耳鸣的防治PPT课件

.,1,首都医科大学附属北京朝阳医院耳鼻咽喉-头颈外科刘锦峰,耳鸣的防治,.,0t0sclerosis,耳鸣的定义耳鸣的分类耳鸣的临床特点耳鸣的治疗要点主观性耳鸣的病因与产生机制（简述）耳鸣的预防耳鸣的治疗,主要内容,.,0t0sclerosis,耳鸣的定义,主观性耳鸣：是指在周围环境中无相应声源和电(磁)刺激源情况下，患者自觉耳内或颅内有声音的一种主观感觉。客观性耳鸣：是指不但患者自己能听到耳周或颅内有响声而且其他人也能听到。客观性耳鸣常可在耳周或颅内有发声源。临床上，主观性耳鸣占多数，客观性耳鸣较少。王洪田,李明,刘蓬,黄治物,胡岢,赖仁淙.耳呜的诊断和治疗指南(建议案).中华耳科学杂志.2009.7(3):185,.,0t0sclerosis,耳鸣的其他分类,依据耳鸣的发源部位耳源性耳鸣非耳源性耳鸣依据耳鸣的病变部位传导性耳鸣感音神经性耳鸣中枢性耳鸣依据耳鸣的病理生理特点生理性耳鸣病理性耳鸣心理性耳鸣病理生理性耳鸣假性耳鸣,依据病程急性耳鸣（3月）慢性耳鸣（3月）依据有无搏动搏动性耳鸣非搏动性耳鸣；,耳鸣病因不清，机制复杂，分类很难,.,0t0sclerosis,耳鸣定义的理解,耳鸣：（1）是无相应的外界声源和电刺激，（2）而主观上在耳内和颅内有声音感感觉（实用耳鼻咽喉头颈外科学（第2版）黄选兆汪吉宝孔维佳主编）。Tinnitusisthesensationofsoundintheabsenceofanexternalsource.,应该排除：搏动性耳鸣，腭咽喉肌阵挛的卡塔声咽鼓管异常开放声。耳内异物（头发丝和耵聍）摩擦鼓膜的声音“幻听”,.,0t0sclerosis,耳鸣的临床特征-患病年龄,.,0t0sclerosis,耳鸣临床特点,突然起病患者的耳鸣严重程度较缓慢起病者更高，耳鸣主调以8000Hz最多见，占22.9，响度主要集中在感觉级510dB；伴有感音神经性聋者占75.6；耳鸣主调为高频时，绝大多数患者听力下降区域也位于高频同时，主调为低频、言语频率时，听力下降也多位于相应频率区域存在不良心理反应者占89.6，表现为心情烦躁者83.8，影响睡眠者63.7，注意力难以集中者30.3,.,0t0sclerosis,耳鸣的治疗要点：病史与检查,详细询问病史（最主要）耳鸣本身的病史：耳鸣的发生时间？双耳还是单耳？是什么声音？持续还是间歇性？有无规律？与呼吸与脉搏的关系？有无耳聋及眩晕？中耳炎相关病史；噪声接触史！查体：外耳道及鼓膜基础听力学检查：评估听力情况纯音测听声导抗耳声发射（反映毛细胞损害较PTA敏感）听性脑干反应耳鸣匹配音调的频率匹配响度匹配心理学调查影像学检查，如CT、MRI,.,0t0sclerosis,耳鸣的治疗要点：问诊要点,耳鸣的病程长短？问诊目的：预测预后，制定不同的治疗方案。耳鸣的病程越短，疗效越好。急性耳鸣治疗方案同突发性聋。慢性耳鸣则要根据是否代偿选择不同的治疗方案。,.,0t0sclerosis,耳鸣的治疗要点：问诊要点,侧别？是单耳还是双耳？还是颅鸣？双侧同频耳鸣和颅鸣常常提示中枢性耳鸣。双侧低调耳鸣要除外内分泌疾病（如甲状腺功能低下）及自身免疫性疾病。双侧耳鸣的音调不一致则提示双侧听觉通路的不同病变。,.,0t0sclerosis,耳鸣的治疗要点：问诊要点,耳鸣的音调？是低频还是高频？还是多种音调？低中频耳鸣往往提示内耳病变，如内耳积水和梅尼埃病等。高频耳鸣往往为神经性或中枢性耳鸣。多种音调的耳鸣常常提示听觉系统有多处病变存在。转头时耳鸣音调发生改变常提示颈椎病引起的颈性耳鸣。,.,0t0sclerosis,耳鸣的治疗要点：问诊要点,在什么情况下耳鸣会减轻或加重？颈性耳鸣在晨起或午睡后耳鸣的程度最重，而其他原因引起的耳鸣多在夜间，安静时最重。是否伴有听力下降、眩晕等症状。单侧高调耳鸣伴/不伴听力下降首先要除外听神经瘤。伴有眩晕症状的患者要除外梅尼埃病、上半规管裂综合症等疾病。,.,0t0sclerosis,耳鸣的治疗要点：诊断,如何诊断？标准？难？容易？,.,0t0sclerosis,主观性耳鸣的原因及机制,不伴听力减退的耳鸣听力减退伴有耳鸣老年性聋长期或高强度噪声刺激耳硬化症感染，如中耳炎自身免疫性疾病梅尼埃病肿瘤耳毒性药物特发性压力及心理因素,.,0t0sclerosis,主观性耳鸣产生的机制,仅指感音神经性耳鸣,.,16,主观性耳鸣的病因及机制,耳鸣起源于中枢而非耳蜗：MRIhasrevealeddifferencesinsound-evokedresponsesbetweentinnitusandnontinnitusgroupsincortical12andsubcorticalauditorynuclei13andfoundevidenceforstructuraldifferencesinthethalamus14,theauditorybrainstem15andtheauditorycortex16.听觉中枢异常电活动：认为耳呜的产生可能由神经元的自发放电率(spontaneousfiringrates)增加、簇状放电(burst-firingactivity)的形成及神经元同步放电(neuralsynchrony)引起伴与不伴有耳聋的耳鸣，其机制不同。