Association Between Diagnostic Time and Functional Hearing Outcomes in Sporadic Vestibular Schwannomas: A Retrospective Cross-Sectional Study from Two Tertiary Care Centers in Mexico

Association Between Diagnostic Time and Functional Hearing Outcomes in Sporadic Vestibular Schwannomas: A Retrospective Cross-Sectional Study from Two Tertiary Care Centers in Mexico | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Association Between Diagnostic Time and Functional Hearing Outcomes in Sporadic Vestibular Schwannomas: A Retrospective Cross-Sectional Study from Two Tertiary Care Centers in Mexico Julia Moscardini-Martelli, Abel Lerma-Talamantes, Gomez-Castro Gerardo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8855893/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose: To analyze the association between diagnostic time and auditory functional status, as measured by the Gardner–Robertson scale, in patients with sporadic vestibular schwannoma. Methods: A retrospective, observational, cross-sectional study was conducted at two tertiary referral centers in Mexico. Adult patients with unilateral sporadic vestibular schwannoma, radiologic confirmation on magnetic resonance imaging, and baseline audiological assessment were included. Total diagnostic time was defined as the interval from symptom onset to diagnosis and was log-transformed due to its right-skewed distribution. Hearing status was categorized as functional or non-functional. Tumor volume was quantified using semi-automated volumetric magnetic resonance imaging. Univariable analyses and Spearman correlations were performed, followed by multivariable logistic regression adjusting for tumor volume. Results: 58 patients were included, of whom 40 (69%) presented with non-functional hearing at diagnosis. Total diagnostic time was longer in patients with non-functional hearing compared with those with functional hearing (median 403 vs. 192 days, p = 0.039). Tumor volume was significantly higher in the non-functional hearing group (median 8.38 vs. 0.88 cm³, p = 0.002) and demonstrated a moderate association with worse auditory functional status (rₛ = 0.535, p < 0.001). Log-transformed total diagnostic time demonstrated a weak but significant correlation with worse hearing status (rₛ = 0.274, p = 0.038) and was associated with non-functional hearing in multivariable analysis (OR 1.49; 95% CI, 1.03–2.17; p = 0.036). Conclusions: Longer diagnostic time was associated with worse auditory functional status at diagnosis in patients with sporadic vestibular schwannoma Vestibular schwannoma Diagnostic time Gardner–Robertson scale Hearing function Tumor volume Hearing loss Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Vestibular schwannomas (VS), also known as acoustic neuromas, are benign tumors that originate from Schwann cells covering the vestibular portion of the eighth cranial nerve. Despite their benign nature, significant complications may occur if not diagnosed in a timely manner [ 1 ]. Delayed diagnosis of VS constitutes a major clinical and diagnostic challenge, as early manifestations—particularly progressive sensorineural hearing loss and tinnitus—are frequently underrecognized or misattributed by both patients and healthcare providers [ 2 ]. Additionally, heterogeneity in symptom progression and the typically painless course contribute to prolonged subclinical intervals [ 3 ]. International studies have documented substantial diagnostic delays in patients with VS with reported mean delays ranging from several months to multiple years and a clear association between longer delays and increased tumor size [ 4 , 5 ]. Although the widespread use of magnetic resonance imaging (MRI) has reduced diagnostic latency in some healthcare systems [ 6 ], this benefit may be limited in fragmented systems such as that of Mexico. Evidence from other tumor conditions in Mexico and Latin America demonstrates that diagnostic delay is consistently associated with more advanced disease at presentation, underscoring the clinical relevance of timely diagnosis [ 7 – 9 ]. National data further reveal a high burden of diagnostic-related complaints, including delayed and erroneous diagnoses, highlighting systemic challenges in diagnostic processes [ 10 ]. Despite this, data on diagnostic delay in vestibular schwannomas within the Mexican population remain scarce, emphasizing the need for focused investigation. Therefore, the objective of this study was to evaluate the association between diagnostic time and the degree of hearing loss, according to the Gardner–Robertson scale, in patients with sporadic vestibular schwannomas in Mexico. METHODOLOGY This was a retrospective, observational, analytical, cross-sectional study conducted at two tertiary-level referral centers in Mexico. The study population consisted of patients diagnosed with sporadic VS evaluated during the study period (January 2024-December 2025). The study was designed to assess the association between diagnostic time and hearing outcomes at the time of diagnosis. Ethical approval was obtained from the corresponding Research Ethics Committees. The study was conducted in accordance with the principles of the Declaration of Helsinki. Given the retrospective nature of the study, informed consent was waived by the ethics committees. Sample size estimation was performed using the formula for estimating a proportion for qualitative variables, as described in standard methodological references [11]. Based on this calculation, a minimum sample size of 57 patients was obtained. Given the retrospective nature of the study, all eligible patients meeting inclusion criteria during the study period were included to achieve the calculated sample size and maximize statistical power. A total of 92 patients were initially identified and screened for eligibility. Of these, 32 patients were excluded due to incomplete medical records. Additionally, one patient was excluded because of presbyacusis at the time of diagnosis, and another patient was excluded due to the presence of an associated intracranial pathology that could introduce potential bias into the analysis. Consequently, 58 patients constituted the final study population. (Figure 1) We included consecutive adult patients (≥18 years) with a diagnosis of unilateral VS. Inclusion criteria were radiologic diagnosis of VS on brain MRI, available baseline audiological assessment including pure-tone audiometry and speech discrimination score (SDS). Patients were excluded if they had preexisting otologic or neurologic conditions that could confound baseline hearing assessment or bias audiologic outcomes, including prior cerebellopontine angle pathology (such as meningioma), clinically relevant otologic disease (e.g., cholesteatoma, Ménière’s disease, or otosclerosis), or other known causes of sensorineural hearing loss. Additional exclusion criteria included a personal or family history of neurofibromatosis type 2, prior surgery or radiotherapy to the ipsilateral cerebellopontine angle before audiologic evaluation, and insufficient clinical documentation. Patients whose medical records contained less than 80% of the required clinical information to allow reliable reconstruction of the referral pathway and diagnostic time intervals were excluded. These criteria were applied to minimize confounding factors affecting baseline hearing status and to ensure the validity of diagnostic timeline analyses. Sociodemographic variables comprised sex, educational level, socioeconomic status, and place of residence. Educational level was categorized as basic education (no formal education, primary, secondary, high school, or technical training) or higher education (undergraduate or postgraduate studies). Socioeconomic status was classified as middle-to-high class or poverty according to institutional criteria. Place of residence was dichotomized into Mexico City and the State of Mexico versus other Mexican states. Healthcare pathway–related variables encompassed the type of referring hospital (public or private), the type of first-contact physician (general physician or specialist), the diagnosing physician, and the physician responsible for ordering imaging and audiometric studies. Clinical variables included side of hearing loss, Koos classification, extracanalicular tumor component size, facial nerve function assessed using the House–Brackmann classification, age at diagnosis, diagnostic time intervals (time from first symptom to first consultation, time from first consultation to diagnosis, and total diagnostic time), tumor volume, and presenting symptoms with corresponding symptom burden at diagnosis. Symptoms were recorded at