(五年制)教案 | (七年制)教案 |
(五年制)教案
  第一篇 鼻科学
 
鼻部应用解剖及生理、慢性鼻炎、急慢性副鼻窦炎
 
变应性鼻炎、鼻出血、鼻外伤、鼻中隔偏曲
  第二篇 咽科学
 
咽部解剖及生理、急慢性咽炎、急慢性扁桃体炎
 
 
喉部解剖及生理、喉部急慢性炎症性疾病
 
喉阻塞、气管切开术、喉肿瘤
 
 
气管食管异物、耳部解剖及生理
 
 
耳部解剖及生理、急慢性化脓性中耳炎及其并发症、分泌性中耳炎
 
分泌性中耳炎、梅尼埃病
 
 
颈部炎症性疾病
 
颈部应用解剖学及生理学

 

 

分泌性中耳炎、梅尼埃病

科目:耳鼻咽喉科学 任课老师姓名:邱元正
授课对象:临床,口腔医学专业(五年制) 年级:
人数: 次数:1次
授课章节、内容:分泌性中耳炎、梅尼埃病
授课时数:3 学时 授课时间:
教学目的要求:
1. 掌握分泌性中耳炎的病因、临床表现、诊断及治疗。
2. 熟悉分泌性中耳炎的病理及鉴别诊断。
3. 掌握梅尼埃病的临床表现及诊断。
4. 熟悉梅尼埃病的鉴别诊断及治疗。
5. 了解梅尼埃病发病病因及机制。

讲授重点:
1. 分泌性中耳炎的病因、诊断及治疗。
2. 梅尼埃病的临床表现。

授课方式:
课堂讲授、辅以提问、多媒体投影。

教具:
幻灯机、多媒体

讲授提要和时间安排:
1. 分泌性中耳炎:1.5学时
2. 梅尼埃病:1.5学时
教课教材:
耳鼻咽喉科学(第六版)

分泌性中耳炎

一、 概述
概念:Secretory otitis media是以鼓室积液及传导性耳聋为主要特征的中耳非化脓性疾病,中耳积液可分为浆液性漏出液或渗出性液亦可为粘液。
命名:渗出性中耳炎、卡他性中耳炎、浆液性中耳炎、中耳积液、非化脓性中耳炎。
分类:急性和慢性。
发病率:冬春季多发病,小儿和成人都可发病,但多见于儿童。2-6岁为常见。多为10岁以下儿童。
二、 病因:未完全明确
a) 咽鼓管功能障碍。(机械性阻塞、功能性障碍)
b) 感染。
c) 免疫反应。
三、 病理:早期为浆液性,晚期为粘液性
中耳腔内负压→中耳粘膜肿胀,毛细血管通透性增强一鼓室出现漏出液。
四、 临床表现
a) 听力减退:主要为传导性聋,自听增强。
b) 耳痛。
c) 耳鸣。
五、 检查
a) 鼓膜:放射性扩张的血管纹,桔黄色、淡黄色、橙红。透明鼓膜可见有气泡,鼓膜外凸,组织液多时。
b) 听力:传导性聋。
c) 声阻抗:B型曲线(平坦型曲线),高负压型(C3型)部分有鼓室积液。(图)
六、 诊断:病史:
体格检查:
辅助检查:
穿刺可以确认:
七、 鉴别诊断:1、传导性耳聋欲与鼓室硬化、听骨链中断
2、鼓膜者欲与胆固醇肉芽肿、鼓室体瘤(颈静脉体瘤)相鉴别。
3、鼓室积液欲与脑脊液耳漏、外淋巴鉴别。
需排除鼻咽部肿瘤。
八、 治疗(20分钟)
治疗原则——清除中耳积液,改善中耳通气引流及病因治疗。对症治疗、对因治疗。
(一)清除中耳积液,改善通气引流。
1、 鼓膜穿剌抽液:鼓膜前下方,7号针头
2、 鼓膜切开术:粘稠,小孔
3、 鼓室置管术:6-8周,长达1年。
4、 保持鼻腔及咽鼓管通畅
5、 咽鼓管吹张。
(二)病因治疗
1、 对因治疗
2、 抗生素治疗
3、 激素治疗。

Meniere’s Disease

(梅尼埃病)

 

l      Definition
Meniere’s disease is an idiopathic endolymphatic hydrocele characterized by sudden onset of paroxysmal vertigo, undulatory tinnitus, undulatory hearing loss and ear/head fullness.
这里的“endolymphatic hydrocele”指的是膜迷路积水或称积液。全句是说梅尼埃病是以突然发作的四个症状为特征的原因不明的膜迷路积液。

 

