听神经瘤术中听力监测及术后听力保留影响因素分析

目的探讨听神经瘤术中听力监测的应用及术后听力保留的可能影响因素。方法16例采用乙状窦后入路手术切除听神经瘤的成年患者,分为两组,术中采用听性脑干反应(auditory brainstem response,ABR)和耳蜗电图(electrocochleogram,ECochG)联合监测为监测组(8例),未监测者为未监测组(8例),比较两组患者术后听力保留情况,采用单因素分析,分析影响听力保留的可能因素,包括:年龄、病程、肿瘤大小、术前纯音听阈和言语识别率、术中是否行ABR和ECochG联合监测、内听道是否扩大、肿瘤和神经是否粘连等。结果前庭诱发肌源性电位(VEMP)提示16例患者肿瘤来源于前庭上神经,监测组中6例术中及术毕ABR波Ⅰ、Ⅴ和复合动作电位(CAP)持续存在,术后听力保留;1例术中ABR波Ⅰ、Ⅴ和ECochG CAP持续存在,但术后无可用听力;1例术中切除肿瘤时ECochG与基线重复性良好,ABR波V消失,手术结束波V仍未恢复;监测组术后听力保留率为75.0%(6/8),未监测组术后无一例保留听力,差异有统计学意义(P=0.007)。单因素分析显示,年龄、病程、肿瘤大小、术前纯音听阈以及内听道扩大与术后听力保留率无关(P>0.05),术前言语识别率、术中ABR和ECochG联合监测、肿瘤和神经粘连与否与术后听力保留率相关(P<0.05)。结论听神经瘤切除术中ABR和ECochG连续监测对指导手术和提高术后听力保留率有重要意义,肿瘤与神经粘连是术后听力保留的重要影响因素,手术技巧、术前听力、肿瘤大小、内听道扩大等是否是术后听力保留的影响因素需扩大样本进一步研究验证。

Analysis of Intraoperative Auditory Monitoring and Hearing Preservation Factors in Acoustic Neuroma Surgery

Objective To study the application of intraoperative hearing monitoring in acoustic neuroma surgery and to analyze the factors of postoperative hearing preservation.Methods A total of 16 patients with auditory neuroma underwent surgical resection via posterior sigmoid sinus approach in the Second Affiliated Hospital of Guangxi Medical University from August 2017 to March 2019 were studied.In the operation,the auditory brainstem response(ABR)and the electrocochleogram(ECochG)combined monitoring technique were used as the monitoring group(n=8),and the unsupervised group was not monitored(n=8).The postoperative hearing preservation and the factors affecting hearing preservation were analyzed and compared between the two groups.Univariate analysis was used to analyze factors affecting hearing retention,including age,course of disease,tumor size,preoperative hearing level(including pure tone audiometry and speech recognition rate),intraoperative ABR and ECochG combined monitoring,internal auditory canal enlargement,tumor and neuroadhesion.Results VEMP suggested that the tumor originated from 16 cases of vestibular superior nerve and 0 cases of vestibular inferior nerve.During the continuous monitoring of ABR and EcochG in 6 cases,I,V wave and compound action potential(CAP)persisted during operation,and postoperative hearing preservation.One patient underwent continuous monitoring of ABR I,V wave,and EcochG CAP,but no hearing was available after surgery.In one case,EcochG had good repeatability with baseline,while ABR V wave disappeared,and no amplitude recovery was observed at the end of the operation.In the postoperative monitoring group,6 patients had hearing preservation,the hearing preservation rate was 75%,and the unsupervised group hearing preservation rate was 0.The difference was statistically significant(P=0.007).Univariate analysis showed that age,course of disease,tumor size,preoperative pure tone audiometry,and internal auditory canal expansion were not associated with postoperative hearing retention(P>0.05).Preoperative speech recognition rate,ABR and EcochG combined monitoring,tumor and neuroadhesive were associated with hearing preservation,and the difference was statistically significant(P<0.05).Conclusion Continuous monitoring of ABR and EcochG during surgery are important for guiding surgery and improving hearing retention.The surgeon's skilled surgical techniques,patient age,preoperative hearing,tumor size,nerve and tumor adhesions,and internal auditory canal may also be factors in postoperative hearing retention,and further expansion of the sample study is needed.