the time of diagnosis and coded as binary variables (absent or present), allowing calculation of a total symptom burden score. A total symptom burden score was calculated for each patient by summing all reported symptoms. Tumor size and volume were obtained from MRI studies performed at the time of diagnosis. Tumor volume was calculated using dedicated volumetric analysis software (Brainlab®, Brainlab AG, Munich, Germany) based on semi-automated segmentation of contrast-enhancing tumor regions. Tumors were classified according to the Koos grading system and, for analytical purposes, were dichotomized into low-stage (grades I–II) and high-stage (grades III–IV) disease. Auditory function was evaluated using the Gardner–Robertson scale, considering only the ear affected by the vestibular schwannoma. Hearing status was dichotomized into functional hearing (grades I–II) and non-functional hearing (grades III–V) for analysis. Facial nerve function, assessed using the House–Brackmann scale, was dichotomized into normal or mild dysfunction (grades I–II) and clinically significant dysfunction (grades III–VI). Diagnostic delay was defined as the time elapsed between the onset of initial symptoms and the definitive diagnosis of vestibular schwannoma. Three diagnostic time intervals were extracted from clinical records when available: (1) time from symptom onset to first contact with any healthcare provider, (2) time from first medical consultation to diagnosis, and (3) total diagnostic time from symptom onset to diagnosis, expressed in days. Statistical Analysis A descriptive analysis of clinical and demographic variables was performed. Categorical variables were summarized using absolute frequencies and percentages. Continuous variables were initially assessed for normality using the Kolmogorov–Smirnov test. Variables with normal distribution were described as mean ± standard deviation, whereas non-normally distributed variables were reported as median and interquartile range. Inter-rater agreement for pure-tone and speech audiometry recordings was evaluated using Cohen’s kappa coefficient. Sociodemographic variables were dichotomized for analysis, including educational level, socioeconomic status, and place of residence. Inferential analyses were conducted using the chi-square test or Fisher’s exact test to evaluate associations between categorical variables. Comparisons between non-normally distributed continuous variables and hearing status were performed using the Mann–Whitney U test, while Student’s t-test was used for normally distributed variables. Correlations between ordinal variables and non-normally distributed continuous variables were assessed using Spearman’s rank correlation coefficient. These analyses were used to explore relationships among clinical variables, tumor-related characteristics, diagnostic time intervals, symptom burden, and auditory functional status. A multivariable logistic regression model was fitted to estimate the adjusted association between diagnostic time, tumor volume, and hearing outcome. Hearing status was analyzed as a dichotomous dependent variable (functional vs. non-functional hearing). Diagnostic time and tumor volume were selected for inclusion in the multivariable model based on their statistical significance in univariable analyses. Tumor volume, expressed in cubic centimeters (cm³), was chosen as the primary tumor size–related covariate due to its continuous and objective nature. Other tumor size descriptors, such as Koos grade or extracanalicular component size, were not included, as these variables are ordinal, and the simultaneous inclusion of multiple tumor size metrics would have introduced collinearity into the model. To ensure appropriate modeling, total diagnostic time was log-transformed using a ln(x+1) transformation prior to inclusion in the regression analysis, given its markedly right-skewed distribution and wide range of values. All statistical analyses were performed using IBM SPSS Statistics 26. Graphical representations of the results were generated using GraphPad Prism 10. A two-tailed p value < 0.05 was considered statistically significant for all analyses. RESULTS A total of 58 patients were included in the final analysis, of whom 40 presented with non-functional hearing and 18 with functional hearing. Inter-rater agreement was assessed to evaluate concordance between two independent observers in the classification of auditory function based on patients’ audiometric records. This analysis demonstrated almost perfect agreement, with Cohen’s kappa coefficients of 0.819 for the right ear and 0.801 for the left ear, confirming the high reliability of the audiological data. Following patient characterization, presenting symptoms at the time of diagnosis were analyzed to describe the clinical profile at presentation. Hearing loss was the most frequently reported symptom (41 patients), followed by vertigo (25 patients), headache (20 patients), tinnitus (16 patients), nausea and/or vomiting (12 patients), and cerebellar manifestations (10 patients). Less frequent symptoms included facial paresthesia (7 patients), visual disturbances (5 patients), trigeminal neuralgia (4 patients), facial palsy (3 patients), limb weakness (3 patients), and otalgia (1 patient). Building on this descriptive analysis, diagnostic timelines were subsequently examined. Total diagnostic time differed significantly between groups, with patients with non-functional hearing experiencing longer delays than those with functional hearing (median 403 vs. 192 days, p = 0.039) (Fig. 2 ). In contrast, total diagnostic time did not differ significantly according to the type of first-contact physician (Kruskal–Wallis: H = 4.156, p = 0.385), and the type of initial medical evaluation was not significantly associated with tumor volume at diagnosis (Kruskal–Wallis: H = 1.696, p = 0.791) (Table 1 ). Table 1 Clinical and sociodemographic variables associated with auditory functional status Variable n (%) / median (IQR) Gardner–Robertson Scale Non-functional (Grade ≥ 3) Functional (Grade ≤ 2) p value n (%) / median (IQR) n (%) / median (IQR) Qualitative variables Sex 0.746 Female 39 (68) 24 (63) 10 (71) Male 19 (33) 14 (37) 4 (29) Educational Level 1.000 Basic education 40 (69) 28 (74) 10 (71) Higher education 18 (31) 10 (26) 4 (29) Socioeconomic status 0.189 High and middle class 26 (45) 14 (37) 8 (57) Poverty 32 (55) 24 (63) 6 (43) Place of residence 0.453 State of Mexico and Mexico City 33 (57) 20 (53) 9 (64) Other Mexican states 25 (43) 18 (47) 5 (36) Type of referring hospital 0.961 Public 35 (60) 22 (58) 8 (57) Private 23 (40) 16 (42) 6 (43) First-contact physician 0.611 General physician 32 (55) 22 (58) 7 (50) Specialist 26 (45) 16 (42) 7 (50) Diagnosing physician 1.000 General physician 3 (5) 1 (3) 1 (7) Specialist 55(95) 37 (97) 13 (93) Physician who ordered imaging 0.602 General physician 5 (9) 3 (8) 2 (14) Specialist 53 (91) 35 (92) 12 (86) Physician who ordered audiometry 1.000 General physician 1 (2) 1 (3) 0 (0) Specialist 57 (98) 37 (97) 14 (100) Clinical variables Side of hearing loss 0.647 Left 27 (47) 19 (50) 8 (57) Right 25 (43) 19 (50) 6 (43) Koos classification 0.030 Grade I–II 17 (29) 8 (20) 9 (50) Grade III–IV 41 (71) 32 (80) 9 (50) Extra canalicular component size 0.003 ≤ 2 cm 25 (43) 12 (30) 13 (72) ≥ 3 cm 33 (57) 28 (70) 5 (27) House–Brackmann classification 0.217 No deficit 41 (71) 26 (65) 15 (83) Deficit 17 (29) 14 (35) 3 (17) Quantitative variables Age at diagnosis 46 .5 (23.5) 45 (24) 52 (29) 0.687 Time from first symptom to first consultation 152 (30–684) 182 (1046) 136.5 (166) 0.096 Time from first consultation to diagnosis 77 (14–215) 98 (203) 17.50 (190) 0.094 Total diagnostic time 353(152–1114) 403 (1037) 192 (460) 0.039 Tumor volume 2.735 (0.820-23.325) 8.38 (28.09) 0.88 (2.34) 0.002 Symptoms present at diagnosis 2 (2–3) 2 (1) 2 (2) 0.195 To further explore factors associated with auditory outcome, univariate analyses were performed. Auditory functional status according to the Gardner–Robertson scale was significantly associated with tumor-related characteristics. Patients with non-functional hearing more frequently presented with advanced tumor stage based on the Koos classification (grades III–IV) compared with those with functional hearing (80% vs. 50%, p = 0.030). Similarly, extracanalicular tumor size showed a significant association with hearing status, with tumors ≥ 3 cm being more prevalent among patients with non-functional hearing, whereas tumors ≤ 2 cm were more commonly observed in patients with functional hearing (p = 0.003). Tumor volume was also significantly greater in the non-functional hearing group (median 8.38 vs. 0.88 cm³, p = 0.002) (Fig. 3 ; Table 1 ). In contrast, no significant associations were identified between hearing status and sociodemographic variables, including sex, educational level, socioeconomic status, place of residence, healthcare sector (public vs. private), or characteristics of the first-contact physician. Likewise, clinical variables such as side of hearing loss, facial nerve dysfunction according to the House–Brackmann scale, and total symptom burden at diagnosis were not significantly associated with auditory functional status. To further characterize the relationships between continuous clinical variables and auditory outcome, Spearman correlation analyses were performed. A moderate positive correlation was observed between tumor volume and auditory functional status according to the Gardner-Robertson scale (rₛ = 0.535, p ≤ 0.001), indicating worse hearing outcomes with increasing tumor volume. A weak but statistically significant positive correlation was also identified between log- transformed total diagnostic time and auditory functional status (rₛ = 0.274, p = 0.038), suggesting worse hearing outcomes with longer diagnostic time. In addition, total symptom burden showed a weak positive correlation with tumor volume (rₛ = 0.295, p = 0.025), indicating that larger tumors tended to be associated with a higher number of presenting symptoms. In contrast, tumor volume was not significantly correlated with total diagnostic time (rₛ = −0.010, p = 0.938), and no significant correlation was observed between Koos classification and total diagnostic time (rₛ = 0.049, p = 0.713). Variables demonstrating statistical significance in univariate analyses were subsequently entered into a multivariable logistic regression model. To address the skewed distribution of diagnostic time and mitigate the influence of high-variance outliers, total diagnostic time was log-transformed prior to model inclusion. In the adjusted analysis, log-transformed total diagnostic time remained significantly associated with non-functional hearing status. Specifically, each unit increase in log-transformed diagnostic time was associated with higher odds of non-functional hearing (odds ratio [OR] 1.494; 95% confidence interval [CI], 1.027–2.174; p = 0.036). Although tumor volume showed a positive adjusted association with hearing outcome, this association did not reach statistical significance (OR 1.052; 95% CI, 0.997–1.109; p = 0.063). Results of the multivariable logistic regression analysis are summarized in Fig. 4 . Model calibration and goodness of fit were assessed using the Hosmer–Lemeshow test, which indicated adequate fit to the data (χ² = 6.454, df = 8, p = 0.597). Graphical representation of the variables included in the multivariable logistic regression analysis, with corresponding odds ratios (ORs) displayed on the horizontal axis. Squares indicate point estimates, and horizontal lines represent 95% confidence intervals (95% CI). The vertical red dotted line denotes the null effect (OR = 1.0). Total diagnostic time was log-transformed prior to inclusion in the regression model due to its skewed distribution. Numerical values for ORs, 95% CIs, and p-values are reported in the adjacent columns. Tumor volume is expressed in cubic centimeters (cm³). DISCUSSION The primary objective of this study was to estimate the association between diagnostic time and the degree of hearing loss according to the Gardner–Robertson scale in patients with sporadic vestibular schwannomas in Mexico. The main finding was that longer diagnostic time was associated with a non-functional hearing status, maintaining statistical significance after adjustment for tumor volume in the multivariable model. This result indicates that diagnostic time contributes meaningfully to auditory outcome beyond its relationship with tumor volumetric characteristics. Our findings align with prior literature documenting prolonged diagnostic time as a frequent phenomenon in vestibular schwannomas. Since the late 1980s, Thomsen and Tos reported that the majority of patients experienced extended diagnostic intervals, in many cases spanning several years, underscoring the magnitude of delayed diagnosis in this pathology [ 4 ]. Subsequently, van Leeuwen et al. described shorter, yet still clinically relevant, diagnostic times and reported an association between longer diagnostic time and increased tumor size at the time of diagnosis [ 5 ]. In contrast to these latter observations, no significant correlation between total diagnostic time and tumor volume was identified in our population. This finding is consistent with more recent reports in vestibular schwannomas, such as that of Teppo et al., who similarly found no significant association between diagnostic time and tumor size at diagnosis [ 6 ]. Collectively, these data reinforce the notion that vestibular schwannoma growth does not follow a linear relationship with time to diagnosis and that intrinsic biological factors play a decisive role in determining tumor volumetric behavior. Notably, in contrast to the findings reported by Teppo et al., who did not identify an impact of diagnostic time on pretreatment morbidity or functional outcomes, the present study demonstrated a significant association between longer total diagnostic time and non-functional hearing status. Importantly, this association does not appear to be explained by greater tumor volume at diagnosis, but rather by the cumulative effect of time elapsed from symptom onset to diagnostic confirmation. These findings suggest that auditory deterioration may progress as a function of diagnostic time, even in the absence of proportional tumor growth. This interpretation is further supported by contemporary evidence on the natural history of hearing loss in sporadic vestibular schwannoma. Recent reviews have emphasized that hearing loss represents both the most common and earliest symptom of this disease and that auditory function frequently deteriorates over time, even among patients with small tumors or minimal radiographic progression. Longitudinal observations indicate that a substantial proportion of patients with initially serviceable hearing experience progressive decline during follow-up, underscoring that temporal factors and neural vulnerability play a central role in auditory deterioration, independent of tumor size or growth rate. Within this framework, the association observed in our study between longer diagnostic time and non-functional hearing status appears biologically plausible and consistent with the known natural history of hearing loss in sporadic vestibular schwannoma [ 12 ]. Regarding symptomatology at diagnosis, the spectrum and frequency of presenting symptoms observed in this study are consistent with prior reports, in which hearing loss, vertigo and tinnitus predominate at presentation [ 2 , 13 ]. Despite the high prevalence of these symptoms, neither total symptom burden nor specific symptom patterns were associated with total diagnostic time or auditory functional outcome. This finding indicates that symptom-based clinical presentation alone is insufficient to anticipate diagnostic trajectories or functional deterioration in patients with vestibular schwannoma, supporting the notion that factors beyond initial symptomatology contribute to prolonged diagnostic processes. With respect to clinical decision-making, tumor volume remains a central variable for therapeutic planning. In our multivariable analysis, tumor volume showed a positive association with auditory outcome; however, this association did not reach statistical significance and remained close to the conventional threshold of significance. This observation suggests that the effect of tumor volume may gain greater relevance in models with larger sample sizes, potentially allowing for a more precise estimation of its relative contribution within the statistical framework. Nevertheless, diagnostic time emerged as the factor with the greatest statistical consistency, highlighting its relevance as a potentially modifiable determinant through strategies aimed at earlier detection and optimization of diagnostic pathways. Study limitations include the retrospective design, the potential for recall bias in documenting symptom onset, and the relatively limited sample size, which may have restricted the detection of associations of smaller magnitude. Despite these limitations, this study presents relevant strengths, including rigorous audiometric classification, high interobserver agreement, and a comprehensive evaluation of clinical, tumor-related, and healthcare pathway–related variables. Collectively, these