神经反应遥测技术在人工耳蜗植入术中的监测应用

目的：探讨在人工耳蜗植入术中能快速,准确地判断人工蜗装置的完好性和患者客观听觉反应的监测方法。方法：在40例患儿人工耳蜗植入术中先测定电极阻抗,然后使用神经反应遥测技术（neural response telemetry,NRT)监测6个电极的电诱发听神经复合动作电位（electrically evoked auditory nerve compound action potentials,ECAP)。结果：患儿所有电极阻抗正常,ECAP的检出率分别为97．5％（39例／40例）和92．1％（221个电极／240个电极）,其中33例内耳无畸形的患儿所有198个测试电极中有195个电极测出清晰的ECAP波形（98．5％）,7例内耳Mondini畸形患者共42个测试电极中有26个电极测得ECAP波形（61．9％）,两组之间差异有极显著性,靠近耳蜗底回（高频区）的电极比靠近蜗尖（低频区）的电极具有较高的ECAP反应阈值的ECAP饱和阈值。结论：NRT技术可以简便,快速和准确地判断患者的听神经反应,可望成为术中常规监测方法。内耳Mondini畸形是影响ECAP检出的重要因素。     

人工耳蜗植入前电刺激听神经复合动作电位检测方法的建立和初步应用

目的 建立术中利用探测电极施行电刺激听神经复合动作电位(electrically evoked auditory nerve compound active potentials,ECAP)检测的方法,在植入人工耳蜗装置前评估患者耳蜗听神经功能状况.方法 选择20例人工耳蜗植入患者,其中耳蜗形态发育正常12例,5例双侧前庭导水管扩大,3例双侧耳蜗Mondini畸形.测试完成后全部使用Cochlear人工耳蜗.全麻后常规人工耳蜗手术进路,行标准耳蜗鼓阶开窗,将自制测试用多通道试验电极置入鼓阶,电极连接Cochlear公司体外言语处理器及自制电刺激发生器,连接电脑,采用Custom Sound EP 2.0软件,调整优化刺激参数进行神经反应遥测(neural responsetelemetry,NRT)初步了解听神经功能状态;刺激强度以5 CL为步长递减或递增至反应阈值给予电刺激脉冲,同时自动记录ECAP波形和阈值.植入人工耳蜗后常规进行NRT检测,记录ECAP波形和阈值;术后1个月患者开机后采集T、C值,将两种电极测试所得阈值和开机C值进行相关性研究,并进行数据统计分析.结果 试验电极ECAP引出率为90%,商业电极ECAP引出率为90%,平均阈值分别为(160.50±15.12)CL和(160.00±11.27)CL,两者经统计学检验没有显著性差异(P>0.05);和开机后C值(177.40±10.61)有明显相关性(R2=0.844,r=0.919).结论 成功建立了术中植入人工耳蜗装置前的ECAP检测方法,为内耳和/或听觉通路发育异常及无残余听力患者提供有效的听神经反应信息,对了解听觉系统发育程度及初步预测术后患者康复情况提供客观依据.     

神经反应遥测技术应用于婴幼儿人工耳蜗植入的作用和体会

目的探讨应用神经反应遥测技术（NRT）在人工耳蜗植入术中监测,术后调机中的作用和经验体会。方法回顾性分析38例经历人工耳蜗植入的婴幼儿的临床资料,收集每例患者在术中、术后开机、调机应用NRT测试电诱发听神经复合动作电位（ECAP）的阈值数据,应用听觉整合量表（IT MAIS）评估行为听觉言语功能。结果38例婴幼儿在术中植电极进入耳蜗后均实施NRT测试,每例测试5个电极,分别为1、6、11、16、22号电极,共测试了190个电极,其中163个电极（85.8%）引出了ECAP,其平均阈值为（163.8±21.2）CL。近端1号电极ECAP阈值显著高于远端22号电极（P<0.05）。从开机到开机后12个月,各电极ECAP阈值无显著变化。3岁以下患儿中,25例患儿在各次NRT测试时所有电极都能引出ECAP,而8例患儿存在1~5个电极不能引出ECAP,在开机12个月后,后者的IT MAIS积分与前者比较差异无统计学意义（P>0.05）。结论人工耳蜗植入后NRT测试的ECAP阈值在近端电极显著高于远端电极,耳蜗内数个电极引不出ECAP不影响术后的听觉言语康复。     

