Summary:A new application of auditory evoked potentials using direct cochlear nerve action potentials (CNAPs) for monitoring middle fossa acoustic neuroma resection with attempted hearing preservation is described. Twenty patients have been studied to date. With this technique, a monitoring electrode is secured between the floor of the internal auditory canal and the dura adjacent to the cochlear nerve in an extradural location. Standard auditory evoked potential techniques with click stimuli and microelectrical recording allow observation of nearfield waveforms in seconds versus several minutes required for farfield potentials recorded from the scalp. Advantages of this technique over auditory brainstem response monitoring may include nearly real time measurement of potentials, improved surgeon learning curve and possibly higher rates of hearing preservation, and applicability to all patients undergoing hearing-preservation surgery independent of presence or absence of ABR tracing. Immediate changes in amplitude and latency of waveforms appear to compare with reversible and irreversible intraoperative auditory system damage, thereby guiding surgical maneuvers.