findings contribute novel evidence on the role of diagnostic time in auditory outcomes among patients with vestibular schwannoma in the Mexican healthcare context and may inform future efforts aimed at improving early diagnosis and functional preservation. CONCLUSIONS In patients with sporadic vestibular schwannoma, diagnostic time emerged as a key determinant of auditory outcome. The association between longer diagnostic time and non-functional hearing underscores the clinical relevance of temporal factors in the progression of auditory deterioration and highlights that functional loss may occur even in the absence of proportional tumor growth. These findings suggest that diagnostic time represents a potentially modifiable variable with meaningful implications for hearing preservation. By emphasizing the importance of earlier recognition and more efficient diagnostic pathways, this study provides a framework to inform future strategies aimed at optimizing timely diagnosis, improving patient counseling, and ultimately preserving auditory function in this population. Statements and Declarations Funding The authors received no specific funding for this work. Competing Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Author Contributions All authors made substantial contributions to the conception, execution, and interpretation of this study. JM-M, AL-T, and SM-J conceived and designed the study. JM-M, GG-C, and CJ-A were responsible for data collection, curation, and verification. JM-M and AL-T performed the formal analysis, contributed to data interpretation, and prepared the figures and tables. JM-M, GG-C, SR-F, LAO-P, JAP-G, and SM-J contributed to manuscript drafting, supervision, and assessment of clinical relevance. All authors critically revised the manuscript for important intellectual content, approved the final version, and agree to be accountable for all aspects of the work. Data Availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Ethical Approval This study was approved by the corresponding Research Ethics Committees, including a national neurological referral center (Protocol No. 018/24) and the Research and Bioethics Committee of a private tertiary medical center (Protocol No. CMABC-24-20). The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent to Participate Given the retrospective nature of the study, the requirement for informed consent was waived by the ethics committees. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Feb, 2026 Reviews received at journal 24 Feb, 2026 Reviews received at journal 16 Feb, 2026 Reviewers agreed at journal 16 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor assigned by journal 13 Feb, 2026 Submission checks completed at journal 13 Feb, 2026 First submitted to journal 11 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8855893","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":592992538,"identity":"ec91aa15-e9f4-45ea-9712-bf02e9920550","order_by":0,"name":"Julia Moscardini-Martelli","email":"data:image/png;base64,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","orcid":"","institution":"Universidad Anáhuac","correspondingAuthor":true,"prefix":"","firstName":"Julia","middleName":"","lastName":"Moscardini-Martelli","suffix":""},{"id":592992539,"identity":"a4ad01c9-069c-452e-8668-c48e480e5aeb","order_by":1,"name":"Abel Lerma-Talamantes","email":"","orcid":"","institution":"Universidad Anáhuac","correspondingAuthor":false,"prefix":"","firstName":"Abel","middleName":"","lastName":"Lerma-Talamantes","suffix":""},{"id":592992540,"identity":"7802cb84-b3ad-4feb-82ae-eec661f0f892","order_by":2,"name":"Gomez-Castro Gerardo","email":"","orcid":"","institution":"Instituto Nacional de Neurología y Neurocirugía","correspondingAuthor":false,"prefix":"","firstName":"Gomez-Castro","middleName":"","lastName":"Gerardo","suffix":""},{"id":592992541,"identity":"19b4b53b-fde5-4505-a54a-df75be117596","order_by":3,"name":"Luis Alberto Ortega-Porcayo","email":"","orcid":"","institution":"Centro Médico ABC","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Alberto","lastName":"Ortega-Porcayo","suffix":""},{"id":592992542,"identity":"90da056d-0214-4d79-90a0-236faeeca2dd","order_by":4,"name":"Samuel Romano-Feinholz","email":"","orcid":"","institution":"Centro Médico ABC","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Romano-Feinholz","suffix":""},{"id":592992544,"identity":"dffd3380-3067-4fef-9835-45ead270e0a7","order_by":5,"name":"Juan Antonio Ponce-Gomez","email":"","orcid":"","institution":"Centro Médico ABC","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"Antonio","lastName":"Ponce-Gomez","suffix":""},{"id":592992546,"identity":"79f210ac-16c2-4d8f-8c21-e947919121b9","order_by":6,"name":"Alan Candelas-Juarez","email":"","orcid":"","institution":"Instituto Nacional de Neurología y Neurocirugía","correspondingAuthor":false,"prefix":"","firstName":"Alan","middleName":"","lastName":"Candelas-Juarez","suffix":""},{"id":592992547,"identity":"2f426f95-f2a6-4274-90de-31c33bfca423","order_by":7,"name":"Sergio Moreno-Jimenez","email":"","orcid":"","institution":"Instituto Nacional de Neurología y Neurocirugía","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"","lastName":"Moreno-Jimenez","suffix":""}],"badges":[],"createdAt":"2026-02-11 22:23:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8855893/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8855893/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102991546,"identity":"212e4d0a-f99b-4563-86a4-a23f9b1992b5","added_by":"auto","created_at":"2026-02-19 11:32:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80929,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of patient selection\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8855893/v1/74a1d21fd15cd5bcbaf6e3e8.png"},{"id":102991549,"identity":"555d30dd-6feb-4db9-9d14-b6db8164844c","added_by":"auto","created_at":"2026-02-19 11:32:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51212,"visible":true,"origin":"","legend":"\u003cp\u003eTotal diagnostic time according to functional hearing status in patients with sporadic vestibular schwannomas. Non-functional hearing was associated with a significantly longer diagnostic time compared with functional hearing (Mann–Whitney U test, \u003cem\u003ep\u003c/em\u003e = 0.039). Boxes indicate the interquartile range and median; whiskers correspond to Tukey limits, and dots represent individual observations.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8855893/v1/47fcc3a8c4516c8a427520cf.png"},{"id":103049831,"identity":"40383e9c-ba1e-4914-b346-3cd8ed0d6132","added_by":"auto","created_at":"2026-02-20 07:46:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":36958,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between tumor volume and functional hearing status according to the Gardner–Robertson scale, dichotomized into functional and non-functional hearing. Data are presented as box-and-whisker plots constructed using the Tukey method, with boxes representing the interquartile range and whiskers extending to 1.5× the interquartile range. The y-axis is displayed on a logarithmic scale due to the skewed distribution of tumor volume (p = 0.002).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8855893/v1/08b52833a2c2d79c765c7502.png"},{"id":103050133,"identity":"b5ccc9d6-bdc3-463a-b1c3-fb39e032f8cb","added_by":"auto","created_at":"2026-02-20 07:48:23","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":59628,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariate logistic regression analysis of predictors for functional hearing. Graphical representation of the variables included in the multivariable logistic regression analysis, with corresponding odds ratios (ORs) displayed on the horizontal axis. Squares indicate point estimates, and horizontal lines represent 95% confidence intervals (95% CI). The vertical red dotted line denotes the null effect (OR = 1.0). Total diagnostic time was log-transformed prior to inclusion in the regression model due to its skewed distribution. Numerical values for ORs, 95% CIs, and p-values are reported in the adjacent columns. Tumor volume is expressed in cubic centimeters (cm³).