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人工耳蝸植入手術中使用持續面神經監測的經驗報告

Experience of Continuous Facial Nerve Monitoring in Cochlear Implant Surgery

摘要


背景:人工耳蝸手術後造成面神經的損傷是可能的併發症,但是損傷的嚴重度不一定,但如果變成永久的面神經麻痺(facial paralysis)就是非常嚴重的後遺症,在醫療、社會、經濟、及法律上都會有相關問題產生。使用面神經監控除了可以幫忙醫師辨別面神經位置,對於避免造成面神經損傷也會有示警作用。有報告顯示使用面神經監控系統可以降低術中傷害面神經的可能性,也有些報告顯示使用與否並沒有差別。在中耳及乳突手術(包括人工耳蝸手術)是否常規使用仍有爭議性,本研究提供本院人工耳蝸植入手術使用面神經監測的經驗以為參考,並探討是否面神經監測的使用能有效降低人工耳蝸植入手術時面神經傷害的機率。方法:回溯病歷總共32名人工耳蝸手術,使用Nerve Integrity Monitoring(NIM)Response-2(Xomed, Minneapolis,MN,USA)面神經監測儀,術前在眼輪匝肌和口輪匝肌紮針監測,手術方法分為耳後微創切口和乳突鑿開,刺激器採單極固定電流,初始電流刺激為1.0 mA(範圍為0.1-3.0 mA),頻率4次/秒,每次時間100 μs,設定在肌電圖(EMG)的閾值100 μV以上,監測儀才會有警告聲音。結果:這32名患者接受人工耳蝸植入的年齡由1歲7個月到65歲(平均9.5歲),男比女是15:17,術前所有患者均接受顳骨高解析度電腦斷層(High resolution computed tomography)檢查,沒有發現結構畸形,術中亦沒有發現自發性面神經裂開(dehiscence),但其中1名病患當金鋼鑽(diamond burr)磨到面神經鞘(sheath)監測儀有警告聲,在初始電流刺激1.0 mA的原始設定下只有3名患者面神經監測儀沒有警告聲,其中2名需提高刺激強度到1.2和2.0 mA才能偵測到面神經,1名在2.0 mA刺激下可見鐙骨肌收縮但是沒有警告聲。術中25名可以發現鼓索神經,其中18名經0.3-3.0 mA不等的電流刺激會造成面神經監測儀有警告聲。術後所有32名病患都沒有面神經麻痺的現象。結論:本研究結果顯示,面神經監測儀在人工耳蝸植入術中雖然可以幫忙早期偵測面神經,避免傷到面神經,但還是可能有偽陽性、偽陰性或是誤判的情況發生。整體而言,面神經監測系統對於人工耳蝸手術中面神經的辨識僅具輔助辨識的功能,臨床上對於面神經的相對解剖位置的熟悉和累積的手術技術才能避免術中面神經損傷的發生。

並列摘要


Background: Iatrogenic facial nerve injury is one of the most severe complications of cochlear implant surgery. Facial nerve paralysis has a significant functional and emotional impact on patients. Intraoperative facial nerve monitoring (IFNM) is used as an adjunctive modality in a variety of neurotologic and temporal bone surgical procedures. Despite the utility of IFNM in reducing the risk of iatrogenic facial nerve injury during neurotologic surgery, the routine use during middle ear or mastoid surgery remains controversial. The purpose of this study was to share our experience in the use of IFNM during cochlear implant surgery. Methods: This retrospective analysis included 32 patients (15 males and 17 females) who underwent cochlear implant surgery. Facial potentials were recorded from needles placed in the orbicularis oculi and oris muscles. Cochlear implantation was performed with a minimally invasive incision and limited mastoidectomy. The facial nerve was directly stimulated with a monopolar stimulator (constant current pulses, 0.1-3.0 mA, 4 Hz, 100 μs). An event threshold was set at 100 μV. Results: The mean age of the 32 patients was 9.5 years (range 18 months to 65 years). No spontaneous facial nerve dehiscence was noted during surgery, however the monitor sounded a warning when the diamond burr touched the facial nerve sheath of one case. There was no warning sound at the initial setting (1.0 mA) in three patients, of whom two had the stimulation intensity increased to 1.2 and 2.0 mA. There was also a visible stapes muscle contraction at 2.0 mA stimulation with no warning sound in another case. Chorda tympani nerve stimulation was noted in 25 patients, and a warning sound was emitted in 18 of these cases. No postoperative facial paresis was noted in any of the 32 patients. Conclusions: Although not a substitute for the anatomic identification of the facial nerve, IFNM is of great value in the early identification of dehiscent facial nerve anatomy, assisting in the maintenance of its integrity, and functionality postoperatively. However, false-positive and false-negative results may occur when using IFNM. Nevertheless, IFNM can still be used as an additional technique to optimize surgical success.

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