Introduction:

l      The term “Meniere’s Disease” is named in honour of a French doctor Prosper Meniere who, for the first time, found and reported the major clinical manifestation of this disease. 以发现这个疾病并首次报道其临床表现的法国医师Prosper Meniere的名字命名。

l      The pathological entity of the disease is hydrocele of the membranous labyrinthine of the cochlea. 此病的病理变化的实质是膜迷路积水。

l      The incidence 发病率
Meniere’s disease is commonly found in young people, its incidence in women is slightly higher than that in man. And, it usually onset unilaterally. However, minority of the patients may be involved in both ears, if so, the two ears usually onset earlier or later within 2-3 years.
常见于年轻人,女性发病率稍高于男性;
通常为单侧;少数双侧受累者,两耳一般在2-3年内先后发病。

l      Onset: the disease may recurrently attack for many years. There is no any sign before attack, no any symptom during the intervals of the attacks. It may also stop recurring after attack.
此病可多次反复发作,持续多年。发作前无明显征兆,发作间期无任何症状;也可在某一次发作后不再复发。

 

l      Etiology and pathogenesis  病因和发病机理

The etiology and pathogenesis of Meniere’s D. is not well elucidated yet. So, there is no affirmative answer.

Of cause, it is clear that the abnormal increase of the endolymph formation and/or its decreased absorption is the main pathophysiological changes of the disease. Be sure that I just said “pathophysiological changes”, but not the mechanism of this disease. 这里强调了两点:一是病因和发病机理仍未阐明;二是肯定地说,其主要的病理生理变化是内淋巴液产生过多和/或吸收过少。特别提醒学生注意,我刚才讲已经被人们弄明白的是梅尼埃病的病理生理变化,而不是发病机理。

    Dysfunction of inner ear microcirculation induced local ischemia has been put forward by many as a main cause. Ischemia of inner ear → metabolic disorder increased osmotic pressure of endolymph → hydrocele.
内耳微循环功能障碍是主要原因。缺血代谢紊乱内淋巴渗透压上升积水

    Faulty absorption of endolymph by the endolymphatic sac: mainly caused by stenosis or atresia of vestibular aqueduct, malformation of endolymphatic duct/sac.  —— 内淋巴吸收障碍,主要是由于前庭水管纤维化、狭窄或闭锁,内淋巴管和内淋巴囊解剖或发育异常等原因引起。

    Endolymph formation is abnormally increased: allergy or autoimmune lesions of the inner ear, abnormal activity of inner ear enzymesdisorder of endocritic function, viral infection, etc. 内淋巴生成过多:内耳变态反应或自身免疫性病变,内耳酶活性异常,内分泌功能紊乱或病毒感染等。

 

l      Pathology and Pathophysiology 病理和病理生理
  The most important pathological finding in Meniere’s disease is the dilatation of the endolymphatic compartment of the inner ear. (show a picture)
 
In early stage of endolymphatic hydrocele, the disruptions of the membranous structure (such as Reissner’s membrane, show a picture) induce a disturbance of the ions balances between perilymph and endolymph, leading to temporary sensorineural deafness and tinnitus. They will return to normal or nearly normal after attacks by healing up the disrupted membrane.
   
the mechanism of clinical manifestation – hydrocele → rupture → healing up → hydrocele; … 临床表现的机理:积水(头、耳胀满感)膜破裂(突发症状)破口愈合(间隔长短不一的恢复期)积水(开始再次发作)……
   
The basic pathological and pathophysiological process may contribute the 4 major symptoms of the disease, that is paroxysmal vertigo, undulatory hearing loss, undulatory tinnitus, and ear/head fullness.
基本的病理和病理生理变化导致此病的四大临床表现的产生,即发作性眩晕、波动性听力下降、波动性耳鸣,以及头、耳胀满感。

 

    Variety of inner ear cells and tissues will be gradually degeneralted if the attacks recur and pathological lesions continuously progresses. As a result, the deafness will become persistent and more and more severe.  若病变反复发作,病理损害持续进展,可引起内耳细胞和组织逐渐发生退行性变;其后果是耳聋持续存在,并进行性加重。


