Skip to main content
Log in

Intraoperative Funktionsüberwachung des N. facialis

Operationen an Vestibularisschwannomen

Intraoperative monitoring of the facial nerve

Vestibular schwannoma surgery

  • Leitthema
  • Published:
HNO Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Bei Operationen an Vestibularisschwannomen gehören Schädigungen des N. facialis mit konsekutiven funktionellen Defiziten zu den bedeutendsten Komplikationen. Die intraoperative Funktionsüberwachung soll dazu dienen, diese Komplikation zu vermeiden.

Fragestellung

Welche Methoden zur intraoperativen Funktionsüberwachung haben sich entwickelt? Welche Methoden sind aktuell in Gebrauch, und welche Ziele können damit sinnvoll verfolgt werden?

Material und Methoden

Auswertung und Zusammenfassung der Literatur, Diskussion der vorhandenen Methoden und ihrer Fähigkeiten, die gesteckten Ziele zu erreichen.

Ergebnisse

Die intraoperative Funktionsüberwachung soll es ermöglichen, den N. facialis intraoperativ sicher zu identifizieren. Sie soll potenziell schädigende Ereignisse anzeigen und während der Operation eine Einschätzung über den zu erwartenden postoperativen Funktionszustand des Nervs erlauben. Zur Verfügung stehen die elektrische Direktstimulation, das freilaufende Elektromyogramm (EMG), evozierte Potenziale des N. facialis und das prozessierte EMG.

Schlussfolgerungen

Die Identifikation und Verfolgung des Nervs im Operationssitus mittels der elektrischen Direktstimulation ist gut möglich. Potenziell schädigende Ereignisse können mit allen anderen Methoden in Echtzeit oder nahezu in Echtzeit angezeigt werden. Die intraoperative Prognostik wird derzeit aber bei allen verfügbaren Methoden durch falsch-positive Untersuchungsergebnisse belastet und ist nur bedingt verlässlich.

Abstract

Background

In vestibular schwannoma surgery, facial nerve injury with consecutive functional impairment is one of the most important complications. Intraoperative monitoring of facial nerve function has been developed in order to avoid this complication.

Objective

Which methods for intraoperative monitoring have been developed? Which methods are in use today and what can they achieve in modern vestibular schwannoma surgery?

Material and methods

This article provides an evaluation and summary of the literature, as well as a discussion of the methods and their ability to achieve the goals of intraoperative monitoring.

Results

Intraoperative functional monitoring aims to identify and map the facial nerve in the surgical field during surgery. It also aims to identify potentially damaging events and allow for intraoperative prognosis of functional outcome. Available methods are direct electrical stimulation, free-running electromyogram (EMG), facial nerve evoked potentials, and processed EMG.

Conclusion

Identification and mapping of the facial nerve in the surgical field can be reliably achieved by direct electrical stimulation; potentially dangerous events can be identified in real time by the free-running EMG and the processed EMG, and almost in real time by facial nerve evoked potentials. Intraoperative prognostics are hampered by false-positive results with all available methods and have limited reliability.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. Acioly MA, Liebsch M, Carvalho CH, Gharabaghi A, Tatagiba M (2010) Transcranial electrocortical stimulation to monitor the facial nerve motor function during cerebellopontine angle surgery. Neurosurgery 66:354–362

    Article  PubMed  Google Scholar 

  2. Alfieri A, Rampp S, Strauss C, Fleischhammer J, Rachinger J, Scheller C, Prell J (2014) The relationship between nervus intermedius anatomy, ultrastructure, electrophysiology, and clinical function. Usefulness in cerebellopontine microsurgery. Acta Neurochir (Wien) 156:403–408

    Article  Google Scholar 

  3. Deletis V (2005) What does intraoperative monitoring of motor evoked potentials bring to the neurosurgeon? Acta Neurochir (Wien) 147:1015–1017

    Article  CAS  Google Scholar 

  4. Delgado TE, Bucheit WA, Rosenholtz HR, Chrissian S (1979) Intraoperative monitoring of facila muscle evoked responses obtained by intracranial stimulation of the facila nerve: a more accurate technique for facila nerve dissection. Neurosurgery 4:418–421

