Use of intraoperative auditory evoked potentials to preserve hearing in unilateral acoustic neuroma removal

View More View Less
  • 1 Neurosurgical and Neurology Services, Massachusetts General Hospital, Boston; Otolaryngology Service and Eaton Peabody Laboratory, Massachusetts Eye and Ear Infirmary, Boston; and Departments of Surgery, Neurology, and Otolaryngology, Harvard Medical School, Boston, Massachusetts
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

✓ Twenty-two patients with unilateral acoustic neuromas and preoperative speech discrimination scores of 35% or more had intraoperative monitoring of the electrocochleogram (ECoG) using a transtympanic electrode, and of the brain-stem auditory evoked potentials (BAEP's) using scalp electrodes. Rapid feedback was provided about the status of the cochlear microphonics from the hair cells of the inner ear (CM of the ECoG), the compound action potential of the auditory nerve (N-1 of the ECoG or Wave I of the BAEP's) and the potentials from the lower brain stem (Wave V of the BAEP's). All patients had total removal of the tumor. In 21, the cochlear nerve was anatomically preserved, and 20 had good postoperative facial nerve function. Correlation of tumor size with postoperative hearing was as follows: discrimination scores of more than 35% in three of four patients with 1-cm tumors, two of eight with 1.5-cm tumors, two of six with 2- to 2.5-cm tumors, and one of four with tumors of 3 cm or more. Two other patients with 1.5-cm tumors had discrimination scores of less than 35%, and one patient with a 2-cm tumor had only sound perception. In two patients, the discrimination scores improved. At the end of the operation, all patients with hearing had a detectable N-1, and, when recorded, CM. All but one patient with no hearing had lost N-1, and CM was absent or reduced. Unless Wave V was unchanged, it was a poor predictor of postoperative hearing, and its absence did not preclude preservation of good hearing.

The electrophysiological changes during each stage of the operation were analyzed and correlated with events during surgery. Areas in which there was an increased risk of loss of the potentials were determined. In some patients monitoring was unnecessary, because either there were no significant changes or the changes were abrupt and no recovery occurred. However, in other patients, monitoring alerted the surgeon to a possible problem and the method of dissection was altered. Possible mechanisms of hearing loss were suggested from the changes in the recordings.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address reprint requests to: Robert G. Ojemann, M.D., Neurosurgical Service, Massachusetts General Hospital, Boston, Massachusetts 02114.
  • 1.

    Allen A, , Starr A, & Nudleman K: Assessment of sensory function in the operating room utilizing cerebral evoked potentials: a study of fifty-six surgically anesthetized patients. Clin Neurosurg 28:457481, 1981 Allen A, Starr A, Nudleman K: Assessment of sensory function in the operating room utilizing cerebral evoked potentials: a study of fifty-six surgically anesthetized patients. Clin Neurosurg 28:457–481, 1981

    • Search Google Scholar
    • Export Citation
  • 2.

    Belal A Jr, , Linthicum FH Jr, & House WF: Acoustic tumor surgery with preservation of hearing. A histopathologic report. Am J Otol 4:916, 1982 Belal A Jr, Linthicum FH Jr, House WF: Acoustic tumor surgery with preservation of hearing. A histopathologic report. Am J Otol 4:9–16, 1982

    • Search Google Scholar
    • Export Citation
  • 3.

    Brackmann DE: Acoustic neuroma surgery: Otologic Medical Group results, in Silverstein H, & Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 248259 Brackmann DE: Acoustic neuroma surgery: Otologic Medical Group results, in Silverstein H, Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 248–259

    • Search Google Scholar
    • Export Citation
  • 4.

    Brackmann DE: Middle cranial fossa approach, in House WF, & Luetje CM (eds): Acoustic Tumors. Baltimore: University Park Press, 1979, Vol 2, pp 1541 Brackmann DE: Middle cranial fossa approach, in House WF, Luetje CM (eds): Acoustic Tumors. Baltimore: University Park Press, 1979, Vol 2, pp 15–41

    • Search Google Scholar
    • Export Citation
  • 5.