神经反应遥测技术在人工耳蜗植入术中的应用

目的 探讨人工耳蜗植入术中神经反应遥测(neural response telemetry，NRT)技术的应用情况。方法 对10例Nucleus CI24M及4例Nucleus CI24R(CS)人工耳蜗植入术的患儿在术中及术后一个月进行NRT检测，比较两者术中和术后的电诱发复合动作电位(electrically-evoked compound action potential，ECAP)阈值差异，并利用术中ECAP阈值指导首个言语处理器映射图。结果 14例患儿术中各电极的ECAP平均阈值均高于术后一个月开机时相应电极的ECAP平均阈值，CI24M植入体各电极的术中ECAP阈值比术后相应电极的ECAP阈值平均高11CL；术中10个电极相应的ECAP波形采集只需5分钟；术后开机整个过程约1小时。结论 术中应用NRT技术可快捷地了解植入体安置的情况，指导术后首个映射图的调试，明显节省了术后开机调试的时间，操作简单、方便，值得推广。     

神经反应遥测技术在人工耳蜗手术中的应用

目的 通过分析神经反应遥测(neural response telemetry, NRT)技术在人工耳蜗手术中的应用,帮助电极定位及预测术后效果。方法 受试对象为使用Nucleus CI24M型多导人工耳蜗系统的患者10例,其中2名患者的耳蜗发育畸形。选取10名患者的13个电极进行NRT测试。结果 NRT波形检出率为100% (n=13)。13个电极的NRT阈值为190.4±21.6CL。两名耳蜗畸形患者均记录到了NRT波形,其中一名阈值较高,为225 CL 。结论 术中10名患者的13个电极均记录到了NRT反应波形,提示NRT技术可有效地用于人工耳蜗植入患者的术中监测,特别为耳蜗畸形患者植入电极的定位提供帮助。     

内耳结构异常的语前聋人工耳蜗植入儿童听觉语言康复效果评价

目的评价不同类型内耳结构异常的语前聋儿童人工耳蜗植入术后听觉语言康复效果。方法选取人工耳蜗植入儿童10例(12耳),其中内耳结构发育正常的3例,前庭导水管扩大3例,Mondini畸形1例,蜗孔狭窄1例,内听道狭窄听神经纤细2例,分别采用电刺激诱发听神经复合动作电位(electrically evoked compound action potential,eCAP)、助听听阈、听障儿童听觉能力、语言能力评估标准及方法,从听神经客观电生理水平、听察觉阈、听觉辨识与理解能力以及语言能力4方面评价患儿的康复效果。结果①客观电生理:单纯前庭导水管扩大患者听神经对电刺激敏感度与内耳发育正常者相似,Mondini畸形患者比内耳发育正常者略高,蜗孔狭窄及听神经纤细患者听神经敏感度较差;②听察觉阈:与内耳结构正常及轻度畸形(Mondini畸形)患者相比,蜗孔狭窄及听神经纤细患者听察觉阈偏高,高频比低频阈值低;③听觉辨识与理解能力:在安静环境近距离交谈情境下,单纯前庭导水管扩大、Mondini畸形及蜗孔狭窄患者对熟悉语词和短句的辨识与理解能力与内耳发育正常者无差别,听神经纤细患者得分较低;④语言能力:单纯前庭导水管扩大、Mondini畸形患者与内耳发育正常者无差别,蜗孔狭窄患者的语言交往与表达能力落后于内耳发育正常者,听神经纤细患者在语法、理解、交往、表达4个维度均落后于内耳发育正常者。结论语前聋儿童人工耳蜗植入术后听觉语言康复效果需要使用多种方法综合评价。Mondini畸形患者给予足够电刺激量后,其听觉语言能力可达到内耳发育正常者水平。蜗孔狭窄、听神经纤细等严重内耳畸形患者,人工耳蜗对其听觉语言能力发展有一定帮助,家长需要建立合理期望值并坚持长期康复。     

内耳畸形聋儿人工耳蜗植入术常见类型及手术并发症

目的 探讨内耳畸形聋儿实施人工耳蜗植入术时常见的类型及并发症。方法 回顾性分析电子耳蜗植入术病历资料170例,对其中的32例双侧内耳畸形患者加以畸形类型及手术并发症总结。结果 ①人工耳蜗植入患儿内耳畸形所占比例(32/170,18.8%)明显高于其他文献报道;②32例内耳畸形中,大前庭导水管23例(占全部畸形数71.3%),大前庭导水管伴其他类型畸形者5例(并发Mondini畸形4例,并发外半规管未发育1例),Mondini畸形2例,Mondini畸形并发外半规管未发育前庭腔扩大1例,耳蜗CT影像疑似为“三叉”无法分类1例;③术中发生严重井喷3例(耳蜗CT影像疑似为“三叉”畸形、Mondini畸形并发外半规管未发育前庭腔扩大1例,及大前庭导水管并发Mondini畸形1例);④耳蜗影像疑似为“三叉”患者,术中发生严重井喷,电极植入困难,4个电极不能植入,术后听力未改善,半年后行对侧耳植入成功;⑤Mondini畸形并发外半规管未发育前庭腔扩大患儿术后半年并发脑脊液耳鼻漏、反复脑膜炎发作,术后1年行手术探查,后治愈。结论 ①人工耳蜗植入常见的内耳畸形包括,大前庭导水管综合征及其相伴发或单发的各类内耳畸形;②内耳畸形非人工耳蜗植入术的绝对禁忌证,但术中严重井喷多见,电极植入不完全多见,术后脑脊液耳鼻漏并发脑膜炎也多发生于畸形耳蜗,术前详细的影像学检查可以对各类畸形进行详细分类,并在术前对手术难度有充分的准备,可以减少相关并发症的发生。     

