“难治性”特发性聋高压氧综合治疗临床研究
发布时间：2018-08-07 11:09
【摘要】：背景 特发性聋(ISHL),国内也称突发性聋(SHL),相当于美国的“特发性突发感音神经性聋”(ISSNHL),发病率逐年上升并呈现年轻化趋势。“难治性”ISHL是经初始治疗失败的ISHL,具有中重度、病程较长、疗效差、合并特殊疾病治疗手段局限等特点。 ISHL的诊治面临“争议”的现状：发病机制不清,多学科研究热点；临床界治疗方案侧重点不同,疗效差别大；国内外指南对定义标准、辅助检查、治疗方法、疗效标准、预后和随访阐述不一；高压氧(HBO)治疗方案亟需完善。 “难治性”ISHL是ISHL的特殊类型,目前概念模糊,缺乏科学系统的阐述；近年来流行病学特点呈现新的变化：逐渐成为一种以耳部症状为主,严重影响生活质量的全身性疾病。 海军总医院全军高压氧治疗中心近年来收治的ISHL患者越来越多,前来就诊的多是外院治疗疗效差,或错过最佳治疗时间窗,或重度听力损害,或合并特殊疾病的“难治性”ISHL。观察发现：该类“难治性”ISHL患者多有明显的情绪问题或紧迫的生活环境,发病后极其烦恼；临床界对该病的认识程度和治疗方法不一,疗效差异大,存在诸多分歧。为此开展并设计本研究。 目的 通过半随机、部分双盲、临床对照试验研究,探讨：(1)“难治性”ISHL临床新特点；(2)“难治性”ISHL与应激的关系、可能的一元化病因机制学说及量化的应激评估指标；(3)糖皮质激素联合HBO综合治疗“难治性”ISHL的疗效；(4)不同吸氧方式对“难治性”ISHL疗效的影响；(5)合并特殊疾病人群“难治性”ISHL的个体化治疗方案。旨在为临床再认识该类疾病、提高治疗效果作一参考。 对象与方法 1.研究对象 挑选海军总医院全军高压氧治疗中心2012.02-2013.12病房收治的53例、2012.01-2014.02病房收治的67例、2012.01-2014.02门诊及病房收治的79例、2011.02-2014.01门诊及病房收治的101例、2012.02-2014.01收治的6例合并特殊疾病(4例合并慢性肾功能不全、2例合并白血病)及1例小儿ISHL患者。 2.纳入标准 ①符合中华医学会耳鼻咽喉头颈外学科分会制定的SHL诊断标准；②均为单耳发病,未经糖皮质激素静脉或足疗程治疗；③符合“难治性”ISHL条件,纳入研究时病程14d；④头颅或颞骨(内听道)影像学检查未见异常；⑤无糖皮质激素全身治疗及高低压氧治疗绝对禁忌症；⑥否认心律失常、甲状腺机能亢进或减退、2型糖尿病、贫血病史。 3.研究方法 3.1“难治性”ISHL临床特点分析 所有患者入院48h内：采用自制量表收集发病时基本资料,匹兹堡睡眠质量问卷(PSQI)评估睡眠质量,90项症状量表(SCL-90)测评心理健康状态。SCL-90测评结果与中国正常人常模(N=1388)对比分析；于海军总医院耳鼻喉科隔音屏蔽室内完成纯音测听、鼓室声阻抗检查。收集数据进行流行病学分析。 3.2“难治性”ISHL发病机制探讨 所有患者均于入院48h内、治疗开始前完成应激(压力)反应问卷(SRQ)、纯音测听、心率变异率(HRV)、甲功三项(T3、T4、TSH)检查或化验。应激状态评估借助应激(压力)反应问卷测评；心率变异率(HRV)借助“FLY-2型神经生理信息工作站”,采用短程(5min)测定方法采集并分析。 所有患者采取统一“应激改善”治疗方案。治疗第14d复查纯音测听,并依据听力疗效分为“无效组”、“治疗有效果组(包含有效、显效、治愈)”。回顾性分析两组治疗前检查、化验指标差异,并结合文献解读。 3.3糖皮质激素联合HBO治疗“难治性”ISHL临床研究 参考患者意愿,依据随机分配原则,将入选患者分为：HBO联合糖皮质激素治疗组44例,单纯HBO组35例。另外在我院同期耳鼻喉科收治的ISHL患者,选取使用糖皮质激素但未进行HBO治疗患者32例,作为单纯糖皮质激素治疗组。 治疗前后进行纯音测听检测;听力改善率=(治疗前听力-治疗后的听力)／(治疗前听力-未受影响的对侧耳的听力)×100%。比较三组治疗效果。 3.4不同吸氧方式综合治疗“难治性”ISHL临床研究 101例患者,随机分为A、B、C三组,A组37例,B组37例,C组27例。在统一治疗方案的基础上：A组联合0.20MPa HBO治疗,B组联合0.16MPa HBO治疗,C组联合0.10MPa(常压)面罩吸纯氧治疗,1次/d,疗程14d。A、B组治疗期间出现耳闷加重,查鼓室声阻抗“C型曲线”患者9例,调整为0.07MPa(海拔3000米大气压)吸纯氧治疗3-5次,纳入D组。