大型听神经瘤的显微手术技巧及面神经保护

Microsurgical techniques and facial nerve preservation in resection of large acoustic neuroma

目的探讨大型听神经瘤的显微手术技巧、效果及术中面神经的保护。方法回顾性分析解放军总医院耳鼻咽喉头颈外科2010年1月～2010年12月收治的采用显微外科手术治疗30例大型听神经瘤患者的临床资料。其中男性18例，女性12例；年龄19—71岁，平均39．6±4．2岁；病程3个月一2年。主要临床表现为桥小脑角综合征和颅内压增高征，首发症状表现为耳呜、听力下降12例，头痛、恶心、呕吐10例，行走不稳4例，面部麻木7例，三叉神经痛2例，面瘫6例。30例术中均行面神经监测，显微镜下切除肿瘤，术毕刺激面神经的脑干端对术后面神经功能进行预测。结果本组30例大型听神经瘤全切除28例，次全切除1例，部分切除1例。术中面神经完整保留29例（96．67％），无死亡病例。肿瘤切除后，面神经刺激阈值的大小与术后面神经功能存在明显的相关性。刺激阈值越小，术后面神经功能越好。结论熟练地采用显微外科技术选择合适的手术入路可明显提高肿瘤的全切除率和面神经的解剖及功能保留率。手术入路的正确选择，娴熟的显微外科操作技术，术中应用面神经监测技术，能有效地保护桥小脑角周围的重要结构及面神经功能，并可预测术后面神经功能。

Objective To review microsurgical techniques and facial nerve preservation issues in resection of large acoustic neuroma, and report treatment results.. Method Clinical data of 30 patients with large acoustic neuroma who were surgically treated in our hospital from Jan 2010 to Dec 2010 were retrospectively analyzed. There were 18 males and 12 fe- males, aged from 19 to 71 years （mean age 39.6＋4.2 years）, The course of disease ranged from 3 months to 2 years. Their clin- ical features included cerebellopontine angle syndrome and increased intracranial pressure. Tinnitus and hearing loss were seen in 12 cases, headache, nausea and vomiting in 10 cases, dysequilibrium in 4 cases, facial numbness in 7 cases, tri- geminal neuralgia in 2 cases and facial paralysis in 6 cases. Intraoperative facial nerve monitoring was performed in all cases. Result Total excision was achieved in 28 patients, sub-total excision in 1 patient and partial removal in 1 patient. There was no surgery-related fatality. Lower facial nerve stimulation threshold after tumor resection was correlated to better facial function outcomes. Conclusion Microscopic neurosurgery with proper choice of approach can improve the rate of tumor resection and facial nerve preservation. Surgeon＇ s skills in microsurgery are important to preservation of important structures in the cerebellopontine angle and facial nerve function. Intraoperative facial nerve monitoring can help predict postoperative facial nerve outcomes.