A Systematic Review of Audiological Criteria Used to Determine the Need for MRI Screening in Patients With Suspected Vestibular Schwannoma

OBJECTIVE: To evaluate the diagnostic accuracy of non-imaging screening tools used to guide magnetic resonance imaging (MRI) referral in adults with asymmetric sensorineural hearing loss undergoing investigation for suspected vestibular schwannoma (VS). DATABASES REVIEWED: Medline (via Ovid; 1946 to August 19, 2025), PubMed, Embase, Cochrane Library, and Scopus. MATERIALS AND METHODS: A PRISMA-compliant systematic review (PROSPERO CRD420251131909) included prospective and retrospective cohort and case-control studies assessing clinical or audiological screening criteria against MRI in adults (above 16 y) investigated for possible VS. Primary outcomes were sensitivity and specificity. Two reviewers independently screened studies, extracted data, and assessed study quality using the Newcastle-Ottawa Scale. Due to clinical and methodological heterogeneity, results were synthesized narratively without meta-analysis. RESULTS: Twenty studies comprising 9119 patients (1169 VS cases) were included. Pure tone audiometry thresholds were most frequently evaluated (10 studies), followed by auditory brainstem response (ABR; 7 studies), vestibular testing (2 studies), and audiometric configuration (1 study). Audiometric threshold demonstrated an inverse relationship between sensitivity and specificity: lower thresholds achieved sensitivities approaching 100% but markedly reduced specificity. Stricter criteria improved specificity but often reduced sensitivity below the 90% threshold considered acceptable for screening. ABR showed high sensitivity in some cohorts but reduced detection of tumors ≤10 mm. Caloric and hyperventilation testing demonstrated variable sensitivity, and audiometric configuration showed poor sensitivity. Most studies were retrospective, with heterogeneity in thresholds and risk-of-bias assessments limiting comparability. CONCLUSIONS: No screening test consistently achieved high sensitivity and specificity for VS detection. Audiometric protocols remain the best first-line screening tools, though prospective validation is required to maximize diagnostic yield while minimizing unnecessary MRI utilization.