失代偿性耳鸣的心理声学和临床特征及复合声治疗突发性聋患者耳鸣的临床研究

发布时间：2018-01-19 21:36

本文关键词： 耳鸣临床特征诱发因素复合声突发性聋评价　出处：《南方医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：背景与目的耳鸣,被誉为耳科学三大难题(耳鸣、耳聋、眩晕)之首。随着我国社会事业的高速发展,耳鸣发病率也随着人群所承受的社会压力及噪声污染的加重而逐步提高。根据流行病学调查保守估计,我国耳鸣发生率约为10%,患者人群多达1.3亿人,其中约有20%-25%的耳鸣患者在不断地求医。久治不愈的耳鸣可导致失眠、焦虑、恐惧、抑郁,并带来家庭、生活和工作等种种社会问题,严重影响人们的生活质量。但耳鸣的发病机制复杂,至今研究仍不十分清楚。但现有相关研究证实,听觉传导途径中的神经纤维异常电活动、边缘系统与自主神经系统的紊乱等机制共同参与并形成了耳鸣及其相关症状。不同性质的耳鸣决定了诊疗方式的不同。“失代偿性耳鸣”表现为耳鸣较为严重,可分散患者注意力,并可引起睡眠障碍、焦虑、抑郁、恐惧等精神症状,这类耳鸣患者需要接受个体化的干预和综合治疗。但如何量化患者的失代偿程度,目前在临床上尚没有统一的方法和标准。国内外的耳鸣指南,给出了一些耳鸣评价量表,用以评估患者的失代偿程度,但尚缺乏耳鸣专家的共识和统一的评分标准。针对这一类耳鸣人群的临床研究,国外文献报道甚少,检索国内文献,尚没有相关报道。所以针对这类人群的临床特征有必要做进一步的探讨和研究,为临床诊疗提供参考依据。声治疗常用于病因不明且治疗方法不多的慢性耳鸣,较少应用于药物治疗常有效的急性耳鸣。突发性耳聋是耳科常见疾病,全国多中心突聋临床研究结果显示,在1024例单侧突聋患者中,864例(84.38%)伴有耳鸣,18例(1.76%)伴有颅鸣。突发性聋治疗不及时或不规范有较高的耳聋和耳鸣致残率。为更好的治疗突发性聋伴有的耳鸣症状,减轻耳聋、耳鸣致残率,本文观察了应用与不应用复合声治疗突发性聋伴耳鸣患者的疗效差异,探讨了疗程设计和治疗方式,总结了复合声治疗耳鸣的临床经验,为更好地应用复合声治疗急性耳鸣提供参考依据。1观察对象及方法1.1失代偿性耳鸣的心理声学及临床特征分析1.1.1受试对象收集于2013年10月至2014年7月,就诊于南方医科大学南方医院耳鼻咽喉头颈外科门诊的耳鸣患者,其临床资料628例,823耳(单耳433例,双耳195例)。1.1.2检测项目纯音测听、耳鸣匹配、残余抑制试验：耳鸣减轻大于20%记为残余抑制阳性,无改变或减轻小于20%记为阴性。1.1.3量表填写《耳鸣问诊量表》包含患者的就诊经历、耳鸣性质,患者是否伴有全身性疾病和疾病类型、响度VAS标尺等。《耳鸣严重程度自评表》根据6项指标的总评分将耳鸣的严重程度由轻到重分为Ⅰ-Ⅴ级。失代偿型耳鸣患者入组标准：在《耳鸣严重程度自评表》中,耳鸣对(睡眠、工作、情绪)的影响的选项(不影响、有时影响、经常影响、非常影响),3个问题没有勾选(不影响)的患者。1.1.4统计学分析用SPSS13.0软件完成统计学处理,按资料类型和检验目的,分别进行t检验、卡方检验、Pearson相关性检验,显著性水准为0.05。1.2复合声治疗突发性聋患者耳鸣的临床对照研究1.2.1受试对象收集于2013年9月至2014年4月,就诊于南方医科大学南方医院耳鼻咽喉科门诊及收治住院的突发性聋伴耳鸣患者96例。突发性聋的诊断标准采用《突发性聋的诊断和治疗指南》(2005年,济南)。按就诊时间顺序持随机序列号分入试验组和对照组,每组48例。1.2.2试验过程试验组采用突发性聋常规药物治疗+复合声治疗,对照组仅用药物治疗。1.2.3试验组检测项目纯音测听、耳鸣问诊、复合声匹配、残余抑制试验。复合声匹配步骤：类比法在纯音、脉冲纯音、白噪声、窄道噪声、言语噪声等声源中选择最近似的声音作为掩蔽声,强度为最小掩蔽响度+10dBHL,同时加入患者喜欢的音乐,根据检测结果得出最佳复合声。1.2.4复合声治疗方法疗程掩蔽声单耳给声,响度不得高于90dBHL,若患耳对应频率听力损失超过90dBHL,则采用健侧耳给声；音乐声双耳给声,响度控制在40-70 dBHL间,以健侧耳舒适为标准。2次/日,30分钟/次,治疗30天,30天后患者在家中用电脑通过高保真耳机双耳播放轻音乐治疗,治疗60天,2次/日,60分钟/次。1.2.5评价指标记录患者就诊或入院时、治疗第30天及第90天的耳鸣视觉量表响度评分(Visual Analogue Scale, VAS)、耳鸣致残量表评分(Tinnitus Handicap Inventory, THI)中文版、焦虑自评量表评分(Self-rating Anxiety Scale, SAS)及纯音听阈阈值。1.2.6统计学分析用SPSS13.0软件完成统计学处理,按资料类型和检验目的,分别进行t检验、卡方检验、Pearson相关性检验,显著性水准为0.05。2结果2.1失代偿性耳鸣的心理声学及临床特征分析2.1.1代偿性和失代偿性各年龄段人数构成比有差异(χ2=16.535,V=3,P=0.001)。30岁组失代偿性人数比例最高,≥60组岁男性代偿性人数比例最高(χ2=13.786,V=3,P=0.003)。2.1.2失代偿性453例中,持续性耳鸣434例(95.8%),代偿性175例中,持续性耳鸣110例(62.9%),两者间构成比有统计学差异(χ2=118.275,V=1,P=0.000)。2.1.3 175例代偿性耳鸣与453例失代偿性耳鸣响度VAS评分均数的t检验：4.85±2.46 vs 6.61±2.40,两者有显著性差异(P=0.000)。2.1.4就诊分类①既往有1-3次耳鸣就诊经历的236例(52.2%)；②急性耳鸣患者首次就诊107例(23.6%)；③因耳鸣反复求医60例(13.2%)；④长期患有耳鸣,但首次就诊50例(11%)。2.1.5耳鸣音调描述呈蝉鸣音、嗡嗡声的占62%,左侧耳鸣最多,右耳其次,双耳最少；单调、复调性耳鸣的左、右、双侧别构成比有显著性差异(χ2=49.012,V=2,P=0.000)；耳、颅鸣的左、右、双侧构成比有显著性差异(χ2=7.426,V=2,P=0.024)：正常、受损听力的左、右、双侧构成比无显著性差异(χ2=1.781,V=1,P=0.41)。2.1.6失代偿性耳鸣音调最多的是8000、6000和500 Hz,残余抑制阳性率最高的是500、6000和8000 Hz；呈现低频和高频残余抑制阳性率高,中频相对较低。残余抑制阳性率：梅尼埃病突发性耳聋其他类型耳鸣。2.1.7 153例听力曲线呈下降型的感音神经性聋患者中有112例耳鸣音调在8000Hz,41例音调非8000Hz；以听阈50dBHL为界,8000Hz听阈50dBHL和8000Hz听阈_50dBHL两组的耳鸣音调8000 Hz和音调非8000Hz人数分布有统计学差异(χ2=5.108,V=1,P=0.023)。2.1.8 267/453例(59%)表示有明确诱因导致耳鸣的发生；195/453例(44%)怀疑耳鸣与自身伴随疾病的转归有关；既有诱因又有伴随疾病的患者为96/453例(21.2%)。2.1.9伴有疾病和不伴有疾病的患者耳鸣严重程度分级人数分布无显著性差异(χ2=8.792,V=4,P=0.067)2.2复合声治疗突发性聋患者耳鸣的临床对照研究2.2.1治疗30天后两组患者数据比较：VAS评分(P=0.214)和听力恢复率无统计学差异,THI评分(P=0.004)和SAS(P=0.000)评分有统计学差异。