鼓室硬化不同分型的纯音听阈特点及其手术方式研究

发布时间：2018-05-18 12:58

本文选题：鼓室硬化 + 纯音听阈　；参考：《南方医科大学》2013年硕士论文

【摘要】：研究背景鼓室硬化(tympanosclerosis)多继发于中耳粘膜慢性感染或炎症,可发生于鼓室的任何部位,主要表现为进行性的传导性耳聋。1869年Von Troltsch首先提出了“硬化(sclerosis)"一词,并在1873年将其描述为中耳粘膜最深层纤维组织的硬化。过去常称为鼓室硬化症,现统称为鼓室硬化。国外文献报道人慢性化脓性中耳炎中鼓室硬化发病率为20%-43%,国内报道为3.7%-11.7%。鼓室硬化的病因与发病机制目前尚未明了,术前诊断亦无明确标准,临床上大多靠听力学诊断,确诊靠病理；鼓室硬化治疗以手术为主,随着耳显微技术的应用和鼓室成形术的广泛开展,特别是人工听骨赝复物、骨导助听器、人工中耳的出现,鼓室硬化的手术适应症不断扩大、手术方式日益增多,但术式的选择一直存在争议,都是当前耳科学的难题。临床上常根据Wielinga和Kerr的分类方法,将鼓室硬化分为鼓膜硬化型、锤砧固定型、镫骨固定型和全鼓室硬化型。其中鼓膜硬化型在术前可通过纯音听阂测定和耳内镜较容易诊断出来,但锤砧固定型、镫骨固定型及全鼓室硬化型术前不易准确诊断。有学者对鼓室硬化的纯音听阈特点进行了分析,但不同分型的鼓室硬化纯音听阈特点报道极少。掌握不同分型的鼓室硬化纯音听阈特点,可为术前诊断及预后评估起着不可替代的作用。听骨链重建术是使鼓膜和外淋巴液之间恢复稳定的传声连接,以达到恢复或改善中耳传声系统功能的手术。自20世纪50年代Wullstein和Zollner开展听骨链重建术以来,耳科医生为之进行了不少探索,取得了诸多进展,但对于鼓室硬化等听骨存在病变的中耳炎病例的手术治疗仍然是临床中的难点,Eleftheriadou等报道,PORP听骨链重建术后,随访14年,手术有效率仅为68.8%。许多学者从手术方式的选择、人工听骨材料的种类及术前病人的中耳情况等相关方面着手,研究影响鼓室硬化手术疗效的因素,但始终没有形成一个统一的意见,术中锤骨的处理对术后疗效的影响更鲜有报道。本研究通过回顾性分析鼓室硬化患者临床资料,分析不同分型鼓室硬化患者术前的纯音听阈特点；探讨听骨链重建术中锤骨的3种不同处理方式对鼓室硬化患者疗效的影响。为鼓室硬化的术前诊断、术式选择及疗效评估提供较好的理论参考。第一部分鼓室硬化不同分型的纯音听阈特点分析目的探讨不同分型的鼓室硬化患者纯音听阈测定特点,为术前诊断及预后评估提供理论参考。方法 1.1临床资料：对南方医科大学珠江医院2002年1月～2012年1月的1021份慢性化脓性中耳炎病案逐份详细阅读其入院及手术记录。对纳入本实验研究的条件为：根据病史记录、术中显微镜下探查及术后病理检查诊断为鼓室硬化。本研究102例(102耳)资料完整的鼓室硬化病例中男40例,女62例,年龄12～60岁,平均34.15±11.26岁,病史最长50年,最短2年,平均17.97±10.13年。主要临床表现为反复耳漏伴听力下降,部分患者伴耳鸣。所有患者手术前干耳1个月以上。 1.2方法： 1.2.1实验步骤：本研究102例患者术前1周内行纯音听阈测定和耳内镜检查。采用美国GSI61临床听力计和STORZ耳内镜进行检测。各变量指标：测试250、500、1000、2000、4000Hz气导(AC)和骨导(BC)听阈(气导上限：120dBHL,骨导上限：80dBHL,超出、未测出者定为缺失值)。500、1000和2000Hz的均值作为言语频率平均纯音听阈(PTA)。气骨导差(ABG)为同期言语频率气导阈值减去骨导阈值。观察鼓膜一般情况。 1.2.2病灶分类：根据Wielinga和Kerr的分类方法结合术中显微镜下探查硬化灶的部位和范围,将病例分成4型,Ⅰ型：鼓膜硬化型(24例),硬化灶累及鼓膜,听骨链完整,活动好；Ⅱ型：锤砧骨固定型(30例),硬化灶累及上鼓室导致锤砧骨固定,镫骨结构完整,活动度好；Ⅲ型：镫骨固定型(23例),上中鼓室硬化灶累及镫骨导致镫骨固定,锤砧关节完整,活动好；Ⅳ型：全鼓室硬化型(25例),鼓室内硬化组织导致听骨链包裹固定,部分听骨破坏吸收伴或不伴鼓室腔胆脂瘤或肉芽形成。 