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Title: [Intraoperative cochlear nerve monitoring in microvascular decompression of hemifacial spasm and resection of vestibular schwannoma].
Author: Wang XY, Cong J, Zhang J, Zhang D, Li C.
Journal: Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi; 2023 Dec 07; 58(12):1225-1231. PubMed ID: 38186097.
Abstract:
Objective: To analyze the application of direct cochlear nerve monitoring technology-cochlear nerve action potential (CNAP) monitoring in resection of vestibular schwannoma (VS) and to compare with which in microvascular decompression (MVD) of hemifacial spasm (HFS), in order to provide reference for identification of the cochlear nerve during VS resection surgery and predicting postoperative hearing preservation. Methods: From June 2018 to March 2022, patients with facial spasm and vestibular schwannoma who underwent retrosigmoid approach surgery at the Chinese PLA General Hospital were collected. Before surgery, there were a total of 11 HFS patients and 30 VS patients. Before surgery, the former had hearing level of class A(AAO-HNS), while the latter had serviceable hearing (AAO-HNS class A-B), with a maximum tumor diameter of≤20 mm. CNAP combined with Auditory Brainstem Response (ABR) monitoring was performed during surgery. SPSS 23.0 software was used to analyze the differences of ABR and CNAP parameters between the two groups. Results: The preoperative ABR test in the VS group showed that the latency of wave V and I-V interval were significantly prolonged compared to the HFS group (t=8.36, P<0.001; t=4.61, P<0.001).In VS group, all tumors were totally removed with preserved facial nerve function (House-Brackmann grade Ⅰ-Ⅱ). The serviceable hearing preservation rate was 63.3%. In the HFS group, the initial CNAP waveforms were triphasic and biphasic, with N1 wave latency of (4.32±0.37) ms and amplitude of 25.20 [15.63, 35.40]μV. The distribution of CNAP waveforms before tumor resection in the VS group was the same as that in the HFS group, and which in the hearing preservation group after surgery was also the same. Compared with the HFS group, the latency of N1 wave was prolonged (t=2.670, P=0.011;t=4.584, P<0.001), and the amplitude of N1 wavein the VS group before tumor resection was lower (Z=-3.001, P=0.003). The amplitude of N1 wave in the hearing preservation group after surgery was 20.20 [6.23, 40.90] μV,which was significantly higher than that before tumor resection (Z=-2.133, P=0.033), but there was no statistically significant difference compared to the HFS group (Z=-0.495, P=0.621). Conclusions: The reference range of CNAP in normal hearing population can be preliminarily obtained by the analysis of CNAP in MVD surgery. The latency of N1 wave in VS patients is prolonged and the amplitude of N1 wave is decreased due to tumor compression. The CNAP waveform combined with the change of N1 wave amplitude can provide reference for intraoperative mapping of the cochlear nerve and prediction of postoperative hearing preservation. 目的： 分析蜗神经直接监测技术——蜗神经动作电位（cochlear nerve action potential，CNAP）监测在前庭神经鞘瘤（vestibular schwannoma，VS）切除术中的应用，并与半面痉挛（hemifacial spasm，HFS）显微血管减压术中CNAP监测进行比较，初步探讨CNAP的正常参考值范围，为VS切除术中识别蜗神经及预估术后听力保留情况提供参考。 方法： 收集2018年6月至2022年3月在解放军总医院行经乙状窦后入路手术的HFS及VS患者。HFS患者共11例，其中男5例、女6例，年龄（50.1±12.4）岁，术前听力水平为美国耳鼻咽喉头颈外科协会（AAO-HNS）听力分级A级。VS患者共30例，其中男18例、女12例，年龄（46.2±10.5）岁，术前具有实用听力（A~B级），肿瘤最大直径≤20 mm。术中采用CNAP联合听性脑干反应（ABR）监测听力，应用SPSS 23.0软件分析比较两组患者术前ABR检查结果及术中CNAP监测数据。 结果： 术前ABR检查VS组Ⅴ波潜伏期及Ⅰ-Ⅴ间期均较HFS组明显延长，差异有统计学意义（t=8.36，P<0.001；t=4.61，P<0.001）。VS组肿瘤均全切，术后1个月面神经功能良好，House-Brackmann（HB）分级Ⅰ~Ⅱ级，实用听力保留率为63.3%（19/30）。HFS组术中初始CNAP波形为三相波和双相波，N1波潜伏期为（4.32±0.37）ms（x¯±s），波幅为25.20［15.63，35.40］μV（M［Q₂₅， Q₇₅］）。VS组切肿瘤前及术后听力保留组CNAP波形分布同HFS组；与HFS组比较，N1波潜伏期均延长，差异有统计学意义（切肿瘤前：t=2.670，P=0.011；听力保留组：t=4.584，P<0.001）；VS组切肿瘤前N1波幅低于HFS组，差异有统计学意义（Z=-3.001，P=0.003），术后听力保留组N1波幅为20.20［6.23，40.90］μV，与切肿瘤前比较明显增加（Z=-2.133，P=0.033），但与HFS组比较差异无统计学意义（Z=-0.495，P=0.621）。 结论： 显微血管减压术中初始CNAP数据，可以初步得出听力正常人群CNAP参考范围。肿瘤压迫可导致VS患者CNAP的N1波潜伏期延长、波幅减低；CNAP波形结合N1波幅改变，可为术中蜗神经的定位及预估术后听力保留情况提供参考。.

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