治疗90天后数据比较：VAS评分(0.041)、THI评分(0.000)和SAS评分(0.001)有统计学差异,听力恢复率仍无统计学差异。2.2.2试验组与对照组耳鸣响度VAS评分有统计学差异的变化,出现在治疗前30天(P=0.041),而非31-90天；两组听力恢复率在前30天和31-90天变化值的比较,均无统计学差异。2.2.3对照组内部(前30天与31-90天)耳鸣VAS评分无统计学差异,听力恢复率前30天明显好于31-90天(P=0.000)；试验组内部耳鸣VAS评分和听力恢复率前30天明显好于31-90天(P=0.000)。2.2.4治疗30天的患者仅耳鸣响度VAS评分与THI评分、THI评分与听力恢复率不存在相关性(P≥0.05),治疗90天仅THI评分与听力恢复率不存在相关性(P≥0.05),其余指标均存在两两线性相关(P0.05)。3结论3.1失代偿性耳鸣的心理声学及临床特征分析3.1.1睡眠、工作、情绪均有受影响的失代偿性耳鸣453例(单耳313例,双耳140例)占72.2%。3.1.2调查人群中30岁组年龄段失代偿性人数比例高,这可能与年轻人听觉和边缘神经系统较为敏感,且与工作压力大有关。而≥60岁男性组代偿性人数比例高,可能与患者耳鸣时间较长、老年人耐受能力增强有关。3.1.3失代偿性耳鸣响度VAS评分均数及持续性耳鸣的人数比例,显著高于代偿性耳鸣,这两项指标可能是导致失代偿的重要因素。3.1.4失代偿性耳鸣中52.2%的患者可以耐受,无法耐受的仅占13.2%；大部分的患者仅需通过宣教和咨询,可解除其对耳鸣的担忧或恐惧。3.1.5耳鸣呈蝉鸣音和嗡嗡声的最多；左侧耳鸣、颅鸣均多于右侧；复调性耳鸣在双侧耳鸣患者中出现的比例,显著高于单侧耳鸣患者,可能与双侧不对称性听力下降有关。3.1.6在陡降或缓降型感音神经性听力曲线中,听阈处在50～60dBHL的频率对耳鸣主频有一定影响。3.1.7在伴有感音神经性听力损失的耳鸣中,急性期患者的残余抑制阳性率高于慢性期,在急性期时给予声治疗可能效果更佳。3.1.8耳鸣与诱发因素和全身伴随疾病有密切的联系,生活中尽量避免其诱发因素的同时,应加强对全身伴随疾病的控制。3.1.9本研究暂未发现全身伴随疾病和耳鸣严重程度之间的关系。3.2复合声治疗突发性聋患者耳鸣的临床对照研究3.2.1复合声治疗耳鸣的过程中,所有患者依从性均较好,相对较单纯的掩蔽和习服治疗患者更易接受。3.2.2随着治疗的进行,试验组患者耳鸣响度和焦虑情绪逐渐减轻,复合声治疗效果显现。3.2.3突发性聋伴耳鸣发病后应尽快对耳鸣进行声治疗。3.2.4通过对比可以看出,实验组前30天耳鸣的治疗效果要好于第31-90天,对照组无差异,这可能与试验组应用了声治疗,而对照组没有采用,但也可能与复合声和音乐声治疗效果有差异有关。3.2.5治疗30天耳鸣响度VAS评分与THI评分、THI评分与听力恢复率不存在相关性,治疗90天仅THI评分与听力恢复率不存在相关性,这可能与THI量表包含更丰富的评价功能有关,也可能与发病仅1周的患者THI量表认知理解存在误差,影响了总体相关性评价有关。
[Abstract]:Background and objective tinnitus, known as the three major problems of otology (tinnitus, deafness, vertigo) first. With the rapid development of social undertakings in China, the incidence of tinnitus with increased population social stress and noise pollution gradually increased. According to the epidemiological investigation of a conservative estimate, China's incidence of tinnitus about 10% people, as many as 130 million people, of which about 20%-25% in the treatment of patients with tinnitus constantly. Persistent tinnitus can cause insomnia, anxiety, fear, depression, and family, social problems in life and work, seriously affecting people's quality of life. But the pathogenesis of tinnitus is complex, since the study but that is still not very clear. The existing research, the nerve fibers of abnormal electrical activity in the auditory pathway, limbic system and autonomic nervous system disorders such as joint participation and the formation mechanism of tinnitus and related disorders Like. The different nature of the different ways of diagnosis and treatment of tinnitus decided. "Decompensated tinnitus tinnitus" is more serious, can disperse the patients' attention, and can cause sleep disorders, anxiety, depression, fear and other psychiatric symptoms, the tinnitus patients need to accept individualized intervention and comprehensive treatment. But how to quantify patients in the current clinical decompensation degree, there is no unified method and standard. Tinnitus guide at home and abroad, gives some tinnitus assessment scale to assess patients with decompensated degree, but there is still a lack of standard for evaluation of tinnitus expert consensus and unity. According to the clinical study of this type