1.2.3主要观察指标：鼓膜硬化型、锤砧固定型、镫骨固定型、全鼓室硬化型这四组病人言语频率(500、1000、2000Hz)气导听阈(AC)、骨导听阈(BC)及气骨导差(ABG)值,鼓膜硬化型病例各频率(250、500、1000、2000、4000Hz)气导听阈及骨导听阈,锤砧固定型、镫骨固定型、全鼓室硬化型这三组总的病例各频率气导听阈及骨导听阈。耳内镜检查鼓膜穿孔及硬化灶分布情况。 1.2.4统计学处理：计量资料用均数±标准差(x±sdB HL)表示,四组均数的比较经方差齐性检验后行方差分析(One-way ANOVA),组间均数的两两比较采用LSD检验。以p0.05为差异有统计学意义,所有统计分析采用SPSS13.0软件完成。结果鼓室硬化Ⅰ型、Ⅱ型、Ⅲ型、Ⅳ型术前气骨导差分别为25.97±4.42dB、37.83±6.95dB、39.64±5.43dB、39.2±7.42dB,其中Ⅰ型较其它三型气骨导差小,差异有统计学意义(P0.05),其它三型之间的差异无统计学意义(P0.05),各型气导曲线大致呈平坦型,Ⅱ型、Ⅲ型和Ⅳ型骨导曲线部分频率下降。所有102例病例中,鼓膜完整3耳,穿孔99耳,47耳残存鼓膜见硬化灶,74例为传导性耳聋,28例为混合性耳聋,39例听力图出现Carchart切迹改变,除Ⅰ型之外的几乎所有病例ABG30dB。结论鼓室硬化患者多呈传导性耳聋,气导表现为全部频率受损,低频略重于高频,当ABG30dB时,可能预示着听骨链病变；鼓室硬化Ⅱ型、Ⅲ型、Ⅳ型的听力下降程度与硬化灶的范围和程度无明显关系。虽然我们不能通过术前纯音听阈特点确诊鼓室硬化,但对于长期慢性化脓性中耳炎鼓膜穿孔者,纯音听阈测定显示ABG30dB,要重点考虑鼓室硬化听骨链固定或破坏的可能。第二部分听骨链重建术中锤骨的处理对鼓室硬化患者疗效的影响目的探讨鼓室硬化患者行听骨链重建术中,锤骨的不同处理方式对术后疗效的影响,为术式的选择提供参考。方法 1.1临床资料：对南方医科大学珠江医院2002年1月～2012年1月的1021份慢性化脓性中耳炎病案逐份详细阅读其入院及手术记录。对纳入本实验研究的条件为：1、根据术中显微镜下探查所见和术后病理检查诊断为鼓室硬化；2、术中镫骨上结构固定、破坏或缺如,镫骨完整,活动好；3、用多孔聚乙烯听骨赝复物(Partial ossicular replacement prostheses, PORP)行听骨链重建术。本研究59例(62耳)资料完整的鼓室硬化病例中男22例,女37例,年龄14～59岁,平均32.19±9.66岁,病史最长40年,最短5年,平均17.47±8.21年。所有患者手术前干耳1个月以上。术后随访15-21个月,平均16.1月。 1.2方法： 1.2.1实验步骤：回顾性分析59例(62耳)经听骨链重建术的鼓室硬化锤砧固定型病例资料,按术中对锤骨的处理方式不同,分为去除锤骨组(24耳),仅保留锤骨柄组(18耳)和完整保留锤骨组(20耳)。分析3组患者术前、术后3个月、术后1年的言语频率平均纯音听阈,计算气骨导差及气骨导差改善值,并用耳内镜观察鼓膜移植物存活情况,比较3种锤骨处理方式对疗效的影响。 1.2.2手术方法：18岁以下患者采用全身麻醉,其余均为局部浸润麻醉,取患者仰卧位,头偏向对侧,术耳向上,所有患者均采用耳内切口,在距鼓环6-8mm平面作外耳道皮瓣,分离皮瓣,挑起鼓环进入鼓室,术中凿开上鼓室,探查听骨链,清除锤骨、砧骨周围硬化灶,分离锤砧和砧镫关节,将砧骨取出,对锤骨的处理有去除锤骨、剪掉锤骨头仅保留锤骨柄和完整保留锤骨,然后用部分人工听骨PORP桥接锤骨柄和镫骨头,或桥接鼓膜和镫骨头,两者之间嵌以一薄层耳屏软骨。对于合并鼓膜硬化者,术中清除鼓环或锤骨柄周围影响鼓膜运动的鼓膜硬化斑,鼓膜其它部位硬化斑超过鼓膜面积1/3的予以清除,用颞肌筋膜按内置法行鼓膜成形术。明胶海绵和碘仿纱条填塞术腔,术部加压包扎2-3天,2周后取出外耳道填塞物。 1.2.3数据收集及主要观察指标：所有病例均在术前1周内行纯音听阈测定和耳内镜检查,并收集术后3月及术后1年的纯音听阈测定、耳内镜资料。测量工具：采用美国GSI61临床听力计和STORZ耳内镜进行检测。各变量指标：记录500、1000、2000Hz气导阈值和骨导阈值(气导上限：120dBHL,骨导上限：80dBHL,超出、未测出者定为缺失值)。