乙状窦周骨壁缺失性耳鸣的影像及建模研究

发布时间：2018-04-15 09:37

本文选题：耳鸣 + 蛛网膜颗粒　；参考：《首都医科大学》2014年博士论文

【摘要】：搏动性耳鸣(Pulsatile Tinnitus, PT)是耳科常见症状之一，长期存在严重影响生活工作质量，甚至导致抑郁、自杀。病因主要包括动脉性、静脉性及肿瘤性，明确病因是去除耳鸣的关键。既往临床对静脉性病因普遍认识不足，近年来关于静脉性耳鸣的报道逐渐增多。其中，乙状窦周骨壁缺失已经手术证实为PT常见病因之一，经骨壁缺失部位行修补术后耳鸣可完全消失。过去4年于我院行颞骨双期增强CT检查的PT患者共1032例，乙状窦周骨壁缺失者约占44%。共计85例患者经骨壁缺失部位行修补术，术后近40%患者耳鸣无明显减轻、不变甚至加重[1]；另外，目前对于骨壁缺失性耳鸣缺乏其它安全有效的治疗方法。其关键在于骨壁缺失性耳鸣的发病机制不明。目前关于该类耳鸣的研究尚在起步阶段，均为小样本量疗效描述性报道，缺乏对骨壁缺失特征的系统评估归纳，更无关乎其发病机制的研究。本研究的目的在于评估骨壁缺失的CT特征，建立CT基础上的标准化评估模式，在此基础上制作模型探讨骨壁缺失性耳鸣的发病机制。本论文分两部分：1.通过评估骨壁缺失性耳鸣的影像特点，制定骨壁缺失标准化的评估方案以助术中定位；归纳骨壁缺失的相关特点，为骨壁缺失性耳鸣的机制研究奠定基础；2.基于影像学特征，建立骨壁缺失性耳鸣的尸头模型，探讨骨壁缺失性耳鸣的发生机制，为创新治疗方法奠定基础。第一部分乙状窦周骨壁缺失性耳鸣的CT评估目的评估乙状窦周骨壁缺失性耳鸣的CT特征，建立骨壁缺失的标准化评估方案。方法分析骨壁修补术后耳鸣完全消失的30例单侧耳鸣患者的颞骨双期增强CT图像；纳入性别、年龄匹配且符合纳入标准的对照组30例，该组患者均行头CTA检查，并同时行骨窗及软组织窗重建。由两位经验丰富的头颈部影像医师评估耳鸣组中骨壁缺失个数、部位、范围，同时评估两组颈静脉球窝高位、导静脉个数及管径、垂体及垂体窝高度、颞骨气化程度、静脉回流优势、横窦狭窄、横窦区蛛网膜颗粒的发生情况。结果在30例乙状窦周骨壁缺失性耳鸣患者中，乙状窦周骨壁缺失共44处，以单处缺失者略多见（17例）；将乙状窦周骨壁纵向分为上中下三段，上段骨壁最常受累（29处）；将乙状窦周骨壁横向分为前壁、外壁、后壁，，外壁最常受累（40处）。骨壁缺失多发生在乳突尖、外耳道中心的后上方，平均坐标点约（-3.82,31.58）mm、（-18.37,12.19）mm。骨壁缺失平均横径约(2.83±1.29)mm，平均面积约(7.97±5.17)mm2。此外，对侧单处骨壁缺失者3例，平均横径约1.9mm，平均面积约3.7mm2。与对照组相比，骨壁缺失组中颈静脉窝高位（28vs19）、双侧横窦狭窄（25vs5）、同侧横窦狭窄（25vs6）、对侧横窦狭窄（30vs9）、非全程狭窄患者中同侧蛛网膜颗粒例数（25vs12）、非全程狭窄患者中对侧蛛网膜颗粒例数（21vs8）、同侧静脉回流优势（22vs8）均多见；垂体窝高度较大[(10.04±2.70)mm vs(8.61±2.70)mm]、垂体高度较小[(3.04±2.06)mm vs (4.88±2.06)mm]，差异有统计学意义。乳突导静脉（21vs21）、岩鳞窦（2vs1）、板障静脉（20vs20）、颅板蛛网膜颗粒压迹（18vs18）的发生情况及颞骨气化程度[(3.70±1.81)ml vs (4.10±1.81)ml]差异无统计学意义。术后行颞骨双期增强CT复查者共11例;修补不完全者6例，残余缺失面积平均1.9mm2。术后颞骨气化容积平均2.69ml，与术前容积相比差异有统计学意义；手术侧静脉窦形态较术前未见明显变化；结论乙状窦周骨壁缺失可为单处或多处，以上段、外壁最常受累，范围小且不规则；对缺失部位行标准化评估有助于影像及术中定位；耳鸣的产生可能与多种因素协同所致的血流状态有关，如静脉回流优势、颅压增高、横窦狭窄、颈静脉窝高位等；骨壁缺失是血流噪音被内耳所接收的关键因素；传道通路上的颞骨气化程度与正常人相似。