{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T03:07:32Z","timestamp":1789182452003,"version":"build-2803163510"},"reference-count":59,"publisher":"Wiley","issue":"S6","license":[{"start":{"date-parts":[[2026,5,23]],"date-time":"2026-05-23T00:00:00Z","timestamp":1779494400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,5,23]],"date-time":"2026-05-23T00:00:00Z","timestamp":1779494400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["The Laryngoscope"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Management of vestibular schwannoma (VS) remains controversial. Very small VSs represent a pivotal group: on one hand, they pose the least risk to the patient from the perspective of being small; yet, not recommending treatment may result in missing a critical window for achieving the best outcome. This debate fundamentally hinges on whether treatment improves upon the natural history of the disease. There is an unproven assumption that very small tumors behave similarly to the broader observed population. To address this central question, we conducted a multicenter retrospective review to compare the natural history of tumor growth and hearing for patients with very small VS (1\u20133\u2009mm) with a referent cohort with larger tumors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>All patients diagnosed with sporadic VS 1\u20133\u2009mm were reviewed at 3 large skull base referral centers and compared with a referent cohort of patients with tumors &gt;\u20093\u2009mm. Tumor growth\u2010free survival rates, treatment\u2010free survival rates, and rates of maintenance of class A, B, or C hearing were estimated using the Kaplan\u2013Meier method.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      In total, 123 patients with very small VS and a referent cohort of 326 patients were studied. Seventeen patients with very small VS experienced tumor growth at a median of 3.2\u2009years after diagnosis (IQR 2.6\u20135.1), demonstrating a median growth rate of 1.0\u2009mm per year (IQR 0.9\u20131.8). In comparison, 167 of the patients in the referent cohort experienced tumor growth at a median of 1.7\u2009years after diagnosis (IQR 0.8\u20133.1). Tumor growth\u2010free survival rates (95% CI, number still at risk) at 5\u2009years after diagnosis for the 2 cohorts were 84% (75\u201393, 39) and 45% (40\u201352, 100), respectively (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Six patients with very small VS underwent treatment after tumor growth at a median of 3.2\u2009years after diagnosis (IQR 3.2\u20133.8), compared with 138 patients in the referent cohort at a median of 2.2\u2009years after diagnosis (IQR 1.4\u20133.6). Treatment\u2010free survival rates (95% CI, number still at risk) at 5\u2009years after diagnosis for the 2 cohorts were 92% (86\u201398, 55) and 54% (49\u201361, 125), respectively (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Among the 105 patients with very small VS and class A, B, or C hearing at diagnosis, 3 progressed to class D. Comparatively, among the 225 patients in the referent cohort with class A, B, or C hearing at diagnosis, 70 progressed to class D at a median of 2.6\u2009years after diagnosis (IQR 1.0\u20134.8). Rates of maintenance of class A, B, or C hearing (95% CI, number still at risk) at 5\u2009years after diagnosis were 96% (92\u2013100, 28) for patients with very small VS and 65% (57\u201373, 70) for the referent cohort (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The natural history of tumor growth and hearing for very small VS diverges favorably from the cumulative natural history data and provides a more appropriate benchmark to compare clinical outcomes of upfront surgery or radiosurgery for this population. At 5\u2009years after diagnosis, 96% of very small VS maintained class A, B, or C hearing and only 8% received treatment for growth within this multicenter cohort. Cumulatively, these data substantiate initial wait\u2010and\u2010scan management via size threshold surveillance in this population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>3.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/lary.70632","type":"journal-article","created":{"date-parts":[[2026,5,23]],"date-time":"2026-05-23T13:10:24Z","timestamp":1779541824000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Unique Natural History of Very Small Vestibular Schwannoma Substantiates Size Threshold Surveillance"],"prefix":"10.1002","volume":"136","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4925-8593","authenticated-orcid":false,"given":"Matthew L.","family":"Carlson","sequence":"first","affiliation":[{"name":"Department of Otolaryngology\u2010Head and Neck Surgery Mayo Clinic  Rochester Minnesota USA"},{"name":"Department of Neurologic Surgery Mayo Clinic  Rochester Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3479-1309","authenticated-orcid":false,"given":"Jacob B.","family":"Hunter","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2010Head and Neck Surgery Thomas Jefferson University  Philadelphia Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John P.","family":"Marinelli","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2010Head and Neck Surgery Mayo Clinic  Rochester Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8370-9071","authenticated-orcid":false,"given":"Ankita","family":"Patro","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2010Head and Neck Surgery Vanderbilt University  Nashville Tennessee 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