鼻咽癌初诊患者中耳功能的相关多因素量化分析

发布时间：2018-07-05 01:29

本文选题：鼻咽癌 + 初诊患者　；参考：《南方医科大学》2014年硕士论文

【摘要】：背景与目的鼻咽癌是发生在鼻咽部上皮组织的恶性肿瘤,为我国南方地区尤其是广东多发常见的头颈部恶性肿瘤之一。鼻咽癌好发于鼻咽部的咽隐窝和顶后壁,因此与中耳疾病有着密切关系。虽然听力下降、耳鸣、耳闷等耳部症状不及鼻咽癌原发病灶对患者的生存影响大,但是亦严重影响了患者的生活质量及治疗。因此重视鼻咽癌患者的中耳功能,对提高鼻咽癌患者的生存质量具有重要意义,全面了解影响鼻咽癌患者中耳功能的相关因素对后续的治疗非常重要。关于鼻咽癌初诊患者的中耳功能障碍的致病机制,早期认为鼻咽部机械性阻塞是鼻咽癌并发分泌性中耳炎的主要原因,其影响的机制主要有：肿物的直接压迫阻塞,表现为阻塞型咽鼓管功能障碍,此外鼻咽癌肿物造成阻塞所产生的炎性介质可致管腔表面活性物质减少,增加表面张力,咽鼓管主动开放功能受损,表现为闭锁不全型咽鼓管功能障碍。腭帆张肌、腭帆提肌、咽鼓管受累是目前一致认可的致病机制之一。肿瘤侵犯咽鼓管或者侵及腭帆张肌或相应的神经而致其麻痹,使咽鼓管开放障碍,可致分泌性中耳炎。但是目前仍少有学者从临床的思维出发,从鼻咽癌的原发病灶的生长情况、咽鼓管功能、咽鼓管咽口等多因素的角度研究鼻咽癌初诊患者中耳障碍的影响因素。关于鼻咽癌初诊患者中耳功能障碍的发病机制、评估及治疗目前还存在很多争议。对鼻咽癌初诊患者的中耳功能障碍的相关影响因素的研究仍然缺乏深度,对其评估让缺乏一个客观、全面的量化评价方式。本研究在总结鼻咽癌初诊患者资料的基础上,首次尝试采用多因素及量化的方法分析鼻咽癌初诊患者的中耳功能,对可能影响鼻咽癌初诊患者中耳功能的相关因素进行系统分析,力求较为全面、量化和客观评地价鼻咽癌初诊患者的中耳功能,尽可能为鼻咽癌患者出现中耳功能障碍的早期诊断和防治提供临床依据,从而进一步提高患者的生存质量。实验对象及方法 1、受试对象：收集广州南方医院和深圳市宝安区石岩人民医院2009年1月～2012年12月经病理学检查确诊为鼻咽癌的初诊患者320例(320耳),有完整的临床资料,并均行耳镜、声导抗检测、纯音听阈测试、鼻咽部及中耳CT或MRI扫描、咽鼓管功能检查、电子鼻咽镜等检查。 2、检测仪器：丹麦产Madsen ZODIAC-901型声导抗仪、GSI16纯音测听仪、美国通用电气公司的Lightspeed16排全身螺旋CT扫描机、美国通用电气公司的MRI (GE Signa1.5T)、日本产的Olympus电子纤维鼻咽喉镜。 3、将以下检查结果进行计分式量化,得分越高者,表明中耳功能受影响越严重：①根据鼓膜体征：正常记1分,鼓膜内陷、无液平线记2分,鼓膜见气泡或液平线记3分：②根据纯音听阈结果,气导正常听阈(25dBHL)记1分,轻度聋(26～40dBHL)2分,中度聋(41～55dBHL)3分,中重度聋(56～70dBHL)记4分,重度聋(71～90dBHL)记5分,极重度聋(91dBHL)记6分；③根据鼓室导抗图：A型记1分,C型记2分,B型记3分；④根据镫骨肌反射：患耳同侧或健耳对侧引出记1分,未引出记2分；⑤采用捏鼻鼓气法检查咽鼓管功能：正常记1分,功能障碍记2分；⑥根据咽鼓管咽口形态：椭圆形记1分,喇叭形记2分,三角形记3分,缝隙形记4分；⑦根据是否并发鼓室积液,无积液征象者记1分,有者记2分。判别标准是鼓膜穿刺、MRI或CT影像学证据；⑧根据影像学是否并发鼻窦炎,无鼻窦炎者记1分,有者记2分；⑨根据MRI或CT是否并发乳突炎,无乳突炎者记1分,有者记2分；⑩根据耳部症状出现的时间：无症状记1分,有耳部症状但≤6月者记2分,有耳部症状且6月者记3分。 4、统计学分析应用SPSS13.0软件包进行统计分析,进行单因素分析、多因素Logistic回归模型分析。单因素分析采用t检验,将单因素分析有统计学意义的因素纳入Logistic回归模型进行多因素分析。检验水准a=0.05。结果 1、单因素分析：经单因素分析后表明性别、年龄、N分期、M分期、病理类型对患者的中耳功能得分的影响无统计学意义；而T分期、临床分期、咽鼓管咽口形态、咽鼓管功能、肿物部位、肿物扩散类型、肿物形态、影像学侵犯范围(鼻腔、颅底、咽隐窝、咽旁间隙、腭帆张肌、腭帆提肌)侵犯与否对患者的中耳功能得分的影响均有统计学意义。 ①T分期 T1、T2、T3、T4的中耳功能得分分别为13.25±3.22、18.52±6.24、21.29±3.42、24.37±3.35,随着T分期的进展,中耳功能越差,得分也越高。T1、T2、T3、T4的中耳得分两两比较,P均0.05。 ②临床分期 Ⅰ、Ⅱ、Ⅲ、Ⅳ组的中耳功能得分12.54±1.70、16.73±5.67、20.18±4.96、23.65±4.39,两两进行比较时均有统计学差异(P0.05)。 ③局部肿物部位咽隐窝、顶后壁23.47±4.69、15.64±4.34,生长于咽隐窝肿物的中耳功能得分与生长于顶后壁肿物的中耳得分进行比较时有统计学差异(P0.05)。 ④局部的肿物扩散类型局限型、上行型、下行型、混合型14.10±3.99、22.45-2.84、16.13±5.78、24.22±3.62,不同扩散类型的中耳功能得分两辆比较P均0.05。 ⑤局部肿物形态局限型、孤立肿块型、浸润型的中耳得分分别是：14.94±4.27、18.03±4.39、25.56±2.11,进行两两比较时有统计学差异(P0.05)。 ⑥咽鼓管咽口分型椭圆形、喇叭形、三角形、缝隙形的中耳功能的得分分别是13.20±2.81、20.58±3.46、23.31±4.02、25.00±4.12,咽鼓管咽口各分型之间进行比较时均有统计学差异(P0.05)。 ⑦咽鼓管功能咽鼓管正常、咽鼓管障碍的中耳功能得分14.84±4.05、23.37±4.18,咽鼓管正常组与咽鼓管障碍两组中耳得分之间进行比较时有统计学差异(P0.05)。 ⑧影像学6个分变量影像学6个分变量(鼻腔、颅底、咽隐窝、咽旁间隙、腭帆张肌、腭帆提肌)侵犯与否两组中耳得分之间进行比较时有统计学差异(P0.05)。 2、多因素分析将单因素分析有统计学意义的T分期、临床分期、肿物部位、肿物形态、肿物扩散类型、咽鼓管功能障碍、咽鼓管咽口形态、影像学范围侵犯(鼻腔、咽隐窝、咽旁间隙、腭帆张肌、腭帆提肌、颅底)等8个主变量和6个分变量进入多因素Logistic回归模型。结果显示：T分期、肿物部位、咽鼓管功能、腭帆张肌侵犯、颅底侵犯组P均0.05,提示这些因素是影响鼻咽癌初诊患者的中耳功能的独立因素。结论 1、本研究的结果表明,T分期、临床分期、肿物部位、肿物扩散类型、肿物形态、咽鼓管功能障碍、咽鼓管咽口形态、影像学侵犯范围(鼻腔、颅底、咽隐窝、咽旁间隙、腭帆张肌、腭帆提肌)是影响鼻咽癌初诊患者的中耳功能单因素,而性别、年龄、病理类型、N分期、M分期对鼻咽癌初诊患者中耳功能无影响；多因素分析显示,T分期、肿物部位、咽鼓管功能、腭帆张肌侵犯、颅底侵犯是影响鼻咽癌初诊患者的中耳功能的独立因素。 2、T分期、临床分期较晚、生长于咽隐窝、上行型及混合型、咽鼓管功能障碍、咽鼓管咽口为裂隙形、影像学侵犯鼻腔、颅底、咽隐窝、咽旁间隙、腭帆张肌、腭帆提肌等组织以及并发鼻窦炎、乳突炎等均可加重中耳功能障碍。 3、采用耳镜、声导抗测试、纯音测听、鼻咽部影像学检查、咽鼓管功能检查、电子鼻咽镜检查等的综合量化评估,可充分了解鼓膜、鼓室功能、中耳情况、肿物的浸润程度、咽鼓管功能、咽鼓管开口等中耳的解剖和功能,能较为全面、客观地评估了鼻咽癌初诊患者的中耳功能和病变程度。通过对鼻咽癌初诊患者中耳功能的综合评估,提供临床提供诊疗依据,有利于预防和治疗患者的咽鼓管功能障碍及中耳病变,进一步提高患者的生活质量。 4、根据本研究的结果,结合患者的中耳病变及患者症状,可将鼻咽癌初诊患者的中耳功能分为：11分,无耳鸣、听力下降等不适者为中耳功能正常；11-15分,可有耳鸣、听力下降,但程度轻、对生活影响较小者为轻度中耳功能异常；16-23分,多有耳鸣、听力下降,可有耳闷塞感者为中度中耳功能异常；24分以上,常有耳鸣、听力下降、闷塞感等,明显影响生活者为重度中耳功能异常。 5、本研究的结果还有待更多的临床资料加以充实和完善,尤其在评价的项目因素及评分权重比例的合理性、根据患者的中耳障碍量化得分提出相应的治疗方案、进一步开展动态和远期的中耳功能评估等方面仍有很多的研究领域。
[Abstract]:Background and purpose
Nasopharyngeal carcinoma is a malignant tumor occurring in the epithelium of the nasopharynx, which is one of the most common head and neck malignant tumors in southern China, especially in Guangdong. Nasopharyngeal carcinoma is well distributed in the pharyngeal recess and the posterior wall of the nasopharynx. Therefore, it is closely related to the middle ear diseases. The focus has a great impact on the survival of the patients, but it also seriously affects the quality of life and treatment of the patients. Therefore, it is of great significance to pay more attention to the middle ear function of the patients with nasopharyngeal carcinoma to improve the quality of life of the patients with nasopharyngeal carcinoma.
