内听道内听神经瘤残留病灶清除术中内镜技术的应用

目的 探讨乙状窦后径路听神经瘤切除术中应用内镜技术减少术后肿瘤残留发生率方面的价值和意义。方法 观察和比较常规乙状窦后径路听神经瘤切除术（15例）与术中使用内镜检查和切除内听道底残留肿瘤病灶（11例）的两组手术病人手术前后听觉、前庭功能、面神经功能和MRI检查结果。结果 常规乙状窦后径路听神经瘤切除术组病人术后有3例发现有残留肿瘤，而术中使用内镜使用内镜组病人均无残留；手术前后听觉和前庭功能障碍发生率、术后面神经麻痹发生率两组之间差异均无显著性。结论 乙状窦后径路跌神经瘤切除术术中结合使用内镜非常方便和安全，未出现由此而引起的任何并发症，并可有效防止或减少单纯乙状窦后径路听神经瘤切除术后病灶的残留及肿瘤的复发，有临床推广应用价值。     

内窥镜技术在乙状窦后径路听神经瘤切除术中的应用

目的：探讨乙状窦后径路听神经瘤切除术中应用内窥镜的方法及其在减少残瘤发生率中的价值。方法：常规乙状窦后径路切除听神经瘤（常规手术组）15例，乙状窦后径路加内窥镜检查切除听神经瘤（结合窥镜组）11例，比较其疗效。结果：常规手术组术后3例有残留肿瘤，而结合窥镜组均为阴性；术后听功能，前庭功能障碍发生率及面神经麻痹发生率两组之间差异均无显著性意义。结论：乙状窦后径路听神经瘤切除术，术中使用内窥镜操作方便，安全，未出现由此引起的并发症，并可防止或减少残留病灶及肿瘤复发的发生率，有临床推广应用价值。     

听神经瘤手术的听力保护

探讨听神经瘤手术的听力保护.方法报告两例经乙状窦后进路、内镜辅助和术中用CAP和ABR连续适时监测下切除听神经瘤的结果.结果例1 MRI示内听道口外瘤体直径约1.5cm,术前语频纯音听阈平均在30dB,能引出ABR各波.术中以ABR适时监测,完全切除瘤体后仍可引出清楚的ABR Ⅰ、Ⅲ、Ⅴ波,术后无面瘫.术后7个月复诊,纯音听阚及ABR波间期恢复术前水平.例2为双侧听神经瘤.MRI示左右听神经瘤直径分别为4cm和5cm.一侧肿瘤切除后间隔4个月行另一侧听神经瘤切除术.为保留第二次手术耳听力,术中用CAP监测.术中虽未能保留蜗神经,但切除肿瘤后仍可记录到CAP.结论听神经瘤手术中的CAP监测结果无法评判术后能否保留听力,而ABR则能够及时反映听神经及其通路的功能状态,肿瘤切除后引出ABR Ⅰ、Ⅲ、Ⅴ波可有望保存术前听力.     

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.     

耳内镜辅助下听神经瘤切除术

目的:观察耳内镜辅助下听神经瘤切除术的疗效及并发症.方法:在硬管耳内镜辅助下采用迷路进路及乙状窦后进路行听神经瘤手术11例.结果:肿瘤全切除9例(81.8%),2例(18.2%)残留部分囊壁;术中内镜下探查面神经均完整.其中9例(81.8%)术后无面瘫表现,2例(18.2%)术后出现轻度周围性面瘫;术中内镜下探查蜗神经均完整,2例(18.2%)术后听力与术前比较保持不变,9例(81.8%)出现不同程度听力下降,其中,中度感音神经性聋1例,中重度2例,重度3例,极重度3例.结论:听神经瘤切除术中使用耳内镜可提高血管、神经保全率及肿瘤全切率,但也有其不足,仅能作为显微镜手术的辅助手段.     