气骨导差(ABG)为同期言语频率气导阈值减去骨导阈值,气骨导差改善值为术前气骨导差减去术后气骨导差；观察术后鼓膜移植物生长情况。1.2.4统计学处理：计量资料用均数±标准差(x±s dB HL)表示,手术前后均数的比较采用配对样本t检验,三组间均数的比较经方差齐性检验后行方差分析(One-way ANOVA),组间均数的两两比较采用LSD检验。以p0.05为差异有统计学意义,所有统计分析采用SPSS13.0软件完成。结果去除锤骨组、仅保留锤骨柄组、完整保留锤骨组术前气骨导差分别为40.07±7.56dB、37.31±6.45dB、36.75±6.72dB,三组之间的差异无统计学意义(p0.05),术后3个月3组病例平均气骨导差较术前分别缩小18.15±8.64dB、17.69±6.65dB、18.17±8.39dB,差异无统计学意义(F=0.092,p0.05)。术后1年,气骨导差较术前分别缩小17.92±9.28dB、16.76±5.19dB、10.58±7.38dB,其中完整保留锤骨组气骨导差缩小程度明显小于去除锤骨组和仅保留锤骨柄组(p0.05),而去除锤骨组和仅保留锤骨柄组气骨导差缩小的差异无统计学显著性(p0.05)。术后1年,去除锤骨组和仅保留锤骨柄组各1例鼓膜穿孔人工听骨脱落,其余鼓膜完整,少有塌陷。结论听骨链重建术中锤骨的不同处理方式对鼓室硬化患者短期疗效无显著影响；长期疗效方面,完整去除锤骨和仅保留锤骨柄效果相当,均显著优于完整保留锤骨。
[Abstract]:Research background
Tympanosclerosis (tympanosclerosis) is secondary to chronic infection or inflammation of the middle ear mucosa, which can occur at any part of the tympanum, mainly as progressive deafness.1869 Von Troltsch first proposed the word "sclerosis", and in 1873 it was described as the sclerosis of the deepest fibrous tissue of the middle ear mucosa. For tympanosclerosis, it is known as tympanosclerosis. The incidence of tympanosclerosis in chronic suppurative otitis media in foreign literature is 20%-43%. It is reported that the etiology and pathogenesis of 3.7%-11.7%. tympanosclerosis is not clear at home, and there is no clear standard for preoperative diagnosis. Most of them depend on the diagnosis of hearing and pathology; tympanic cavity is hard. With the application of surgery and the extensive development of ear microtechnology and tympanoplasty, especially artificial auditory osseous prostheses, bone guided hearing aids, artificial middle ear, tympanosclerosis, surgical indications are constantly expanding, and surgical methods are increasing. However, the selection of surgical methods has been controversial, which are the problems of the current otology.