    Bremond G, , Garcin M, & Magnan J: Preservation of hearing in the removal of acoustic neuroma. (“Minima” posterior approach by retrosigmoidal route). J Laryngol Otol 94:11991204, 1980 Bremond G, Garcin M, Magnan J: Preservation of hearing in the removal of acoustic neuroma. (“Minima” posterior approach by retrosigmoidal route). J Laryngol Otol 94:1199–1204, 1980

    • Search Google Scholar
    • Export Citation
  • 6.

    Buchheit WA, & Gastaldo JA: The posterior fossa approach to acoustic tumors: preservation of hearing, in Silverstein H, & Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1977, Vol 1, pp 263266 Buchheit WA, Gastaldo JA: The posterior fossa approach to acoustic tumors: preservation of hearing, in Silverstein H, Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1977, Vol 1, pp 263–266

    • Search Google Scholar
    • Export Citation
  • 7.

    Cohen NL: Acoustic neuroma surgery with emphasis on preservation of hearing. Laryngoscope 89:886896, 1979 Cohen NL: Acoustic neuroma surgery with emphasis on preservation of hearing. Laryngoscope 89:886–896, 1979

    • Search Google Scholar
    • Export Citation
  • 8.

    Domb GH, & Chole RA: Anatomical studies of the posterior petrous apex with regard to hearing preservation in acoustic neuroma removal. Laryngoscope 90:17691776, 1980 Domb GH, Chole RA: Anatomical studies of the posterior petrous apex with regard to hearing preservation in acoustic neuroma removal. Laryngoscope 90:1769–1776, 1980

    • Search Google Scholar
    • Export Citation
  • 9.

    Eckermeier L, , Pirsig W, & Mueller D: Histopathology of 30 non-operated acoustic schwannomas. Arch Otorhinolaryngol 222:19, 1979 Eckermeier L, Pirsig W, Mueller D: Histopathology of 30 non-operated acoustic schwannomas. Arch Otorhinolaryngol 222:1–9, 1979

    • Search Google Scholar
    • Export Citation
  • 10.

    Fischer G, , Costantini JL, & Mercier P: Improvement of hearing after microsurgical removal of acoustic neurinoma. Neurosurgery 7:154159, 1980 Fischer G, Costantini JL, Mercier P: Improvement of hearing after microsurgical removal of acoustic neurinoma. Neurosurgery 7:154–159, 1980

    • Search Google Scholar
    • Export Citation
  • 11.

    Glassock ME III, , Dickins JRE, & Wiet RJ: Preservation of hearing in acoustic tumor surgery: middle fossa technique, in Silverstein H, & Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 284286 Glassock ME III, Dickins JRE, Wiet RJ: Preservation of hearing in acoustic tumor surgery: middle fossa technique, in Silverstein H, Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 284–286

    • Search Google Scholar
    • Export Citation
  • 12.

    Glasscock ME III, , Hays JW, & Miller GW, et al: Preservation of hearing in tumors of the internal auditory canal and cerebellopontine angle. Laryngoscope 88:4355, 1978 Glasscock ME III, Hays JW, Miller GW, et al: Preservation of hearing in tumors of the internal auditory canal and cerebellopontine angle. Laryngoscope 88:43–55, 1978

    • Search Google Scholar
    • Export Citation
  • 13.

    Grundy BL, , Jannetta PJ, & Procopio PT, et al: Intraoperative monitoring of brain-stem auditory evoked potentials. J Neurosurg 57:674681, 1982 Grundy BL, Jannetta PJ, Procopio PT, et al: Intraoperative monitoring of brain-stem auditory evoked potentials. J Neurosurg 57:674–681, 1982

    • Search Google Scholar
    • Export Citation
  • 14.

    Hardy RW Jr, , Kinney SE, & Lueders H, et al: Preservation of cochlear nerve function with the aid of brain stem auditory evoked potentials. Neurosurgery 11:1619, 1982 Hardy RW Jr, Kinney SE, Lueders H, et al: Preservation of cochlear nerve function with the aid of brain stem auditory evoked potentials. Neurosurgery 11:16–19, 1982

    • Search Google Scholar
    • Export Citation
  • 15.