of tinnitus groups, foreign reports the literature about the domestic literature retrieval, there is no relevant reports. So the clinical features for this kind of people it is necessary to do further study and research, to provide reference for clinical diagnosis and treatment. The sound is usually used to treat disease For unknown and few treatment options for chronic tinnitus acute tinnitus is rarely applied in drug therapy is often effective. Sudden deafness is a common disease in otology, multicenter clinical study showed that sudden deafness, in 1024 cases of patients with unilateral sudden deafness in 864 cases (84.38%) accompanied by tinnitus, 18 cases (1.76%) with cranial Ming. The treatment of sudden deafness is not timely or not standardized high deafness and tinnitus disability. For better treatment of sudden deafness accompanied by tinnitus symptoms, reduce the morbidity of deafness, tinnitus, the curative effect difference between application and application of composite sound is not the treatment of sudden deafness and tinnitus patients, discusses the course design and the treatment methods, summarized the clinical experience in the treatment of tinnitus sound composite, for better application of composite sound to provide reference for.1 observation and clinical features of psychological acoustic object and method of 1.1 decompensated tinnitus by analysis of 1.1.1 treatment of acute tinnitus Samples collected from October 2013 to July 2014, admitted to Nanfang Hospital of Southern Medical University Department of Otolaryngology Head and neck surgery outpatient tinnitus patients, the clinical data of 628 cases, 823 ears (single ear in 433 cases, 195 cases of binaural).1.1.2 detection program, pure tone audiometry, tinnitus, tinnitus, residual inhibition test: reduce more than 20% recorded as residual inhibition positive, no change or reduce less than 20% can fill in "inquiry scale > tinnitus patients contain experience tinnitus properties table was negative for.1.1.3, whether patients with systemic disease and disease types, etc.. VAS scale loudness of tinnitus severity questionnaire > tinnitus severity from light to heavy according to 1 V - according to the total score of 6 indicators. The decompensated type tinnitus patients enrolled in < tinnitus severity questionnaire >, tinnitus (to sleep, work, emotional) influence the options (not, sometimes, often Effect of impact, 3) is not checked (not) with.1.1.4 statistical analysis software SPSS13.0 statistical processing, according to data type and testing purposes, respectively, t test, chi square test, Pearson correlation test, the level of significance for clinical 0.05.1.2 composite sound treatment of tinnitus patients with sudden deafness control study of 1.2.1 subjects were collected from September 2013 to April 2014, admitted to Nanfang Hospital of Southern Medical University Department of Otorhinolaryngology clinic and admitted to hospital sudden deafness and tinnitus in 96 patients. The diagnostic criteria of sudden deafness by "the diagnosis and treatment of sudden deafness Guide > (2005, Ji'nan). According to