第二部分乙状窦周骨壁缺失性耳鸣的建模研究目的探讨利用尸头颞骨制作乙状窦周骨壁缺失性耳鸣模型的可行性，并基于模型探讨该类耳鸣的发生机制。方法利用CT采集颞骨区尸头图像22侧，利用Mimics和Geomagic软件获取乙状窦三维结构，行三维打印得到实物血管内腔，利用化学物质浇注、成型、冷却、脱离，得到与乙状窦沟形态一致的薄壁人工血管。分别利用水和60%甘油模拟静脉血液；利用微型水泵模拟心脏泵血；利用振动/声音信号接收仪接收振动/噪声；利用Labview2012软件记录信号形态、强度；利用石蜡封闭模型。分别建立乙状窦沟区结构模型、乳突模型，探讨改变骨壁的完整性、颞骨气化程度对乙状窦周骨壁缺失性耳鸣强度的影响。建立完整的乙状窦骨壁缺失性耳鸣模型，改变水流速度、近段管径，探讨血流动力学改变对耳鸣强度的影响；改变骨壁缺失的范围，评估骨壁缺失在耳鸣发生中的作用；并探讨相同条件下，不同介质对耳鸣强度的影响。结果对于完整骨壁的乙状窦区结构模型，振动/噪声接收器并不能接收到“水流”信号；利用骨钻在乙状窦上段磨除直径2mm的骨壁缺失，规律噪音形成并可被噪声接收仪接收但不能被振动接收仪接收。对于气化容积分别为2.6ml、5.2ml的颞骨模型，前者所接收的耳鸣噪音明显大于后者。在完整耳鸣模型中：噪声强度随着骨壁缺失增大而增大，二者并不成线性相关；分别比较20ml/s、12ml/s的"水流"，前者产生噪音更大；近段管腔狭窄者耳鸣噪声较无狭窄者大。相同条件下，"水流"产生的噪音明显较甘油大。结论骨壁缺失部位的血流状态是耳鸣噪声产生的根本原因，而骨壁缺失则是噪声被内耳接收的关键因素。血流状态、骨壁缺失范围共同影响噪声强度。传导通路上的气化程度与耳鸣噪声强度负相关。
[Abstract]:Pulseural tinnitus ( PT ) is one of the most common symptoms in the ear , which has a long - term effect on the quality of life work and even leads to depression and suicide .
In addition , there is a lack of other safe and effective treatment methods for the deficiency of bone wall . The key is that the pathogenesis of the deficiency of bone wall is unknown . At present , there is no systematic assessment of the loss of bone wall . The aim of this study is to evaluate the CT features of the missing characteristic of bone wall .
To sum up the relevant characteristics of the loss of bone wall , lay a foundation for the mechanism study of the deficiency of bone wall ;
2 . Based on the imaging features , the body head model of the missing tinnitus of the bone wall was established , and the mechanism of the disappearance of the bone wall was discussed , which laid the foundation for the innovative treatment method .

