【作者】 金毅；

【导师】 曹克利；

【作者基本信息】 北京协和医学院 ， 耳鼻咽喉科学， 2013， 博士

【摘要】 第一部分：不同脉宽条件下人工耳蜗植入者EABR检测的特点分析目的：比较不同脉宽条件下人工耳蜗植入者EABR的特点,分析脉宽与EABR波V引出率和阈值之间的关系,总结不同脉宽条件对EABR波V引出率和阈值的影响,选择更优化的EABR脉宽测试参数。方法：无残余听力的人工耳蜗植入患者24例(其中耳蜗形态正常12例、LVAS4例、Mondini畸形4例、共同腔畸形2例、内听道狭窄2例)(实验组),筛选条件相近的24例有残余听力的人工耳蜗植入者配对(对照组)。应用改装的Cochlear Freedom人工耳蜗及自制的铂铱合金球电极对拟行人工耳蜗植入的两组者术中分别给予50μs、100μs、200μs不同脉宽的电刺激,Bio-logic Navigator Pro听觉诱发电位仪记录不同脉宽条件下EABR波V引出率和阈值。结果：脉宽50μs、100μs、200μs时,EABR波V引出率实验组(分别为91.7%、91.7%、91.7%)低于对照组(分别为100%、100%、95.8%),而EABR阈值实验组(分别为183.73±8.96CL、151.28±10.05CL、120.56±12.82CL)高于对照组(分别为175.50±9.14CL、142.71±11.45CL、110.63±10.24CL),差异均有统计学意义(P值均〈0.05,t值分别为18.87、16.82、17.64)。结论：蜗内单极刺激能诱发出良好的的EABR波形。无残余听力的患者EABR阈值要明显高于有残余听力的患者。脉宽50μs、100μs相对于脉宽200μs, EABR波形波V引出率高；脉宽50μ s波形分化更好、动态范围广,畸形严重可能需要适当加大刺激量(如将脉宽改为100μ s)。第二部分：不同刺激速率条件下人工耳蜗植入者EABR检测的特点分析目的：比较不同刺激速率条件下人工耳蜗植入者EABR的特点,分析刺激速率与EABR波V引出率之间的关系,总结不同刺激速率对EABR波V引出率影响,选择更优化的EABR刺激速率测试参数,比较优化参数下的EABR阈值和潜伏期。方法：无残余听力的人工耳蜗植入患者16例(其中耳蜗形态正常10例、LVAS3例、Mondini畸形2例、共同腔畸形1例)(实验组),筛选条件相近的16例有残余听力的人工耳蜗植入者配对(对照组)。对拟行人工耳蜗植入的两组者术中分别给予23Hz、35Hz、70Hz不同刺激速率的电脉冲刺激,记录不同刺激速率条件下EABR波V引出率。结果：刺激速率23Hz时EABR波V引出率实验组和对照组都是100%,35Hz、70Hz时EABR波V引出率实验组(分别为87.5%、68.8%)低于对照组(分别为93.8%、87.5%)。脉宽50μs、刺激速率23Hz时,EABR阈值实验组(180.1±6.33CL)高于对照组(172.50±8.37CL)有显著性差异(P<0.05t=8.85),而EABRV波潜伏期实验组(4.42±0.13ms)和对照组(4.43±0.09ms)无显著性差异(P=0.80t=0.27)。结论：刺激速率对EABR波形的波V引出率影响较大,较低的刺激速率所测的EABR波V引出率高。耳蜗畸形的患者对测试所用刺激速率变化更为敏感。脉宽主要影响EABR的阈值及波形分化,而刺激速率主要影响EABR的波V引出率。脉宽50us、刺激速率23Hz是比较理想的刺激条件。第三部分：内听道狭窄患者人工耳蜗术中EABR特点及术后疗效评估目的：探讨内听道狭窄患者EABR特点及与人工耳蜗植入术后听力言语康复效果关系。方法：分析内听道狭窄(IACS)的语前聋人工耳蜗植入患者16例(IACS组),筛选条件相近的16例无内听道狭窄的语前聋人工耳蜗植入者配对(对照组),术中人工耳蜗植入前采用电刺激听觉脑干诱发电位(EABR)评估听觉传导通路,记录EABR波形、阈值和动态范围；对患者的家长和康复教师进行调查随访,根据听觉行为分级标准(CAP)和言语可懂度分级标准(SIR)对患者听力言语康复效果分级评估。采用配对样本T检验比较术前和术后1年患者CAP和SIR评分,Spearman检验对术中EABR分级和术后CAP评分进行相关性分析。结果：IACS组2例患者术中未记录到典型EABR波形,术后开机无反应。IACS组EABR波形分化差于对照组,其EABR阈值(192.5±11.73)高于对照组(168.75±6.94),动态范围(32.50±19.69)小于对照组(80.63±9.04)。术后1年IACS组的听觉言语康复效果的CAP和SIR值(分别为3.47±1.09和1.62±0.50)得分低于对照组(分别为5.06±0.79和2.59±0.58)(P<0.05),但都较术前差异有统计学意义。术中EABR分级和术后CAP评分具有明显相关性(r=0.78,P<0.05)。结论：EABR能够较准确地反映听觉传导通路功能完整性,有利于判断内听道狭窄患者人工耳蜗植入后能否获得听觉反应。EABR辅助人工耳蜗植入前的全面评估,内听道狭窄患者的听觉言语能力可以得到不同程度的康复。更多还原