听神经瘤切除与面神经功能的保存

目的探讨听神经瘤切除手术的面神经功能的保存.方法回顾性分析自1998年2月至2003年6月,在术中面神经监测下完成的听神经瘤切除手术48例,对三种手术进路的结果进行了比较.术前接受纯音测听、声阻抗测试、听觉脑干反应(ABR)、复合动作电位(CAP)及眼震电图(ENG)检查,并进行桥小脑角CT及MRI检查.术中皆进行面神经监测,面神经功能判断标准采用House-Brackmann(简称H-B)分级法.手术采用经迷路进路、乙状窦后进路和颅中窝进路三种.结果根据MRI结果,肿瘤限于内听道内者3耳,内听道外瘤体直径在1～2cm者8耳,2～3cm者12耳,大于3～5cm者25耳.48例中肿瘤完全切除者46例(96%),解剖学上保存面神经者47例(98%),术后7天内面神经功能达到H-B Ⅰ～Ⅱ级者达83%(40/48),其中乙状窦后进路组为84%(21/25),迷路进路组为83%(15/18),经颅中窝进路组为80%(4/5),各手术进路组之间基本相近.经乙状窦后进路组中有3例采用耳窥镜辅助下切除内听道内残存肿瘤,且完整保留面神经功能.结论听神经瘤切除术中应用面神经监测仪监测有助于提高面神经功能的保存率.耳窥镜辅助下克服了传统乙状窦后进路术式的难以完全暴露内听道内肿瘤的弊端.     

颅后窝进路听神经瘤切除术

近年来,听神经瘤切除术均由颅后窝、迷路和颅中窝三途径进入手术。各途径均有其优缺点。经内耳道听神经瘤切除(DiTullio等),易识别面神经内耳道段。颅后窝进入,可早期定位面神经。颅后窝和经迷路联合进路(Glasscock)则能保留乙状窦,且可较好地暴露脑干,适于大听神经瘤切除。颅中窝进入用于内耳道内的小听神经瘤,术后可能保存听力。作者自1978至1980年间,取半坐位经颅后窝进路先后进行了74例听神经瘤切除术。无一例死亡,并发症亦少。其中脑脊液耳、鼻漏7例。脑膜炎3例和术后出血2例。术后无脑干梗塞形成。74例患者中,73例均一次手术切除肿瘤。1     

直接第Ⅷ颅神经监测和听觉脑干反应在听神经瘤切除和听力保存术中的应用[英]／Danner C, Mastrodimos B, Cueva RA／／Otol Neurotol.

回顾性分析了直接第Ⅷ颅神经监测(directeighth nerve monitoring, DENM)和听觉脑干反应(auditory brainstem response, ABR)在乙状窦后径路听神经瘤切除及听力保存术中的应用。     

192例听神经瘤术中神经电生理监测

目的探讨听神经瘤术中电生理监测技术常见问题的处理,提高面神经解剖保留率。方法 192例听神经瘤患者手术时均在面神经电生理监测下进行,采用枕下乙状窦后经内听道入路,显微外科切除肿瘤,术后对面神经功能进行评估。结果肿瘤全切1 8 3例(95.3%),面神经完整解剖保留185例(96.4%)。长期随访病例面神经功能良好率83.0%,术中F波监测结果与术后面神经功能之间有较好的一致性。结论听神经瘤术中神经电生理监测的运用可明显提高面神经的解剖保留率和功能保留优良率,术中F波监测不仅可实时反馈面神经功能状态,而且可为术后面神经功能的预测提供依据。     

并发慢性中耳乳突炎的大听神经瘤经扩大迷路进路二期手术切除

目的：探讨经扩大迷路进路摘除伴发慢性中耳乳突炎的大听神经瘤的手术方法。方法：先一期手术彻底清除鼓室乳突病灶，术毕封闭中耳乳突腔；2周后行二期手术，经一期径路进行听神经瘤切除术。结果：2例并发慢性中耳炎的大听神经瘤均得到全切，术后面神经功能正常，切口一期愈合。随访半年以上无感染发生。结论：并发慢性中耳乳突炎的大听神经瘤同样可经扩大迷路进路进行手术切除。     

Factors which influence the facial nerve outcome in vestibular schwannoma surgery