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8855893/v1/bf2344a89a1ce8296e84aeaa.png"},{"id":103051321,"identity":"5c38e4fe-6620-4732-b95e-245dc8280e77","added_by":"auto","created_at":"2026-02-20 07:59:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1146397,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8855893/v1/4ecb2d5d-0451-4391-91af-2fc4d3497ed2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association Between Diagnostic Time and Functional Hearing Outcomes in Sporadic Vestibular Schwannomas: A Retrospective Cross-Sectional Study from Two Tertiary Care Centers in Mexico","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eVestibular schwannomas (VS), also known as acoustic neuromas, are benign tumors that originate from Schwann cells covering the vestibular portion of the eighth cranial nerve. Despite their benign nature, significant complications may occur if not diagnosed in a timely manner [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Delayed diagnosis of VS constitutes a major clinical and diagnostic challenge, as early manifestations\u0026mdash;particularly progressive sensorineural hearing loss and tinnitus\u0026mdash;are frequently underrecognized or misattributed by both patients and healthcare providers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, heterogeneity in symptom progression and the typically painless course contribute to prolonged subclinical intervals [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInternational studies have documented substantial diagnostic delays in patients with VS with reported mean delays ranging from several months to multiple years and a clear association between longer delays and increased tumor size [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although the widespread use of magnetic resonance imaging (MRI) has reduced diagnostic latency in some healthcare systems [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], this benefit may be limited in fragmented systems such as that of Mexico. Evidence from other tumor conditions in Mexico and Latin America demonstrates that diagnostic delay is consistently associated with more advanced disease at presentation, underscoring the clinical relevance of timely diagnosis [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. National data further reveal a high burden of diagnostic-related complaints, including delayed and erroneous diagnoses, highlighting systemic challenges in diagnostic processes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Despite this, data on diagnostic delay in vestibular schwannomas within the Mexican population remain scarce, emphasizing the need for focused investigation. Therefore, the objective of this study was to evaluate the association between diagnostic time and the degree of hearing loss, according to the Gardner\u0026ndash;Robertson scale, in patients with sporadic vestibular schwannomas in Mexico.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eThis was a retrospective, observational, analytical, cross-sectional study conducted at two tertiary-level referral centers in Mexico. The study population consisted of patients diagnosed with sporadic VS evaluated during the study period (January 2024-December 2025).\u0026nbsp;The study was designed to assess the association between diagnostic time and hearing outcomes at the time of diagnosis.\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the corresponding Research Ethics Committees. The study was conducted in accordance with the principles of the Declaration of Helsinki. Given the retrospective nature of the study, informed consent was waived by the ethics committees.\u003c/p\u003e\n\u003cp\u003eSample size estimation was performed using the formula for estimating a proportion for qualitative variables, as described in standard methodological references\u0026nbsp;[11]. Based on this calculation, a minimum sample size of 57 patients was obtained. Given the retrospective nature of the study, all eligible patients meeting inclusion criteria during the study period were included to achieve the calculated sample size and maximize statistical power. A total of 92 patients were initially identified and screened for eligibility. Of these, 32 patients were excluded due to incomplete medical records. Additionally, one patient was excluded because of presbyacusis at the time of diagnosis, and another patient was excluded due to the presence of an associated intracranial pathology that could introduce potential bias into the analysis. Consequently, 58 patients constituted the final study population. (Figure 1)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe included consecutive adult patients (\u0026ge;18 years) with a diagnosis of unilateral VS. Inclusion criteria were radiologic diagnosis of VS on brain\u0026nbsp;MRI, available baseline audiological assessment including pure-tone audiometry and speech discrimination score (SDS). Patients were excluded if they had preexisting otologic or neurologic conditions that could confound baseline hearing assessment or bias audiologic outcomes, including prior cerebellopontine angle pathology (such as meningioma), clinically relevant otologic disease (e.g., cholesteatoma, M\u0026eacute;ni\u0026egrave;re\u0026rsquo;s disease, or otosclerosis), or other known causes of sensorineural hearing loss. Additional exclusion criteria included a personal or family history of neurofibromatosis type 2, prior surgery or radiotherapy to the ipsilateral cerebellopontine angle before audiologic evaluation, and insufficient clinical documentation. Patients whose medical records contained less than 80% of the required clinical information to allow reliable reconstruction of the referral pathway and diagnostic time intervals were excluded. These criteria were applied to minimize confounding factors affecting baseline hearing status and to ensure the validity of diagnostic timeline analyses.\u003c/p\u003e\n\u003cp\u003eSociodemographic variables comprised sex, educational level, socioeconomic status, and place of residence. Educational level was categorized as basic education (no formal education, primary, secondary, high school, or technical training) or higher education (undergraduate or postgraduate studies). Socioeconomic status was classified as middle-to-high class or poverty according to institutional criteria. Place of residence was dichotomized into Mexico City and the State of Mexico versus other Mexican states.\u003c/p\u003e\n\u003cp\u003eHealthcare pathway\u0026ndash;related variables encompassed the type of referring hospital (public or private), the type of first-contact physician (general physician or specialist), the diagnosing physician, and the physician responsible for ordering imaging and audiometric studies.\u003c/p\u003e\n\u003cp\u003eClinical variables included side of hearing loss, Koos classification, extracanalicular tumor component size, facial nerve function assessed using the House\u0026ndash;Brackmann classification, age at diagnosis, diagnostic time intervals (time from first symptom to first consultation, time from first consultation to diagnosis, and total diagnostic time), tumor volume, and presenting symptoms with corresponding symptom burden at diagnosis. Symptoms were recorded at the time of diagnosis and coded as binary variables (absent or present), allowing calculation of a total symptom burden score. A total symptom burden score was calculated for each patient by summing all reported symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTumor size and volume were obtained from MRI studies performed at the time of diagnosis. Tumor volume was calculated using dedicated volumetric analysis software (Brainlab\u0026reg;, Brainlab AG, Munich, Germany) based on semi-automated segmentation of contrast-enhancing tumor regions. Tumors were classified according to the Koos grading system and, for analytical purposes, were dichotomized into low-stage (grades I\u0026ndash;II) and high-stage (grades III\u0026ndash;IV) disease.\u003c/p\u003e\n\u003cp\u003eAuditory function was evaluated using the Gardner\u0026ndash;Robertson scale, considering only the ear affected by the vestibular schwannoma. Hearing status was dichotomized into functional hearing (grades I\u0026ndash;II) and non-functional hearing (grades III\u0026ndash;V) for analysis. Facial nerve function, assessed using the House\u0026ndash;Brackmann scale, was dichotomized into normal or mild dysfunction (grades I\u0026ndash;II) and clinically significant dysfunction (grades III\u0026ndash;VI).\u003c/p\u003e\n\u003cp\u003eDiagnostic delay was defined as the time elapsed between the onset of initial symptoms and the definitive diagnosis of vestibular schwannoma. Three diagnostic time intervals were extracted from clinical records when available: (1) time from symptom onset to first contact with any healthcare provider, (2) time from first medical consultation to diagnosis, and (3) total diagnostic time from symptom onset to diagnosis, expressed in days.