In the early diagnosis of nasopharyngeal carcinoma, the mechanism of the middle ear dysfunction in nasopharyngeal cancer patients is that mechanical obstruction of the nasopharynx is the main cause of the nasopharyngeal carcinoma complicated with secretory otitis media. The main mechanisms are the direct compression of the tumor, the obstruction of the eustachian tube dysfunction, and the inflammation caused by the obstruction of the nasopharyngeal carcinoma. The sexual medium can reduce the surface activity of the lumen, increase the surface tension, and the active open function of the eustachian tube is impaired. The tensor palatine tensor muscle, the levator palatine levator, and the eustachian tube are one of the unanimous pathogenetic mechanisms. The tumor invades the pharynx drum tube or invades the tensor Palatine tensor palatine muscle or the corresponding nerve. Its paralysis makes the eustachian tube open and can cause secretory otitis media. But there are still few scholars from the clinical thinking, from the perspective of the growth of the primary focus of nasopharyngeal carcinoma, Eustachian tube function, Eustachian tube pharynx and other factors to study the influencing factors of the middle ear obstruction in nasopharyngeal carcinoma.
There are still many controversies about the pathogenesis, evaluation and treatment of middle ear dysfunction in nasopharyngeal cancer patients. The research on the related factors of the middle ear dysfunction of nasopharyngeal cancer patients is still lack of depth, and the evaluation is lacking an objective and comprehensive quantitative evaluation method. This study summarizes nasopharyngeal cancer patients in the first diagnosis. On the basis of the data, it is the first attempt to analyze the middle ear function of nasopharyngeal carcinoma patients with nasopharyngeal carcinoma (nasopharyngeal carcinoma) for the first time by using multiple factors and quantifying methods, and systematically analyze the related factors that may affect the middle ear function of nasopharyngeal carcinoma, and try to quantify and objectively evaluate the middle ear function of the first diagnosed patients with nasopharyngeal carcinoma, and to make the nasopharyngeal cancer patients as possible as possible. It provides a clinical basis for early diagnosis and prevention of middle ear dysfunction, so as to further improve the quality of life of patients.
