耳外伤及轻度闭合性颅脑损伤致听力损害的临床研究

发布时间：2018-06-27 10:09

本文选题：纯音测听 + 听性脑干反应　；参考：《河北医科大学》2010年硕士论文

【摘要】： 目的:近年来,创伤逐渐成为危害人类生命和健康的突出医学问题和社会问题,创伤后耳聋作为后天性聋的一个重要组成部分,常常涉及纠纷,因此其诊断与鉴定就显得更为重要。有关外伤后听力损害的程度、特点及外伤后未见鼓膜穿孔、不伴颞骨及颅骨骨折患者的听力损害情况研究较少,因此,本研究通过纯音测听(pure tone audiometry,PTA)、声导抗(acoustic immittance,AT)、听性脑干反应(auditory brainstem response, ABR)、40Hz听觉相关电位(40Hz auditory event related potential,40Hz AERP)及畸变产物耳声发射(distortion evoked otoacoustic emission,DPOAE)等检查方法,统计外伤造成的听力损失情况,分析耳外伤致鼓膜穿孔及轻度闭合性颅脑损伤后不伴鼓膜穿孔的听力损失程度及特点,探讨内耳损伤(迷路震荡)在外伤后听力损失中的发生及重要影响,为临床诊断与法医学鉴定提供一定理论依据。方法:在临床实践中,选取耳外伤致鼓膜穿孔或轻度闭合性颅脑损伤后不伴鼓膜穿孔患者245例(共265耳受伤),伤后主诉听力下降、耳鸣及耳堵塞感,部分伴有眩晕、恶心及呕吐等症状。耳外伤组患者154例(157耳受伤),男110例,女44例,年龄15～55岁,平均年龄29.73岁,就诊时间1小时～3月余不等,其中≤1天45耳,1天且≤3天46耳,3天且≤14天48耳,14天18耳;轻度闭合性颅脑损伤组患者91例(108耳受伤),男66例,女25例,年龄15～55岁,平均年龄31.92岁,就诊时间4小时～1年余不等,其中≤3天21耳,3天且≤14天36耳,14天且≤3个月19耳,3个月15耳,全部患者均经详细询问病史,耳科相关检查,然后进行纯音测听、声导抗、ABR及40Hz AERP检查,部分进行DPOAE检查,结合48小时内的颞骨或头颅CT未见异常,神经系统检查无阳性体征。选取35名听力正常志愿者作为正常对照组,其中男25名(50耳),女10名(20耳),年龄18～52岁,平均30.31岁,各项检查均未见异常。所有受试者既往均无噪声暴露史,无耳毒性药物使用史,无耳聋家族遗传史,无耳科及神经系统疾病史,结合各项听力测试结果,已经明确排除伪聋。对伤后不同就诊时间的听力学检查进行统计分析,探讨外伤造成的听力损害。统计学处理:应用SPSS13.0软件,采用χ-±s表示,统计方法采用非参数检验、两个独立样本t检验、χ2检验及方差分析进行分析,以p0.05为差异有统计学意义。结果:1耳外伤致鼓膜穿孔及轻度闭合性颅脑损伤后不伴鼓膜穿孔的患耳均有明显听力损害,各项听力检查平均阈值均明显高于正常对照组,两组患耳的听力损失程度分布差异有统计学意义。 2耳外伤组中90.45%患耳PTA与ABR结果一致,其中PTA平均听阈值多≤60dB,占93.66%,≥61dB(重度及极重度)占6.34%;其中66.90%为传导性聋,23.24%为混合性聋或感音神经性聋,9.86%纯音测听各频率阈值均≤25dB;不同就诊时间组的PTA平均听阈、ABR阈值及40Hz AERP阈值与正常对照组比较差异均有统计学意义,14天组各项检查平均听阈值均最小,但与其他就诊时间组差异无统计学意义;PTA结果中就诊时间≤1天组各频率听力损失差异有统计学意义,最严重在0.125kHz,其他就诊时间组内各频率听力损失差异均无统计学意义;与正常对照组比,ABR各波潜伏期明显延长,除Ⅰ-Ⅴ波间期差异无统计学意义外,其他波间期比较差异均有统计学意义。 3轻度闭合性颅脑损伤组84.26%患耳PTA与ABR结果一致,其中PTA平均听阈值多≤60dB,占70.33%,≥61dB(重度及极重度)占29.67%,其中74.72%为感音神经性耳聋,25.28%为混合性聋或传导性聋;不同就诊时间组的PTA平均听阈、ABR阈值及40Hz AERP阈值与正常对照组比较差异均有统计学意义,3个月组各项检查平均听阈值均最小,但与其他就诊时间组差异无统计学意义;PTA结果中除就诊时间3个月组各频率听力损失差异无统计学意义外,其他就诊时间组内各频率听力损失差异均有统计学意义,其中以4kHz及8kHz听力损失最严重;DPOAE结果也示在4kHz听力损失严重,ABR及40Hz AERP阈值引出率分别为88.89%及98.15%,且ABR阈值较40Hz AERP阈值高;与正常对照组比,ABR各波潜伏期明显延长,除Ⅰ-Ⅲ波间期差异无统计学意义外,其他波间期差异均有统计学意义。18例配合随访患者分别在伤后1、3及6个月复诊,纯音测听各频率听阈均见降低,主要在低频区最明显(0.25kHz和0.5kHz),40Hz AERP阈值也较ABR阈值明显降低。结论:1耳外伤致鼓膜穿孔后的听力损害主要为轻中度传导性聋,PTA结果示损害最明显在0.125kHz,不同就诊时间组中14天组的PTA平均听阈、ABR及40Hz AERP阈值均较其他组小,但差异没有统计学意义;部分患耳听力损失较重、造成混合性聋或感音神经性聋,结合ABR、40Hz AERP检查及临床症状,我们认为耳外伤不仅可以造成中耳损伤,而且在受伤同时可伴发一定程度的内耳损伤。 2轻度闭合性颅脑损伤后不伴鼓膜穿孔的听力损害主要为轻中度感音神经性聋,少数听力损失较重或为混合性聋,还可伴脑干功能受损,综合各项听力检查结果示主要为高频听力损害(4kHz最明显);伤后6个月内可见听阈降低,以低频区明显(0.25kHz和0.5kHz),结合患者临床表现及辅助检查,认为迷路震荡在内耳损伤机制中起着重要作用。 3外伤后听力损害的准确评估及合理鉴定,需要临床医生或鉴定人员详细询问病史,并结合临床、影像及听力学等辅助检查。一方面充分认识不同听力学检查的特点,联合使用以互相弥补各自不足,另一方面认真把握受试者的心理状态,取得受试者的配合,最终使主客观听力检查结果相一致,此外,还应考虑到伤后不同时期听力变化规律,合理把握鉴定时间,最终做出客观合理的临床诊断或法医学鉴定。