According to the classification of Wielinga and Kerr, tympanic sclerosis is divided into tympanic sclerosis type, hammer anvil fixed type, stapes fixation type and total tympanosclerosis type. The tympanosclerosis can be easily diagnosed by pure tone audiometry and ear endoscopy before operation, but the hammer anvil fixation, stapes fixation and total tympanosclerosis are not easy before operation. Accurate diagnosis. Some scholars have analyzed the characteristics of the pure tone hearing threshold of the tympanosclerosis, but there are few reports on the characteristics of the different types of tympanosclerosis pure tone threshold.
The reconstruction of auditory ossicle chain is to restore a stable sound connection between the tympanic membrane and the lymph, in order to recover or improve the function of the sound system of the middle ear. Since the reconstruction of the ossicular chain was carried out in Wullstein and Zollner in 1950s, many explorations have been made by the ear doctors, and many progress have been made, but the auditory ossicles, such as tympanosclerosis, have been taken. Surgical treatment of cases of otitis media with pathological changes is still a difficult problem in clinical. Eleftheriadou and other reports, after the PORP ossicular chain reconstruction, 14 years of follow-up, the operation efficiency is only 68.8%. many scholars from the selection of surgical methods, the types of artificial ossicular materials and the situation of the middle ear of the patients before the operation, and study the influence of the tympanum hard. However, there has never been a unified view on the effect of surgical treatment, and the effect of operative malleus on the postoperative outcome is rarely reported.
Through a retrospective analysis of the clinical data of tympanosclerosis patients, the characteristics of pure tone hearing threshold in different types of tympanic sclerosis patients were analyzed, and the effects of 3 different treatments of the malleus on the effect of tympanosclerosis in the reconstruction of the ossicular chain were discussed. On the reference.
Part one characteristics of pure tone audiometry in different types of tympanosclerosis
objective
Objective to investigate the characteristics of pure tone audiometry in patients with different types of tympanosclerosis, and to provide theoretical reference for preoperative diagnosis and prognosis evaluation.
Method
1.1 clinical data: 1021 cases of chronic suppurative otitis media in Zhujiang Hospital of Southern Medical University from January 2002 to January 2012 were read through their admission and surgical records in detail. The conditions included in this study were: according to the records of the disease, the diagnosis of the tympanosclerosis by microscopy under microscope and postoperative pathophysiological examination was 102 cases of this study. (102 ears) of the complete cases of tympanosclerosis, there were 40 males and 62 females, with an average age of 12~60 years and an average of 34.15 + 11.26 years old. The duration of the disease was 50 years, the shortest, 2 years, and the average of 17.97 + 10.13 years. The main clinical manifestations were recurrent ear leakage with hearing loss and some patients with tinnitus. All the patients were above the dry ear for more than 1 months.
The 1.2 method:
1.2.1 experimental steps: 102 patients in this study were performed pure tone audiometry and ear endoscopy within 1 weeks before operation. The American GSI61 clinical audiometer and STORZ ear endoscopy were used to test the variables: the test of 250500100020004000Hz gas conductance (AC) and bone conduction (BC) hearing threshold (the upper limit of air conductivity: 120dBHL, bone conduction upper limit: 80dBHL, excess, and undetected) The mean value of.5001000 and 2000Hz is regarded as the average tone threshold of speech frequency (PTA). The bone conductance (ABG) subtracts the threshold of bone conduction from the air conduction threshold of the speech frequency at the same time.