A组剩余患者纳为A1组(34例),B组剩余患者纳为B1组(31例)。所有患者分别于治疗前、第14d查纯音测听和鼓室声阻抗。比较四组治疗疗效。 3.5合并特殊疾病人群“难治性”ISHL HBO综合治疗临床研究 观察、分析7例(4例合并慢性肾功能不全、2例合并白血病、1例小儿)患者病例资料,总结诊疗、护理体会,结合文献复习。 4.治疗方法 所有患者均给予地塞米松磷酸钠注射液(10mg,莫非氏管入,1/d,连续5-7d；5mg,莫非氏管入,1/d,连续5-7d)、银杏叶提取物注射液(20m1,静脉滴注,1/d,共10～14d)、天麻素注射液(0.6g,静脉滴注,1/d,共10～14d),甲钴胺片口服(500ug,3/日),静脉输液同时行HBO(1/d,每周治疗5d,共10～20次)或常压面罩吸纯氧治疗。根据病情辅以改善睡眠药物、抗焦虑抑郁类药物、科普宣教及心理疏导。 5.统计学处理 采用SPSS13.0软件进行统计学处理,计量资料以均数±标准差(x±s)表示,组间比较采用t检验；三种疗法的治愈率和有效率采用卡方检验,有效率比较采用秩和检验；平均听阈差值比较采用方差分析。以P0.05为差异显著。 结果 1.“难治性”ISHL临床特点分析 “难治性”ISHL好发于夏季(43.4%),女性占64.2%,大学、大专、硕士学历人群占84.9%,脑力劳动者占75.5%,A型血占47.2%,O型血占30.2%,反复突聋发作人群占35.8%；发病前常见诱发因素为：睡眠差、劳累、发脾气、熬夜、饮酒、噪音接触；合并基础疾病中,高脂血症(41.5%)比例最大；60.4%患者存在睡眠差,PSQI8.5±2.6分；躯体化、强迫、抑郁、焦虑、敌对、精神病性因子分值较常模比较有统计学差异(P0.05)。 2.“难治性”ISHL发病机制探讨 治疗总有效率79.1%。两组SRQ差异有统计学意义(P0.05),两组分值均高于常模。HRV中,有效果组HF、LF、LF/HF三项指标值均高于无效组,差异有统计学意义(P0.05)。无效组中,LF、LF/HF两项指标均数都低于正常范围下限值；有效果组中,LF均数明显高于正常范围上限值。两组T3、TSH的浓度有统计学差异(P0.05)。T3浓度,有效果组高于无效组；TSH浓度,无效组高于有效果组。 3.糖皮质激素联合HBO治疗“难治性”ISHL临床研究 治疗过程中,因血压和血糖控制不理想未能坚持糖皮质激素治疗1例,因中耳调压不良自行中断HBO治疗4例。最后,有效果44例(41.5%),治愈17例(16%)。与单纯糖皮质激素组和单纯HBO组比较,HBO联合糖皮质激素组的有效率(59.52%)明显高于其它两组,治愈率三组间无显著差异(P0.05),HBO联合糖皮质激素组的听力改善率(61.3±4.7%)显著高于其它两组(P0.05)。 4.不同吸氧方式综合治疗“难治性”ISHL临床研究 总有效率比较,A1、B1、C三组有统计学差异(X2=6.218,P0.05),A1、B1、D三组差异无统计学意义(X2=0.876,P0.05)；治疗前后PTA提高值比较,A1、B1组均高于C组(F=3.63,P0.05；A1与C组比较Dunneet-t=2.34, P0.05；B1与C组比较Dunnett-t=3.01, P0.005)。 D组患者治疗14d后鼓室声阻抗均为A型曲线,耳闷堵感症状减轻优于A1、B1组。 5.合并特殊疾病人群“难治性”ISHL HBO综合治疗临床研究 “难治性”ISHL合并肾功能不全人群,多为“全聋型”感音神经性听力损害；治疗中主要采用“糖皮质激素”治疗,特别是鼓室内给药途径,辅以维生素、中药汤剂、HBO治疗；患者情绪的控制和睡眠改善是应激缓解、治疗配合和疗效提高的重点；血液透析虽然没有被证实有效,但血液透析可以保证患者肾功能对治疗药物的安全耐受性；促红细胞生成素、叶酸、铁剂对贫血的改善影响可能起到一定的促进听力恢复作用。 “难治性”ISHL合并白血病患者疗效差。没有进行足疗程、有效的抗病毒治疗,或许是疗效差的部分原因；白血病患者长期使用免疫抑制剂或糖皮质激素,易引起糖皮质激素受体亲和力下降或糖皮质激素抵抗,减低抗炎效价,故常规剂量和疗程的糖皮质激素可能抗炎治疗效果差；反复波动的贫血缺氧、粒细胞增减或凝血功能变化,可引起内耳经常性的应激刺激,造成内耳细胞持续性的水肿反应和炎性损害；HBO治疗受粒细胞水平、贫血程度及感染性发热等影响,难以足疗程实施；白血病患者使用药物广、并发症多,易并存焦虑等神经症症状,治疗难度大,依从性较差。 小儿“难治性”ISHL多发现较晚、听力损害程度重。病毒感染可能是其主要病因,听觉多频稳态诱发电位(MFSSR)是其重要的听力学检查。