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA descriptive analysis of clinical and demographic variables was performed. Categorical variables were summarized using absolute frequencies and percentages. Continuous variables were initially assessed for normality using the Kolmogorov\u0026ndash;Smirnov test. Variables with normal distribution were described as mean \u0026plusmn; standard deviation, whereas non-normally distributed variables were reported as median and interquartile range.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInter-rater agreement for pure-tone and speech audiometry recordings was evaluated using Cohen\u0026rsquo;s kappa coefficient. Sociodemographic variables were dichotomized for analysis, including educational level, socioeconomic status, and place of residence.\u003c/p\u003e\n\u003cp\u003eInferential analyses were conducted using the chi-square test or Fisher\u0026rsquo;s exact test to evaluate associations between categorical variables. Comparisons between non-normally distributed continuous variables and hearing status were performed using the Mann\u0026ndash;Whitney U test, while Student\u0026rsquo;s t-test was used for normally distributed variables. Correlations between ordinal variables and non-normally distributed continuous variables were assessed using Spearman\u0026rsquo;s rank correlation coefficient. These analyses were used to explore relationships among clinical variables, tumor-related characteristics, diagnostic time intervals, symptom burden, and auditory functional status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA multivariable logistic regression model was fitted to estimate the adjusted association between diagnostic time, tumor volume, and hearing outcome. Hearing status was analyzed as a dichotomous dependent variable (functional vs. non-functional hearing). Diagnostic time and tumor volume were selected for inclusion in the multivariable model based on their statistical significance in univariable analyses. Tumor volume, expressed in cubic centimeters (cm\u0026sup3;), was chosen as the primary tumor size\u0026ndash;related covariate due to its continuous and objective nature. Other tumor size descriptors, such as Koos grade or extracanalicular component size, were not included, as these variables are ordinal, and the simultaneous inclusion of multiple tumor size metrics would have introduced collinearity into the model.\u003c/p\u003e\n\u003cp\u003eTo ensure appropriate modeling, total diagnostic time was log-transformed using a \u003cem\u003eln(x+1)\u003c/em\u003e transformation prior to inclusion in the regression analysis, given its markedly right-skewed distribution and wide range of values.\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics 26. Graphical representations of the results were generated using GraphPad Prism 10. A two-tailed p value \u0026lt; 0.05 was considered statistically significant for all analyses.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 58 patients were included in the final analysis, of whom 40 presented with non-functional hearing and 18 with functional hearing. Inter-rater agreement was assessed to evaluate concordance between two independent observers in the classification of auditory function based on patients\u0026rsquo; audiometric records. This analysis demonstrated almost perfect agreement, with Cohen\u0026rsquo;s kappa coefficients of 0.819 for the right ear and 0.801 for the left ear, confirming the high reliability of the audiological data.\u003c/p\u003e \u003cp\u003eFollowing patient characterization, presenting symptoms at the time of diagnosis were analyzed to describe the clinical profile at presentation. Hearing loss was the most frequently reported symptom (41 patients), followed by vertigo (25 patients), headache (20 patients), tinnitus (16 patients), nausea and/or vomiting (12 patients), and cerebellar manifestations (10 patients). Less frequent symptoms included facial paresthesia (7 patients), visual disturbances (5 patients), trigeminal neuralgia (4 patients), facial palsy (3 patients), limb weakness (3 patients), and otalgia (1 patient).\u003c/p\u003e \u003cp\u003eBuilding on this descriptive analysis, diagnostic timelines were subsequently examined. Total diagnostic time differed significantly between groups, with patients with non-functional hearing experiencing longer delays than those with functional hearing (median 403 vs. 192 days, p\u0026thinsp;=\u0026thinsp;0.039) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In contrast, total diagnostic time did not differ significantly according to the type of first-contact physician (Kruskal\u0026ndash;Wallis: H\u0026thinsp;=\u0026thinsp;4.156, p\u0026thinsp;=\u0026thinsp;0.385), and the type of initial medical evaluation was not significantly associated with tumor volume at diagnosis (Kruskal\u0026ndash;Wallis: H\u0026thinsp;=\u0026thinsp;1.696, p\u0026thinsp;=\u0026thinsp;0.791) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical and sociodemographic variables associated with auditory functional status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) / median (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eGardner\u0026ndash;Robertson Scale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-functional (Grade\u0026thinsp;\u0026ge;\u0026thinsp;3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFunctional (Grade\u0026thinsp;\u0026le;\u0026thinsp;2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%) / median (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%) / median (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQualitative variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.746\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocioeconomic status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh and middle class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoverty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState of Mexico and Mexico City\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Mexican states\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of referring hospital\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.961\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFirst-contact physician\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.611\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosing physician\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55(95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysician who ordered imaging\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysician who ordered audiometry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSide of hearing loss\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKoos classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade I\u0026ndash;II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade III\u0026ndash;IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExtra canalicular component size\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;3 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHouse\u0026ndash;Brackmann classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQuantitative variables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 .5 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.687\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from first symptom to first consultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152 (30\u0026ndash;684)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e182 (1046)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e136.5 (166)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime from first consultation to diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (14\u0026ndash;215)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (203)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.50 (190)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal diagnostic time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e353(152\u0026ndash;1114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e403 (1037)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e192 (460)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.735 (0.820-23.325)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.38 (28.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.88 (2.