the visiting sequence with random sequence number is divided into experiment group and control group, 48 cases in each.1.2.2 experiment process group with sudden deafness routine therapy + composite sound treatment, the control group only treated with medicine.1.2.3 group Test pure tone audiometry, tinnitus interrogation, composite acoustic matching, residual inhibition test. Step matching composite sound: analogy in tone, tone pulse, white noise, channel noise, speech noise sound source in recent voice as the masker intensity, minimum masking loudness +10dBHL, while adding patients love music according to the test results, the optimum composite sound.1.2.4 composite sound treatment course of masker sound to monaural loudness, not more than 90dBHL, if the ear corresponding to the frequency of hearing loss is more than 90dBHL, the normal ear to sound; music for binaural sound, loudness control in 40-70 dBHL, with normal ear comfort as the standard.2 / day, 30 minutes / time, for 30 days, 30 days with computer play light music therapy by high fidelity headset ears at home, for 60 days, 2 times / day, 60 minutes / time.1.2.5 evaluation index records of patients or into The hospital, for thirtieth days and 90 days of the visual scale score of tinnitus loudness (Visual Analogue Scale, VAS), tinnitus handicap scale (Tinnitus Handicap Inventory, THI Chinese version), self rating Anxiety Scale score (Self-rating Anxiety, Scale, SAS) threshold threshold.1.2.6 SPSS13.0 statistical analysis software to statistical treatment and pure tone, according to data type and testing purposes, respectively, t test, chi square test, Pearson correlation test, significant level and clinical characteristics of the psychological acoustic 0.05.2 results of 2.1 decompensated tinnitus 2.1.1 compensated and decompensated age number analysis the proportion difference (x 2=16.535, V=3, P=0.001) the.30 age group decompensated the highest proportion, more than 60 year old male compensatory group the highest proportion (x 2=13.786, V=3, P=0.003).2.1.2 decompensated 453 cases, persistent tinnitus in 434 cases (95.8%), 175 cases of compensatory, holding Continued tinnitus in 110 cases (62.9%), there was significant difference between the constituent ratio (x 2=118.275, V=1, P=0.000) t test.2.1.3 175 cases of decompensated tinnitus and 453 cases of decompensated tinnitus loudness mean VAS scores: 4.85 + 2.46 vs 6.61 + 2.40, there was significant difference between them (P=0.000) from.2.1.4 the classification of 236 cases of 1-3 patients with tinnitus treatment experience of the times (52.2%); the acute tinnitus patients was 107 cases (23.6%); the doctor repeated due to tinnitus in 60 cases (13.2%); the long suffering from tinnitus, but for the first time in 50 cases (11%) were described.2.1.5 tinnitus pitch humming sound of cicadas, accounted for 62%, the left ear tinnitus most, secondly, ears at least; monotonous, polyphonic tinnitus left, right, both don't have significant differences in the constituent ratio (x 2=49.012, V=2, P=0.000); the left ear, right cranial tinnitus, which showed significant difference in bilateral (x 2=7.426, V=2, P=0.024). Normal, impaired hearing left, Right, there was no significant difference between the proportion of bilateral (x 2=1.781, V=1, P=0.41).2.1.6 decompensated tinnitus pitch is up to 80006000 and 500 Hz, the residual inhibition of the highest positive rate is 5006000 and 8000 Hz; showing the residual low frequency and high frequency suppression positive rate and high frequency is relatively low. The positive rate of residual inhibition.2.1.7 of Meniere's disease with sudden deafness tinnitus 153 cases of other types of audiometric curve decreasing type patients with sensorineural hearing loss in 112 cases of tinnitus pitch in 8000Hz, 41 cases of non 8000Hz to 50dBHL tones; hearing threshold for the community, the tinnitus pitch of two groups of 8000Hz 50dBHL and 8000Hz _50dBHL threshold threshold of 8000 Hz and non 8000Hz tone number distribution there were significant differences (2=5.108, V=1, P=0.023).2.1.8 267/453 (59% cases) indicate a clear cause of the occurrence of tinnitus; 195/453 cases (44%) with its suspected tinnitus and prognosis; both cause and with The disease in patients with 96/453 (21.2% cases) of patients with tinnitus severity classification number distribution of.2.1.9 had no significant difference with the disease and without disease (x 2=8.792, V=4, P=0.067) were compared between the two groups data of 2.2 composite sound treatment of tinnitus patients with sudden deafness clinical study of 2.2.1 treatment for 30 days: VAS score (P=0.214) and hearing recovery rate showed no significant difference, THI score (P=0.004) and SAS (P=0.000) score had significant difference. After 90 days of treatment data: (0.041) the VAS score, THI score and SAS score (0) (0.001) had statistical difference, hearing recovery rate is still no significant difference between the test group.2.2.2 score change statistically significant difference between the control group and tinnitus loudness VAS, appeared on the 30 day before treatment (P=0.041), rather than 31-90 days; comparison in the first 30 days and 31-90 days changes in the value of the two groups of hearing recovery rate, there was no statistically significant difference in.2.2.3 group internal (before 3 0 days and 31-90 days) tinnitus VAS was no significant difference between the 30 days before the hearing recovery rate was significantly better than that of 31-90 day (P=0.000); experimental group internal tinnitus VAS score and hearing recovery rate of 30 days before the day was significantly better than that of 31-90 (P=0.000).2.2.4 treatment only VAS tinnitus loudness score and THI scores in patients with 30 days, the THI score and the hearing recovery rate there is no correlation (P = 0.05), only 90 days of treatment with the THI score of hearing recovery rate there is no correlation (P = 0.05), the other indexes are 22 linear correlation (P0.05).3 conclusion the clinical features and psychological acoustics 3.1 decompensated tinnitus analysis 3.1.1 sleep, work, mood have affected decompensated tinnitus in 453 cases (single ear in 313 cases, 140 cases of ears) accounted for 72.2%.3.1.2 population 30 