即使发病2月以上,短效糖皮质激素仍可作为选用药物,且使用疗程宜偏长；可间断加用低压力HBO治疗,疗程10-20次。佩戴大功率助听器或行外科干预前,一切有利于听力恢复的内科综合治疗均应积极应用,特别是糖皮质激素和低压力HBO治疗的应用,以期尽可能的提高或恢复患儿听力。护理中,护士应针对小儿“难治性”ISHL特点加强患儿父母的科普宣教,注重小儿、家长双重心理护理,嘱治疗期间避免激惹和噪音刺激,鼓励家长多与患儿沟通,以正性引导、物质激励为主。 结论 1、“难治性”ISHL夏季高发,好发于更年期女性、高学历、脑力劳动者、A型和0型血、反复突聋发作人群,睡眠质量差、心理情绪异常较明显,应激障碍(负性生活事件、情绪波动、疲劳、失眠等单因素或诸因素联合作用)可能是其发病机制之一。 2、应激障碍可能是“难治性”ISHL发病的诱发因素,或是发病后继发其他损伤的加重因素。HRV结果可作为糖皮质激素治疗“难治性”ISHL敏感性及疗效预测的指标之一,T3和TSH变化可反应ISHL的机体应激程度。 3、HBO联合糖皮质激素对“难治性”ISHL较单纯疗法效果好,在实施HBO联合治疗的过程中需要对糖皮质激素的不良反应加以监控。 4、高压氧联合地塞米松磷酸钠注射液、银杏叶提取物注射液是治疗“难治性”ISHL的有效方法。0.16MPa高压氧治疗,疗效满意,经济成本低,更具优势；耳闷堵感症状明显时可调整为0.07MPa低压舱吸氧治疗。 5、针对不同的“难治性”ISHL人群,在追求最大疗效同时,宜采取个体化原则,尽可能的避免基础疾病加重和减少并发症。
[Abstract]:background
Idiopathic deafness (ISHL), also known as sudden deafness (SHL) in China, is equivalent to "idiopathic sudden sensorineural hearing loss" (ISSNHL) in the United States. The incidence of onset is rising year by year and showing a trend of youth. "Refractory" ISHL is a ISHL with a failure of initial treatment. It has the characteristics of moderate to severe, long course, poor curative effect and limited treatment of special diseases.
The diagnosis and treatment of ISHL is faced with the status of "dispute": the pathogenesis is not clear, the multidisciplinary research hot spot; the clinical community treatment scheme is different and the curative effect is different; the domestic and foreign guidelines are not one of the definition standard, the auxiliary examination, the treatment method, the curative effect standard, the prognosis and the follow-up, and the hyperbaric oxygen (HBO) treatment plan needs to be perfected urgently.
"Refractory" ISHL is a special type of ISHL. At present, the concept is vague and lack of scientific system. In recent years, the characteristics of epidemiology have shown new changes: gradually become a kind of systemic disease which mainly affects the quality of life with the ear symptoms.