1.2.2 focus classification: according to the classification of Wielinga and Kerr combined with microscopic examination of the site and scope of the sclerotic focus under microscope, the cases were divided into 4 types, type I: tympanosclerosis (24 cases), the hardened foci involving the tympanic membrane, the complete ossicular chain and good activity; type II: the hammer anvil fixed (30 cases), and the sclerotic focal involvement of the tympanum leading to the hammer incus fixation. The stapes had a complete structure and good activity; type III: stapes fixation (23 cases). The upper and middle tympanosclerosis was involved in stapes to cause stapes to be fixed, the hammer anvil was complete, and the activity was good; type IV: total tympanosclerosis (25 cases), the sclerosis tissue in the tympanum resulting in the ossicular chain fixation, partial ossicular destruction absorbed with or without tympanic cavity cholesteatoma or granulation. It is.
1.2.3 main observation indexes: tympanosclerosis type, hammer anvil fixed type, stapes fixation type, total tympanosclerosis type four groups of patients' speech frequency (50010002000Hz) air conduction hearing threshold (AC), bone conduction hearing threshold (BC) and air bone conductance (ABG) value, each frequency (250500100020004000Hz) air conduction hearing threshold and bone conduction threshold, hammer anvil fixed type, stapes The three groups were fixed type and total tympanosclerosis. The frequencies of gas conduction audiometry and bone conduction audiometry were examined by ear endoscopy.
1.2.4 statistical treatment: the measurement data were expressed with mean mean + standard deviation (x + sdB HL). The four groups were compared with the square deviation homogeneity test (One-way ANOVA), and the 22 of the average number of groups was compared to LSD test. The difference was statistically significant with P0.05, and all statistical analysis was completed by SPSS13.0 software.
Result
The preoperation of tympanosclerosis type I, type II, type III and IV was 25.97 4.42dB, 37.83 + 6.95dB, 39.64 + 5.43dB, 39.2 + 7.42dB, of which type I was smaller than other three types of gas, and the difference was statistically significant (P0.05). The difference between the other three types was not statistically significant (P0.05), and the gas conductance curves were roughly flat, type II and III type In all 102 cases, all 102 cases had complete 3 ears of tympanic membrane, 99 ears perforated, 47 ears with residual tympanic membrane, 74 cases of conductive deafness, 28 cases of mixed deafness, and 39 hearing maps with Carchart notch change, almost all cases ABG30dB. except type I.
conclusion
The patients with tympanosclerosis are mostly conductive deafness, the air conduction is all frequency impaired and the low frequency is slightly heavier than the high frequency. When ABG30dB, it may indicate the lesion of the ossicular chain. The degree of hearing loss of the tympanosclerosis type II, type III and type IV is not significantly related to the scope and extent of the hardened focus. Although we can not diagnose the drum by the preoperatively pure tone hearing threshold Ventricular sclerosis, but for chronic suppurative otitis media with tympanic membrane perforation, the pure tone audiometry shows ABG30dB, which should focus on the possibility of the fixation or destruction of the tympanic ossicle chain.
The effect of the second part of the ossicular chain reconstruction on the curative effect of tympanosclerosis patients
objective
Objective to explore the effect of different ways of malleus on postoperative outcome of ossicular chain reconstruction in patients with tympanosclerosis.
Method
1.1 clinical data: 1021 cases of chronic suppurative otitis media in Zhujiang Hospital of Southern Medical University from January 2002 to January 2012 were read through their admission and surgical records in detail. The conditions included in the study were 1, the diagnosis of tympanosclerosis by microscopic examination and postoperative pathological examination; 2, the stapes during the operation. The structure was fixed, damaged or absent, the stapes was complete and the activity was good; 3, the ossicular chain reconstruction was performed with Partial ossicular replacement prostheses (PORP). In this study, 59 cases of tympanic sclerosis (62 ears) with complete data of the tympanosclerosis were male, 37 cases, 14~59 years old and 32.19 + 9.66 years, with the longest history of 40 years, and the shortest 5. 5 The average age was 17.47 + 8.21 years. All patients had dry ears for more than 1 months before operation. The average follow-up period was 16.1 months after 15-21 months.