Experimental objects and methods
1, subjects: 320 cases (320 ears) of nasopharyngeal carcinoma were collected from Guangzhou Nanfang Hospital and Baoan District Shiyan people's Hospital of Shenzhen city from January 2009 to 2012. 320 cases of nasopharyngeal carcinoma were diagnosed as nasopharyngeal carcinoma (320 ears) with complete clinical data. All of them were received ear mirror, acoustic conductivity detection, pure tone hearing threshold test, nasopharyngeal and middle ear CT or MRI scan, Eustachian tube function examination. Check, electronic nasopharyngoscopy and other examination.
2, testing instruments: the Madsen ZODIAC-901 acoustic conductance instrument in Denmark, the GSI16 pure tone audiometer, the Lightspeed16 row CT scanner of the Ge Corp in the United States, the MRI (GE Signa1.5T) of the United States Ge Corp (GE Signa1.5T), and the Olympus electronic fiber nasopharyngeal laryngoscope produced in Japan.
3, the following examination results were quantized. The higher the score, the more serious the middle ear function was: (1) according to the signs of the tympanic membrane: 1 points in normal, 2 in the tympanic membrane, 2 in the non liquid line, 3 in the tympanic membrane, by the result of the pure tone hearing threshold, 1 in the normal hearing threshold (25dBHL), and 2 for the mild hearing loss (26 to 40dBHL). Moderate deafness (41 to 55dBHL), moderate to severe deafness (56 to 70dBHL), 4, 5 for severe deafness (71 to 90dBHL), and 6 for extreme deafness (91dBHL); (3) according to the tympanic resistance map: A type 1, C type 2, and B type 3; (4) according to the stapes muscle reflex: the side of the ear or the sound of the ear of the ear was divided 1, no 56 points; 5 Check the function of eustachian tympanum: 1 points in normal, 2 points for dysfunction; 6. According to pharynx tube pharynx shape: Oval record 1 points, horn shape 2 points, triangle 3 points, gap mark 4 points; There were 1 points for sinusitis without sinusitis, 1 points without sinusitis, and 2 points for those with no sinusitis. According to whether MRI or CT was complicated with masttis, there were 1 points without masttis and 2 points.
4, statistical analysis
SPSS13.0 software package was used to carry out statistical analysis, single factor analysis and multiple factor Logistic regression model analysis. Single factor analysis was analyzed by t test. The factors of statistical significance in single factor analysis were included in Logistic regression model for multi factor analysis. The test level a=0.05.
Result
1, single factor analysis:
After single factor analysis, the effects of sex, age, N staging, M staging, and pathological types on the median ear function score were not statistically significant; T staging, clinical staging, Eustachian tube pharynx morphology, Eustachian tube function, tumor site, tumor diffusion type, tumor morphology, imaging invasion range (nasal cavity, skull base, pharyngeal recess, parapharyngeal space, palatine) The influence of the insertion of the tensor veli palatine muscle or the levator veli palatine muscle on the middle ear function score was statistically significant.
T staging
The middle ear function scores of T1, T2, T3 and T4 were 13.25 + 3.22,18.52 + 6.24,21.29 + 3.35 respectively. With the progress of T staging, the worse the function of the middle ear, the higher the score was.T1, T2, T3, and 22 in the middle ear of T4.
Clinical staging
The scores of middle ear function in group I, II, III and IV were 12.54 + 1.70,16.73 + 5.67,20.18 + 4.96,23.65 + 4.39, and 22 were statistically different when compared (P0.05).
Part of local mass
The posterior wall of the pharynx and the posterior wall of the pharynx were 23.47 + 4.69,15.64 + 4.34. The score of the middle ear function for the swelling of the pharyngeal fossa was compared with the middle ear score of the posterior wall mass (P0.05).
Local mass diffusion type
Limited type, ascending type, descending type, mixed type 14.10 + 3.99,22.45-2.84,16.13 + 5.78,24.22 + 3.62, different diffused type middle ear function score two vehicle comparison P all 0.05.
Form of local mass
The central ear scores of localized type, solitary mass type and infiltrating type were: 14.94 + 4.27,18.03 + 4.39,25.56 + 2.11, and 22 compared with statistical difference (P0.05).