    Harner SG, & Laws ER Jr: Posterior fossa approach for removal of acoustic neurinomas. Recent experience. Arch Otolaryngol 107:590593, 1981 Harner SG, Laws ER Jr: Posterior fossa approach for removal of acoustic neurinomas. Recent experience. Arch Otolaryngol 107:590–593, 1981

    • Search Google Scholar
    • Export Citation
  • 16.

    Hausler R, & Levine RA: Brain stem auditory evoked potentials are related to interaural time discrimination in patients with multiple sclerosis. Brain Res 191:589594, 1980 Hausler R, Levine RA: Brain stem auditory evoked potentials are related to interaural time discrimination in patients with multiple sclerosis. Brain Res 191:589–594, 1980

    • Search Google Scholar
    • Export Citation
  • 17.

    House WF (ed): Monograph II. Acoustic neuroma. Arch Otolaryngol 88:576715, 1968 House WF (ed): Monograph II. Acoustic neuroma. Arch Otolaryngol 88:576–715, 1968

    • Search Google Scholar
    • Export Citation
  • 18.

    Jones TA, , Stockard JJ, & Weidner WJ: The effects of temperature and acute alcohol intoxication on brain stem auditory evoked potentials in the cat. Electroencephalogr Clin Neurophysiol 49:2330, 1980 Jones TA, Stockard JJ, Weidner WJ: The effects of temperature and acute alcohol intoxication on brain stem auditory evoked potentials in the cat. Electroencephalogr Clin Neurophysiol 49:23–30, 1980

    • Search Google Scholar
    • Export Citation
  • 19.

    Kiang NYS, , Moxon EC, & Kahn AR: The relationship of gross potentials recorded from the cochlea to single unit activity in the auditory nerve, in Ruben RJ, , Elberling C, & Salomon G (eds): Electrocochleography. Baltimore: University Park Press, 1976, pp 95115 Kiang NYS, Moxon EC, Kahn AR: The relationship of gross potentials recorded from the cochlea to single unit activity in the auditory nerve, in Ruben RJ, Elberling C, Salomon G (eds): Electrocochleography. Baltimore: University Park Press, 1976, pp 95–115

    • Search Google Scholar
    • Export Citation
  • 20.

    Levine RA: Monitoring auditory evoked potentials during acoustic neuroma surgery, in Silverstein H, & Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 287293 Levine RA: Monitoring auditory evoked potentials during acoustic neuroma surgery, in Silverstein H, Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 287–293

    • Search Google Scholar
    • Export Citation
  • 21.

    Levine RA, , Ojemann RG, & Montgomery WW, et al: Monitoring auditory evoked potentials during acoustic neuroma surgery. Insights into the mechanism of the hearing loss. Ann Otorhinolaryngol 93:116123, 1984 Levine RA, Ojemann RG, Montgomery WW, et al: Monitoring auditory evoked potentials during acoustic neuroma surgery. Insights into the mechanism of the hearing loss. Ann Otorhinolaryngol 93:116–123, 1984

    • Search Google Scholar
    • Export Citation
  • 22.

    MacCarty CS: Acoustic neuroma and the suboccipital approach (1967–1972). Mayo Clin Proc 50:1516, 1975 MacCarty CS: Acoustic neuroma and the suboccipital approach (1967–1972). Mayo Clin Proc 50:15–16, 1975

    • Search Google Scholar
    • Export Citation
  • 23.

    Malis LI: Microsurgical treatment of acoustic neuromas, in Handa H (ed): Microneurosurgery. Baltimore: University Park Press, 1975, pp 105120 Malis LI: Microsurgical treatment of acoustic neuromas, in Handa H (ed): Microneurosurgery. Baltimore: University Park Press, 1975, pp 105–120

    • Search Google Scholar
    • Export Citation
  • 24.