The 1.2 method:
1.2.1 experimental steps: retrospective analysis of 59 cases (62 ears) of the tympanosclerosis hammer anvil of the ossicular chain reconstruction, divided into the malleus group (24 ears), only the malleus handle group (18 ears) and the intact malleus group (20 ears). The speech frequency of the 3 groups was analyzed before the operation, 3 months after operation and 1 years after the operation. The average pure tone hearing threshold was used to calculate the improvement of bone conductivity and bone conduction difference. The survival of the tympanic membrane grafts was observed by ear endoscopy, and the effect of 3 kinds of malleus treatment on the curative effect was compared.
1.2.2 operation method: the patients under 18 years of age were anesthetized with general anesthesia, the rest were local infiltration anaesthesia, the patients were taken on the supine position, the head partial to the opposite side, the ear was upward, all the patients were used in the ear incision, the outer ear flap was used as the flap from the drum ring 6-8mm plane, the flap was separated, the drum was picked up into the drum chamber, the tympanic chamber was cut open, the ossicular chain was explored, the malleus scavenged and the malleus was scavenged. The hardened area around the anvil, the anvil and the incus stapes joint were removed, the anvil was removed, the malleus was removed, the hammer bone was removed and the malleus was retained and the malleus was retained, then the malleus and the stapes were bridged with a part of the artificial ossicular PORP, or the tympanic membrane and stapes were bridged with a thin layer of cartilage. In the case of membrane sclerosis, the tympanic membrane plaque that affects the tympanic membrane movement around the drum or the malleus handle is cleared during the operation. The sclerotic plaque of the other parts of the tympanic membrane is cleared over the area of the tympanic membrane 1/3. The tympanoplasty is performed by the built-in method of the temporalis myofascial. The gelatin sponge and iodoform gauze are filled in the cavity, the operation is packed for 2-3 days, and the external auditory canal filling is removed after 2 weeks.
1.2.3 data collection and main observation indicators: all cases were performed pure tone audiometry and ear endoscopy within 1 weeks before operation, and the pure tone audiometry of March and 1 years postoperatively was collected, and the ear endoscopy data. Measurement tools: the American GSI61 clinical audiometer and STORZ ear endoscopy were used. The variables: record 50010002000Hz Air conductivity threshold and bone conduction threshold (upper limit of air conductivity: 120dBHL, upper limit of bone Guide: 80dBHL, exceeding, undetected person as missing value). Air bone conductance (ABG) subtracts bone conduction threshold at the same period of speech frequency gas conduction threshold, and the improvement value of air bone conductance is reduced by bone conduction difference after operation, and the growth of tympanic membrane grafts after operation is observed by.1.2.4 statistics Study treatment: the measurement data were represented by mean number + standard deviation (x + s dB HL). The comparison of the average number between the three groups before and after the operation was compared with the t test of paired samples. The average number of all groups was compared with the variance analysis (One-way ANOVA), and the 22 of the average number of groups was compared with LSD test. The statistical significance of P0.05 was statistically significant. All statistical analysis adopted S. PSS13.0 software is completed.
Result
The malleus group was removed, only the malleus shank was retained. The bone conduction difference was 40.07 7.56dB, 37.31 6.45dB and 36.75 6.72dB before the malleus group. The difference between the three groups was not statistically significant (P0.05). The average gas conductivity of the 3 groups in the 3 months after the operation was 18.15 + 8.64dB, 17.69 + 6.65dB, 18.17 + 8.39dB, respectively, and the difference was not statistically significant. Significance (F=0.092, P0.05). 1 years after operation, the air bone conductivity narrowed by 17.92 + 9.28dB, 16.76 + 5.19dB and 10.58 + 7.38dB respectively. The reduction degree of the gas bone conductivity in the complete malleus group was significantly smaller than that of the malleus group and only the malleus handle group (P0.05), but the difference between the malleus group and the malleus handle group was not statistically significant. Significance (P0.05). In 1 years after operation, 1 cases of tympanic membrane perforation were removed from the malleus group and only the hammer handle group.
The different treatments of ossicular chain reconstruction had no significant effect on the short-term effect of tympanosclerosis patients.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R764.29

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