Subtype of eustachian tube pharyngeal orifice
The scores of the oval, horn, triangular and crevice middle ear functions were 13.20 + 2.81,20.58 + 3.46,23.31 + 4.02,25.00 + 4.12 respectively, and there were statistically significant differences between the pharyngeal orifice types of the eustachian tube (P0.05).
Eustachian tube function
The score of eustachian tube was normal, the score of middle ear function of eustachian tube disorder was 14.84 + 4.05,23.37 + 4.18. There was a statistical difference between the normal group of eustachian tube and the score of middle ear in two groups of eustachian tube disorder (P0.05).
6 sub variables of imaging
The 6 sub variables (nasal cavity, skull base, pharynx recess, parapharyngeal space, palatine sail tensor, palatine sails) were compared with the two groups of middle ear scores (P0.05).
2, multi factor analysis
T staging with statistical significance, clinical staging, tumor location, tumor morphology, tumor diffusion type, Eustachian tube dysfunction, Eustachian tube pharynx morphology, imaging range invasion (nasal cavity, pharyngeal recess, parapharyngeal space, palatine sail tensor, palatopalatine levator, skull base) and other 8 main variables and 6 variables entered the multiple factor Logistic regression model. The results showed that the T staging, the tumor site, the eustachian tube function, the invasion of the palatine tensor muscle, and the P of the skull base invasion group were all 0.05, suggesting that these factors were independent factors affecting the middle ear function of nasopharyngeal carcinoma.
conclusion
1, the results of this study showed that T staging, clinical staging, tumor site, tumor diffusion type, tumor morphology, Eustachian tube dysfunction, Eustachian tube pharynx morphology, imaging invasion range (nasal cavity, skull base, pharyngeal recess, parapharyngeal space, palatine tensor palatine, palatine Levi muscle) are the single factors affecting the middle ear function in nasopharyngeal cancer patients, and sex, age, and disease. Type, N staging and M staging have no effect on the middle ear function of nasopharyngeal carcinoma. Multiple factor analysis shows that T staging, tumor site, Eustachian tube function, palatine tensor muscle invasion and skull base invasion are independent factors affecting the middle ear function of nasopharyngeal carcinoma first diagnosed patients.
2, T staging, the clinical stage is late, growth in the pharyngeal recess, upper and mixed type, Eustachian tube dysfunction, Pharyngal tube pharyngeal mouth is fissures, imaging invasion of the nasal cavity, the skull base, pharyngeal recess, parapharyngeal space, palatine sail tensor, palatine levator muscle and other tissues as well as nasosinusitis, and masttis can aggravate the middle ear dysfunction.
3, the comprehensive quantitative evaluation of the eardrum, the nasopharyngeal imaging examination, the eustachian tube function examination, the electronic nasopharynx examination and so on, can fully understand the tympanic membrane, the tympanic function, the middle ear condition, the infiltration degree of the swelling, the eustachian tube function, the opening of the pharynx drum and so on, which can be more comprehensive and objective evaluation. The function and degree of the middle ear of nasopharyngeal carcinoma first diagnosis patients, through comprehensive evaluation of the middle ear function of nasopharyngeal cancer patients, provide clinical basis for diagnosis and treatment. It is beneficial to prevent and treat the dysfunction of eustachian tube and middle ear, and further improve the quality of life of the patients.
4, according to the results of this study, combined with the patients' middle ear lesions and patients' symptoms, the middle ear function of nasopharyngeal carcinoma patients can be divided into 11 points, no tinnitus and hearing loss as the middle ear function is normal; 11-15 points can have tinnitus and hearing loss, but the degree is light, and the less affected people are mild middle ear dysfunction; 16-23 points and more. There are tinnitus, hearing loss, and the patients with ear stuffy feel a moderate middle ear dysfunction; more than 24 points, often with tinnitus, hearing loss, stuffy stoppage, and so on, which obviously affect the abnormality of severe middle ear function.
5, the results of this study still need more clinical data to be enriched and perfected, especially in the evaluation of the rationality of the project factors and the proportion of the weight of the score, according to the quantitative score of the middle ear disorders of the patient to put forward the corresponding treatment plan, and to further develop the dynamic and long-term evaluation of the middle ear work, there are still a lot of fields of research.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.63

【参考文献】