听神经瘤手术治疗策略

1 概述听神经瘤（acoustic neuroma,AN）发病率居颅内肿瘤第3位（8％～10％）,桥小脑角（cerebellopontineangle,CPA）肿瘤第1位（71％）。AN多见于中年人,尤以35-45岁为主,女：男为2：1。多数研究认为AN起源于听神经的神经鞘膜部分,多发生在前庭支,其中前庭上神经占2／3。AN命名不一,准确命名应为听神经鞘膜瘤。双侧AN占总数的4％,多见于II型AN,其中女性居多。     

听神经瘤手术治疗临床分析

<正>我科地处西部,近年来逐步开展侧颅底手术,其中以听神经瘤发病率较高,较为多见。听神经瘤好发于内耳道、桥小脑角,多起源于前庭神经,生长速度较慢,手术仍是主要治疗手段。现将近3年来我科行9例听神经瘤切除术报道如下。1资料与方法 1.1临床资料。我科于2010年5月~2013年6月,共行听神经瘤切除术9例,其中经迷路入路听神经瘤切除术8例,经乙状窦后入路听神经瘤切除术1例,男5例,女4例,年龄5~55     

颅中窝径路切除小听神经瘤保护面听神经功能的研究

目的 探讨经颅中窝径路切除内听道内小听神经瘤手术对面神经和听神经功能的保护.方法 2004年1月至2013年2月共13例患者接受经颅中窝径路切除内听道内的小听神经瘤,其中男6例,女7例,年龄38 ～ 54岁;瘤体大小为0.8～1.5cm.听神经功能评价根据美国耳鼻咽喉头颈外科学会的标准分为A、B、C、D四级,面神经功能的评估参照House-Brackmann (HB)分级标准,比较患者手术前和手术后1个月时的面听神经功能.结果 13例患者手术顺利,无死亡病例,其中12例患者肿瘤全切,1例近全切除.患者术前听力评估A级10例、B级2例、C级1例,术后复查,2例患者听力由A级下降至B级,1例由B级升至A级,1例由B级下降至C级,术后听力A级保存率为80％(8/10).12例患者术前面神经功能为HB Ⅰ级,术后仍为Ⅰ级,术后面神经功能Ⅰ级保留率为100％(12/12);1例面神经功能Ⅱ级患者术后下降为Ⅲ级.术后随访0.5～5年,均未出现严重并发症.结论 颅中窝径路内听道内小听神经瘤切除术可有效保留听神经和面神经功能,手术切除可以考虑作为小听神经瘤患者的常规治疗手段.     

听神经瘤术后复发再手术

目的 探讨听神经瘤术后复发的相关因素及处理方法。方法 收集本科105例听神经瘤手术的临床资料,随访资料完整的64例,进行回顾性研究。结果 105例听神经瘤手术病例,全切79例（75．2％）,部分切除12例（11．4％）,留有残片14例（13．3％）：随访资料完整的64例,其中复发8例：复发率12．5％（8／64）;复发病例都为早期手术病例（1998年以前）;肿瘤越大,复发率越高;复发率最高的年龄段在40~59岁：全切后复发1例,部分切除或囊内切除术后复发6例,留有残片后复发1例;其中迷路入路复发率为21．1％（4／19）,乙状窦后入路10．5％（4／38）,中颅窝入路为0％;复发时间为术后10个月～9年。复发病例全部进行再次手术;再次手术采用乙状窦后入路,全部切除肿瘤;除面瘫外,无严重并发症出现。结论 听神经瘤术后复发者大部分为术中未完全切除病例,听神经瘤的早期诊断、早期手术、全部切除是减少复发率的主要因素。复发病例需要再手术,对有高风险复发的病例如肿瘤较大、部分切除、高发病的年龄要定期随访,至少随访3年以上。     

听神经瘤治疗策略

听神经瘤是桥脑小脑区最常见肿瘤,是目前耳外科研究的重点.听神经瘤治疗方案主要包括随诊观察、放射治疗和中颅窝入路、乙状窦后入路和经迷路入路等手术治疗方式.如何针对性选择合适治疗方案达到个体化治疗的日的是听神经瘤研究的热点.本文就听神经瘤治疗现状,各种治疗方案的适应证及优、缺点进行概述.     

