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目的 探讨颅中窝入路听神经瘤切除术中听力保留技术。 方法 回顾性收集并分析2006年5月至2021年5月中国人民解放军总医院行经颅中窝入路管内型听神经瘤切除术患者临床资料。术前均行听力测试、颅脑影像学检查，评估患者是否符合听力保留原则。术前与术后，均采用美国耳鼻咽喉-头颈外科学会听力分级标准进行听力分级评定，采用House-Brackmann(HB)分级进行面神经功能评定。总结不同临床特征的患者听力保留情况。 结果 共22例符合纳入和排除标准的管内型听神经瘤患者入选本研究。其术前面神经功能HB分级Ⅰ级21例，Ⅲ级1例；77.3%(17/22, 95% CI: 58.3%~96.3%)术前有实用听力，86.4%(19/22, 95% CI: 70.8%~100%)有可用听力；符合听力保留原则17例，余5例保留残余听力。22例患者均完整切除肿瘤，术后均无脑脊液漏、硬膜外血肿、感染等并发症发生。术后实用听力保留率为52.9%(9/17, 95% CI: 26.5%~79.4%)，可用听力保留率为73.7%(14/19, 95% CI: 51.9%~95.5%)。术前颅脑MRI检查存在/不存在“脑脊液帽”患者术后实用听力保留率分别为60.0%(3/5, 95% CI: 23.1%~96.9%)、50.0%(6/12, 95% CI: 16.8%~83.2%)，可用听力保留率分别为80.0%(4/5，95% CI: 24.5%~100%)、71.4%(10/14，95% CI: 44.4%~98.5%)。肿瘤来源于前庭上神经/前庭下神经患者术后实用听力保留率分别为33.3% (2/6, 95% CI: 0~87.5%)、55.6%(5/9, 95% CI: 14.0%~96.1%)，可用听力保留率分别为57.1%(4/7，95% CI: 7.7%~100%)、80.0%(8/10，95% CI: 49.8%~100%)。肿瘤与蜗神经粘连/无粘连患者术后实用听力保留率分别为41.7% (5/12, 95% CI: 8.9%~74.4%)、80.0% (4/5, 95% CI: 24.5%~100%)，可用听力保留率分别为66.7%(8/12，95% CI: 35.4%~98.0%)、85.7%(6/7，95% CI: 50.8%~100%)。中位随访4.9年，22例患者均无肿瘤复发，末次随访时HB分级I级21例，Ⅳ级1例。 结论 颅中窝入路听神经瘤完整切除术中保留听力，应考虑术前听力水平、影像学特征，以及把握合适的切除时机；术中需准确判断肿瘤来源、肿瘤与蜗神经粘连程度，掌握不同情况下手术操作技巧以保留蜗神经的解剖结构完整性及良好的功能。 Abstract:Objective To discuss the middle fossa approach (MFA) for vestibular schwannoma (VS) and hearing preservation (HP). Methods Retrospectively analyze the database of HP in patients that underwent MFA for intracanalicular VS from May 2006 to May 2021. Examinations of preoperative hearing and craniocerebral imaging were performed to evaluate whether the patients met the criterion of HP. The function of the cochlear nerve was evaluated with American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification; the facial nerve function was evaluated with House-Brackmann (HB) grading. Different clinical characteristics regarding HP were summarized. Results A total of 22 patients with VS that met the inclusion and exclusion criteria were included in this study. Facial nerve function was HB grade Ⅰ in 21 patients, grade Ⅲ in 1 patient. The preoperative serviceable and usable HP rate were 77.3%(17/22, 95% CI: 58.3%-96.3%) and 86.4%(19/22, 95% CI: 70.8%-100%), respectively. Seventeen patients met the criterion of hearing preservation, and the other 5 got their residual hearing reserved. The tumor was completely removed in 22 patients with VS and without postoperative complications, such as cerebrospinal fluid (CSF) leakage, epidural hematoma or infection. The rates of postoperative serviceable and useful HP were 52.9%(9/17, 95% CI: 26.5%-79.4%) and 73.7%(14/19, 95% CI: 51.9%-95.5%), respectively. In the patients present and those absent of CSF cap, the