A series of 276 patients with a unilateral vestibular schwannoma has been analysed with respect to the factors affecting post-operative facial nerve outcome. Age, tumour size, operative approach and the use of intra-operative facial nerve monitoring have been examined. The tumours were removed via either a translabyrinthine or a retrosigmoid approach. In this series increasing age and increasing tumour size were associated with a worse facial nerve outcome. The use of intra-operative facial nerve monitoring and the retrosigmoid approach were both associated with a better facial nerve outcome. Those patients having a retrosigmoid approach had a facial nerve result that was over one House grade better than those having translabyrinthine tumour removal.     

Cerebellopontine angle surgery. Part 2: Specific remarks

OBJECTIVES: Cerebellopontine angle tumors are uncommon lesions that can potentially be cured by microsurgical removal. The primary objective of the surgical treatment differs between vestibular schwannoma and meningioma. This feature may be influenced by the site of tumor origin and displacement of neurovascular structures as well as by their different tumor biology. METHODS: A review of the current literature was conducted. RESULTS AND CONCLUSIONS: Relevant cranial nerves and vascular involvement as well as anatomical location with respect to the cerebellopontine angle are discussed for vestibular schwannoma and meningioma. The main factors influencing the surgical outcome are outlined with special reference to facial and cochlear nerve function and cerebrospinal fluid leakage. The retrosigmoid approach offers a comparable success rate for hearing conservation and probably a superior outcome in terms of facial nerve function when compared with the middle fossa approach. The intrameatal limitations of the retrosigmoid approach can be excluded by the intraoperative assistance of an endoscope. The advantages of endoscope-assisted surgery may include improved visualization of relevant structures, more complete tumor removal, and a lowered risk of cerebrospinal fluid leakage.     

A minimally invasive endoscope assisted retrosigmoid approach for removal of arachnoid cysts in the internal auditory canal: a step by step description

IntroductionArachnoid cyst in the internal auditory canal is a quite rare pathology but due to its compressive action on the nerves in this district should be surgically removed. Several surgical techniques have been proposed but no surgeons have used the minimally assisted endoscope retrosigmoid approach for its removal.ObjectiveTo investigate the feasibility of using a minimally invasive endoscope assisted retro-sigmoid approach for surgical removal of arachnoid cysts in the internal auditory canal.MethodsMinimally invasive endoscope assisted retrosigmoid approach allows to access to the internal auditory canal through a minimally invasive retrosigmoid approach that combines the use of a microscope and an endoscope. It is performed in six steps: soft tissue step, bone step, dura step, cerebellopontine angle step (performed using an endoscope and a microscope), microscope-endoscope assisted arachnoid cysts removal and closure. We tested minimally invasive endoscope assisted retrosigmoid approach for removal of arachnoid cysts in the internal auditory canal on two human cadaveric heads (specimens) of subjects affected from audio-vestibular disorders and with arachnoid cysts in the internal auditory canal confirmed by magnetic resonance imaging.ResultsThe mass was completely and successfully removed from the two specimens with no damage to the nerves and/or vessels in the surgical area.ConclusionThe results of our study are encouraging and support the feasibility of using minimally invasive endoscope assisted retrosigmoid approach for removal of arachnoid cysts in the internal auditory canal. While further clinical in-vivo studies are needed to confirm the accuracy and safety of using the minimally invasive endoscope assisted retrosigmoid approach for this specific surgery, our group has successfully used the minimally invasive endoscope assisted retrosigmoid approach in the treatment of microvascular compressive syndrome, schwannoma removal and vestibular nerve resection.     

