鼓室硬化的术前诊断

发布时间：2018-03-30 09:00

本文选题：鼓室硬化　切入点：术前诊断　出处：《郑州大学》2011年硕士论文

【摘要】：研究背景鼓室硬化(Tympanosclerosis)又称为鼓室硬化症,是指中耳在长期的慢性炎症愈合后,所遗留的中耳结缔组织退行性改变,是引起传导性聋的重要原因之一；其主要病理变化表现为中耳粘膜下层及鼓膜固有层出现透明变性和钙质沉着。鼓室硬化是由Von Troltsch于1869年首次进行详细描述并提出“硬化(sclerosis)'”一词。1956年,Zollner在进行了大量鼓室成形术后发表了“鼓室硬化”论文,鼓室硬化因此得以正式命名。国内外关于鼓室硬化发病率的报道不一,国外为20-43%[2,3],国内为3.7-11.7%。目前,鼓室硬化的病因及发病机制仍不清楚。随着鼓室成形术的广泛开展和手术显微镜的普遍应用,该病越来越受到关注,有关鼓室硬化病因学和治疗效果的研究报道逐渐增多,而诊断方面的较少。目前鼓室硬化通常依赖于手术探查和病理得以确诊。如何提高鼓室硬化的术前诊断水平,即术前确诊、明确病变性质和范围、了解听骨链情况,以便制定恰当的手术方案,更好地与患者进行术前沟通,是目前耳科临床尚待解决的问题。目的 1.研究鼓室硬化的颞骨高分辨率CT (High Resolution computed tomography, HRCT)的特点,探讨HRCT对鼓室硬化的诊断及其病变范围和听骨链状态的判断价值。 2.研究鼓室硬化纯音听闽测定的听力学特点,探讨纯音测听对鼓室硬化听骨链功能状态评估的术前判定价值。 3.研究并探讨耳内窥镜对伴有鼓膜穿孔的鼓室硬化病例的病变性质、病变范围和听骨链状态的诊断价值。 4.研究联合应用HRCT、纯音测听和耳内窥镜三种术前检查方法,对鼓室硬化病例的确诊及漏诊结果进行综合分析,探讨联合诊断对鼓室硬化的确诊、病变性质、病变范围和听骨链状态的判定价值及对术前手术方案制定和预后评估的指导意义。研究对象和方法1.研究对象：纳入标准：①临床诊断需手术探查鼓室或开放乳突的鼓室硬化病例；②临床、听力和影像资料(HRCT数据)均完整；③首次手术,非修正性多次手术；④手术由同一治疗组成员完成。 2006年8月到2010年8由同一治疗组成员完成的鼓室硬化住院手术52例56耳符合研究纳入标准。其中男35例,女17例,年龄12-64岁,平均35.74岁。病史1-40年,平均16.48年。双耳34例,单耳18例,其中双耳均手术的4例。其中鼓膜完整8耳,合并鼓膜穿孔者48耳,其中紧张部穿孔39耳,松弛部穿孔9耳。所有病例均经手术和病理诊断确诊为鼓室硬化。 2.检查方法和结果判断 HRCT:采用美国GE64排Lightspeed VCT扫描仪进行轴位扫描和冠位重建。轴位扫描基线为听眶上线,扫描范围自弓状隆起至外耳道下壁。靶扫描,骨算法重建,矩阵为512×512,扫描层厚、层间距均为1mm,窗宽4000Hu,窗位700Hu, FOV=32。以鼓膜、鼓室及听骨周围出现高密度钙化或骨化影像为鼓室硬化的特征性改变,以鼓膜增厚、鼓室乳突软组织密度影、听骨及鼓室壁破坏等为非特征性改变。纯音测听：术前纯音听阈测定各变量指标：将500,1000,2000,4000Hz气导和骨导的均值作为平均纯音听闽PTA (pure-tone audiometry)气骨导差ABG (air bone gap)为同期气导AC(air conduction)减去骨导BC(bone conduction)的值。以ABG30dB作为听骨链固定或中断的判断标准。耳内窥镜检查：对伴有鼓膜穿孔的病例进行耳内窥镜检查,记录病变情况。以鼓膜、鼓室腔及听骨周围出现钙化或硬化病灶作为鼓室硬化的诊断标准。 3.手术探查和病变分型全麻,常规探查鼓室或/和开放乳突。