In recent years, there are more and more ISHL patients admitted to the whole army hyperbaric oxygen therapy center in Navy General Hospital. Most of the patients who come to the hospital have poor treatment effect, or miss the best time window, or severe hearing impairment, or the "refractory" ISHL. with special diseases: the "refractory" ISHL patients have obvious emotional problems or more obvious emotional problems. The urgent living environment is extremely annoying after the onset of the disease; the degree of understanding and treatment of the disease in the clinical community is different, the curative effect is different and there are many differences. Therefore, the study is carried out and designed.
objective
A semi randomized, partially blind, clinically controlled trial study was conducted to explore: (1) the new clinical characteristics of "refractory" ISHL; (2) the relationship between refractory ISHL and stress, the possible monetized etiological mechanism and quantitative stress evaluation index; (3) the effect of glucocorticoid combined with HBO in the treatment of "refractory" ISHL; (4) different oxygen inhalation The effect of the "refractory" ISHL on the therapeutic effect of "refractory" and (5) the individualized treatment scheme of "refractory" ISHL in the group with special diseases was designed to provide a reference for the clinical recognition of the disease and the improvement of the therapeutic effect.
Object and method
1. research objects
53 cases of 2012.02-2013.12 in Navy General Hospital, 67 cases in 2012.01-2014.02 ward, 79 cases in 2012.01-2014.02 out-patient and ward, 101 cases in 2011.02-2014.01 outpatient and ward, 6 cases with special diseases treated with 2012.02-2014.01 (4 cases with chronic renal insufficiency, 2 cases) And leukaemia) and 1 cases of ISHL in children.
2. inclusion criteria
(1) the SHL diagnostic criteria were established in accordance with the Chinese Medical Association of Otolaryngology and the head and neck branch; both were single ear, without glucocorticoid vein or foot treatment; (3) conformed to the "refractory" ISHL condition and included the course of the study in the course of 14d; (4) the skull or temporal bone (internal auditory) imaging examination was not abnormal; 5 Absolute contraindication of body therapy and hyperbaric oxygen therapy; _Denialof arrhythmia, hyperthyroidism or hypoxia, type 2 diabetes mellitus, anemia history.
3. research methods
Analysis of clinical characteristics of 3.1 "refractory" ISHL
All patients were admitted to 48h: using the self-made scale to collect the basic data of the disease, the Pittsburgh sleep quality questionnaire (PSQI) was used to evaluate the quality of sleep. The 90 symptom checklist (SCL-90) was used to evaluate the psychological health status.SCL-90 results and the Chinese normal norm (N=1388), and the pure sound shielding room of Navy General Hospital was pure. Audiometry, tympanic acoustic impedance test, data collection and epidemiological analysis.
Study on the pathogenesis of 3.2 "refractory" ISHL
All patients were hospitalized in 48h. Before the treatment, stress (stress) response questionnaire (SRQ), pure tone audiometry, heart rate variability (HRV), three items of thyroid function (T3, T4, TSH) were examined or tested. Stress state assessment was assessed with stress (stress) response questionnaire, and heart rate variability (HRV) using "FLY-2 neurophysiological information workstation" and short range (5m). In) the determination method was collected and analyzed.
All patients were treated with unified "stress improvement" treatment. The treatment of 14d was reviewed by the treatment of pure tone audiometry, and the results were divided into "invalid group" according to the hearing effect. "The treatment group (including effective, effective, cure)". Retrospective analysis of two groups before treatment, the difference of test indexes, and the literature interpretation.
3.3 glucocorticoid combined with HBO in the treatment of refractory ISHL
According to the wishes of the patients, according to the principle of random distribution, the selected patients were divided into 44 cases of HBO combined with glucocorticoid treatment group and 35 cases in group HBO alone. In addition, 32 cases of ISHL patients who were treated with glucocorticoids in the Department of ENT at the same period in our hospital were selected as simple glucocorticoid treatment group.
Pure tone audiometry before and after treatment, hearing improvement = (pre treatment hearing treatment hearing) / (pre treatment hearing - unaffected hearing of the side of the lateral ear) * * 100%. were compared in the three groups.
3.4 clinical study of different ways of oxygen inhalation in the treatment of refractory ISHL
101 patients were randomly divided into group A, B, C three, group A 37 cases, B group 37 cases and C group 27 cases. On the basis of unified treatment scheme, A group combined 0.20MPa HBO treatment, B group combined 0.16MPa HBO treatment, group joint (normal pressure) inhalation of pure oxygen therapy, 1 times of treatment, course of treatment, ear aggravation during the treatment, and the sound impedance of tympanum. 9 cases were adjusted to 0.07MPa (altitude of 3000 m) for 3-5 times of pure oxygen therapy. The remaining patients in group.A of group D were included in group A1 (34 cases), and the remaining patients in group B were included in group B1 (31 cases). All patients were treated with pure tone audiometry and tympanic acoustic impedance before treatment, and the treatment effect was compared between the four groups.