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms present at diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo further explore factors associated with auditory outcome, univariate analyses were performed. Auditory functional status according to the Gardner\u0026ndash;Robertson scale was significantly associated with tumor-related characteristics. Patients with non-functional hearing more frequently presented with advanced tumor stage based on the Koos classification (grades III\u0026ndash;IV) compared with those with functional hearing (80% vs. 50%, p\u0026thinsp;=\u0026thinsp;0.030). Similarly, extracanalicular tumor size showed a significant association with hearing status, with tumors\u0026thinsp;\u0026ge;\u0026thinsp;3 cm being more prevalent among patients with non-functional hearing, whereas tumors\u0026thinsp;\u0026le;\u0026thinsp;2 cm were more commonly observed in patients with functional hearing (p\u0026thinsp;=\u0026thinsp;0.003). Tumor volume was also significantly greater in the non-functional hearing group (median 8.38 vs. 0.88 cm\u0026sup3;, p\u0026thinsp;=\u0026thinsp;0.002) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn contrast, no significant associations were identified between hearing status and sociodemographic variables, including sex, educational level, socioeconomic status, place of residence, healthcare sector (public vs. private), or characteristics of the first-contact physician. Likewise, clinical variables such as side of hearing loss, facial nerve dysfunction according to the House\u0026ndash;Brackmann scale, and total symptom burden at diagnosis were not significantly associated with auditory functional status.\u003c/p\u003e \u003cp\u003eTo further characterize the relationships between continuous clinical variables and auditory outcome, Spearman correlation analyses were performed. A moderate positive correlation was observed between tumor volume and auditory functional status according to the Gardner-Robertson scale (rₛ = 0.535, p\u0026thinsp;\u0026le;\u0026thinsp;0.001), indicating worse hearing outcomes with increasing tumor volume. A weak but statistically significant positive correlation was also identified between log-\u003c/p\u003e \u003cp\u003etransformed total diagnostic time and auditory functional status (rₛ = 0.274, p\u0026thinsp;=\u0026thinsp;0.038), suggesting worse hearing outcomes with longer diagnostic time. In addition, total symptom burden showed a weak positive correlation with tumor volume (rₛ = 0.295, p\u0026thinsp;=\u0026thinsp;0.025), indicating that larger tumors tended to be associated with a higher number of presenting symptoms. In contrast, tumor volume was not significantly correlated with total diagnostic time (rₛ = \u0026minus;0.010, p\u0026thinsp;=\u0026thinsp;0.938), and no significant correlation was observed between Koos classification and total diagnostic time (rₛ = 0.049, p\u0026thinsp;=\u0026thinsp;0.713).\u003c/p\u003e \u003cp\u003eVariables demonstrating statistical significance in univariate analyses were subsequently entered into a multivariable logistic regression model. To address the skewed distribution of diagnostic time and mitigate the influence of high-variance outliers, total diagnostic time was log-transformed prior to model inclusion. In the adjusted analysis, log-transformed total diagnostic time remained significantly associated with non-functional hearing status. Specifically, each unit increase in log-transformed diagnostic time was associated with higher odds of non-functional hearing (odds ratio [OR] 1.494; 95% confidence interval [CI], 1.027\u0026ndash;2.174; p\u0026thinsp;=\u0026thinsp;0.036). Although tumor volume showed a positive adjusted association with hearing outcome, this association did not reach statistical significance (OR 1.052; 95% CI, 0.997\u0026ndash;1.109; p\u0026thinsp;=\u0026thinsp;0.063). Results of the multivariable logistic regression analysis are summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eModel calibration and goodness of fit were assessed using the Hosmer\u0026ndash;Lemeshow test, which indicated adequate fit to the data (χ\u0026sup2; = 6.454, df\u0026thinsp;=\u0026thinsp;8, p\u0026thinsp;=\u0026thinsp;0.597).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGraphical representation of the variables included in the multivariable logistic regression analysis, with corresponding odds ratios (ORs) displayed on the horizontal axis. Squares indicate point estimates, and horizontal lines represent 95% confidence intervals (95% CI). The vertical red dotted line denotes the null effect (OR\u0026thinsp;=\u0026thinsp;1.0). Total diagnostic time was log-transformed prior to inclusion in the regression model due to its skewed distribution. Numerical values for ORs, 95% CIs, and p-values are reported in the adjacent columns. Tumor volume is expressed in cubic centimeters (cm\u0026sup3;).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe primary objective of this study was to estimate the association between diagnostic time and the degree of hearing loss according to the Gardner\u0026ndash;Robertson scale in patients with sporadic vestibular schwannomas in Mexico. The main finding was that longer diagnostic time was associated with a non-functional hearing status, maintaining statistical significance after adjustment for tumor volume in the multivariable model. This result indicates that diagnostic time contributes meaningfully to auditory outcome beyond its relationship with tumor volumetric characteristics.\u003c/p\u003e \u003cp\u003eOur findings align with prior literature documenting prolonged diagnostic time as a frequent phenomenon in vestibular schwannomas. Since the late 1980s, Thomsen and Tos reported that the majority of patients experienced extended diagnostic intervals, in many cases spanning several years, underscoring the magnitude of delayed diagnosis in this pathology [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Subsequently, van Leeuwen et al. described shorter, yet still clinically relevant, diagnostic times and reported an association between longer diagnostic time and increased tumor size at the time of diagnosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast to these latter observations, no significant correlation between total diagnostic time and tumor volume was identified in our population. This finding is consistent with more recent reports in vestibular schwannomas, such as that of Teppo et al., who similarly found no significant association between diagnostic time and tumor size at diagnosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Collectively, these data reinforce the notion that vestibular schwannoma growth does not follow a linear relationship with time to diagnosis and that intrinsic biological factors play a decisive role in determining tumor volumetric behavior.\u003c/p\u003e \u003cp\u003eNotably, in contrast to the findings reported by Teppo et al., who did not identify an impact of diagnostic time on pretreatment morbidity or functional outcomes, the present study demonstrated a significant association between longer total diagnostic time and non-functional hearing status. Importantly, this association does not appear to be explained by greater tumor volume at diagnosis, but rather by the cumulative effect of time elapsed from symptom onset to diagnostic confirmation. These findings suggest that auditory deterioration may progress as a function of diagnostic time, even in the absence of proportional tumor growth.\u003c/p\u003e \u003cp\u003eThis interpretation is further supported by contemporary evidence on the natural history of hearing loss in sporadic vestibular schwannoma. Recent reviews have emphasized that hearing loss represents both the most common and earliest symptom of this disease and that auditory function frequently deteriorates over time, even among patients with small tumors or minimal radiographic progression. Longitudinal observations indicate that a substantial proportion of patients with initially serviceable hearing experience progressive decline during follow-up, underscoring that temporal factors and neural vulnerability play a central role in auditory deterioration, independent of tumor size or growth rate. Within this framework, the association observed in our study between longer diagnostic time and non-functional hearing status appears biologically plausible and consistent with the known natural history of hearing loss in sporadic vestibular schwannoma [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding symptomatology at diagnosis, the spectrum and frequency of presenting symptoms observed in this study are consistent with prior reports, in which hearing loss, vertigo and tinnitus predominate at presentation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Despite the high prevalence of these symptoms, neither total symptom burden nor specific symptom patterns were associated with total diagnostic time or auditory functional outcome. This finding indicates that symptom-based clinical presentation alone is insufficient to anticipate diagnostic trajectories or functional deterioration in patients with vestibular schwannoma, supporting the notion that factors beyond initial symptomatology contribute to prolonged diagnostic processes.