根据病变范围和听骨链情况将病例分成4型：Ⅰ型,硬化病灶仅累及鼓膜；Ⅱ型,硬化病灶累及上鼓室致锤砧骨固定,或与盾板融合,镫骨活动良好且结构完整;Ⅲ型,上中鼓室硬化病灶累及听骨链致镫骨固定；Ⅳ型,鼓室及鼓窦充满硬化组织致听骨链包裹固定,部分听骨破坏吸收。 4.对比研究和统计分析 ①颞骨HRCT表现与手术探查结果进行对比分析,统计各型诊断符合率 ②纯音测听结果与术中病变分型和听骨链状态的统计分析。 ③耳内窥镜检查与术中探查结果进行对比研究。 ④分析颞骨HRCT诊断后的漏诊病例的纯音测听特点和耳内窥镜检查结果,对该类病例进行分析。结果 1.颞骨HRCT表现与手术探查结果术前CT表现：①鼓膜：增厚20耳,钙化29耳,穿孔44耳；②鼓窦、鼓室：钙化灶或高密度骨化影23耳,钙化灶或高密度骨化影与软组织影共存9耳,仅见软组织影7耳；③乳突腔：软组织影6耳；④听骨链：钙化包裹21耳,虫蚀样改变或以骨质破坏为主且未见中断15耳,骨质破坏且中断6耳；⑤鼓室腔及听骨链未见明显异常14耳。术中探查发现：①鼓膜：增厚24耳,钙化33耳,穿孔48耳；②鼓窦及鼓室：仅见钙化灶或硬化斑块20耳,合并有肉芽19耳,合并胆脂瘤4耳,合并慢性分泌性中耳炎2耳,鼓窦及鼓室未见异常11耳；③乳突腔肉芽组织6耳；④听骨链：周围硬化灶致听骨固定,其中锤砧骨固定21耳,镫骨固定14耳,全听骨链包埋10耳；仅见听骨的钙化包裹14例,钙化包裹并骨质破坏但尚未中断22耳,钙化包裹并骨质破坏且中断9耳；听骨链未见异常11耳。高分辨CT未见钙化者18(11+7)耳,其中1l耳影像学表现有鼓膜穿孔外未见其他明显异常,此11耳经手术探查存在鼓膜钙化4耳,鼓窦、上鼓室有钙化9耳,鼓岬表面有钙化5耳,听骨链被钙化包裹7耳,5耳为锤、砧骨固定型,2耳为镫骨固定型；另外7耳影像学仅表现为软组织影,手术探查发现鼓膜钙化1耳,鼓窦上鼓室钙化灶2耳,鼓岬表面钙化3耳,听骨链钙化包裹1耳。术中病变分型及CT拟分型诊断符合率：Ⅰ型11耳,符合率9//11=81.82%；Ⅱ型21耳,符合率14/21=66.67%；Ⅲ型14耳,符合率6/14=42.86%；IV型10耳,符合率3/10=30%；其中影像拟诊断病例中分型诊断和手术探查一致的仅有32耳,I型的诊断率高,其他均不高,总的分型诊断符合率为57.14%。 CT诊断总诊断率为67.86%,漏诊率为18/56=32.14% 2.纯音测听特点与术中病变分型术前测听结果：①气导听阈范围为35-65dBHL,②骨气导间距≥30dBHL51耳,≤30dBHL5耳；Ⅰ型之外的所有病例骨气导间距均≥30dBHL。③34耳的听力图出现类Carchart切迹改变。术中探查听骨链功能：完整并活动良好11耳,锤砧骨固定14耳,镫骨固定21耳,全听骨链固定10耳；听骨链钙化包裹22耳,骨质破坏但尚未中断16耳,骨质破坏并中断7耳,听骨链无异常11耳。术中病变分型及各型测听ABG均值：Ⅰ型11耳,ABG=2.60±6.33dBHL;Ⅱ型21耳,ABG=35.70±8.43dBHL;Ⅲ型14耳,ABG=41.33±9.87dBHL;Ⅳ10耳,ABG=39.23+8.75dBHL。 3.耳内窥镜检查 48耳合并鼓膜穿孔者术前耳内镜检查结果：①鼓膜增厚24耳,钙化32耳,穿孔48耳；②鼓岬表面珊瑚礁样或葱皮样钙化灶14耳,合并肉芽10耳,合并胆脂瘤4耳；③听骨链周围出现钙化灶包裹17耳,听骨链合并骨质破坏未见中断7耳,听骨链合并骨质破坏并中断4耳,听骨链未见异常11耳。同一批病人术中发现：①鼓膜增厚24耳,钙化32耳,鼓膜穿孔48耳；②鼓窦及上中鼓室钙化灶或硬化斑块17耳,合并有肉芽10耳,合并胆脂瘤4耳；乳突腔肉芽组织4耳；③听骨链周围硬化灶致锤砧骨固定16耳,镫骨固定11耳,全听骨链包埋10耳；听骨破坏但尚未中断12耳,破坏且中断7耳,听骨链未见明显异常11耳。 4.