3.5 clinical study of refractory ISHL HBO combined treatment for patients with special diseases
Observation and analysis of 7 cases (4 cases with chronic renal insufficiency, 2 cases with leukemia, 1 case of children) case data, summarize the diagnosis and treatment, nursing experience, combined with literature review.
4. treatment methods
All patients were given Dexamethasone Sodium Phosphate Injection (10mg, 1/d, continuous 5-7d; 5mg, 5mg, 1/d, continuous 5-7d), Extract of Ginkgo Biloba Leaves Injection (20m1, intravenous drip, 1/d, 10 to 14d), Gastrodin Injection (0.6g, intravenous drip, 1/d, altogether 10 ~ 14d), Mecobalamin Tablets orally (1/d, 10~20 times a week for 5D, a total of 10~20) or normal pressure mask for pure oxygen therapy. According to the condition, the sleep drugs, antidepressants, science popularization and psychological counseling are improved.
5. statistical treatment
The SPSS13.0 software was used for statistical processing, and the measurement data were expressed with mean standard deviation (x + s), and t test was used among groups. The cure rate and efficiency of the three treatments were checked by chi square test, the efficiency was compared with the rank sum test, and the average hearing threshold difference was compared with the variance analysis. The difference was significant with P0.05.
Result
Analysis of clinical characteristics of 1. "refractory" ISHL
"Refractory" ISHL occurred in summer (43.4%), women accounted for 64.2%, University, college, master degree population accounted for 84.9%, mental workers accounted for 75.5%, A type of blood accounted for 47.2%, O type of blood accounted for 30.2%, and recurrent sudden deafness seizures accounted for 35.8%. The common inducing factors before the onset were sleep poor, tired and angry, staying up late, drinking, noise exposure, combined with basic diseases. The proportion of hyperlipidemia (41.5%) was the largest, and 60.4% patients had poor sleep and PSQI8.5 2.6. The scores of somatization, compulsion, depression, anxiety, hostility and psychotic factors were statistically different compared with those of normal models (P0.05).
Study on the pathogenesis of 2. "refractory" ISHL
The total effective efficiency of the treatment of 79.1%. two groups SRQ difference was statistically significant (P0.05), the two groups were higher than the normal model.HRV, the effect group HF, LF, LF/HF three index values were higher than the invalid group, the difference was statistically significant (P0.05). In the invalid group, LF, LF/HF two indexes are lower than the normal range; LF average in the effective group is obviously higher than the number The concentration of T3 and TSH in the effective group was higher than that in the ineffective group; the concentration of TSH in the ineffective group was higher than that in the effective group.
3. glucocorticoid combined with HBO in the treatment of refractory ISHL
In the course of treatment, 1 cases were failed to adhere to glucocorticoid treatment because of poor blood pressure and blood sugar control. 4 cases were treated by self interruption of HBO because of poor middle ear pressure. Finally, there were 44 cases (41.5%) and 17 cases (16%). Compared with the simple glucocorticoid group and the simple HBO group, the effective rate of HBO combined glucocorticoid group (59.52%) was significantly higher than the other two. There was no significant difference in the cure rate among the three groups (P 0.05). The improvement rate of hearing in HBO combined with glucocorticoid group was significantly higher than that in the other two groups (P 0.05).
4. clinical study of different ways of oxygen inhalation in the treatment of refractory ISHL
There were statistical differences between the three groups of A1, B1 and C (X2=6.218, P0.05), A1, B1, and D three groups had no statistical significance (X2=0.876, P0.05). The acoustic impedance was all A curve, and the symptoms of ear congestion were relieved better than those of group A1 and group B1.
5. clinical study of refractory ISHL HBO combined treatment for patients with special diseases
"Refractory" ISHL combined with renal dysfunction, mostly "fully deaf" sensorineural hearing impairment; the treatment mainly used "glucocorticoid" treatment, especially in the tympanum, supplemented by vitamin, decoction of Chinese medicine, HBO treatment; emotional control and sleep improvement of patients are stress relief, treatment coordination and effective improvement Although hemodialysis is not proved to be effective, hemodialysis can guarantee the safety tolerance of the patient's renal function to the treatment of drugs; the effect of erythropoietin, folic acid, and iron on anemia may play a certain role in promoting hearing recovery.
"Refractory" ISHL combined with leukemia patients have poor curative effect. No foot therapy, effective antiviral therapy, may be part of the cause of poor curative effect; long term use of immunosuppressive agents or glucocorticoids in leukemia patients may cause the decline of glucocorticoid receptor affinity or glucocorticoid resistance to reduce the anti inflammatory potency, so the routine dose The curative effect of the glucocorticoid and the course of glucocorticoid may be poor. Repeated anaemia, anoxia, granulocyte increase or change of blood clotting function can cause frequent stress stimulation of the inner ear, resulting in the persistent edema and inflammatory damage of the inner ear cells; the effect of HBO on the level of granulocyte, the degree of anemia and infectious fever is difficult to foot. Leukemia patients use a wide range of drugs, complications, anxiety and other neurological symptoms, treatment difficulty, poor compliance.