CT evaluation of the missing tinnitus in the first part of sigmoid sinus wall

Objective To evaluate the CT features of the missing tinnitus in the circumferential wall of the sigmoid sinus and to establish a standardized assessment scheme for the loss of bone wall .

Methods The CT images of temporal bone in 30 patients with unilateral tinnitus completely disappeared after bone wall repair were analyzed .
The number , location and range of bone loss in tinnitus group were assessed by two experienced head and neck image doctors .

Results Among 30 patients with atrial septal defect of sigmoid sinus , there were 44 defects in the circumferential wall of the sigmoid sinus , and there were only slightly more missing persons ( 17 cases ) .
The circumferential wall of the sigmoid sinus was longitudinally divided into three sections , the upper and lower sections , and the upper section of the bone wall was most often affected ( 29 ) ;
The average lateral diameter of the bone wall was about ( 2.83 卤 1 . 29 ) mm , the mean area was about ( 7.97 卤 5.17 ) mm , the mean area was about 1.9mm and the average area was about 3.7 mm2 .

Compared with the control group , the high position of the jugular fossa ( 28 vs 19 ) , bilateral transverse sinus stenosis ( 25vs5 ) , the ipsilateral transverse sinus stenosis ( 25vs6 ) , the contralateral lateral sinus stenosis ( 30 vs9 ) , the number of ipsilateral subarachnoid particles ( 21 vs 8 ) and the superior venous reflux ( 22 vs 8 ) were seen in the patients with non - global stenosis .
The height of pituitary fossa was 10.04 卤 2.70 mm vs ( 8.61 卤 2.70 ) mm vs ( 8.61 卤 2.70 ) mm , the height of pituitary was smaller ( 3.04 卤 2.06 ) mm vs ( 4.88 卤 2.06 ) mm , the difference was statistically significant .

There were 11 cases of bilateral enhancement CT in temporal bone after operation ; 6 cases with incomplete repair and 1.9 mm2 of residual missing area . The volume of temporal bone gasification was 2.69 ml , which had statistical significance compared with preoperative volume .
There was no significant change in the shape of sinus sinus during operation .

Conclusion The absence of the circumferential wall of the sigmoid sinus can be single or multiple , the above segment , the outer wall is most often affected , the range is small and irregular ;
The standardized assessment of missing sites facilitates image and intraoperative positioning ;
The generation of tinnitus may be related to the state of blood flow caused by multiple factors , such as venous reflux , elevated intracranial pressure , narrowing of transverse sinus and high level of jugular fossa ;
The lack of bone wall is the key factor for blood flow noise to be received by the inner ear ;
The degree of temporal bone gasification on the passway was similar to that of normal controls .

Modeling and study of second part sigmoid sinus wall missing tinnitus

Objective To explore the feasibility of using corpse - head temporal bone to make the model of circumferential wall loss tinnitus , and to explore the mechanism of this kind of tinnitus based on the model .

Methods 22 sides of the temporal bone were collected by CT . Mimics and Geomagic were used to acquire the three - dimensional structure of sigmoid sinus , and three - dimensional printing was used to obtain the inner lumen of the physical vessel .
the miniature water pump is used for simulating the blood of the heart pump ;
receiving vibration / noise using a vibration / sound signal receiver ;
using Labview 2012 software to record signal form and intensity ;
a paraffin closed model is utilized .

The structure model and mastoid model of the sigmoid sinus were established , and the effect of changing the integrity of the bone wall and the degree of temporal bone vaporization on the intensity of the missing tinnitus were discussed . The effect of hemodynamic changes on tinnitus intensity was discussed .
To change the extent of bone loss and evaluate the role of loss of bone wall in the occurrence of tinnitus ;
The effect of different media on tinnitus intensity under the same conditions was discussed .

Results The vibration / noise receiver could not receive the " water flow " signal for the model of the sigmoid sinus region of intact bone wall .
In the complete tinnitus model , the intensity of noise increases with the loss of bone wall , and the noise intensity is not linearly related .
Compared with 20ml / s , 12ml / s " water flow " , the former produces more noise .
In the proximal canal stenosis , the noise of tinnitus was much larger than that in patients without stenosis . Under the same conditions , the noise produced by " water flow " was significantly higher than that of glycerol .

Conclusion The blood flow state of the missing part of the bone wall is the root cause of tinnitus noise , while the loss of bone wall is the key factor for the noise to be received by the inner ear . The blood flow state and the loss of bone wall affect the noise intensity . The degree of vaporization on the conduction path is negatively correlated with the intensity of tinnitus noise .

【学位授予单位】：首都医科大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R764.45;R816.96

【参考文献】