联合诊断根据术前读片与术中探查结果的对比研究,具鼓室硬化特征性CT表现的38耳的诊断率为100%,占全部鼓室硬化病例的67.86%(38/56)。 CT诊断漏诊18耳,其中鼓膜穿孔12耳,鼓膜完整6耳。对于其中鼓膜穿孔者进行耳内窥镜检查。鼓膜穿孔的12耳病例中,7耳经耳内镜拟诊为鼓室硬化：鼓膜有钙化者4耳,鼓岬表面珊瑚样钙化灶7耳；听骨被钙化包裹4耳；5耳未作出诊断,经手术探查合并肉芽1耳、合并胆脂瘤4耳。对于合并肉芽和胆脂瘤的5耳病例,由于受到合并症的影响通过耳内窥镜并没有做出硬化的诊断,经手术探查确诊为鼓室硬化;而对于其他6耳鼓膜完整的漏诊病例,经手术探查得出4耳为锤、砧骨固定型,2耳为镫骨固定型。漏诊病例中,7耳经耳内窥镜检查能确定诊断,二者的联合诊断率为38+7/56=80.36%。根据术前纯音测听结果和术中探查听骨链情况,Ⅱ——Ⅳ型鼓室硬化,即硬化灶波及听骨链者,纯音测听结果ABG均≥30dBHL。分析CT及耳内窥镜检查仍不能确诊的11耳病例,其纯音测听结果ABG均≥30dBHL,推测其听骨链存在固定或中断,应将鼓室硬化列入可能诊断之一结论 1.鼓室硬化特征性HRCT表现为鼓膜或中耳腔内出现骨化斑点或钙化斑块,听骨链及其周围结构紊乱和钙化包裹。HRCT对鼓室硬化诊断、术前病变范围和听骨链受侵情况预估有较高价值,但存在较高漏诊现象。 2.鼓室硬化累及听骨链者纯音听阈测定听力学特点为ABG≥30dBHL,可有类Carchart切迹出现。纯音测听可较好地评估听骨链功能状态。 3.合并鼓膜穿孔的鼓室硬化病例,术前耳内窥镜检查表现为鼓室腔内白色硬化斑块,可包裹听骨。耳内窥镜检查对明确鼓室硬化诊断,了解部分听骨受累情况有帮助,但对有合并症及鼓膜完整病例的术前评估有限。 4. HRCT、纯音测听和耳内窥镜检查的联合诊断,可提高鼓室硬化的术前诊断率,更好地了解听骨链的功能状态,为手术方案的制定和听功能的预后评估提供依据。
[Abstract]:Research background
Tympanosclerosis (Tympanosclerosis) also known as tympanosclerosis, refers to the middle ear in long-term chronic inflammation after healing, middle ear connective tissue from degenerative changes, is one of the important causes of conductive hearing loss; the main pathological changes in middle ear submucosa and lamina propria of the tympanic membrane appeared hyaline degeneration and calcinosis of tympanosclerosis. By Von Troltsch in 1869 for the first time are described in detail and put forward the "hardening" (sclerosis) "is a term of.1956 years, Zollner wrote a paper called" tympanosclerosis "in a large number of tympanoplasty, so hard to tympanic officially named. At home and abroad on the incidence of tympanosclerosis is reported in a foreign 20-43%[2,3] domestic, 3.7-11.7%.