Clinical manifestations:
1.  The four major symptoms - which may be regarded as the confirmative diagnostic evidence when they present together:
如果四个主要症状同时发生,可以作为确诊的依据。
paroxysmal vertigo: The onset of the vertigo is often sudden, usually without warning and may render the patient completely helpless within the seconds of the onset. If support is not at hand, the patient may fall and injure himself. Accompanying sympotoms: sensation of circumrotating accompanied with nausea and vomiting is the most prominent and common symptoms or complains. The patient prefers to close his eyes to eliminate the uncomfortable feelings. If the patient is seen during an attack, he is completely disorientated and unable to stand or do anything for himself. 没有预兆的突然发作。刚发作数秒钟内病人特别无助,若不能马上扶住支持物,病人可能跌伤。伴随症状:伴有恶心、呕吐的视物旋转感是最突出和常见的症状或主诉。为了减轻不适感,病人常常紧闭双眼,卧床不动。发作期间,病人完全丧失方向感,不能站立或自理。
, undulatory tinnitus and hearing loss: The patient may or may not notice these symptoms during the onset of the vertigo. Hearing capacity will return to normal or near normal after the first and the following several times of attack. It will become persistent, more and more severe as the disease recurrently attacks. 眩晕发作时,病人可能感觉到、也可能感觉不到耳鸣和听力下降。初次发作和随后的数次发作后,听力可回复正常或接近正常。随着疾病的反复发作,听力下降将变为持续性的,而且越来越严重。
ear/head fullness or pressure: it is usually ignored by the patient during the attack of vertigo, but is not an uncommon complain if the vertigo is not too severe. 眩晕发作时,头、耳胀满感常被病人忽视了,但如果眩晕不是太重,头、耳胀满感并不少见。
2. Horizontal nystagmus can be detected during attack with the quick phase towards the involved ears. Vestibular responsibility may decrease in the recurrent cases.
发作期间可检测到快相向患耳的水平性眼震。在反复发作的病例中,前庭系统的反应性可能降低。此处要解释眼震方向。

3.      Glycerin test positive: It is most significant for differential diagnosis of this disease although it may not work in the cases with severe hearing loss.
甘油试验阳性:这是最有意义的鉴别诊断依据,虽然在听力很差的病例中不起作用。
    The method of glycerin test: pure tone audiometry
fasting for 2 hours 50% glycerin (2.5~3.0ml/kg), take it orally→audiometry, once an hour. If the amount of recovery of average conductive hearing loss at the frequencies of 500Hz~2000Hz is equal to or larger than 15dB, the glycerin test is positive.
   
甘油试验的方法纯音测听禁食2小时一次性口服50% 甘油 (2.5~3.0ml/kg) →测听,每小时一次。500Hz~2000Hz平均气导听力损失的恢复量等于或大于15dB时,甘油试验为阳性。
    It intensively indicates that the hearing loss is result from membranous labyrinthine hydrocele. The glycerin test is very useful in differen
tial diagnosis of Meniere’s disease from the disorders with symptoms of vertigo, hearing loss and tinnitus. The test can not work if the patient has a relatively profound deafness before the test.

4.      Important negative features
The patient is completely conscious during attack: it is significant for differential diagnosis. 发作时病人是完全清醒的:这对鉴别诊断很有意义。
There is no any clinical manifestation between attacks: it is significant for differential diagnosis. 发作间期无任何临床表现。这对鉴别诊断也是很有意义的。

 

l      Diagnosis

    A careful enquiring and analysis of the patient’s medical history: Pay attention to the features of the attacks (above); the patient is conscious during attack, and there is no any symptom between attacks. 仔细询问和分析病史:尤其要注意前述的发作特点;病人在发作时神志清醒,发作间期无任何症状。

    The above mentioned 4 major symptoms. If the 4 major symptoms or the first 3 ones were confirmed to present during attacks, the diagnosis may be confidently considered. 上述四大症状。若发作时有上述四个或前3个症状,可考虑梅尼埃病的诊断。

    Glycerin test positive: this is the most important evidence to establish the diagnosis. 甘油试验:是最重要的确诊依据。

      Pure tone audiometry: Slight sensorineural hearing loss mainly at the lower frequency may be detected during or soon after attack. It may be recovered or lightened after the attack. 纯音测听:发作时或发作后不久,可检测到轻度的、以低频听力损失为主的感觉神经性耳聋,发作后恢复正常或减轻。
  The hearing loss may become persistent after recurrent attacks of the disease for many years. Its degree ranges from slight to profound at both lower and higher frequencies. In severe cases, hearing loss may be profound with descending curve, which imply that the hearing loss is severer as the test frequency becomes higher.
经过多年的反复发作,耳聋可变为持续性的。其程度从轻度到重度均有,但一般不会全聋,可累及低频和高频听力。在严重病例,重度的听力下降表现为下降型曲线,即随着测试频率的上升,听力下降的程度越来越重。

    Examination of vestibular function: Horizontal nystagmus can be detected during attack with the quick phase towards the involved ears. The vestibular function may be normal or only slightly involved in the interval of the attacks. Vestibular responsibility may decrease in the recurrent cases.   发作期间可检测到快相向患耳的水平性眼震。在发作的间歇期,前庭功能可正常或仅有轻微异常。在反复发作的病例中,前庭系统的反应性可能降低。此时,眼震的快相可变为朝向健侧耳(眼震恒朝向前庭反应性高的一侧)。   

    Always remember: not every vertigo or dizziness is Meniere’s disease!!!

