Facial nerve prognostication in vestibular schwannoma surgery: the concept of percent maximum and its predictability.

Objectives/hypothesis: To evaluate percent maximum as an intraoperative facial nerve measurement for the long-term prognostication of vestibular schwannoma surgery.
Study Design: Prospective cohort study.
Methods: Evoked amplitude responses to varying levels of stimulus intensity at the nerve root were compared to their supramaximal responses (Mmax) as a percentage, that is, percent maximum. Response charts were constructed for each of the levels of stimulus intensity between 0.05 to 0.3 mA, vis-à-vis facial nerve outcome at 1 year, to establish sensitivities, specificities, and positive predictive values. Logistic regression analyses were used to determine the impact of sex, age, tumor size, and historically defined response parameter on outcomes.
Results: Seventy-eight patients who underwent vestibular schwannoma surgeries between 2005 and 2010 were studied. The positive predictive value (PPV) of a good facial nerve outcome, defined as House-Brackmann (HB) I-II, increases with percent maximum responses. A 90% PPV could be established when the response amplitude was 50% or greater compared to Mmax. Long-term prognostication appeared best at a higher stimulus level of 0.3 mA. Age and sex did not have an impact on outcome, but tumor size did; with each centimeter increase in tumor size, patients were 105% more likely to have a poor outcome (HB III-VI). If the response parameter "≥240 μV at 0.05 mA" was not present, there was a trend toward poor outcome.
Conclusions: Percent maximum is a valid intraoperative monitoring measure to prognosticate long-term facial nerve outcome. It should be considered a complementary method of monitoring when evoked responses do not conform to conventional predictors.
Level of Evidence: 4.
(Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)