At present, the etiology and pathogenesis of tympanosclerosis remains unclear. With the widely application and extensive surgical microscope tympanoplasty, the disease has attracted more and more attention and research reports on tympanosclerosis and treatment effect gradually increased, and the diagnosis is less. The tympanosclerosis usually relies on surgical exploration and pathological to be diagnosed tympanosclerosis. How to improve the level of preoperative diagnosis, the preoperative diagnosis, diagnosis the nature and scope of understanding the situation of ossicular chain, in order to develop appropriate operation scheme, and with better preoperative communication, is currently the clinical otology problem yet to be solved.
objective
1., we studied the characteristics of CT High Resolution computed tomography (HRCT) in tympanosclerosis, and discussed the diagnostic value of HRCT for tympanosclerosis, the range of lesions and the state of ossicular chain.
2. of tympanosclerosis pure tone auditory characteristics of Fujian were discussed, pure tone audiometry value assessment of the state of the chain of tympanosclerosis ossicular before operation.
3. to study and explore the diagnostic value of ear endoscopy in cases of tympanic sclerosis with tympanic membrane perforation, the scope of the lesion and the state of the ossicular chain.
4. of the combined use of HRCT and pure tone test three mirror preoperative examination method of endoscope and ear to listen to, tympanosclerosis diagnosis and misdiagnosis were analyzed, to explore the diagnosis of tympanosclerosis confirmed, the nature of the lesions, the lesion and ossicular chain state and determine the value of preoperative surgical planning and prognostic significance.
Research object and method 1. research object:
Inclusion criteria: (1) clinical diagnosis requires surgical exploration of tympanosclerosis cases of tympanum or open mastoid; second, clinical hearing and imaging data (HRCT data) are complete; 3. First operation, non revision multiple operations; fourth, operation is completed by the same treatment group members.
From August 2006 to 2010 8 completed by the same treatment group tympanosclerosis resident surgery in 52 cases 56 ears studies met the inclusion criteria. There were 35 male and 17 female, age 12-64 years, average 35.74 years old. The history of 1-40 years, an average of 16.48 years. With 34 cases, 18 cases of single ear, the ears are surgery in 4 cases. The intact tympanic membrane perforation of tympanic membrane with 8 ears, 48 ears, of which the edge of perforation in 39 ears, 9 ears. All the slack perforation cases were confirmed by surgery and pathology diagnosed tympanosclerosis.
2. examination method and result judgment
HRCT: using the GE64 Lightspeed row VCT scanner scanning Wacom reconstruction. Axial scanning baseline to orbital line, scan range from arcuate eminence to the external auditory canal. Target scan, bone algorithm reconstruction and 512 * 512 matrix, slice thickness, layer spacing is 1mm, the width of the window window 4000Hu. 700Hu, FOV=32. to the tympanic membrane, around the tympanum and ossicular appeared high density calcification or ossification image characteristic changes of tympanosclerosis, the tympanic membrane tympanic and mastoid thickening, soft tissue density, and the destruction of ossicular tympanic wall for non characteristic changes.
Pure tone audiometry: preoperative pure tone audiometry variables: mean 500100020004000Hz air conduction and bone conduction as the average pure tone of Fujian PTA (pure-tone audiometry) ABG air bone gap (air bone gap) for the same period (air conduction) AC air conduction minus bone conduction (bone conduction) BC value to ABG30dB. As a standard to judge the fixation or disruption of the ossicular chain.
Ear endoscopy: Patients with perforation of tympanic membrane were examined by ear endoscopy. The lesions were recorded. Calcified or sclerotic lesions around tympanic membrane, tympanic cavity and auditory ossicles were used as diagnostic criteria for tympanosclerosis.
3. surgical exploration and pathological classification
General anesthesia, routine tympanic exploration or / and mastoidectomy. According to the extent of the lesion and the situation of ossicular chain were divided into 4 types: type I, sclerosis lesions involving only the tympanic membrane; type II, hardening lesions in the attic by hammer incus fixed or fused with the shield plate, good structural integrity and activity of stapes; type III, in tympanosclerosis lesions involving the ossicular chain by fixation of the stapes; type IV, tympanic cavity and tympanic sinus with sclerotic tissue ossicular chain wrapped fixation, partial ossicular resorption.