The "refractory" ISHL in children is found late and the degree of hearing damage is heavy. The virus infection may be the main cause of the disease. The auditory multi frequency steady-state evoked potential (MFSSR) is an important audiological examination. Even if the onset of the disease is above February, the short effect glucocorticoid can still be used as a drug, and the course should be longer, and the low pressure HBO can be used intermittently. 10-20 times of treatment. Before wearing high power hearing aids or surgical intervention, all comprehensive medical treatment for hearing recovery should be actively applied, especially the application of glucocorticoid and low stress HBO treatment in order to improve or restore children's hearing as much as possible. In nursing, nurses should strengthen children's "refractory" ISHL characteristics. Parents' popularization of science and education, pay attention to children, parents double psychological nursing, to avoid irritation and noise stimulation during the treatment, encourage parents to communicate with children, with positive guidance, material incentives.
conclusion
1, "refractory" ISHL high incidence in summer, good hair in menopause women, high education, mental workers, A and type 0 blood, recurrent sudden deafness attacks, poor sleep quality, psychological and emotional abnormalities, stress disorder (negative life events, emotional fluctuations, fatigue, insomnia and other factors or factors combined) may be one of the mechanisms of the disease.
2, stress
【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】：R764.43
本文编号：2169834
[Abstract]:background
Idiopathic deafness (ISHL), also known as sudden deafness (SHL) in China, is equivalent to "idiopathic sudden sensorineural hearing loss" (ISSNHL) in the United States. The incidence of onset is rising year by year and showing a trend of youth. "Refractory" ISHL is a ISHL with a failure of initial treatment. It has the characteristics of moderate to severe, long course, poor curative effect and limited treatment of special diseases.
The diagnosis and treatment of ISHL is faced with the status of "dispute": the pathogenesis is not clear, the multidisciplinary research hot spot; the clinical community treatment scheme is different and the curative effect is different; the domestic and foreign guidelines are not one of the definition standard, the auxiliary examination, the treatment method, the curative effect standard, the prognosis and the follow-up, and the hyperbaric oxygen (HBO) treatment plan needs to be perfected urgently.
"Refractory" ISHL is a special type of ISHL. At present, the concept is vague and lack of scientific system. In recent years, the characteristics of epidemiology have shown new changes: gradually become a kind of systemic disease which mainly affects the quality of life with the ear symptoms.
In recent years, there are more and more ISHL patients admitted to the whole army hyperbaric oxygen therapy center in Navy General Hospital. Most of the patients who come to the hospital have poor treatment effect, or miss the best time window, or severe hearing impairment, or the "refractory" ISHL. with special diseases: the "refractory" ISHL patients have obvious emotional problems or more obvious emotional problems. The urgent living environment is extremely annoying after the onset of the disease; the degree of understanding and treatment of the disease in the clinical community is different, the curative effect is different and there are many differences. Therefore, the study is carried out and designed.
objective
A semi randomized, partially blind, clinically controlled trial study was conducted to explore: (1) the new clinical characteristics of "refractory" ISHL; (2) the relationship between refractory ISHL and stress, the possible monetized etiological mechanism and quantitative stress evaluation index; (3) the effect of glucocorticoid combined with HBO in the treatment of "refractory" ISHL; (4) different oxygen inhalation The effect of the "refractory" ISHL on the therapeutic effect of "refractory" and (5) the individualized treatment scheme of "refractory" ISHL in the group with special diseases was designed to provide a reference for the clinical recognition of the disease and the improvement of the therapeutic effect.
Object and method
1. research objects
53 cases of 2012.02-2013.12 in Navy General Hospital, 67 cases in 2012.01-2014.02 ward, 79 cases in 2012.01-2014.02 out-patient and ward, 101 cases in 2011.02-2014.01 outpatient and ward, 6 cases with special diseases treated with 2012.02-2014.01 (4 cases with chronic renal insufficiency, 2 cases) And leukaemia) and 1 cases of ISHL in children.
2. inclusion criteria
(1) the SHL diagnostic criteria were established in accordance with the Chinese Medical Association of Otolaryngology and the head and neck branch; both were single ear, without glucocorticoid vein or foot treatment; (3) conformed to the "refractory" ISHL condition and included the course of the study in the course of 14d; (4) the skull or temporal bone (internal auditory) imaging examination was not abnormal; 5 Absolute contraindication of body therapy and hyperbaric oxygen therapy; _Denialof arrhythmia, hyperthyroidism or hypoxia, type 2 diabetes mellitus, anemia history.
