儿童分泌性中耳炎诊治

儿童分泌性中耳炎的诊治,江苏省人民医院南京医科大学第一附属医院,分泌性中耳炎（OME）是以鼓室积液和传导性听力下降为主要特征的中耳非化脓性炎症 Catarrhal inflammation of middle ear cleft that characterized by middle ear effusion and conductive hearing loss.无急性炎症表现（耳痛、发热、鼓膜充血肿胀）的中耳积液，但可源于急性中耳炎 OME is defined as MEE without signs and symptoms of acute inflammation (otalgia, irritability, and fever; bulging of the tympanic membrane),概 述,儿童、婴幼儿听力下降的主要原因之一 One of the most important factor that affecting the Childrens hearing儿童OME确切的发病率不详，因本病通常无明显临床症状。然而，几乎所有3岁左右的儿童都曾经历过至少1次中耳积液的发作 It may be difficult to determine the “true” incidence of OME because, by definition, OME is asymptomatic. However, nearly all children had experienced at least one episode by the age of 3 years,Various factors interact in the pathogenesis of otitis media,病因、病理机制 多因素相互作用,感染,解剖、生理因素,宿主因素,环境因素,咽鼓管 (ET)-中耳 (ME)-乳突 (mast) 通气系统在OME发病中的作用. The three physiologic functions of the eustachian tube are (1) pressure regulation (ventilation), (2) protection, and (3) clearance (drainage). Of these, pressure regulation is the most importantA, Pressure regulation function is related to active dilation of the tube by contraction of the tensor veli palatini muscle (TVP).,以往认为，咽鼓管功能不良是OME发生的始发及主要因素儿童、婴幼儿咽鼓管较成人短、宽、平，更易患OME，7岁以后渐接近成人，OME发生率明显下降,中耳积液的细菌学研究 Comparison of distribution of isolates in 2807 effusions from patients with acute otitis media (AOM) and 4589 effusions from patients with otitis media with effusion (OME) at the Pittsburgh Otitis Media Research Center, 1980 to 1989. Total percentages are greater than 100% because of multiple organisms,现有研究认为: OME可能起源于慢性感染Secretory changes in the middle ear in COME are most likely due to chronic infection多数患者以急性感染起病The majority of cases begin as acute infection of the middle ear 咽鼓管及中耳粘膜的炎症后反应导致持续性鼓室积液Postinflammatory alteration in the middle ear mucosa and eustachian tube (e.g., goblet cell metaplasia and hypersecretion) lead to persistence of effusion咽鼓管功能不良是疾病发生、发展的重要环节Dysfunction of the eustachian tube is an important part of the process.,症状耳闷、听力下降、耳鸣以及自听过显听力下降是儿童就诊的首要原因体格检查听力学测试影像学检查：不作常规,诊 断 Diagnosis,OME可经鼓膜穿刺确诊，但儿童不宜推荐,体检 Physical examination 耳科检查头颈检查：很重要，可发现OME易患因素，如：颅面畸形、腭裂、鼻腔和鼻咽部异常.,OM with retracted drum,OM with air-fluid level,听力学检查 Hearing Tests听阈评价：轻中度传导性听力损失行为测听：视觉强化测听(2岁)，纯音测听(5岁)ABR：不能配合行为测听者，但不能真实反映外周听力声导抗（需外耳道通畅）：很好反映中耳功能状态，可用于OME动态随访和筛查OME：鼓室图B或C型，提示中耳积液或负压,治 疗 Management,原则改善中耳和咽鼓管通气引流清除中耳积液去除病因，预防复发,不治疗-观察内科治疗手术治疗,干预措施,一. 观察随访 watchful waiting,儿童分泌性中耳炎自愈率很高，不影响言语发育和学习的OME可以观察随访（1-3月）如中耳积液持续3个月以上，或有言语发育迟缓、学习困难，或疑有明显听力下降者，应行听力检查平均听阈40 dB，建议手术治疗听力损失2040dB者，处理方案根据积液持续时间及症状严重程度而定,抗生素急性中耳炎：阿莫西林40 mg/kg/day，7-10 dOME：抗生素治疗14d，4周后中耳积液消退率比安慰剂组高一倍，但绝大多数3月后复发- 短期有效。不推荐作为OME的常规治疗抗组胺药/减充血剂治疗OME临床常用药物缺乏询证医学证据,二. 内科治疗 Medical treatment,激素 Short-term corticosteroid有短期疗效，但复发率高不推荐长期使用,粘液稀化剂或促排剂如吉诺通，仙璐贝：稀化粘液、改善纤毛运动，降低咽鼓管粘膜表面张力疗效待证实咽鼓管吹张, Autoinflation 低或无成本，无副反应 推荐使用，尤其是药物治疗和观察随访者,儿童分泌性中耳炎是手术治疗的常见适应症之一，但仅适用于保守治疗无效者手术适应症OME 持续4个月以上伴持久性听力损失或其它表现; 复发性或持续性OME伴发育迟缓风险增加，无论听力如何； OME伴鼓膜或中耳结构受损 儿童OME临床实践指南（2004）美国家庭医师协会，美国耳鼻咽喉-头颈外科学会，美国儿科学会,三. 手术治疗 Surgical Treatment,手术方法,纠正病理生理状态To correct the underlying pathophysiologic condition改善症状，预防复发To prevent recurrent and remediation of symptoms, especially during the key periods for development of speech and language（6 years old）,目 的,鼓膜切开 Myringotomy鼓膜置管 Myringotomy with Tympanostomy Tube Insertion (Grommets)腺样体切除术 Adenoidectomy,鼓膜切开术 Myringotomy 常规鼓膜切开：对慢性OME疗效差激光鼓膜造孔愈合时间为2 3 周，长期疗效不佳结论：单纯鼓膜切开不是儿童OME有效治疗方法,鼓膜(切开)置管术Myringotomy with Tympanostomy Tube Insertion,鼓膜置管手术录像,鼓膜置管并发症 Main complications: 化脓性中耳炎永久性鼓膜穿孔通气管移行到中耳腔,迁延不愈的OME常合并鼻腔、鼻咽部和口咽部的慢性炎症或结构异常，如：慢性腺样体炎和腺样体肥大、慢性鼻-鼻窦炎、变应性鼻炎、鼻中隔偏曲、鼻息肉、腭裂等，需予以处理 病因治疗腺样体切除术 一项研究显示，对211 岁OME儿童行腺样体切除术+鼓膜置管术效果优于单纯腺样体切除术或鼓膜置管术，而同时施行扁桃体切除术并不增加对OME疗效,腺样体切除术 Adenoidectomy,儿童OME临床实践指南（2004） 美国家庭医师协会，美国耳鼻咽喉-头颈外科学会，美国儿科学会适用年龄： 2个月 12岁关于儿童OME的手术治疗：应优先考虑行鼓膜置管术；对合并慢性腺样体炎或因腺样体肥大导致鼻塞等症状者，可同时行腺样体切除术；单纯扁桃体切除或鼓膜切开术不是儿童OME的有效治疗方法 Tympanostomy tube insertion is the initial preferred procedure. Adenoidectomy should not be performed except for a specific indication (i.e., nasal obstruction, chronic adenoiditis). Tonsillectomy alone or myringotomy alone should not be used to treat OME.,小 结,OME是儿童、婴幼儿听力下降的主要原因之一，几乎所有达3岁的儿童