青少年听神经瘤的临床特点及治疗研究

Clinical features and treatment of adolescent vestibular schwannoma

目的探讨青少年听神经瘤的临床特点、手术疗效及其影响因素分析。方法回顾性分析2008年1月至2018年12月解放军总医院第一医学中心神经外科医学部行肿瘤切除术的30例青少年听神经瘤患者(<21岁)的临床资料。术后复查头颅MRI,判断肿瘤的切除程度;行House-Brackman(H-B)面神经功能分级,其中较术前下降≥2个等级定义为面神经损伤。术后对所有患者行门诊随访,复查头颅增强MRI,判断肿瘤是否复发;行美国科学院耳鼻咽喉和头颈外科(AAO-HNS)听力评级。收集患者的发病年龄、性别、临床表现、头颅MRI的影像学表现、面神经功能、手术方式、术中出血量、手术时间、肿瘤切除程度及住院时间。采用单因素logistic回归分析法初步判断影响患者肿瘤切除程度、术后面神经损伤及肿瘤复发的临床因素。结果30例患者的男女比例为1.3∶1.0,年龄为(17.8±3.5)岁(16.0~20.0岁),病程[M(Q_(1),Q_(3))]为10(4,36)个月,临床表现以听力下降[90.0%(27/30)]和耳鸣[53.3%(16/30)]最多见,术前多数患者[96.7%(29/30)]的面神经功能良好(H-B分级Ⅰ级),仅部分患者(6/17)存在可实用听力,肿瘤最大径为(2.9±1.3)cm(0.5~5.0 cm)。术后复查头颅MRI结果显示,21例(70.0%)患者为肿瘤完全切除,9例(30.0%)为近全切除。面神经功能评估结果显示,9例(30.0%)患者术后出现面神经功能损伤。30例患者的随访时间为(75.4±44.7)个月(6~149个月)。随访期间,4例(13.3%)患者发生肿瘤复发;至末次随访,术前存在可实用听力的6例患者,仅2例保留听力。单因素logistic回归分析结果显示,肿瘤最大径(OR=0.45,95%CI:0.20~0.98)和手术时间(OR=0.60,95%CI:0.40~0.92)是青少年听神经瘤患者肿瘤切除程度的影响因素,肿瘤最大径(OR=38.21,95%CI:1.20~1258.40)是术后面神经功能损伤的影响因素,未发现任何因素与术后肿瘤复发有关。结论青少年听神经瘤的临床表现以听力下降和耳鸣多见,肿瘤体积较大,手术是主要的治疗方式;肿瘤体积较大的患者,其术后肿瘤完全切除率低且易出现面神经损伤。

Objective To explore the clinical characteristics,surgical efficacy and influencing factors of vestibular schwannoma in adolescents.Methods A retrospective analysis was conducted on the clinical data of 30 adolescent patients with vestibular schwannoma(<21 years old)who underwent tumor resection at the Department of Neurosurgery,the First Medical Center,Chinese PLA General Hospital from January 2008 to December 2018.Head MRI was reperformed after operation to judge the degree of tumor resection.Assessment using House-Brackman(H-B)facial nerve grading system was performed.A decrease of≥2 grades from the preoperative level was defined as facial nerve function injury.All patients underwent outpatient follow-up after operation,re-examination of enhanced brain MRI to identify tumor recurrence,and hearing was rated based on American Academy of Otolaryngology-Head and Neck Surgery(AAO-HNS).The age of onset,gender,clinical manifestations,imaging manifestations of cranial MRI,facial nerve function,operation method,intraoperative blood loss,operation time,degree of tumor resection and hospitalization time of the patients were documented.Univariate logistic regression analysis was used to preliminarily determine the clinical factors affecting the degree of tumor resection,postoperative facial nerve injury and tumor recurrence.Results The male to female ratio of the 30 patients was 1.3∶1.0,the age was 17.8±3.5 years(16.0-20.0 years),the median course of disease was 10(4-36)months,and the most common clinical manifestations were hearing loss[90.0%(27/30)]and tinnitus[53.3%(16/30)].Before surgery,most patients(96.7%,29/30)had good facial nerve function(H-B gradeⅠ),and a small number of patients(6/17)had practical hearing.The largest tumor diameter was 2.9±1.3 cm(0.5-5.0 cm).Postoperative head MRI results showed that 21 patients(70.0%)had complete resection,and 9 patients(30.0%)had near total resection.Facial nerve function assessment results showed that 9 patients(30.0%)had facial nerve function injury after surgery.The follow-up time of 30 patients was 75.4±44.7 months(6-149 months).During follow-up,4 patients(13.3%)had tumor recurrence.Among 6 patients with practical hearing before surgery,only 2 still had remaining hearing at the last follow-up.The results of univariate logistic regression analysis showed that the maximum tumor diameter(OR=0.45,95%CI:0.20-0.98)and operation time(OR=0.60,95%CI:0.40-0.92)were the influencing factors of tumor resection degree in adolescent patients with vestibular schwannoma.The largest tumor diameter(OR=38.21,95%CI:1.20-1258.40)was the influencing factor of facial nerve function damage after surgery.No factors affecting the recurrence of tumor in adolescent patients with vestibular schwannoma have been identified.Conclusions Hearing loss and tinnitus are common clinical manifestations of vestibular schwannoma in adolescents.In case of large tumor volume,surgery is the main treatment.Patients with large tumor volume have low complete tumor resection rate and are prone to have facial nerve function injury after operation.