4. comparative study and statistical analysis
(1) comparison and analysis of the HRCT findings of the temporal bone and the results of the surgical exploration, and statistics the coincidence rate of each type of diagnosis
(2) the statistical analysis of the results of pure tone audiometry and the classification of the lesions and the state of the ossicular chain during the operation.
A comparative study of the results of ear endoscopy and intraoperative exploration.
The characteristics of pure tone audiometry and the results of ear endoscopy after HRCT diagnosis of temporal bone were analyzed, and the cases were analyzed.
Result
HRCT findings of the 1. temporal bone and the results of surgical exploration
Preoperative CT findings: the tympanic membrane thickening calcification in 20 ears, 29 ears, 44 ears with perforated; II antrum and tympanic cavity: calcification or ossification were found in 23 ears with high density, high density calcification or ossification image and soft tissue image coexist in 9 ears, only the shadow of soft tissue in 7 ears; the mastoid cavity: soft tissue shadow in 6 ears; listen to the bone chain: calcification wrapped in 21 ears, wormhole like changes or main and no interrupt 15 ears with bone destruction, bone destruction and disruption in 6 ears; the tympanum and ossicular chain had no obvious abnormalities in 14 ears.
Intraoperative examination results: tympanic membrane thickening: 24 ears, 33 ears calcified, perforation in 48 ears; the tympanic antrum and tympanic cavity: only calcification or sclerosis plaques in 20 ears, and 19 ears with cholesteatoma granulation, 4 ears with chronic otitis media in 2 ears, antrum and tympanic were normal in 11 ears; the mastoid granulation tissue in 6 ears; the ossicular chain: surrounding sclerosis foci of ossicular fixation, the hammer incus stapes fixation in 21 ears, 14 ears, 10 ears full of ossicular chain embedding; 14 cases of calcification were wrapped ossicular, calcification package and bone destruction but have not yet been interrupted in 22 ears, bone destruction and calcification of the package and interrupt 9 ears; no abnormal ossicular chain in 11 ears.
High resolution CT (11+7) showed no calcification in 18 ears, the ear 1L imaging findings of tympanic membrane perforation no other abnormality, the 11 ears after surgical exploration there eardrum calcification in 4 ears, antrum and tympanic calcification in 9 ears, 5 ears with promontory surface calcification, calcification of the ossicular chain was wrapped in 7 ears in 5 ears, hammer incus, fixed type, 2 ears of the stapes; the other 7 ear imaging soft tissue showed only surgical exploration showed calcification in 1 ear tympanic membrane, antrum attic calcification in 2 ears, 3 ears promontory surface calcification, calcification of the ossicular chain wrapped in 1 ears.
Intraoperative pathological type and CT type quasi coincidence rate of diagnosis: type 11 ears, the coincidence rate of 9//11=81.82%; type II in 21 ears, the coincidence rate of 14/21=66.67%; type III in 14 ears, with the rate of 6/14=42.86%; 10 ears with type IV, the coincidence rate of 3/10=30%; differential diagnosis and surgical exploration consistent with only 32 ears which image fitting the diagnosis of cases, the diagnosis of the I rate is high, the other is not high, the total diagnostic coincidence rate was 57.14%.
The total diagnostic rate of CT was 67.86%, and the rate of missed diagnosis was 18/56=32.14%
2. characteristics of pure tone audiometry and intraoperative pathological classification
Preoperative audiometric results: the air conduction threshold range of 35-65dBHL, the bone conduction spacing is greater than or equal to 30dBHL51 less than 30dBHL5 ear, ear; type I outside of all cases of bone conduction interval greater than or equal to 30dBHL. the 34 hearing figure Carchart notch.
Functional exploration of ossicular chain operation: complete and good activity in 11 ears, 14 ears fixed hammer incus stapes, 21 ear, the fixation of the ossicular chain in 10 ears; calcification of ossicular chain wrapped in 22 ears, 16 ears but not interrupt bone destruction, bone destruction and disruption of the ossicular chain in 7 ears, 11 ears without exception.