    Martuza RL, & Ojemann RG: Bilateral acoustic neuromas: clinical aspects, pathogenesis, and treatment. Neurosurgery 10:112, 1982 Martuza RL, Ojemann RG: Bilateral acoustic neuromas: clinical aspects, pathogenesis, and treatment. Neurosurgery 10:1–12, 1982

    • Search Google Scholar
    • Export Citation
  • 25.

    Møller AR, & Jannetta PJ: Monitoring auditory functions during cranial nerve microvascular decompression operations by direct recording from the eighth nerve. J Neurosurg 59:493499, 1983 Møller AR, Jannetta PJ: Monitoring auditory functions during cranial nerve microvascular decompression operations by direct recording from the eighth nerve. J Neurosurg 59:493–499, 1983

    • Search Google Scholar
    • Export Citation
  • 26.

    Nedzelski JM, & Tator CH: Surgical management of cerebellopontine angle tumors. J Otolaryngol 9:105112, 1980 Nedzelski JM, Tator CH: Surgical management of cerebellopontine angle tumors. J Otolaryngol 9:105–112, 1980

    • Search Google Scholar
    • Export Citation
  • 27.

    Ojemann RG: Acoustic neuroma. Contemp Neurosurg 20:16, 1979 Ojemann RG: Acoustic neuroma. Contemp Neurosurg 20:1–6, 1979

  • 28.

    Ojemann RG: Comments on Fischer G, Costantini JL, Mercier P: Improvement of hearing after microsurgical removal of acoustic neuroma. Neurosurgery 7:158159, 1980 Ojemann RG: Comments on Fischer G, Costantini JL, Mercier P: Improvement of hearing after microsurgical removal of acoustic neuroma. Neurosurgery 7:158–159, 1980

    • Search Google Scholar
    • Export Citation
  • 29.

    Ojemann RG: Microsurgical suboccipital approach to cerebellopontine angle tumors. Clin Neurosurg 25:461479, 1978 Ojemann RG: Microsurgical suboccipital approach to cerebellopontine angle tumors. Clin Neurosurg 25:461–479, 1978

    • Search Google Scholar
    • Export Citation
  • 30.

    Ojemann RG, & Crowell RC: Acoustic neuromas treated by microsurgical suboccipital operations. Prog Neurol Surg 9:337373, 1978 Ojemann RG, Crowell RC: Acoustic neuromas treated by microsurgical suboccipital operations. Prog Neurol Surg 9:337–373, 1978

    • Search Google Scholar
    • Export Citation
  • 31.

    Ojemann RG, , Montgomery WW, & Weiss AD: Evaluation and surgical treatment of acoustic neuroma. N Engl J Med 287:895899, 1972 Ojemann RG, Montgomery WW, Weiss AD: Evaluation and surgical treatment of acoustic neuroma. N Engl J Med 287:895–899, 1972

    • Search Google Scholar
    • Export Citation
  • 32.

    Perlman HB, , Kimura R, & Fernandez C: Experiments on temporary obstruction of the internal auditory artery. Laryngoscope 69:591613, 1959 Perlman HB, Kimura R, Fernandez C: Experiments on temporary obstruction of the internal auditory artery. Laryngoscope 69:591–613, 1959

    • Search Google Scholar
    • Export Citation
  • 33.

    Piffkó P, & Pásztor E: Operated bilateral acoustic neurinoma with preservation of hearing and facial nerve function. J Otorhinolaryngol 43:255261, 1981 Piffkó P, Pásztor E: Operated bilateral acoustic neurinoma with preservation of hearing and facial nerve function. J Otorhinolaryngol 43:255–261, 1981

    • Search Google Scholar
    • Export Citation
  • 34.

    Pulec JL, , House WF, & Britton BH Jr, et al: A system of management of acoustic neuroma based on 364 cases. Trans Am Acad Ophthalmol Otolaryngol 75:4855, 1971 Pulec JL, House WF, Britton BH Jr, et al: A system of management of acoustic neuroma based on 364 cases. Trans Am Acad Ophthalmol Otolaryngol 75:48–55, 1971

    • Search Google Scholar
    • Export Citation
  • 35.

