Understanding and informing patients about health-related QoL outcomes is crucial to conveying risk, projecting long term morbidity and for informed decision making. In this study, the overall Penn Acoustic Neuroma QoL score was significantly higher in the observation cohort (p = 0.001). This is consistent with some studies,Reference Chweya, Tombers, Lohse, Link and Carlson18 whilst others have reported no significant difference between treatment modalities.Reference Neve, Jansen, Koot, Ridder, van Bentham and Stiggelbout19–Reference Lodder, van der Laan, Lesser and Leong21 Interestingly, in a longitudinal study comparing Penn Acoustic Neuroma QoL scores in observation versus stereotactic radiosurgery groups, the baseline Penn Acoustic Neuroma QoL score was higher in the observation group, but the scores were equivalent at the end of follow up.Reference Miller, Brant, Chen, Kaufman and Ruckenstein22 Conversely, another longitudinal study reported that Penn Acoustic Neuroma QoL scores remained consistent with no effect of time since diagnosis, irrespective of the initial management modality.Reference Newman, Sandridge and Jacobson17

Comparison of questionnaire scores by tumour size identified that larger tumours showed a significantly lower score for the facial function domain of the Penn Acoustic Neuroma QoL only (p = 0.039). This is anticipated for two reasons. Firstly, larger tumours are more likely to affect the facial nerve causing compression and weakness. Secondly, large tumours are more likely to be managed with microsurgery or radiotherapy, which is associated with a higher risk of facial dysfunction.

Penn Acoustic Neuroma QoL subdomain scores demonstrated perceived pain being significantly lower in the observation group. The disease process in vestibular schwannomas is not characterised by pain and very rarely associated with trigeminal neuralgia.Reference Onoda, Ogasawara, Hirokawa, Sashida, Fujiwara and Wakamiya23 In contrast, protracted headache and neuralgia is a recognised sequela of microsurgery and stereotactic radiosurgery.Reference North, Weishaar, Nuru, Anderson and Leonetti24,Reference Jakubeit, Sturtz, Sow, Groß, Mosch and Patt25

The Penn Acoustic Neuroma QoL balance subdomain was significantly lower in the microsurgery and radiotherapy groups, demonstrating less favourable outcome. The overall dizziness handicap inventory score was significantly worse in patients who underwent surgery compared to observation and radiotherapy (p = 0.005). It may be expected that the patient would centrally compensate over time from the initial imbalance due to a unilateral vestibular loss after tumour removal, however this is not reflected in our patient cohort. Alternatively, it could be that a higher proportion of the microsurgery group had vestibular complaints (compounded by other patient factors) prior to treatment and thus were more likely to have intervention. Importantly, long term vertigo and balance symptoms have repeatedly been shown to have the most detrimental effect on health-related QoL over other domains such as hearing loss or tinnitus, making them key considerations.

The hearing handicap inventory score was not found to be different across the three treatment modality groups, reflecting that regardless of the management, hearing reduces which is well recognised. Interestingly though, the Penn Acoustic Neuroma QoL did identify a difference in hearing among the management groups. The hearing subdomain score was significantly higher in the observation group, indicating a more favourable outcome, compared with the stereotactic radiotherapy and microsurgery groups (p = 0.014).

Operating to preserve hearing has variable success rates. Only patients with good hearing (American Academy of Otolaryngology Head and Neck Surgery class A or B) with tumours up to 2.5 cm in size usually considered for hearing preservation.Reference Saliba, Friedman and Cueva26 In this study, hearing-preservation surgery was attempted in few patients. In a meta-analysis of hearing preservation after vestibular schwannoma resection, immediate post-operative usable hearing (classified as American Academy of Otolaryngology Head and Neck Surgeons class A and B or Gardner Robinson grade 1 and 2) was preserved in 50–70 per cent of patients.Reference Ahsan, Huq, Seidman and Taylor27 Of these, 70 per cent retained usable hearing after five years post-surgery. There was no difference in hearing preservation between a middle-cranial fossa or retrosigmoid approach. In a meta-analysis of long-term hearing preservation after stereotactic radiosurgery, preservation was achieved in almost 60 per cent more than six years post treatment.Reference Balossier, Tuleasca, Delsanti, Troude, Tomassin and Roche28 In 100 per cent of patients with speech discrimination at presentation that were managed with observation, 69 per cent continued to have good hearing more than 10 years post treatment.Reference Stangerup, Thomsen, Tos and Ceyé-Tomasen29

• The Penn Acoustic Neuroma Quality of Life questionnaire is a validated disease-specific health-related quality-of-live instrument for vestibular schwannomas

• Comparing questionnaire scores by tumour size identified that patients with larger tumours had a significantly lower Penn Acoustic Neuroma Quality of Life facial-function score

• The Penn Acoustic Neuroma Quality of Life balance score was significantly lower in the microsurgery and radiotherapy groups

• The Penn Acoustic Neuroma Quality of Life scores for anxiety and energy were not affected by treatment modality, suggesting that once recovered from microsurgery or radiotherapy, energy levels return to normal

• The hearing handicap inventory score did not differ across treatment modalities, reflecting that hearing reduces regardless of management

• When suitable, depending on tumour size and symptoms, conservative management with active observation allows a better health-related quality of life, although this must be weighed against the risks of a growing tumour

Interestingly the Penn Acoustic Neuroma QoL scores for anxiety and energy were not affected by treatment modality. This may indicate that once patients have recovered from microsurgery or radiotherapy their energy levels return to normal. One study reported better anxiety outcomes in patients managed with microsurgery, which the authors attributed to the tumour having been removed.Reference Chweya, Tombers, Lohse, Link and Carlson18 Conversely, another study identified worse anxiety outcomes over time in patients managed with microsurgery.Reference Neve, Jansen, Koot, Ridder, van Bentham and Stiggelbout19 It is well recognised that, regardless of treatment modality, at the time of diagnosis patients report increased anxiety and a temporary reduction in QoL.Reference Carlson, Tombers, Kerezoudis, Celda, Lohse and Link30