3. research methods
Analysis of clinical characteristics of 3.1 "refractory" ISHL
All patients were admitted to 48h: using the self-made scale to collect the basic data of the disease, the Pittsburgh sleep quality questionnaire (PSQI) was used to evaluate the quality of sleep. The 90 symptom checklist (SCL-90) was used to evaluate the psychological health status.SCL-90 results and the Chinese normal norm (N=1388), and the pure sound shielding room of Navy General Hospital was pure. Audiometry, tympanic acoustic impedance test, data collection and epidemiological analysis.
Study on the pathogenesis of 3.2 "refractory" ISHL
All patients were hospitalized in 48h. Before the treatment, stress (stress) response questionnaire (SRQ), pure tone audiometry, heart rate variability (HRV), three items of thyroid function (T3, T4, TSH) were examined or tested. Stress state assessment was assessed with stress (stress) response questionnaire, and heart rate variability (HRV) using "FLY-2 neurophysiological information workstation" and short range (5m). In) the determination method was collected and analyzed.
All patients were treated with unified "stress improvement" treatment. The treatment of 14d was reviewed by the treatment of pure tone audiometry, and the results were divided into "invalid group" according to the hearing effect. "The treatment group (including effective, effective, cure)". Retrospective analysis of two groups before treatment, the difference of test indexes, and the literature interpretation.
3.3 glucocorticoid combined with HBO in the treatment of refractory ISHL
According to the wishes of the patients, according to the principle of random distribution, the selected patients were divided into 44 cases of HBO combined with glucocorticoid treatment group and 35 cases in group HBO alone. In addition, 32 cases of ISHL patients who were treated with glucocorticoids in the Department of ENT at the same period in our hospital were selected as simple glucocorticoid treatment group.
Pure tone audiometry before and after treatment, hearing improvement = (pre treatment hearing treatment hearing) / (pre treatment hearing - unaffected hearing of the side of the lateral ear) * * 100%. were compared in the three groups.
3.4 clinical study of different ways of oxygen inhalation in the treatment of refractory ISHL
101 patients were randomly divided into group A, B, C three, group A 37 cases, B group 37 cases and C group 27 cases. On the basis of unified treatment scheme, A group combined 0.20MPa HBO treatment, B group combined 0.16MPa HBO treatment, group joint (normal pressure) inhalation of pure oxygen therapy, 1 times of treatment, course of treatment, ear aggravation during the treatment, and the sound impedance of tympanum. 9 cases were adjusted to 0.07MPa (altitude of 3000 m) for 3-5 times of pure oxygen therapy. The remaining patients in group.A of group D were included in group A1 (34 cases), and the remaining patients in group B were included in group B1 (31 cases). All patients were treated with pure tone audiometry and tympanic acoustic impedance before treatment, and the treatment effect was compared between the four groups.
3.5 clinical study of refractory ISHL HBO combined treatment for patients with special diseases
Observation and analysis of 7 cases (4 cases with chronic renal insufficiency, 2 cases with leukemia, 1 case of children) case data, summarize the diagnosis and treatment, nursing experience, combined with literature review.
4. treatment methods
All patients were given Dexamethasone Sodium Phosphate Injection (10mg, 1/d, continuous 5-7d; 5mg, 5mg, 1/d, continuous 5-7d), Extract of Ginkgo Biloba Leaves Injection (20m1, intravenous drip, 1/d, 10 to 14d), Gastrodin Injection (0.6g, intravenous drip, 1/d, altogether 10 ~ 14d), Mecobalamin Tablets orally (1/d, 10~20 times a week for 5D, a total of 10~20) or normal pressure mask for pure oxygen therapy. According to the condition, the sleep drugs, antidepressants, science popularization and psychological counseling are improved.
5. statistical treatment
The SPSS13.0 software was used for statistical processing, and the measurement data were expressed with mean standard deviation (x + s), and t test was used among groups. The cure rate and efficiency of the three treatments were checked by chi square test, the efficiency was compared with the rank sum test, and the average hearing threshold difference was compared with the variance analysis. The difference was significant with P0.05.
Result
Analysis of clinical characteristics of 1. "refractory" ISHL
"Refractory" ISHL occurred in summer (43.4%), women accounted for 64.2%, University, college, master degree population accounted for 84.9%, mental workers accounted for 75.5%, A type of blood accounted for 47.2%, O type of blood accounted for 30.2%, and recurrent sudden deafness seizures accounted for 35.8%. The common inducing factors before the onset were sleep poor, tired and angry, staying up late, drinking, noise exposure, combined with basic diseases. The proportion of hyperlipidemia (41.5%) was the largest, and 60.4% patients had poor sleep and PSQI8.5 2.6. The scores of somatization, compulsion, depression, anxiety, hostility and psychotic factors were statistically different compared with those of normal models (P0.05).