Retrosigmoid versus middle fossa surgery for small vestibular schwannomas

OBJECTIVES/HYPOTHESIS: The objective was to determine the effect of approach, middle fossa versus retrosigmoid, on the hearing and facial nerve outcome of surgery for small vestibular schwannomas. STUDY DESIGN: The study had two parts, a case study of patient data entered into a prospectively designed database at the author's institution, and a meta-analysis of similar published data. METHODS: There were 73 of the author's private practice patients who met the inclusion criteria of intracanalicular vestibular schwannoma and total tumor removal by a retrosigmoid approach. American Academy of Otolaryngology-Head and Neck Surgery standardized hearing and facial nerve classifications of these patients and similar data from 11 other institutions were used to compare results of the two surgical approaches. RESULTS: Median facial nerve results for all institutions were significantly better with the retrosigmoid approach (grade I: 95% for retrosigmoid and 81% for middle fossa). Median hearing results trended toward better outcome with the middle fossa approach (same preoperative hearing class: 48% for middle fossa and 39% for retrosigmoid). Individual institution had an equal or greater effect on outcome than the choice of surgical approach. CONCLUSION: Surgical team accounted for more variability in hearing and facial nerve outcome than did approach. Retrosigmoid approach yielded significantly better facial nerve outcome. The trend toward better hearing outcome with the middle fossa approach may never achieve statistical significance across institutions because of high variability among surgical teams and small numbers of teams reporting results.     

A comparison of direct eighth nerve monitoring and auditory brainstem response in hearing preservation surgery for vestibular schwannoma.

OBJECTIVE: The objective of this study was to compare the effectiveness of direct eighth nerve monitoring (DENM) and auditory brainstem response (ABR) in facilitating hearing preservation during vestibular schwannoma resection. STUDY DESIGN: This was a retrospective study. SETTING:: Tertiary referral center. METHODS: We conducted a retrospective clinical study of the use of ABR and DENM during vestibular schwannoma removal. Tumors were removed through a retrosigmoid craniotomy. The rate of hearing preservation between the two monitoring modalities was compared. The additional outcome measures of facial nerve function and cerebral spinal fluid leak rate were also evaluated. RESULTS: Hearing preservation was attempted in 77 patients with vestibular schwannomas. Tumor sizes ranged from 0.5 cm to 2.5 cm. Hearing was preserved in 71% of patients with tumors 1 cm or less and in 32% of patients with tumors between 1 and 2.5 cm when direct eighth nerve monitoring was used. Hearing preservation rates with ABR for tumors 1 cm or less were 41% and 10% in patients with tumors between 1 and 2.5 cm (p=0.03) Facial nerve preservations rates were 94% (House-Brackmann 1-2) for tumors less than 2 cm. CONCLUSIONS: DENM provides significantly higher rates of hearing preservation during vestibular schwannoma resection when compared with ABR.     

Comparison of postoperative headache after retrosigmoid approach: vestibular nerve section versus vestibular schwannoma resection

OBJECTIVE: To evaluate intradural drilling as a mechanism for the development of postoperative headache after retrosigmoid craniectomy. STUDY DESIGN: A retrospective review of charts was performed on 565 retrosigmoid approaches to the cerebellopontine angle performed between January 1980 and January 1998. Patients treated with retrosigmoid vestibular nerve section without intradural drilling were compared with patients who underwent retrosigmoid removal of vestibular schwannomas in which intradural drilling was performed for exposure of the internal auditory canal. SETTING: Private practice tertiary referral center. PATIENTS: Consecutive patients undergoing retrosigmoid approach between January 1980 and January 1998 were reviewed. MAIN OUTCOME MEASURES: The presence of headache, duration of headache, and severity of headache were noted. RESULTS: In this large series, 54% of patients experienced headaches after vestibular schwannoma removal, and 5% of patients experienced headaches after vestibular nerve section (p < 0.01, chi-square). CONCLUSIONS: Postoperative headache is not a characteristic of retrosigmoid craniectomy in the absence of intradural drilling. Intradural drilling is a probable cause of headache after the retrosigmoid approach. Cranioplasty is not necessary to prevent a high incidence of postoperative headache after retrosigmoid approach.     