听神经瘤治疗策略

听神经瘤是桥脑小脑区最常见肿瘤,是目前耳外科研究的重点。听神经瘤治疗方案主要包括随诊观察、放射治疗和中颅窝入路、乙状窦后入路和经迷路入路等手术治疗方式。如何针对性选择合适治疗方案达到个体化治疗的目的是听神经瘤研究的热点。本文就听神经瘤治疗现状,各种治疗方案的适应证及优、缺点进行概述。     

听神经瘤术后脑脊液漏影响因素和治疗策略

目的 探讨听神经瘤术后脑脊液漏的影响因素和治疗策略.方法 回顾分析2004年1月～2006年12月共137例听神经瘤手术病例,比较术者经验、手术径路、肿瘤大小、岩骨气化程度对术后脑脊液漏的影响,探讨不同治疗策略.结果 术后脑脊液漏发生率6.6%(9/137),按年份统计:2004年为8.3%(2/24),2005年为7...     

听神经瘤手术的听力保存技术

目的 探索听神经瘤切除术中保留术前残余听力的可能性,以及评价术中动态听力监测和耳内镜技术对听力保护的效果.方法 2003年至2007年7月共收治听神经瘤手术患者138例,对术前有残余听力18例(18耳)施行术中连续听力监测.男6例,女12例;左12耳,右6耳;年龄14～64岁;15例为单发的听神经鞘瘤,3例为神经纤维瘤病Ⅱ型.MRI测得肿瘤最大直径在12～33 min,中位数19.5 min.均采用经乙状窦后入路,10耳辅以耳内镜下手术.18例均行听性脑干反应(ABR)及耳蜗电图术中连续听力监测;术中常规监测面神经功能.术后随访时间为6个月～2.5年,以最后一次听力结果为准.术前及术后听力评价标准采用1995年美国耳鼻咽喉头颈外科学会分级法.结果 手术全切16例,大部分切除2例(均为神经纤维瘤病Ⅱ型).无死亡病例,术后均恢复顺利,无脑脊液漏,无皮下血肿等术后并发症.18例术前均无面神经麻痹,术中面神经均得以保存,解剖结构连续完整.术后7 d面神经功能Ⅰ～Ⅱ级占50.0%(9/18);术后6个月面神经功能Ⅰ～Ⅱ级占88.9%(16/18).18耳中11耳术后听力得以保存(61.1%),术后听力A级4耳,B级4耳,C级2耳,D级1耳.术前肿瘤>20 min者共5耳仅2耳保存听力,<20 mm者共13耳术后听力保存9耳(69.2%).耳内镜辅助下手术10耳,听力保存8耳(80.0%).术中监测发现,手术过程中当磨钻内耳道后唇、内耳道口附近处牵拉或电凝止血,尤其是夹持内听动脉、处理内耳道处肿瘤及夹持或电凝肿瘤表面最内层蛛网膜血管时,对ABR和耳蜗电图波形影响很大.结论 对术前有良好听力的听神经瘤患者应在术中辅以实时动态听力监测,并结合术中耳内镜技术进行听力保护,术后能够获得较好的听力保存效果.听神经瘤表面蛛网膜的保留及其血供状况对保留听力起重要作用,而内听动脉的损伤是术后听觉丧失的最主要原因.     

听神经瘤手术并发症的处理

目的探讨听神经瘤手术并发症及其处理。方法对105例（110例次）听神经瘤手术的并发症进行回顾性研究，总结手术期问出现的各种并发症及其影响因素。结果105例（110例次）听神经瘤手术，并发症中，全聋86．4％（95／110），面瘫63．6％（70／110），其他并发症的发生依次是脑脊液漏12．7％（14／110）、颅内血肿5．5％（6／110）、颅神经麻痹4．5％（5／110）、脑膜炎3．6％（4／110）、肢体活动障碍3．6％（4／110）、平衡障碍1．8％（2／110）、偏瘫失语0．9％（1／110）；术中彻底止血、术后控制血压、术后24h内有效的镇静方式是防止术后颅内血肿的重要步骤，术后48h为出血期，发生颅内血肿应尽早手术处理；术后脑脊液耳鼻漏的主要原因乳突气房开放后封闭不严，脑脊液切口漏的原因是切口缝合不严、加压包扎不够；经再次治疗均痊愈；术前脑室引流术是高颅压患者减少其他并发症的重要步骤。结论听神经瘤手术严重并发症的发生率很低，其相关因素有肿瘤大小及手术方式；手术医生组的经验和技巧是避免出现并发症的关键因素。     