rates of postoperative serviceable HP were 60.0% (3/5, 95% CI: 23.1%-96.9%), 50.0% (6/12, 95% CI: 16.8%-83.2%), and the rates of useful HP were 80.0% (4/5, 95% CI: 24.5%-100%), and 71.4% (10/14, 95% CI: 44.4%-98.5%), respectively. In the tumor originating from the superior vestibular nerve, the rates of postoperative serviceable HP and useful HP were 33.3% (2/6, 95% CI: 0-87.5%) and 57.1% (4/7, 95% CI: 7.7%-100%), respectively. Whereas in patients with tumors originating from the inferior vestibular nerve, the rates of serviceable HP and useful HP were 55.6% (5/9, 95% CI: 14.0%-96.1%) and 80.0% (8/10, 95% CI: 49.8%-100%), respectively. For the patients in the presence and those in the absence of adhesion between the tumor and the cochlear nerve, the rates of serviceable HP were 41.7%(5/12, 95% CI: 8.9%-74.4%), 80.0% (4/5, 95% CI: 24.5%-100%), and the rates of useful HP were 66.7% (8/12, 95% CI: 35.4%-98.0%), 85.7% (6/7, 95% CI: 50.8%-100%), respectively. The median follow-up was 4.9 years. None of the patients had tumor recurrence. Postoperatively, the facial nerve function was HB grade Ⅰ in 21 patients and grade Ⅳ in 1 patient. Conclusions The preoperative hearing classification and the features of imaging should be considered for complete excision of the tumor with the middle fossa approach and HP. As well, sufficient surgical skills need to be grasped in the condition of different nerve origin and the degree of adhesion between the tumor and cochlear nerve to preserve the anatomy and function of the cochlear nerve. -
Key words:
- vestibular schwannoma /
- middle fossa approach /
- hearing preservation /
- tumor origin /
- adhesion
作者贡献：陈继跃负责病例收集、数据分析及文稿撰写；马晓彦、丁志伟、张驰、曹伟、王方园负责病例收集、术后随访及数据分析；吴南、王国建、韩维举、戴朴、韩东一负责研究设计及数据分析指导；申卫东、杨仕明负责课题方案、研究思路与研究方法设计，以及论文修改。利益冲突：无 -
图 1 1例管内型听神经瘤患者(男，13岁)术前影像学检查结果
A. 颞骨CT示内听道口处骨质变薄(箭头)、肿瘤侧内听道(箭头)；B.颞骨CT示非肿瘤侧内听道无明显扩大；C.颅脑MRI水平位T2加权成像可见肿瘤(黄色箭头)与脑脊液(红色箭头)；D.颅脑MRI冠状位T1增强成像示肿瘤明显强化(箭头)
图 2 经颅中窝入路听神经瘤切除术操作要点
A. 寻找内听道标志岩浅大神经、面神经裂孔、面神经骨管及上半规管；B.磨除内听道上壁骨质，暴露瘤体；C.对来源于前庭上神经的肿瘤，切断前庭上神经，充分暴露和分离瘤体；D.游离瘤体并完整切除肿瘤；E.采用颞筋膜封闭内听道骨质缺损区
表 1 22例听神经瘤患者手术前后美国耳鼻咽喉-头颈外科学会听力分级标准(n)
术前听力分级 术后听力分级 总计 A B C D A级 5 0 0 4 9 B级 0 4 4 0 8 C级 0 0 1 1 2 D级 0 0 0 3 3 总计 5 4 5 8 22 
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表 2 22例听神经瘤患者术后听力保留结果
指标 保留实用听力[n(%, 95% CI)] 保留可用听力[n(%, 95% CI)] “脑脊液帽” 存在 3(60.0，23.1~96.9) 4(80.0，24.5~100) 不存在 6(50.0，16.8~83.2) 10(71.4，44.4~98.5) 肿瘤来源 前庭上神经 2(33.3，0~87.5) 4(57.1，7.7~100) 前庭下神经 5(55.6，14.0~96.1) 8(80.0，49.8~100) 无法明确 2(100) 2(100) 肿瘤与蜗神经粘连 是 5(41.7，8.9~74.4) 8(66.7，35.4~98.0) 否 4(80.0，24.5~100) 6(85.7，50.8~100)
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