    Raudzens PA, & Shetter AG: Intraoperative monitoring of brain-stem auditory evoked potentials. J Neurosurg 57:341348, 1982 Raudzens PA, Shetter AG: Intraoperative monitoring of brain-stem auditory evoked potentials. J Neurosurg 57:341–348, 1982

    • Search Google Scholar
    • Export Citation
  • 36.

    Rhoton AL Jr: Microsurgical removal of acoustic neuromas. Surg Neurol 6:211219, 1976 Rhoton AL Jr: Microsurgical removal of acoustic neuromas. Surg Neurol 6:211–219, 1976

    • Search Google Scholar
    • Export Citation
  • 37.

    Smith MFW, , Clancy TP, & Lang JS: Conservation of hearing in acoustic neurilemmoma excision. Trans Am Acad Ophthalmol Otolaryngol 84:704709, 1977 Smith MFW, Clancy TP, Lang JS: Conservation of hearing in acoustic neurilemmoma excision. Trans Am Acad Ophthalmol Otolaryngol 84:704–709, 1977

    • Search Google Scholar
    • Export Citation
  • 38.

    Sterkers JM: Removal of bilateral and unilateral acoustic tumors with preservation of hearing: a comparison of the retrosigmoid and translabyrinthine approach, in Silverstein H, & Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 269277 Sterkers JM: Removal of bilateral and unilateral acoustic tumors with preservation of hearing: a comparison of the retrosigmoid and translabyrinthine approach, in Silverstein H, Norrell H (eds): Neurological Surgery of the Ear. Birmingham, Ala: Aesculapius, 1980, Vol 2, pp 269–277

    • Search Google Scholar
    • Export Citation
  • 39.

    Sterkers JM, & Hamann KF: The retrosigmoidal approach — a possibility to preserve hearing function in operations of acoustic neuromas. Arch Otorhinolaryngol 223:463465, 1979 Sterkers JM, Hamann KF: The retrosigmoidal approach — a possibility to preserve hearing function in operations of acoustic neuromas. Arch Otorhinolaryngol 223:463–465, 1979

    • Search Google Scholar
    • Export Citation
  • 40.

    Sugita K, , Kobayashi S, & Mutsuga N, et al: Microsurgery for acoustic neurinoma — lateral position and preservation of facial and cochlear nerves. Neurol Med Chir 19:637641, 1979 Sugita K, Kobayashi S, Mutsuga N, et al: Microsurgery for acoustic neurinoma — lateral position and preservation of facial and cochlear nerves. Neurol Med Chir 19:637–641, 1979

    • Search Google Scholar
    • Export Citation
  • 41.

    Tarlov E: Total one-stage suboccipital microsurgical removal of acoustic neuromas of all sizes, with emphasis on arachnoid planes and on saving the facial nerve. Surg Clin North Am 60:565591, 1980 Tarlov E: Total one-stage suboccipital microsurgical removal of acoustic neuromas of all sizes, with emphasis on arachnoid planes and on saving the facial nerve. Surg Clin North Am 60:565–591, 1980

    • Search Google Scholar
    • Export Citation
  • 42.

    Wanxing C: Preservation of facial and acoustic nerves in the total removal of large and small acoustic tumors. Report of two cases. J Neurosurg 54:268272, 1981 Wanxing C: Preservation of facial and acoustic nerves in the total removal of large and small acoustic tumors. Report of two cases. J Neurosurg 54:268–272, 1981

    • Search Google Scholar
    • Export Citation
  • 43.

    Yaşargil MG, , Smith RD, & Gasser JC: Microsurgical approach to acoustic neurinomas, in Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien/New York: Springer-Verlag, 1977, Vol 4, pp 93129 Yaşargil MG, Smith RD, Gasser JC: Microsurgical approach to acoustic neurinomas, in Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien/New York: Springer-Verlag, 1977, Vol 4, pp 93–129

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 559 188 8
Full Text Views 204 4 1
PDF Downloads 77 3 2
EPUB Downloads 0 0 0