    Article  CAS  PubMed  Google Scholar 

  5. Dong CC, Macdonald DB, Akagami R, Westerberg B, Alkhani A, Kanaan I, Hassounah M (2005) Intraoperative facial motor evoked potential monitoring with transcranial electrical stimulation during skull base surgery. Clin Neurophysiol 116:588–596

    Article  PubMed  Google Scholar 

  6. Eisner W, Schmid UD, Reulen HJ, Oeckler R, Olteanu-Nerbe V, Gall C, Kothbauer K (1995) The mapping and continuous monitoring of the intrinsic motor nuclei during brain stem surgery. Neurosurgery 37:255–265

    Article  CAS  PubMed  Google Scholar 

  7. Fukuda M, Oishi M, Takao T, Saito A, Fujii Y (2008) Facial nerve motor-evoked potential monitoring during skull base surgery predicts facial nerve outcome. J Neurol Neurosurg Psychiatr 79:1066–1070

    Article  CAS  PubMed  Google Scholar 

  8. Harner R (2009) Automatic EEG spike detection. Clin EEG Neurosci 40:262–270

    Article  PubMed  Google Scholar 

  9. Harner SG, Daube JR, Ebersold MJ, Beatty CW (1987) Improved preservation of facial nerve function with use of electrical monitoring during removal of acoustic neuromas. Mayo Clin Proc 62:92–102

    Article  CAS  PubMed  Google Scholar 

  10. Harper CM, Daube JR (1998) Facial nerve electromyography and other cranial nerve monitoring. J Clin Neurophysiol 15:206–216

    Article  CAS  PubMed  Google Scholar 

  11. House JW, Brackmann DE (1985) Facial nerve grading system. Otolaryngol Head Neck Surg 93:146–147

    Article  CAS  PubMed  Google Scholar 

  12. Kartush JM (1989) Neurography for intraoperative monitoring of facial nerve function. Neurosurgery 24:300–301

    Article  CAS  PubMed  Google Scholar 

  13. Kartush JM, Niparko JK, Bledsoe SC, Graham MD, Kemink JL (1985) Intraoperative facial nerve monitoring: a comparison of stimulating electrodes. Laryngoscope 95:1536–1540

    Article  CAS  PubMed  Google Scholar 

  14. Kombos T, Suess O, Pietila T, Brock M (2000) Subdural air limits the elicitation of compound muscle action potentials by high-frequency transcranial electrical stimulation. Br J Neurosurg 14:240–243

    Article  CAS  PubMed  Google Scholar 

  15. Matthies C, Raslan F, Schweitzer T, Hagen R, Roosen K, Reiners K (2011) Facial motor evoked potentials in cerebellopontine angle surgery: technique, pitfalls and predictive value. Clin Neurol Neurosurg 113:872–879

    Article  PubMed  Google Scholar 

  16. Moller AR, Jannetta PJ (1984) Preservation of facial function during removal of acoustic neuromas. Use of monopolar constant-voltage stimulation and EMG. J Neurosurg 61:757–760

    Article  CAS  PubMed  Google Scholar 

  17. Moller AR, Jannetta PJ (1985) Monitoring of facial nerve function during removal of acoustic tumor. Am J Otol Suppl:27–29

    CAS  PubMed  Google Scholar 

  18. Morota N, Deletis V, Constantini S, Kofler M, Cohen H, Epstein FJ (1997) The role of motor evoked potentials during surgery for intramedullary spinal cord tumors. Neurosurgery 41:1327–1336

    Article  CAS  PubMed  Google Scholar 

  19. Pechstein U, Cedzich C, Nadstawek J, Schramm J (1996) Transcranial high-frequency repetitive electrical stimulation for recording myogenic motor evoked potentials with the patient under general anesthesia. Neurosurgery 39:335–343

    Article  CAS  PubMed  Google Scholar 

  20. Prass RL, Kinney SE, Hardy RW Jr., Hahn JF, Luders H (1987) Acoustic (loudspeaker) facial EMG monitoring: Part II. Use of evoked EMG activity during acoustic neuroma resection. Otolaryngol Head Neck Surg 97:541–551

    Article  CAS  PubMed  Google Scholar 

  21. Prass RL, Luders H (1986) Acoustic (loudspeaker) facial electromyographic monitoring: Part 1. Evoked electromyographic activity during acoustic neuroma resection. Neurosurgery 19:392–400