Study on the pathogenesis of 2. "refractory" ISHL
The total effective efficiency of the treatment of 79.1%. two groups SRQ difference was statistically significant (P0.05), the two groups were higher than the normal model.HRV, the effect group HF, LF, LF/HF three index values were higher than the invalid group, the difference was statistically significant (P0.05). In the invalid group, LF, LF/HF two indexes are lower than the normal range; LF average in the effective group is obviously higher than the number The concentration of T3 and TSH in the effective group was higher than that in the ineffective group; the concentration of TSH in the ineffective group was higher than that in the effective group.
3. glucocorticoid combined with HBO in the treatment of refractory ISHL
In the course of treatment, 1 cases were failed to adhere to glucocorticoid treatment because of poor blood pressure and blood sugar control. 4 cases were treated by self interruption of HBO because of poor middle ear pressure. Finally, there were 44 cases (41.5%) and 17 cases (16%). Compared with the simple glucocorticoid group and the simple HBO group, the effective rate of HBO combined glucocorticoid group (59.52%) was significantly higher than the other two. There was no significant difference in the cure rate among the three groups (P 0.05). The improvement rate of hearing in HBO combined with glucocorticoid group was significantly higher than that in the other two groups (P 0.05).
4. clinical study of different ways of oxygen inhalation in the treatment of refractory ISHL
There were statistical differences between the three groups of A1, B1 and C (X2=6.218, P0.05), A1, B1, and D three groups had no statistical significance (X2=0.876, P0.05). The acoustic impedance was all A curve, and the symptoms of ear congestion were relieved better than those of group A1 and group B1.
5. clinical study of refractory ISHL HBO combined treatment for patients with special diseases
"Refractory" ISHL combined with renal dysfunction, mostly "fully deaf" sensorineural hearing impairment; the treatment mainly used "glucocorticoid" treatment, especially in the tympanum, supplemented by vitamin, decoction of Chinese medicine, HBO treatment; emotional control and sleep improvement of patients are stress relief, treatment coordination and effective improvement Although hemodialysis is not proved to be effective, hemodialysis can guarantee the safety tolerance of the patient's renal function to the treatment of drugs; the effect of erythropoietin, folic acid, and iron on anemia may play a certain role in promoting hearing recovery.
"Refractory" ISHL combined with leukemia patients have poor curative effect. No foot therapy, effective antiviral therapy, may be part of the cause of poor curative effect; long term use of immunosuppressive agents or glucocorticoids in leukemia patients may cause the decline of glucocorticoid receptor affinity or glucocorticoid resistance to reduce the anti inflammatory potency, so the routine dose The curative effect of the glucocorticoid and the course of glucocorticoid may be poor. Repeated anaemia, anoxia, granulocyte increase or change of blood clotting function can cause frequent stress stimulation of the inner ear, resulting in the persistent edema and inflammatory damage of the inner ear cells; the effect of HBO on the level of granulocyte, the degree of anemia and infectious fever is difficult to foot. Leukemia patients use a wide range of drugs, complications, anxiety and other neurological symptoms, treatment difficulty, poor compliance.
The "refractory" ISHL in children is found late and the degree of hearing damage is heavy. The virus infection may be the main cause of the disease. The auditory multi frequency steady-state evoked potential (MFSSR) is an important audiological examination. Even if the onset of the disease is above February, the short effect glucocorticoid can still be used as a drug, and the course should be longer, and the low pressure HBO can be used intermittently. 10-20 times of treatment. Before wearing high power hearing aids or surgical intervention, all comprehensive medical treatment for hearing recovery should be actively applied, especially the application of glucocorticoid and low stress HBO treatment in order to improve or restore children's hearing as much as possible. In nursing, nurses should strengthen children's "refractory" ISHL characteristics. Parents' popularization of science and education, pay attention to children, parents double psychological nursing, to avoid irritation and noise stimulation during the treatment, encourage parents to communicate with children, with positive guidance, material incentives.
conclusion
1, "refractory" ISHL high incidence in summer, good hair in menopause women, high education, mental workers, A and type 0 blood, recurrent sudden deafness attacks, poor sleep quality, psychological and emotional abnormalities, stress disorder (negative life events, emotional fluctuations, fatigue, insomnia and other factors or factors combined) may be one of the mechanisms of the disease.
2, stress
【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】：R764.43
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