The retrosigmoid approach for auditory brainstem implantation.

OBJECTIVE: To describe our experience with the retrosigmoid-transmeatal (RS-TM) approach in auditory brainstem implantation (ABI) as well as the anatomosurgical guidelines for this route. STUDY DESIGN: Retrospective case review. SETTING: Ear, Nose, and Throat Department of the University of Verona. PATIENTS: Five patients with neurofibromatosis type 2 (NF2) were operated on for vestibular schwannoma removal with ABI implantation from April 1997 to June 1999. The patients were four men and one woman, whose ages ranged from 22 to 37 years. The tumor sizes ranged from 12 to 30 mm. The records of a total of 179 patients operated on for vestibular schwannoma (VS) removal via the RS-TM approach from January 1990 to June 1999 were also evaluated. Their ages ranged from 18 to 88 years (average 54 years). The tumor sizes ranged from 4 to 50 mm. Five patients had a solitary VS in the only hearing ear. INTERVENTION: The classic RS-TM approach was used in all patients. After tumor excision, for ABI implantation, the landmarks (seventh, eighth, and ninth cranial nerves, choroid plexus) for the foramen of Luschka were carefully identified. The choroid plexus was then partially removed, and the tela choroidea was divided and bent back. The floor of the lateral recess of the fourth ventricle and the convolution of the dorsal cochlear nucleus became visible. The electrode array was then inserted into the lateral recess and correctly positioned with the aid of electrically evoked auditory brainstem responses (EABRs). MAIN OUTCOME MEASURES: Intraoperative EABR and postoperative speech perception evaluation. RESULTS: Auditory sensations were induced in all patients with various numbers of electrodes. Different pitch sensations could be identified with different electrode stimulation. CONCLUSIONS: In the authors' experience, the RS-TM approach is the route of choice for patients who are candidates for ABI when there is a chance of hearing preservation during surgery. If auditory function is lost during surgery, anatomical preservation of the cochlear nerve may allow hearing restoration with a cochlear implant. Direct intraoperative recording of cochlear nerve action potentials (CNAPs) and round window electrical stimulation are mandatory for these purposes. In addition, decompression of the intrameatal portion of the vestibular schwannoma and planned partial tumor resection with hearing preservation are also possible with the RS-TM approach.

Click-evoked responses from the exposed intracranial portion of the eighth nerve during vestibular nerve section: bipolar and monopolar recordings.

We compare the click-evoked compound action potentials from the exposed intracranial portion of the eighth nerve using bipolar and monopolar recording electrodes in patients undergoing vestibular nerve section. It is assumed that a bipolar recording electrode will only record propagated neural activity in the auditory nerve, whereas a monopolar recording electrode may in addition record electrical activity that is conducted passively to the recording site. The results of the present study confirm that the earliest detectable propagated neural activity in the intracranial portion of the auditory nerve occurs with a latency that is close to that of peak II of the brain-stem auditory evoked potentials, and the results also confirm that the late components in the click-evoked compound action potentials that have been demonstrated previously using the monopolar recording technique represent propagated neural activity in the auditory nerve. The results also indicate that the responses that are recorded by a bipolar recording electrode, when the small tips of which are placed on the eighth nerve when it is relatively dry, represent only small populations of nerve fibers. Even when an attempt is made to align the two tips of a bipolar electrode with the course of the auditory nerve, this type of electrode may record from different populations of nerve fibers.