[Abstract]:Objective: in recent years, trauma has gradually become a prominent medical and social problem endangering human life and health. Deafness after trauma is an important part of acquired deafness, often involving disputes, so its diagnosis and identification is more important. The degree of post traumatic hearing impairment, characteristics and no tympanic membrane perforation after trauma, There are few studies on hearing impairment in patients without temporal bone and skull fracture. Therefore, this study was conducted through pure tone audiometry (pure tone audiometry, PTA), acoustic impedance (acoustic immittance, AT), auditory brainstem response (auditory brainstem response, ABR), 40Hz auditory related potential and teratometry. Distortion evoked otoacoustic emission (DPOAE) and other methods were used to analyze the hearing loss caused by trauma, and to analyze the degree and characteristics of hearing loss without tympanic membrane perforation after ear trauma and mild closed craniocerebral injury, and to explore the occurrence of inner ear injury (labyrinthine concussion) in hearing loss after trauma. And important influence, providing a theoretical basis for clinical diagnosis and forensic identification.
Methods: in clinical practice, 245 cases (265 ears) without tympanic membrane perforation after ear trauma or mild closed craniocerebral injury were selected. The main complaints were hearing loss, tinnitus and ear blockage, partly accompanied by vertigo, nausea and vomiting, 154 cases (157 ears), 110 men, 44 women and 15~55 age. The average age of 29.73 years was 1 hours to 3 months, including 1 days and 45 ears, 1 days and less than 3 days, 46 ears, 3 days and less than 14 days, 14, 18 ears, and mild closed craniocerebral injury patients. 3 days and less than 14 days 36 ears, 14 days and less than 3 months 19 ears, 3 months 15 ears, all the patients were asked the detailed history of the medical history, the ear related examination, and then carried out pure tone audiometry, acoustic conductivity, ABR and 40Hz AERP examination, part of the DPOAE examination, combined with 48 hours of the temporal bone or skull CT without abnormal signs. 35 hearing positive signs were selected. 35 hearing positive were selected. There were 25 men (50 ears), 10 women (20 ears), 18~52 years old and 30.31 years old, with an average age of 30.31. All the subjects had no history of noise exposure, no history of ototoxic drugs, no hereditary history of deafness, no history of auricular and nervous system diseases, combined with the results of hearing tests. The false hearing loss was clearly excluded. The audiological examination of different visiting time after injury was statistically analyzed to explore the hearing impairment caused by trauma.