\u003c/p\u003e \u003cp\u003eWith respect to clinical decision-making, tumor volume remains a central variable for therapeutic planning. In our multivariable analysis, tumor volume showed a positive association with auditory outcome; however, this association did not reach statistical significance and remained close to the conventional threshold of significance. This observation suggests that the effect of tumor volume may gain greater relevance in models with larger sample sizes, potentially allowing for a more precise estimation of its relative contribution within the statistical framework. Nevertheless, diagnostic time emerged as the factor with the greatest statistical consistency, highlighting its relevance as a potentially modifiable determinant through strategies aimed at earlier detection and optimization of diagnostic pathways.\u003c/p\u003e \u003cp\u003eStudy limitations include the retrospective design, the potential for recall bias in documenting symptom onset, and the relatively limited sample size, which may have restricted the detection of associations of smaller magnitude. Despite these limitations, this study presents relevant strengths, including rigorous audiometric classification, high interobserver agreement, and a comprehensive evaluation of clinical, tumor-related, and healthcare pathway\u0026ndash;related variables. Collectively, these findings contribute novel evidence on the role of diagnostic time in auditory outcomes among patients with vestibular schwannoma in the Mexican healthcare context and may inform future efforts aimed at improving early diagnosis and functional preservation.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn patients with sporadic vestibular schwannoma, diagnostic time emerged as a key determinant of auditory outcome. The association between longer diagnostic time and non-functional hearing underscores the clinical relevance of temporal factors in the progression of auditory deterioration and highlights that functional loss may occur even in the absence of proportional tumor growth. These findings suggest that diagnostic time represents a potentially modifiable variable with meaningful implications for hearing preservation. By emphasizing the importance of earlier recognition and more efficient diagnostic pathways, this study provides a framework to inform future strategies aimed at optimizing timely diagnosis, improving patient counseling, and ultimately preserving auditory function in this population.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eAll authors made substantial contributions to the conception, execution, and interpretation of this study. JM-M, AL-T, and SM-J conceived and designed the study. JM-M, GG-C, and CJ-A were responsible for data collection, curation, and verification. JM-M and AL-T performed the formal analysis, contributed to data interpretation, and prepared the figures and tables. JM-M, GG-C, SR-F, LAO-P, JAP-G, and SM-J contributed to manuscript drafting, supervision, and assessment of clinical relevance. All authors critically revised the manuscript for important intellectual content, approved the final version, and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study was approved by the corresponding Research Ethics Committees, including a national neurological referral center (Protocol No. 018/24) and the Research and Bioethics Committee of a private tertiary medical center (Protocol No. CMABC-24-20). The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eGiven the retrospective nature of the study, the requirement for informed consent was waived by the ethics committees.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDurham AR, Tooker EL, Patel NS, Gurgel RK (2023) Epidemiology and Risk Factors for Development of Sporadic Vestibular Schwannoma. 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Acta Neurochir (Wien) 165(10):2903\u0026ndash;2911. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00701-023-05665-9\u003c/span\u003e\u003cspan address=\"10.1007/s00701-023-05665-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuro-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neon","sideBox":"Learn more about [Journal of Neuro-Oncology](https://www.springer.com/journal/11060)","snPcode":"11060","submissionUrl":"https://submission.nature.com/new-submission/11060/3","title":"Journal of Neuro-Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Vestibular schwannoma, Diagnostic time, Gardner–Robertson scale, Hearing function, Tumor volume, Hearing loss","lastPublishedDoi":"10.21203/rs.3.rs-8855893/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8855893/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e \u003cp\u003eTo analyze the association between diagnostic time and auditory functional status, as measured by the Gardner\u0026ndash;Robertson scale, in patients with sporadic vestibular schwannoma.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA retrospective, observational, cross-sectional study was conducted at two tertiary referral centers in Mexico. Adult patients with unilateral sporadic vestibular schwannoma, radiologic confirmation on magnetic resonance imaging, and baseline audiological assessment were included. Total diagnostic time was defined as the interval from symptom onset to diagnosis and was log-transformed due to its right-skewed distribution. Hearing status was categorized as functional or non-functional. Tumor volume was quantified using semi-automated volumetric magnetic resonance imaging. Univariable analyses and Spearman correlations were performed, followed by multivariable logistic regression adjusting for tumor volume.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003e58 patients were included, of whom 40 (69%) presented with non-functional hearing at diagnosis. Total diagnostic time was longer in patients with non-functional hearing compared with those with functional hearing (median 403 vs. 192 days, p\u0026thinsp;=\u0026thinsp;0.039). Tumor volume was significantly higher in the non-functional hearing group (median 8.38 vs. 0.88 cm\u0026sup3;, p\u0026thinsp;=\u0026thinsp;0.002) and demonstrated a moderate association with worse auditory functional status (rₛ = 0.535, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Log-transformed total diagnostic time demonstrated a weak but significant correlation with worse hearing status (rₛ = 0.274, p\u0026thinsp;=\u0026thinsp;0.038) and was associated with non-functional hearing in multivariable analysis (OR 1.49; 95% CI, 1.03\u0026ndash;2.17; p\u0026thinsp;=\u0026thinsp;0.036).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eLonger diagnostic time was associated with worse auditory functional status at diagnosis in patients with sporadic vestibular schwannoma\u003c/p\u003e","manuscriptTitle":"Association Between Diagnostic Time and Functional Hearing Outcomes in Sporadic Vestibular Schwannomas: A Retrospective Cross-Sectional Study from Two Tertiary Care Centers in Mexico","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-19 11:32:15","doi":"10.21203/rs.3.rs-8855893/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-24T22:47:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T21:05:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T22:13:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308491287737854878256171347581855788271","date":"2026-02-16T08:12:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134231794812021741855845469727047915851","date":"2026-02-15T16:11:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T12:41:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-13T06:01:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-13T05:58:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Neuro-Oncology","date":"2026-02-11T22:10:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-neuro-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neon","sideBox":"Learn more about [Journal of Neuro-Oncology](https://www.springer.com/journal/11060)","snPcode":"11060","submissionUrl":"https://submission.nature.com/new-submission/11060/3","title":"Journal of Neuro-Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"66004420-5584-492e-b507-f87fd03ec985","owner":[],"postedDate":"February 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T17:09:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-19 11:32:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8855893","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8855893","identity":"rs-8855893","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}