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目的探讨听神经瘤外科术中连续听力监测的意义。方法采用乙状窦入路,在听性脑干反应(auditory brainstemresponse,ABR)和耳蜗电图(electrocochleogram,ECochG)监测下完成的听神经瘤切除术10例。对手术过程和术后听力结合术中监测进行分析。结果10例听神经瘤术前听力A级3耳,B级4耳,C级3耳(美国耳鼻咽喉头颈外科学会分级标准)。术前的ABR检查Ⅰ、Ⅲ、Ⅴ波存在者5耳(A级3耳,B级2耳),仅见Ⅰ波者5耳(B级2耳,C级3耳)。麻醉后手术前的监测显示:Ⅰ、Ⅲ、Ⅴ波存在者2耳,仅Ⅰ波存在者6耳,以复合动作电位(compound action potential,CAP)的N1波代替波Ⅰ;无波形者2耳。术后听力保留2耳,肿瘤均<2cm,术前听力都为A级;连续听力监测显示1耳术中及术毕时Ⅰ、Ⅲ、Ⅴ持续存在,1耳Ⅰ、Ⅲ波存在,Ⅴ波消失;术后听力均为A级。听力未保留8耳,其中6耳术中监测时仅CAP的N1(波Ⅰ)存在,手术过程中夹內听动脉或处理内耳道处肿瘤时,4耳CAP波幅明显下降,甚至下降至0,术毕又恢复至术前的50%~60%或正常;1耳蜗神经与肿瘤一并切除,但CAP始终存在;1耳因牵拉脑干侧的耳蜗神经,CAP波幅降至0,手术结束亦未恢复。2耳为全身麻醉后术前监测中未引出任何波形者,其中1耳术中切除部分肿瘤后,出现CAP波,但波幅低,直至术毕;1耳始终未出现波形。结论联合应用ABR和ECochG术中监测,对提高听力保护率有积极意义,能及时反映术中与保留听力相关的敏感手术步骤,然而外科医师的熟练的解剖和精确的手术技巧是手术成功的最基本因素。
Objective To investigate the significance of continuous hearing monitoring in acoustic neuroma surgery. Methods 10 cases of acoustic neuroma resected under auditory brainstem response (ABR) and electrocochleogram (ECochG) were performed by sigmoid sinus approach. Surgical procedures and postoperative hearing combined with intraoperative monitoring were analyzed. Results 10 cases of acoustic neuroma preoperative hearing A grade 3 ears, B grade 4 ears, C grade 3 ears (American Academy of Otolaryngology Head and Neck Surgery grading standards). Preoperative ABR examination Ⅰ, Ⅲ, Ⅴ wave exists in 5 ears (A grade 3 ears, B grade 2 ears), only Ⅰ wave seen in 5 ears (B grade 2 ears, C grade 3 ears). Surgical monitoring before anesthesia showed that there were 2 ears with Ⅰ, Ⅲ and Ⅴ waves and 6 ears with Ⅰ wave only, and N1 was replaced by N1 with compound action potential (CAP) . The postoperative hearing retention of 2 ears, tumors were <2cm, preoperative hearing was grade A; continuous hearing monitoring showed that 1 otoscopy and surgery at the end of Ⅰ, Ⅲ, Ⅴ persistence, 1 ear Ⅰ, Ⅲ wave exists, Ⅴ wave Disappeared; postoperative hearing are A level. There was no ear in 8 ears, of which only N1 (wave Ⅰ) of CAP existed in 6 ears during the operation, and the amplitude of CAP in 4 ears decreased obviously or even decreased to 0 when the artery in the clip was treated or the tumor in the ear canal was treated. Surgery and returned to preoperative 50% to 60% or normal; 1 cochlear nerve and tumor resection, but there is always CAP; 1 ear traction brainstem side of the cochlear nerve, CAP amplitude decreased to 0, the end of surgery Has not been restored. 2 ears were not lead to any waveform after preoperative monitoring of general anesthesia, including 1 ear surgery after resection of some tumors, the CAP wave appeared, but the amplitude was low until the operation completed; 1 ear waveform does not appear. Conclusion The combined application of ABR and ECochG intraoperative monitoring has positive significance to improve the rate of hearing protection, which can promptly reflect the sensitive surgical procedures related to reserved hearing during operation. However, the proficient anatomy and accurate surgical skills of surgeons are the most successful in operation Basic factors.