人工耳蜗植入的术中检测

目的　评估人工耳蜗植入术中的电极阻抗测试、神经反应遥测的临床意义 ,探讨术中检测的方式。方法　对 6 5例植入NucleusCI2 4人工耳蜗的患者在术中进行电极阻抗测试 ,其中 37例进行了神经反应遥测 (neuralresponsetelemetry ,NRT)对测试步骤及注意事项进行了分析。结果　 9.2 %的患者术中电极阻抗测试显示个别电极出现短路或开路 ;5 .4 %的患者 ,术中NRT测试得不到分化良好的ECAP。结论　电极坏损与植入过程中的重复插拔有一定的因果关系。不应把ECAP引出与否作为衡量手术成功的唯一指征 ,即使ECAP引不出 ,也不要多次插拔电极序列 ,以免出现电极坏损     

Nucleus24型人工耳蜗使用者电诱发听神经复合动作电位的测定

目的 :探讨电诱发听神经复合动作电位 (ECAP)的特点及在人工耳蜗临床中的应用价值和意义。方法 :应用NRT(neuralresponsetelemetry)软件 ,通过体外言语处理器和耳蜗内的植入电极系统 ,采用单极模式电极刺激和近场记录方法 ,对 37例NucleusCI2 4M装置使用者进行ECAP的记录。对其中 12例使用者做了行为测试。结果 :87.6 %的使用者记录到ECAP波形。分析了有行为阈值的 12例测试者的ECAP阈值和行为阈值的关系 ,二者之间存在显著的相关性。结论 :ECAP的检出率高且波形稳定可靠 ,在临床人工耳蜗装置的调试中可作为对行为测试的补充 ;对于年幼儿童和首次开机的患者的调试尤其重要     

儿童人工耳蜗植入术后电诱发复合动作电位分析

目的 应用神经反应遥测(NRT)技术,观察人工耳蜗植入后不同时间段的电诱发复合动作电位(ECAP)阈值变化,探讨其对人工耳蜗术后调机的指导意义。方法 对33例使用Nucleus CI24R(CA)型人工耳蜗植入的患儿,于术中及术后1、1.5、2、4、6个月进行ECAP 阈值测试,统计分析其变化规律。结果 33例165个电极的波形检出率为93.3%。电极1、7、11、17、22的术中ECAP阈值与术后30d开机时的ECAP阈值的差异有统计学意义。同一测试电极,随术后开机时间的增长,ECAP阈值呈逐渐增加的趋势。经单因素方差分析,术后不同测试时间ECAP阈值差异有统计学意义。结论 ECAP检出率高,术中可用于检测神经反应;术后可协助估算患者的行为反应T、C级,指导调机,尤其对儿童患者更为重要。     

Neural response telemetry with the nucleus CI24M cochlear implant

OBJECTIVES: To review our intraoperative and postoperative testing protocol for cochlear implant patients. This study describes the methodologies and applications of a new technique called neural response telemetry (NRT) for the Nucleus CI24M cochlear implant system. NRT uses radiofrequency telemetry technology to measure the action potentials of the auditory nerve. STUDY DESIGN: We have developed a specific protocol for intraoperative testing of the implant device before, during, and after implantation. This includes device integrity tests, visual detection of electrical stapedius muscle reflexes (VESR), and NRT. METHODS: Our methodologies use the commercial software (Windows-based Diagnostic and Programming System [WIN-DPS] and NRT) for the Nucleus CI24M. We describe the details of our protocol used on all of the patients (14 adults and 14 children) who received CI24M implants at Mayo Clinic (Rochester, MN). Our protocol correlates the NRT threshold with the behavioral responses for each patient on at least four electrodes. RESULTS: From August 1, 1998, to December 31,1998, we completed electrode integrity tests, NRT, and VESR testing intraoperatively on 12 patients with the Nucleus CI24M. We have measured normal implant function on all 28 of our CI24M patients with one exception. One of our children had a device failure after approximately 4 months as a result of head trauma. We have also obtained NRT results from an additional 10 patients postoperatively. CONCLUSIONS: The measurement of device and electrode array function is quite simple with the CI24M software. These measurements can be obtained intraoperatively as well as postoperatively. We conclude that VESR and NRT measurements can be very helpful in programming for patients with cochlear implants, especially children, because they provides us with target settings for the speech processor.     