,.,17,主观性耳鸣的病因及机制,AdjamianP,etal.Themechanismsoftinnitus:Perspectivesfromhumanfunctionalneuroimaging.HearingResearch253(2009)1531,伴有耳聋的耳鸣,图：耳鸣与耳聋的联系(Konigetal.,2006).Themeanfunctionrepresentsthedatafrom24patientswhomatchedthedominantpitchoftheirtinnitustoasingle-frequencytone.Tinnituspitchisrepresentedbytheverticalbars.Thearrowpointstothemeanaudiogramedgeofthehearingloss.Notethatmostpatientsmatchedtheirsensationtotheregionofhearingloss.,85%的耳鸣患者伴有听力减退耳聋的频率与耳鸣频率匹配,.,18,主观性耳鸣的病因及机制,外周听力损害所致耳鸣的机制耳聋所致传入冲动减少，对听觉中枢的抑制性减弱，使得听觉中枢自放电增强。Theprevailingopinionisthattinnitusisaperceptualconsequenceofalteredpatternsofintrinsicneuralactivitygeneratedalongthecentralauditorypathwayfollowingdamagetoperipheralauditorystructures(EggermontandRoberts,2004).Whilethelossofafferentinputtothecentralauditorysystemcaninitiatetinnitus,thereafter,centralmechanismsplayanimportantroleinmaintainingit.Theprimaryhypothesisofcellularmechanismsunderlyingtinnitusdevelopmentisthathearinglossleadstoadown-regulationofinhibitionandreorganizationofthecentralauditorysystem.为什么要放电增强？Thecentralauditorysystemappearstoincreaseitsgaintocompensateforthereducedsensorineuralinputfromthecochlea.Asaresult,hyperactivityoftendevelopsinthecochlearnucleus29,30,theinferiorcolliculus23,24560-564.DalyKA,HunterLL,LindgrenBR,etal.Chronicotitismediawitheffusionsequelaeinchildrentreatedwithtubes.ArchOtolaryngolHeadNeckSurg,2003,126;517-522.,.,30,VagusnervestimulationElectricalstimulationoftheDCNTranscranialdirectcurrentstimulationDeepbrainstimulation,电刺激治疗,.,31,电刺激治疗,对耳鸣的电刺激抑制首先于1855年被报道，共包含两种电刺激方式深部脑电刺激,.,32,ElectricalstimulationoftheDCN,Previousstudiesindicatethatthedorsalcochlearnucleus(DCN)mayserveasageneratorand/ormodulatorofnoise-inducedtinnitus.ThispromptedaninteresttoinvestigatethemodulatoryroleoftheDCNintinnitussuppression.Inthisstudy,wechronicallyimplantedtheDCNofratswithbehavioralevidenceofintensetone-inducedtinnitus.Behavioralevidenceoftinnituswasmeasuredusingagapdetectionacousticstartlereflexparadigm.OurresultsdemonstratedthatelectricalstimulationoftheDCNsuppressedbehavioralevidenceoftinnitus,especiallyathighfrequencies.ThedatasuggestthattheDCNmaybeusedasatargettosuppresstinnitusthroughabottom-upneuromodulationapproach.TheunderlyingmechanismofDCN-stimulation-inducedtinnitussuppressionwasdiscussedbycomparingitwithotherstimulationmodalities.,LuoH,ZhangX,NationJ,etal.Tinnitussuppressionbyelectricalstimulationoftheratdorsalcochlearnucleus.NeuroscienceLetters522(2012)1620,.,33,DCN植入电极刺激治疗耳鸣的机制,First,noise-inducedDCNhyperactivityisbelievedtoresultfromalackofperipheralauditoryinputtothecentralauditorysystemthatleadstodisinhibition12.DCNstimulationmayhavecompensatedforthetone-inducedlossofperipheralinputbyrestoringtheimbalancebetweenexcitatoryandinhibitoryprocesses.Second,DCNstimulationmaymodulatethehyperactivitybydirectstimulationoftheneuronalcircuitrywithintheDCN,leadingtotheobservedtinnitussuppression.Third,stimulation-inducedDCNactivationcouldmasktinnitussignalsthuscontributingtotinnitussuppression.Fourth,tinnitusperceptsmaybegeneratedormaintainedbythetransmissionoftinnitus-relatedhyperactivityfromtheDCNtotheinferiorcolliculusorotherhigherbraincenters7,17,19,22.DCNstimulationmaydisruptthesepathways.,.,34,Deepbrainstimulation,S.W.CheungandP.S.larson.Tinnitusmodulationbydeepbrainstimulationinlocusofcaudateneurons(arealc).Neuroscience169(2010)17681778,(A)CartoonofDBS(deepbrainstimulation)lead(verticalsegment)incontactwithareaLC(redcircumscription)ofthecaudatenucleus(pink).Lateralventricle(blue).Putamen(purple).,(B)CoronalviewofaDBSleadtraversingareaLC(redcircle).R,right.(C)SagittalviewofaDBSleadtraversingareaLC(redcircle).Post,posterior;Ant,anterior.,NeuromodulationofareaLCmaybeinterruptingperceptualintegrationofphantomsensationsgeneratedinthecentralauditorysystem.Thisnew,basalgangliabasedapproachtotinnitusmodulationwarrantsfurtherinvestigationandmaybeultimatelyrefinedtotreatpatientswithrefractorysymptoms.,.,0t0sclerosis,综合治疗,1、对耳鸣患者治疗需要综合疗法，治疗方案包括耳鸣咨询、声治疗、其他治疗方案2、通过耳鸣综合疗法绝大多数特发性耳鸣可以得到有效控制。3、“特发性耳鸣”-当前治疗的重点是针对因耳鸣诱发的不良心理反应。,心理疏导（咨询）：解惑是耳鸣治疗过程中,.,0t0sclerosis,总结：误区,耳鸣患者希望通过某种特效方法彻底消除耳鸣，而这在目前很难做的到。从某种意义上来说，很多耳鸣症状的出现是各种原因造成的听觉神经系统提前出现的退化反应，而退化一旦形成是很难被控制的。所以耳鸣治疗的重点，不在于降低耳鸣响度本身，而是实实在在去努力减少失眠等不良心理反应的发生或加重，让患者尽快达到最大限度的适应代偿，通过缓解患者症状，改善患者的生活质量，而非去做彻底解决潜在疾病病因的无谓工作。当然对于急性耳鸣，首先还是要采用各种方法尽量降低耳鸣的响度甚至消除耳鸣的努力。,.,0t0sclerosis,耳鸣的处理,耳鸣的严