Results in the surgical treatment of giant acoustic neuromas

Introduction and objectivesTo compare the results obtained in the resection of 21 giant vestibular schwannomas via retrosigmoid (RS) and combined retrosigmoid/translabyrinthine (RS/TL) approaches with respect to intra- and postoperative complications, facial nerve preservation and postsurgical sequelae.MethodsThis was a retrospective study of 21 patients who underwent a resection of a giant vestibular neuroma according to the Tos &; Thomsen Scale (greater than or equal to 4 centimetres) in a tertiary care centre in the period between 2000 and 2008. We present the most significant characteristics of the series studied and the analysis of the advantages and inconveniences of each approach. We also analyse the results regarding facial nerve function preservation.ResultsWe highlight the absence of mortality in the 21-patient group. There were no important intraoperative complications. Total resection of the lesion was achieved in the 87% of the cases, with facial nerve preservation of 73% using the combined RS/TL approach, in comparison to 40% using the RS. Facial nerve function after two years was acceptable or good in 67% (including those with heteronerve anastomosis). A global percentage of 14.3% of cerebrospinal liquid fistula was observed, as well as 9.5% of meningitis.ConclusionsThe results of the study demonstrate that the combined retrosigmoid translabyrinthine approach for giant schwannoma treatment offers increased facial nerve preservation and lower morbidity, constituting an important option in the treatment of this kind of tumours thanks to a multidisciplinary approach.     

Surgical management of vestibular schwannoma in elderly patients

This study aimed to evaluate surgical results of vestibular schwannoma in elderly patients using a retrospective study in a Quaternary Neurotology and Skull Base Referral Center setting. The data of 232 elderly patients (above 65 years) operated on for vestibular schwannoma in the period between April 1987 and July 2009 were reviewed. Most patients were operated on via translabyrinthine approach (TLA) using transapical extension for large tumors. Other approaches used were retrosigmoid, middle cranial fossa, and transcochlear. Total tumor removal was achieved in the majority of cases, while planned subtotal removal was used in specific occasions. Postoperative complications included facial nerve palsy, other cranial nerves injury, persistent instability, intracranial hemorrhage, CSF leak, meningitis, and death. Patients were followed after surgery for tumor regrowth or occurrence of complications. The results showed low rate of morbidity and mortality. Despite that complete removal is the main target of the surgery; adoption of subtotal removal in selected cases can improve postoperative facial nerve results and reduce the duration of surgery.     

乙状窦后径路内镜下选择性前庭神经切断术治疗梅尼埃病

OBJECTIVE: To investigate the micro-wound technique and the signification of reducing brain tissue oppression and complication at the surgery with utilizing endoscopic technique during the operation of selective vestibular neurotomy (SVNT) by retrosigmoid approach. METHODS: Twelve patients were preceded the SVNT by retrosigmoid approach (as routine operation group, ROG), and nine patients were utilized endoscope for review and neurotomy during the process of the SVNT by retrosigmoid approach (as endoscopic operation group, EOG). All of them were examined by auditory level, vestibular function, facial nerve function and observed of clinical situation (including complication and equilibrium function and so on) before and after operation. RESULTS: Two patients appeared cerebral edema and demanded the treatment of dehydration and depressing intracranial pressure in ROG after operation. In each group, the average auditory threshold in 2 patients rose more than 15 dB post-operation. The interval time of average equilibrium function compensation is (29.00 +/- 9.60) d in ROG and (28.56 +/- 7.91) d in EOG after surgery. Peripheral facial paralysis didn't happen to any patient in two groups. After follow-up two years post-operation, the vertigo recurred in 2 patients (4 times and 1 times, respectively) in ROG and 1 patient (2 times) in EOG. CONCLUSIONS: The SVNT by retrosigmoid approach is widespread adopted presently as expedience and safe surgery method for Ménière's disease, and could effectively eliminate vertigo and simultaneously conserve the hearing function and the integration of facial nerve. This surgery process became micro-wound, more facility and safe following the endoscopic technique utilization, which could reduce the brain tissues depression and trauma and could not cause any of complications. Therefore, the endoscopic operation of the SVNT by retrosigmoid approach is worth to clinically popularize as the therapy method of vertigo for the patients of Ménière's disease, especially who associate with contralateral sensorineural hearing loss.