【Abstract】 Part I analysis of intra-operative EABR characteristics under the conditions of different pulse width in cochlear implant recipientsObjective:To compare the intra-operative electrical evoked auditory brain stem response(EABR) characteristics under the conditions of different pulse width, analysis the relationship of pulse width with EABR wave V lead-out rate and threshold, summarize the affects of different pulse width conditions on EABR wave V lead-out rate and threshold, and select optimized EABR pulse width test parameters.Method:A study was performed on24patients with no residual hearing (12cases with normal cochlear,4cases with LVAS,4cases with Mondini deformation,2cases with common cavity deformation,2cases with internal auditory canal stenosis)(test group) matched with24implantees with residual hearing (control group). With modified Freedom cochlear implant and ball-end platinum-iridium wire electrode, the two groups were given the electrical stimulation of50μs,100μs and200μs pulse width, recording EABR wave V lead-out rate and the threshold under the conditions of different pulse width with Bio-logic Navigator Pro evoked potential instrument.Result:EABR wave V lead-out rate of the test group(91.7%、91.7%and91.7%) was lower than that of the control group(100%、100%and95.8%),while the threshold of the test group(183.73±8.96CL、151.28±10.05CL、120.56±12.82CL) was higher than that of the control group (175.50±9.14CL、142.71±11.45CL、110.63±10.24CL) and differences were statistically significant.(P<0.05, t=18.87、16.82and17.64)Conclusion:Intra-cochlear monopolar stimulation can induce good EABR waveform. Patients with no residual hearing EABR threshold are significantly higher than in patients with residual hearing. EABR wave V lead-out rate under pulse width50μs and100μs was higher than that under pulse width200μs. EABR waveform differentiation was better under pulse width50μs, severe deformity may need to increase the amount of stimulation (pulse width instead of100μs). PartⅡ analysis of intra-operative EABR characteristics under the conditions of different stimulation rate in cochlear implant recipientsObjective:To compare the intra-operative electrical evoked auditory brain stem response(EABR) characteristics under the conditions of different stimulation rate, analysis the relationship of stimulation rate with EABR wave Ⅴ lead-out rate, summarize the affects of different stimulation rate conditions on EABR wave Ⅴ lead-out rate, select optimized EABR stimulation rate test parameters, and compare the EABR threshold value and latency. Method:A study was performed on16patients with no residual hearing (10cases with normal cochlear,3cases with LVAS,2cases with Mondini deformation,1cases with common cavity deformation)(test group) matched with16implantees with residual hearing (control group). The two groups were given the electrical stimulation rate of23Hz、35Hz and70Hz, recording EABR wave Ⅴ lead-out rate under the conditions of different stimulation rate. Result: EABR wave Ⅴ lead-out rate of the two groups was100%under the conditions of23Hz.EABR wave Ⅴ lead-out rate of the test group(87.5%and68.8%) was lower than that of the control group(93.8%and87.5%) under the conditions of35Hz and70Hz. The threshold of the test group(180.1±6.33CL) was higher than that of the control group (172.50±8.37CL) and differences were statistically significant.(P<0.05, t=8.85),while the difference of EABR wave Ⅴ latency between two groups was not statistically significant.(P=0.80t=0.27) Conclusion:The cochlear with malformations is more sensitive to the changes of the stimulation rate. Pulse width mainly affects EABR threshold and waveform differentiation, while stimulation rate mainly affects EABR wave Ⅴ lead-out rate, lower stimulation rate inducing higher EABR wave Ⅴ lead-out rate. The pulse width50us and stimulation rate23Hz is an ideal stimulus condition. Part III Evaluation of intra-operative EABR characteristics and rehabilitation effects of cochlear implantation in patients with internal auditory canal stenosisAbstract Objective:To investigate the intra-operative electrical evoked auditory brain stem response(EABR) characteristics and the hearing and speech rehabilitation effects of cochlear implantation(CI) in patients with internal auditory canal stenosis(IACS). Method:A retrospective study was performed on16patients with IACS(IACS group) matched with16implantees without IACS(control group),who received multi-channel CI because of pre-lingual sensorineural hearing loss. The integrity and functional status of the auditory pathway were assessed by EABR, recording waveforms, threshold sand dynamic ranges intra-operation before Cl. Interviewed the implantees’ parents or teachers, asking them to rate the implantees’ hearing and speech ability according to Categories of Auditory Performance(CAP)and Speech Intelligibility Rating(SIR).Paired T test was performed to compare scores of CAP and SIR between before and1year after CI, while Spearman test was performed to compare correlation between EABR grades and post-operative CAP scores. Result: Among the IACS group,2cases weren’t recorded typical EABR waveforms and without auditory response1year after a successful CI. The EABR waveforms in the IACS group were poorer than that in the control group, their EABR thresholds higher than the control group, and their EABR dynamic ranges less than the control group. The hearing and speech rehabilitation after CI showed that the results of CAP and SIR values (3.47±1.09and1.62±0.50) scored significantly lower than the control group(5.06±0.79and2.59±0.58)(P<0.05), but significantly increased compared with pre-operation. Intra-operative EABR grades and post-operative CAP scores showed significant correlation(r=0.78, P<0.05). Conclusion:Intra-operative EABR can accurately monitor the integrity and functional status of the auditory pathway, be of important clinical value in predicting whether patients can acquire auditory responses with the aid of CI. CI can help patients with IACS to improve the ability of hearing and speech with EABR to screen out compatible implantees.更多还原