    Article  CAS  PubMed  Google Scholar 

  22. Prell J, Rachinger J, Scheller C, Alfieri A, Strauss C, Rampp S (2010) A real-time monitoring system for the facial nerve. Neurosurgery 66:1064–1073

    Article  PubMed  Google Scholar 

  23. Prell J, Rampp S, Romstock J, Fahlbusch R, Strauss C (2007) Train time as a quantitative electromyographic parameter for facial nerve function in patients undergoing surgery for vestibular schwannoma. J Neurosurg 106:826–832

    Article  PubMed  Google Scholar 

  24. Prell J, Strauss C, Rachinger J, Alfieri A, Scheller C, Herfurth K, Rampp S (2014) Facial nerve palsy after vestibular schwannoma surgery: dynamic risk-stratification based on continuous EMG-monitoring. Clin Neurophysiol 125:415–421

    Article  PubMed  Google Scholar 

  25. Prell J, Strauss C, Rachinger J, Scheller C, Alfieri A, Herfurth K, Rampp S (2015) The intermedius nerve as a confounding variable for monitoring of the free-running electromyogram. Clin Neurophysiol 126:1833–1839

    Article  PubMed  Google Scholar 

  26. Rahman I, Sadiq SA (2007) Ophthalmic management of facial nerve palsy: a review. Surv Ophthalmol 52:121–144

    Article  PubMed  Google Scholar 

  27. Rampp S, Prell J, Rachinger JC, Scheller C, Strauss C (2011) Does electrode placement influence quality of intraoperative monitoring in vestibular schwannoma surgery? Cen Eur Neurosurg 72:22–27

    Article  CAS  Google Scholar 

  28. Rampp S, Prell J, Thielemann H, Posch S, Strauss C, Romstock J (2007) Baseline correction of intraoperative electromyography using discrete wavelet transform. J Clin Monit Comput 21:219–226

    Article  PubMed  Google Scholar 

  29. Rampp S, Rachinger J, Scheller C, Alfieri A, Strauss C, Prell J (2012) How many electromyography channels do we need for facial nerve monitoring? J Clin Neurophysiol 29:226–229

    Article  PubMed  Google Scholar 

  30. Romstock J, Strauss C, Fahlbusch R (2000) Continuous electromyography monitoring of motor cranial nerves during cerebellopontine angle surgery. J Neurosurg 93:586–593

    Article  CAS  PubMed  Google Scholar 

  31. Sala F, Manganotti P, Tramontano V, Bricolo A, Gerosa M (2007) Monitoring of motor pathways during brain stem surgery: What we have achieved and what we still miss? Neurophysiol Clin 37:399–406

    Article  CAS  PubMed  Google Scholar 

  32. Samii M, Gerganov VM, Samii A (2010) Functional outcome after complete surgical removal of giant vestibular schwannomas. J Neurosurg 112:860–867

    Article  PubMed  Google Scholar 

  33. Schmitt WR, Daube JR, Carlson ML, Mandrekar JN, Beatty CW, Neff BA, Driscoll CL, Link MJ (2013) Use of supramaximal stimulation to predict facial nerve outcomes following vestibular schwannoma microsurgery: results from a decade of experience. J Neurosurg 118:206–212

    Article  PubMed  Google Scholar 

  34. Strauss C, Prell J, Rampp S, Romstock J (2006) Split facial nerve course in vestibular schwannomas. J Neurosurg 105:698–705

    Article  PubMed  Google Scholar 

  35. Szelenyi A, Deletis V (2004) Motor evoked potentials. J Neurosurg 101:563–564

    PubMed  Google Scholar 

  36. Taniguchi M, Cedzich C, Schramm J (1993) Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. Neurosurgery 32:219–226

    Article  CAS  PubMed  Google Scholar 

  37. Zentner J (1989) Influence of anesthetics on the electromyographic response evoked by transcranial electrical cortex stimulation. Funct Neurol 4:299–300

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to J. Prell.

Ethics declarations

Interessenkonflikt

J. Prell, C. Strauss, S. K. Plontke und S. Rampp geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Prell, J., Strauss, C., Plontke, S.K. et al. Intraoperative Funktionsüberwachung des N. facialis. HNO 65, 404–412 (2017). https://doi.org/10.1007/s00106-017-0340-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00106-017-0340-1

Schlüsselwörter

Keywords

Navigation