Statistical processing: the SPSS13.0 software was used, the X + s was used, the statistical method was nonparametric test, two independent sample t test, x 2 test and variance analysis were used to analyze the difference. The difference was statistically significant with the difference of P0.05.
Results: the hearing loss of the ears of the tympanic membrane perforation and the mild closed craniocerebral injury without tympanic membrane perforation in 1 ears and the average threshold of hearing examination were significantly higher than that of the normal control group. The difference of hearing loss in the two groups was statistically significant.
The results of 90.45% ears PTA in 2 ears were the same as that of ABR, of which the average threshold value of PTA was more than 60dB, 93.66% and 6.34%, and 66.90% of them were conductive deafness, 23.24% was mixed deafness or sensorineural hearing loss, and 9.86% pure tone audiometry was less than 25dB at each frequency threshold, and the PTA average hearing threshold, ABR threshold and 40 in different time group. The difference of Hz AERP threshold was statistically significant compared with that of the normal control group. The average hearing threshold value of each examination in the 14 day group was the smallest, but there was no significant difference with the other time group. The difference of hearing loss at each frequency in the group of PTA and the group of less than 1 days was statistically significant, the most serious was in 0.125kHz and in the other time group. There was no significant difference in the difference of force loss. Compared with the normal control group, the latency of each wave of ABR was obviously prolonged, except for the difference in the interval of I - V wave interval, the difference of other wave intervals was statistically significant.
3 in 3 mild closed craniocerebral injury group, the results of 84.26% ears were consistent with the results of ABR, of which the average threshold value of PTA was more than 60dB, 70.33%, and 61dB (severe and extremely severe) accounted for 29.67%, of which 74.72% were sensorineural deafness, 25.28% was mixed deafness or conduction deafness; the PTA average hearing threshold in different time group, ABR threshold and 40Hz AERP threshold and normal The difference of the control group was statistically significant, the average hearing threshold value of all the 3 months group was the smallest, but there was no statistical difference with the other time group, and there was no significant difference in the hearing loss in the PTA results in the 3 months group, and the differences in the hearing loss in the other time group were statistically significant. The hearing loss of 4kHz and 8kHz was the most serious; DPOAE results also showed severe hearing loss in 4kHz, ABR and 40Hz AERP threshold extraction rates were 88.89% and 98.15% respectively, and ABR threshold was higher than 40Hz AERP threshold. Compared with normal control group, ABR wave latency was obviously prolonged, except for the difference of I - III wave interval, the difference of other wave interval There were statistical significance in.18 cases combined with follow-up patients at 1,3 and 6 months after injury. The hearing threshold of pure tone audiometry decreased, mainly in low frequency region (0.25kHz and 0.5kHz), and 40Hz AERP threshold was also significantly lower than the ABR threshold.
Conclusion: the hearing impairment after tympanic membrane perforation in 1 ears was mainly light and moderate conduction deafness. PTA results showed the most obvious damage in 0.125kHz. The average hearing threshold of the 14 day group in the group of different visits, the ABR and 40Hz AERP threshold were smaller than the other groups, but the difference was not statistically significant; the hearing loss was heavy in some ears, resulting in mixed deafness or sense. Acoustic nerve deafness, combined with ABR, 40Hz AERP, and clinical symptoms, we think that ear trauma can not only cause middle ear injury, but also can be associated with a certain degree of inner ear injury at the same time.
2 the hearing impairment without tympanic membrane perforation after mild closed craniocerebral injury was mainly mild to moderate sensorineural hearing loss, a few heavy hearing loss or mixed deafness, and impaired brain stem function. The results of comprehensive hearing examination showed high frequency hearing impairment (4kHz most obvious), and the hearing threshold decreased in 6 months after injury, with low frequency area. Obvious (0.25kHz and 0.5kHz), combined with clinical manifestations and auxiliary examinations, suggest that labyrinthine concussion plays an important role in the mechanism of inner ear injury.
3 the accurate assessment and reasonable identification of hearing impairment after trauma requires the clinicians or appraisers to inquire the history of the disease in detail, combined with the auxiliary examination of clinical, image and audiology. On the one hand, we fully understand the characteristics of different audiology examination, combined use to make up for each other's shortcomings, on the other hand, take the psychological state of the subjects seriously, take the psychological state of the subjects, and take the psychological state of the subjects carefully, and take the psychological state of the subjects carefully, In addition, we should take into account the law of hearing change in different periods after injury, reasonably grasp the time of identification, and finally make an objective and reasonable clinical diagnosis or forensic identification.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2010
【分类号】：R764

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