听神经瘤的再手术(附11例分析)

为进一步提高听神经瘤手术的临床疗效，对１５８例听神经瘤手术后１１例再次手术患者进行临床分析，发现肿瘤大小、切除方式以及手术进路与临床症状复发密切相关。肿瘤越大，复发机会越多；大部切除，次全切除及全切除的复发再手术率分别是１９．４％、１３．２％和０；迷路后进路手术复发再手术率最高，达３３．３％。防止临床复发最根本的措施是术中尽量减少肿瘤残留，力争全切。为达此目的要求早期诊断，选择适当的手术进路。对不能全切的较大肿瘤，次全切除能有效地延缓临床复发时间，减少并发症。计算了术前以及术后肿瘤的增长速度以及肿瘤倍增时间及再手术间期，建议术后每半年进行一次影像检查，对于早期发现复发有重要意义。Ｘ刀是对付早期肿瘤复发的有效办法。再手术中的并发症除损伤面神经外，其它少见。     

内听道型听神经瘤的外科治疗

摘要：目的探讨和总结内听道型听神经瘤的临床显微手术技巧,以期提高手术疗效。方法回顾性分析2007年8月~2015年8月期手术的34例内听道型听神经瘤患者临床资料,探讨手术操作技巧,并总结肿瘤切除程度、术后并发症及远期随访情况。结果34例患者均采用枕下乙状窦后入路,肿瘤最大径小于10 mm 11例,介于10~20 mm之间23例;肿瘤全切34例。无一例死亡。术后3个月轻度周围性面瘫2例,听力较术前下降17例。术后随访2年以上,听力较术前下降13例。结论乙状窦后硬膜下入路是切除内听道型听神经瘤的良好办法,磨除内听道后壁及锐性分离是操作核心。     

Frequency selectivity in patients with acoustic neuroma

Frequency selectivity was compared in subjects with hearing loss due to acoustic neuroma and cochlear pathology, and normal listeners. A particular interest was the role of probe tone parameters on the shape of the tuning curve. Psychophysical tuning curves (PTCs) were measured for each of two equal energy 2000-Hz probe tones (10 dB SL/300 msec and 17 dB SL/60 msec), using simultaneous 1/3-octave narrowband noise maskers centered at 1, 1.25, 1.6, 2.5, 3.15, and 4 kHz. The results showed that the critical masker levels obtained for impaired listeners were significantly greater than those from normal subjects. The slope of the low-frequency limb of the PTC was steeper for normal compared to hearing-impaired listeners but there was no difference due to site of lesion. In all three groups, the critical masker levels obtained with the short probe were significantly greater than those for the long probe, negating the hypothesis that equal energy probes would yield the same outcomes. Tuning in listeners with hearing loss was highly correlated with audiometric threshold but not with tumor size, width of the internal auditory canal, or tumor location within the cerebellopontine angle. The main conclusion was that cochlear and retrocochlear hearing loss are similar with respect to their effect on frequency selectivity.     

Gait instability in patients with acoustic neuroma

OBJECTIVE: To investigate pathological gait in patients with unilateral acoustic neuroma using tactile sensors placed under both feet. MATERIAL AND METHODS: Forty-three patients were enrolled in the study. They were categorized into two groups: the small tumor group had tumors < 2 cm from the porus acousticus without any brainstem compression and the large tumor group had tumors > 2 cm from the porus acousticus with brainstem compression. Eighteen healthy subjects served as controls. Subjects were asked to walk freely with eyes open or closed for a distance of nearly 8 m. The coefficients of variation (CVs) of stance, swing and double support were calculated. The stability of the trajectories of the center of force and the foot pressure difference were also studied. RESULTS: The CVs of stance, swing and double support were significantly greater with eyes closed and, with the exception of double support, these differences were greater in the tumor groups. The instability of the trajectories of the center of force was significantly greater in the tumor group, and in the large tumor group the horizontal component of sway movement of the trajectories of the center of force of the foot on the same side as the lesion was greater than that on the intact side with eyes closed. Regarding foot pressure differences between the two feet, the large tumor group had a greater foot pressure for the foot on the same side as the lesion than for the foot on the intact side, especially with eyes closed. No significant difference was found in the small tumor group. CONCLUSION: The presence of acoustic neuroma may cause unstable gait, and steady gait is considerably dependent on visual input. Larger tumors may produce shifts in the body's center of gravity to the lesioned side during gait, especially under conditions of visual deprivation. These abnormalities may reflect some influences on gait control systems such as phase and muscular tonus control systems.     