years old age groups in decompensated high proportion, which may be hearing with young people and the edge of the nervous system is more sensitive, and work pressure. But more than 60 years old male group compensatory proportion is high, and the longer time of patients with tinnitus, tolerance of the elderly increase.3.1.3 decompensated tinnitus loudness VAS scores and the number of the number of persistent tinnitus ratio was significantly higher than that of decompensated tinnitus, these two indicators may be caused by the loss of important factors of decompensated.3.1.4 52.2% patients with compensatory tinnitus can be tolerated, intolerance accounted for only 13.2%; most of the patients only through education and counseling, most can relieve the worry or fear of tinnitus, tinnitus is.3.1.5 sound and hum of cicadas; the left cranial tinnitus, Ming were more than right; polyphonic tinnitus in bilateral tinnitus patients the proportion was significantly higher than that in patients with unilateral tinnitus, may be related to.3.1.6 in the steep drop or slow down the sensorineural hearing curve decreased and bilateral asymmetry in the hearing threshold, 50 ~ 60dBHL frequency The frequency of tinnitus tinnitus.3.1.7 sensorineural hearing loss in patients with certain effects in patients with positive rate of residual inhibition was higher than that in chronic phase, given the sound treatment may be better.3.1.8 tinnitus and predisposing factors and systemic diseases are closely linked with in the acute phase, to avoid the predisposing factors and life that should strengthen the body with control of.3.1.9 disease in this study has not yet found the body accompanied by.3.2 composite sound between disease and severity of tinnitus treatment of tinnitus patients with sudden deafness clinical study of 3.2.1 composite sound treatment of tinnitus in the process, all the patients compliance were better than the pure relative masking and acclimatization treatment patients are more likely to accept.3.2.2 as the treatment, experimental group patients with tinnitus loudness and anxiety is reduced gradually, the treatment effect of complex sound show.3.2.3 sudden deafness tinnitus After the onset of.3.2.4 treatment should be performed as soon as possible sound of tinnitus can be seen by comparing the experimental group 30 days before the treatment of tinnitus is better than the first 31-90 days, control group had no difference, which could be applied with the acoustic treatment and the experimental group, while the control group did not use, but also may have therapeutic difference about.3.2.5 30 days tinnitus loudness VAS and the THI score and the composite sound and music therapy, THI score and hearing recovery rate there is no correlation, only 90 days of treatment with the THI score of hearing recovery rate there is no correlation, which may contain more abundant assessment function and THI scale, also may be associated with the onset of only 1 weeks in patients with THI scale cognitive

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R764.4

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