Intraoperative lesion classification and audiometric ABG mean of each type: type 11 ears, ABG=2.60 + 6.33dBHL; type II 21 ears, ABG=35.70 + 8.43dBHL; type III 14 ears, ABG=41.33 + 9.87dBHL; IV 10 ears, ABG=39.23+8.75dBHL..
3. ear endoscopy
Preoperative endoscopy results of 48 ears with ear tympanic membrane perforation: 24 ear tympanic membrane thickening, calcification in 32 ears, 48 ears with perforated promontory; the surface like coral reef or onion like calcification in 14 ears, 10 ears with cholesteatoma and granulation, calcification in 4 ears; 17 ears around the parcel of ossicular chain, listen with no interruption of bone chain bone destruction in 7 ears, with bone destruction and disruption of the ossicular chain in 4 ears, 11 ears showed no abnormalities of ossicular chain.
That same group of patients: the tympanic membrane thickening calcification in 24 ears, 32 ears, 48 ears of the tympanic membrane perforation; tympanic sinus and mesotympanum calcification or sclerosis plaques in 17 ears, with granulation in 10 ears, 4 ears with cholesteatoma; mastoid granulation tissue in 4 ears; the ossicular chain around the lesion induced by hammer hardening fixed incus in 16 ears, 11 ears with stapes, the ossicular chain embedded in 10 ears; but not interrupt 12 ear ossicular destruction, damage and disruption of the ossicular chain in 7 ears, 11 ears had no obvious abnormalities.
4. joint diagnosis
According to the results of preoperative reading and intraoperative exploration, the diagnosis rate of 38 ears with tympanosclerosis characteristic CT is 100%, accounting for 67.86% of all cases of tympanosclerosis (38/56).
CT missed diagnosis in 18 ears, 12 ears of the tympanic membrane perforation of tympanic membrane, complete 6 ear. Ear endoscopy for the tympanic membrane perforation. 12 cases of perforation of the tympanic membrane in the ear, 7 ears with ear endoscopy diagnosed tympanosclerosis: the tympanic membrane calcification in 4 ears, promontory surface coral calcification foci in 7 ears; listen to bone is wrapped calcification in 4 ears; 5 ears did not make the diagnosis, surgical exploration with granulation in 1 ears, 4 ears with cholesteatoma. For patients with granulation and cholesteatoma 5 ears were affected by the complications through the ear endoscope does not make diagnosis of MS, diagnosed by surgical exploration and tympanic sclerosis; for the other 6 eardrum complete cases of misdiagnosis, surgical exploration in 4 ears that hammer incus fixed type, 2 ears of the stapes. Misdiagnosis cases, 7 ears with ear endoscopy can confirm the diagnosis, diagnosis rate for 38+7/56=80.36%. two
According to the preoperative pure tone audiometry exploration situation of ossicular chain and surgery, II type IV tympanosclerosis, namely sclerosis lesion of ossicular chain spread, the results of pure tone audiometry ABG greater than or equal to 30dBHL. and CT analysis of ear endoscopy is still not confirmed 11 cases of ear, the pure tone audiometry results of ABG were more than 30dBHL, the ossicular there is a fixed chain or interrupted, should be included in the possible diagnosis of tympanosclerosis
conclusion
1. TS HRCT features of the tympanic membrane or middle ear cavity ossification spots or calcified plaque, ossicular chain and its surrounding structure disorder and calcification encapsulated.HRCT on tympanosclerosis diagnosis, preoperative lesion and ossicular chain invasion prediction has high value, but there is a high misdiagnosis phenomenon.
2. tympanosclerosis involving the ossicular chain were pure tone audiometry audiology features for the ABG is larger than 30dBHL, with Carchart notch. Pure tone audiometry can better assess the state of the ossicular chain function.
Tympanosclerosis 3. with tympanic membrane perforation, preoperative ear endoscopy showed a white plaque within the tympanic cavity, can be wrapped to clear ear ossicle. Endoscopy diagnosis of tympanosclerosis, understand partial ossicular involvement helps, but the complications and the tympanic membrane complete cases preoperative evaluation is limited.
4. HRCT, combined diagnosis of pure tone audiometry and ear endoscopy can improve the preoperative diagnostic rate of tympanosclerosis, and better understand the functional state of ossicular chain, so as to provide evidence for the formulation of operation plan and prognosis of auditory function.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2011
【分类号】：R764

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