Tumor-associated hemorrhage in patients with acoustic neuroma

OBJECTIVE: To describe the clinical significance of tumor-associated hemorrhage in patients with acoustic neuromas. STUDY DESIGN: Retrospective chart review. SETTING: University-based, tertiary care teaching hospital. PATIENTS: Three patients with acoustic neuromas who experienced symptomatic tumoral bleeding. INTERVENTIONS: Radiographic imaging, surgical removal of tumors, and pathologic analysis. MAIN OUTCOME MEASURES: Patient histories, radiologic characteristics, surgical results, and pathologic findings. RESULTS: Tumoral hemorrhage can occur in patients with acoustic neuromas. These three cases and a review of the world literature suggest that tumor size may be the most important risk factor for tumor-related hemorrhage. CONCLUSION: These findings have implications for those patients with acoustic neuromas who choose not to have surgical removal.     

Audiometric findings in patients with acoustic neuroma

OBJECTIVE: Hearing loss remains the most common symptom associated with acoustic neuroma. This study documents the audiometric findings from 721 acoustic neuroma procedures. STUDY DESIGN: This was a retrospective study. The preoperative audiometric data were compiled and were analyzed by patient age, gender, tumor size, time of surgery, and neurofibromatosis Type 2 (NF 2). Postoperative audiometric data were arranged and compiled in the same way. The hearing classification proposed by the AAO-HNS was applied to all preoperative and postoperative cases. SETTING: Tertiary referral center. PATIENTS: Surgically confirmed acoustic neuroma patients who had not previously received surgical or radiosurgical therapy. Patients underwent surgery by the retrosigmoid approach. INTERVENTION: Surgical removal of an acoustic neuroma. MAIN OUTCOME RESULT: Provision of pure tone and speech data from a group of acoustic neuroma patients, including application of the recently introduced and accepted AAO-HNS hearing classification system. RESULTS: Preoperative audiometric data were obtained from 694 of 721 patients (96%), of whom 619 had measurable hearing. Postoperative audiometry was performed on 606 patients; 152 had usable data. The combined preoperative audiometric data revealed a high frequency sensorineural hearing loss. Word recognition was servicable. The postoperative pure tones and word recognition scores were worse than preoperative scores. Age, gender, tumor size, and time of surgery had some impact on the preoperative hearing and the postoperative result; NF 2 did not. CONCLUSIONS: The study confirms that hearing alteration is almost universal in acoustic neuroma patients. Hearing preservation is possible in a significant number of cases; however, the postoperative auditory function tends to be worse.     

Critical bandwidth in patients with acoustic neuroma

Eleven patients with verified acoustic neuroma had critical band estimation performed by the method of loudness summation using noise bands centered around 1 kHz. The normal loudness difference between broad band noise and narrow band noise was reduced at all levels except the highest. Judged as single individuals, 9 of the 11 patients had a normal critical band. The pooled data indicated a normal critical band, both in patients with hearing loss less than 50 dB HL and in patients with hearing loss greater than or equal to 50 dB HL. The results are similar to those obtained in patients with Ménière's disease (Bonding, 1978c) and thus CB-measurements cannot be utilized for differentiating between cochlear and retrocochlear lesions. However, at the highest test levels applied the loudness difference between broad band noise and narrow band noise appeared to have some correlation to the presence or absence of recruitment.     

