目的:显微外科技术和技术的进步继续改善颅底肿瘤患者的预后。用于前庭神经鞘瘤(VSs)的听力保留手术的主要颅神经八监测系统是直接颅神经八监测(DCNEM)和听觉脑干反应(ABR),尽管由于有关该主题的文献有限,目前的指南无法明确推荐其中一项。因此,需要进一步的研究来确定DCNEM和ABR的实用性。作者进行了一项回顾性队列研究,并创建了一个交互式模型,该模型根据接受ABRDCNEM和仅接受ABR监测的患者的肿瘤大小比较了听力保留结果。
方法:2008年1月至2022年11月期间,有28名患者接受ABR+DCNEM,72名患者在VS听力保留手术期间接受了仅ABR监测。纳入标准包括术前美国耳鼻咽喉头颈外科学会(AAO-HNS)听力分类为A或B的成年患者。测量肿瘤大小为最大内侧到外侧长度,包括内耳道组件。
结果:31例仅ABR监测患者(43.1%)和18例ABRDCNEM患者(64.3%)实现了总体听力保留(单词识别评分[WRS]>0%)。在仅进行ABR监测的19例患者(26.4%)和ABRDCNEM的11例患者(39.3%)中,实现了有效的听力保留(AAO-HNSA级或B级)。两组之间的总体听力保留没有差异(p=0.13)。肿瘤大小的变化与仅ABR组的有效听力保留的几率无关(p=0.89);然而,对于ABR+DCNEM,有一些迹象表明肿瘤大小与ABR+DCNEM和仅ABR监测的相关性之间存在相互作用,有效的听力保留的可能性为p=0.089。此外,ABR+DCNEM,在多变量分析中,肿瘤大小每增加0.5-cm与听力保留有效的几率降低相关(p=0.05).对于整体和有用的听力保护,术前AAO-HNS分类较差与保存几率降低相关(OR分别为0.43,95%CI0.19~0.97,p=0.042;OR0.17,95%CI0.053~0.55,p=0.0031).
结论:这项交互式模型研究的结果表明,对于较小的肿瘤,使用ABR+DCNEM而不是单独使用ABR时,听力保留的机会可能更高,随着肿瘤大小的增加,这种关系会逆转。
OBJECTIVE: Advancements in microsurgical technique and technology continue to improve outcomes in patients with skull base tumor. The primary cranial nerve eight monitoring systems used in hearing preservation surgery for vestibular schwannomas (VSs) are direct cranial nerve eight monitoring (DCNEM) and auditory brainstem response (ABR), although current guidelines are unable to definitively recommend one over the other due to limited literature on the topic. Thus, further research is needed to determine the utility of DCNEM and ABR. The authors performed a retrospective cohort study and created an interactive model that compares hearing preservation outcomes based on tumor size in patients receiving ABR+DCNEM and ABR-only monitoring.
METHODS: Twenty-eight patients received ABR+DCNEM and 72 patients received ABR-only monitoring during VS hearing preservation surgery at a single tertiary academic medical center between January 2008 and November 2022. Inclusion criteria consisted of adult patients with a preoperative American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification of A or B. Tumor size was measured as the maximal medial to lateral length, including the internal auditory canal component.
RESULTS: Overall hearing preservation (word recognition score [WRS] > 0%) was achieved in 31 patients with ABR-only monitoring (43.1%) and in 18 patients with ABR+DCNEM (64.3%). Serviceable hearing preservation (AAO-HNS class A or B) was attained in 19 patients with ABR-only monitoring (26.4%) and in 11 patients with ABR+DCNEM (39.3%). There was no difference in overall hearing preservation between the two groups (p = 0.13). Change in tumor size was not associated with the odds of serviceable hearing preservation for the ABR-only group (p = 0.89); however, for ABR+DCNEM, there was some indication of an interaction between tumor size and the association of ABR+DCNEM versus ABR-only monitoring, with the odds of serviceable hearing preservation at p = 0.089. Furthermore, with ABR+DCNEM, every 0.5-cm increase in tumor size was associated with a decreased odds of serviceable hearing preservation on multivariable analysis (p = 0.05). For both overall and serviceable hearing preservation, a worse preoperative AAO-HNS classification was associated with a decreased odds of preservation (OR 0.43, 95% CI 0.19-0.97, p = 0.042; OR 0.17, 95% CI 0.053-0.55, p = 0.0031, respectively).
CONCLUSIONS: The result of this interactive model study proposes that there may be a higher chance of hearing preservation when using ABR+DCNEM rather than ABR alone for smaller tumors, with that relationship reversing as tumor size increases.