小儿耳蜗植入后电诱发复合动作电位的阈值及其临床应用

目的：研究应用神经反应遥测（neural response telemetry,NRT)技术，测试电诱发复合动作电位（electrically-evoked compound action potential,ECAP)阈值以指导小儿人工耳蜗映射调图的策略与时机。方法：应用NRT3．0软件对辐值增长函数进行线性拟合，确定ECAP阈值。比较6例儿童植入者在术后1、2、3个月ECAP阈值的变化，同时比较了7例儿童术中、术后ECAP阈值的差异。结果：ECAP幅值增长函数在接近阈值或进入饱和时不再呈线性。术后ECAP阈值保持稳定。各导电极的术中ECAP阈值比术后阈值平均高约15CL，二者有显著性相关（R2＝0．9154）。结论：应选取幅值增长函数的直线段部分进行拟合以确定ECAP阈值。术后应用ECAP阈值指导小儿映射调图时，测试一次ECAP阈值即可。术中ECAP阈值可用作开机时映射图的C值。     

Electrically evoked compound action potential (ECAP) in cochlear implant children: Changes in auditory nerve response in first year of cochlear implant use

AimRecording of the electrically evoked compound action potential (ECAP) of the auditory nerve in cochlear implant (CI) patients represents an option to assess changes in auditory nerve responses and the interaction between the electrode bundle and the neural tissue over time. The aim of the present work is to assess ECAP changes during the first year of cochlear implant for the purpose of predicting thresholds and adjustment of the patients’ programs over time.MethodData were collected from 25 children using Cochlear Nucleus 24 implants. ECAP thresholds were examined at the time of surgery, at initial stimulation, and 3, 6 and 12 months post-stimulation. Five electrodes located at basal, middle, and apical positions in the cochlea were tested at each time interval and ECAP thresholds were analyzed and compared.ResultsThere was a significant decrease in ECAP thresholds between the intraoperative measure and fitting time at all electrode sites. Mean ECAP thresholds measured at 3, 6 and 12 months post-stimulation remained similar to initial stimulation levels. Although there was no significant difference in ECAP thresholds recorded at fitting time and 12 months follow up session, there was significant increase in behavioral T and C levels from initial stimulation to the 12 months’ time point.ConclusionMost electrodes undergo non-significant change in ECAP thresholds over time, and therefore thresholds obtained on the day of initial stimulation can be used to estimate the patients’ map levels at any time. On the other hand, intraoperative thresholds demonstrated significant change relative to postoperative recording times, limiting the ability to use intraoperatively recorded ECAP thresholds to predict postoperative measurements.     

小儿正常耳蜗与内耳畸形人工耳蜗植入术后电极阻抗及NRT值对比研究

目的：探讨小儿正常耳蜗与内耳畸形人工耳蜗植入手术后,植人体电极阻抗值及神经反应遥测（NRT）值的变化特点及规律。方法：将88例澳大利亚CochlearNucleus24型人工耳蜗植人手术患儿分为正常耳蜗组与内耳畸形耳蜗组,测试手术中及手术后1年阻抗值及NRT值,并分析对比。结果：两组患者阻抗值差异有统计学意义（P〉0．05）,其阻抗变化趋势相同。开机3个月内阻抗值变化明显,其后趋于稳定。两组患者NRT值差异有统计学意义（P〈0．05）,其NRT值变化趋势相同。总的趋势是低频值较低,高频值较高,术中至术后1年NRT值逐渐增高。结论：电极阻抗值及NRT值开机3个月内变化明显,故需多次调机,以使患者语言感知达到最佳状态。     

Electrophysiologic and objective monitoring of the cochlear implant during surgery: implementation, audit and outcomes

Electrophysiologic and objective measures are reviewed with respect to their implementation as monitoring tools for cochlear implants in the operating room and their value in the management of children. The current intraoperative test protocol in Nottingham consists of back-telemetry (BT) diagnostic testing of implant function, including impedance telemetry (ImpT), integrity testing (IT), electrical stapedius reflex response (ESR), electrical auditory brainstem response (EABR) and Neural Response Telemetry (NRT). Of 427 cases of implantation in the period 1990-2003, 303 (71%) were completely normal for all components of the protocol. In the remaining cases, some results were either simply anomalous, with no direct impact on management during surgery, and some were more significant, resulting in actions such as the use of the back-up device or repositioning of the electrode array. Normal intraoperative findings provided immediate reassurance to the implant team and parents of young children that the implant was fully functioning and that electrical stimulation was activating the auditory pathways These objective measures also identified potentially challenging cases, such as those with low levels of sensitivity to electrical stimulation and susceptibility to facial nerve stimulation. An audit showed that intraoperative measures provided valuable assistance in the initial fitting of the device.