    永远要记住:并非所有的眩晕或头晕都是梅尼埃病!

 

l      Differential diagnosis
   
We should differentiate Meniere’s disease from the following disorders: vestibular neuritis, (benign paroxysmal) positional vertigo, intoxication of the ototoxic drugs, labyrinthitis, sudden deafness, Hunter’s syndrome, acoustic neuroma and cervical spondylosis. 我们应将梅尼埃病与下列疾病相鉴别:前庭神经元炎、位置性眩晕、耳毒性药物中毒、迷路炎、突发性耳聋、Hunter氏综合症、听神经瘤和颈椎病。

 

l      Treatment

1.        hetero’pathy in the attack stage: 发作期间的对症治疗
sedative: e.g. valium (diazepam, 地西泮) 5mg tid. The dose can be doubled at the first day in severe case. /  chlorpromazine hydrochloride(盐酸氯丙嗪)25mg tid. or 25mg im. st.  The chlorpromazine is a potent sedative, can only be used under the control of the doctors. 镇静剂:如安定,5mg tid,严重病例第一天可加倍;或可用盐酸氯丙嗪,25mg tid,或25mg im. st。氯丙嗪是一种强力镇静剂,只能在医生监控下谨慎使用。
dehydrant: e.g. 50% Glucose Sol. 40ml iv. st.  or mannitol 250ml iv. drip. st 脱水剂:……
antihistamine (mainly for anti-vertigo and anti-vomiting), e.g. phenergan (promethazine hydrochloride,盐酸异丙嗪)  25mg q.d. or bid.;  25mg im. st. 抗组胺药:主要用于抗眩晕和呕吐。如:非那根,25mg q.d.bid 25mg im. st
  The mechanisms of anti-vertigo and anti-vomiting effects of phenergan is unkown. It is assumed that the effects are based on the anti-coline effect of phenergan.
非那根抗眩晕和呕吐的机理尚不明了,推测可能是由于其抗胆碱作用。
corticoid: prednisone, or, dexamethasone. 肾上腺皮质类固醇:强的松或地塞米松。短期、较大剂量。

 

2.        medicinal therapy during the interphase between attacks: 发作间期的药物治疗
there is no specific medicine for this disease up to now. 迄今仍无有效药物;
intra-tympanic injection of streptomycin or gentamicin: which can destroy the sensory epithelium of the peripheral vestibular organ, so the vertigo symptom is subsequently eliminated. But this can only be used in the patient who has profound deafness in the affected ear. 链霉素或庆大霉素鼓室内注射:可破坏周围前庭器官的感觉上皮,因而消除症状。但这种治疗仅限于听力严重破坏的病变侧耳。

3.        surgery:
endolymphatic sac surgery: There is a controversy on the effect/ necessity of such operation, because the outcome of it remains unknown. 内淋巴囊手术:对这个手术的效果和必要性存在争议,因为其疗效仍不明确。
vestibular neurectomy: Theoretically speaking, it is the ideal therapy for this condition, but the result of the operation is often unsatisfactory. Many factors may affect the final outcome. 前庭神经切除术:从理论上说,这是个理想的治疗方法;但其疗效往往不满意。这是由于许多因素可能影响最后的效果。
labyrinthectomy: It should only be used in the profound deafness, and he/she is oppressively disturbed by the symptoms of Meniere Disease. Nevertheless, the tinnitus may not disappear even the labyrinthine is totally removed because the spontaneous spark of the neurons in the central auditory system after the operation. 迷路切除术:仅可用于耳聋严重、且病人受到梅尼埃病的严重干扰时。但即使迷路被完全切除了,耳鸣仍不一定消失。这是因为手术后中枢听觉系统的神经元仍然在自发地放电。

 

 

References

 

1.       田勇泉主编,全国高等学校五年制临床医学专业规划教材《耳鼻咽喉科学》,第七版,北京:人卫出版社,2001

2.       孔维佳主编,七年制全国规划教材《耳鼻咽喉科学》,北京:人卫出版社,2002

3.       J. F. Birrell. Logan Turner’s Diseases of the Nose, Throat and Ear. 9th edition. Wright. PSG, Bristol,  London, Boston, 1982

4.       Michael M. Paparella, Donald A. Shumrick. Otolaryngology. Vol. 2, Ear. W. B. Saunders Company. Philadelphia: 1973

5.       Luis C. Junqueira, Jose Carneiro, Alexander N. contopoulos. Basic Histology. 4th edition. LANGE Medical Publications. Los Altos, California. 1983