巨大实性高血运听神经瘤的外科治疗

目的探讨和总结巨大实性高血运听神经瘤的临床显微手术技巧,以期提高手术疗效。方法回顾性分析2008年8月~2016年8月手术的21例巨大实性高血运听神经瘤患者临床资料,探讨手术操作技巧,总结肿瘤切除程度、术后面瘫情况及其余并发症。结果21例患者均采用枕下乙状窦后入路,肿瘤最大径62 mm,最小直径40 mm;肿瘤全切6例,近全切除15例。无一例死亡。术后面神经功能H B 1级7例,2级7例,3级5利,4级2例;共济运动障碍者2例。术后2年以上随访H B 2级患者有3例恢复至1级。结论合理控制出血是切除巨大实性高血运听神经瘤的关键步骤,内听道后壁的精细打磨、面神经扇形扩张平面的确认与保护是保留面神经功能的重要步骤。     

Sporadic acoustic neuroma in pediatric patients

OBJECTIVE: Sporadic acoustic neuroma, usually occur between the ages of 40 and 70 years, are very rare in children. We review the experiences of 10 cases of sporadic (non-NF2) acoustic neuromas in pediatric patients. METHOD: During last 26 years 2000 skull base procedures were performed in the Otorhinolaryngology Unit of the Ospedali Riuniti di Bergamo. Among these almost 900 cases were acoustic neuromas. Only 10 were at or under the age of 18 years. RESULTS: The age of the youngest patient in our series was 12 years. Deafness were the commonest presentation and were seen in eight patients. It varied between 10 and 65 dB sensorineural hearing loss. Among these eight cases, two patients have sudden onset of hearing loss. Two patients presented with dizziness. The duration of complaints were between 2 months and 5 years in these patients. The diameter of the tumors varied widely with minimum of 10 mm to maximum up to 60 mm. Five patients each underwent resection of the tumor by translabyrinthine and retrosigmoid approach, respectively. The minimum postoperative follow-up was 3 years and maximum was 22 years in our series. Postoperatively seven cases the facial nerve recovered to grade I, and one each to grade II and grade VI of House-Brackmann classification. All five cases who underwent retrosigmoid approach had moderate (40 dB) to total sensorineural hearing loss postoperatively. The youngest patient with largest tumor diameter of 60 mm developed transient hemiparesis in the immediate postoperative period and he recovered fully in due course. CONCLUSION: We found preservation of facial nerve function is more easier than hearing in this group of patients.     

听神经瘤的耳声发射观察

目的 观察和分析听神经瘤的耳声发射特点,为评估听神经瘤患者的耳蜗功能和选择保护听力的术式提供参考依据.方法 对20例（22耳）听神经瘤患者行纯音听阈、阻抗、听性脑干反应（auditory brainstem response,ABR）、诱发性耳声发射（evoked otoacoustic emissions,EOAE）测试及CT和（或）MRI扫描,能引出EOAE的瘤耳检测其自发性耳声发射（spontaneous otoacoustic emissions,SOAE）和传出抑制功能.结果 28.57%听神经瘤耳能引出EOAE,按其畸变产物耳声发射（distortion product otoacoustic emissions,DPOAE）特点分为三型：①“耳蜗型”3耳;②“非耳蜗型”2耳;③“混合型”1耳;“非耳蜗型”耳能引出强大的SOAE;能引出EOAE的6耳均有内侧橄榄耳蜗传出系统功能障碍.结论 EOAE可精确分析听神经瘤患者的耳蜗（外毛细胞）功能,部分听神经瘤病人存在“离断耳”现象.耳声发射（otoacousticemissions,OAE）在诊断重度感音神经性聋（包括听神经瘤病人）方面有一定潜能.     

Normal auditory brainstem response in patients with acoustic neuroma

Auditory brainstem response testing has been a major breakthrough in audiologic screening for acoustic neuroma because of its high degree of sensitivity. Although it is not uncommon for other cerebellopontine angle masses to present with normal ABR findings, reports of eighth nerve tumors with false-negative auditory brainstem response tests are quite rare. A series of 120 acoustic neuromas resected at the University of Michigan was reviewed and revealed two such patients. These two patients presented with asymmetric sensorineural hearing loss and unilateral tinnitus and were found to have completely normal auditory brainstem response. The diagnosis of acoustic neuroma would have been delayed if a comprehensive evaluation had not been pursued.