y
Valid methods used for identification of condition for all
participants
YY Y Y Y Y Y
Consecutive inclusion of participants Y Y Y Y Y Y Y
Complete inclusion of participants Y Y Y Y Y Y Y
Clear reporting of the demographics of participants N Y Y N N N N
Clear reporting of clinical information of participants N Y Y N Y Y Y
Outcomes or follow-up results of cases clearly reported N Y Y Y N Y Y
Clear reporting of presenting site/clinic demographic information Y Y Y N Y Y Y
Statistical analysis appropriate NA NA NA NA NA NA NA
Y indicates yes; N, no; NA = not applicable.
6 A. JAVED ET AL.
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INCIDENCE OF VS IN PATIENTS WITH UNILATERAL TINNITUS 7
Otology & Neurotology, Vol. 00, No. 00, 2023
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