發(fā)布時間：2018-06-27 10:09

  本文選題：純音測聽 + 聽性腦干反應(yīng)��； 參考：《河北醫(yī)科大學(xué)》2010年碩士論文

【摘要】： 目的:近年來,創(chuàng)傷逐漸成為危害人類生命和健康的突出醫(yī)學(xué)問題和社會問題,創(chuàng)傷后耳聾作為后天性聾的一個重要組成部分,常常涉及糾紛,因此其診斷與鑒定就顯得更為重要。有關(guān)外傷后聽力損害的程度、特點及外傷后未見鼓膜穿孔、不伴顳骨及顱骨骨折患者的聽力損害情況研究較少,因此,本研究通過純音測聽(pure tone audiometry,PTA)、聲導(dǎo)抗(acoustic immittance,AT)、聽性腦干反應(yīng)(auditory brainstem response, ABR)、40Hz聽覺相關(guān)電位(40Hz auditory event related potential,40Hz AERP)及畸變產(chǎn)物耳聲發(fā)射(distortion evoked otoacoustic emission,DPOAE)等檢查方法,統(tǒng)計外傷造成的聽力損失情況,分析耳外傷致鼓膜穿孔及輕度閉合性顱腦損傷后不伴鼓膜穿孔的聽力損失程度及特點,探討內(nèi)耳損傷(迷路震蕩)在外傷后聽力損失中的發(fā)生及重要影響,為臨床診斷與法醫(yī)學(xué)鑒定提供一定理論依據(jù)。 方法:在臨床實踐中,選取耳外傷致鼓膜穿孔或輕度閉合性顱腦損傷后不伴鼓膜穿孔患者245例(共265耳受傷),傷后主訴聽力下降、耳鳴及耳堵塞感,部分伴有眩暈、惡心及嘔吐等癥狀。耳外傷組患者154例(157耳受傷),男110例,女44例,年齡15～55歲,平均年齡29.73歲,就診時間1小時～3月余不等,其中≤1天45耳,1天且≤3天46耳,3天且≤14天48耳,14天18耳;輕度閉合性顱腦損傷組患者91例(108耳受傷),男66例,女25例,年齡15～55歲,平均年齡31.92歲,就診時間4小時～1年余不等,其中≤3天21耳,3天且≤14天36耳,14天且≤3個月19耳,3個月15耳,全部患者均經(jīng)詳細詢問病史,耳科相關(guān)檢查,然后進行純音測聽、聲導(dǎo)抗、ABR及40Hz AERP檢查,部分進行DPOAE檢查,結(jié)合48小時內(nèi)的顳骨或頭顱CT未見異常,神經(jīng)系統(tǒng)檢查無陽性體征。選取35名聽力正常志愿者作為正常對照組,其中男25名(50耳),女10名(20耳),年齡18～52歲,平均30.31歲,各項檢查均未見異常。所有受試者既往均無噪聲暴露史,無耳毒性藥物使用史,無耳聾家族遺傳史,無耳科及神經(jīng)系統(tǒng)疾病史,結(jié)合各項聽力測試結(jié)果,已經(jīng)明確排除偽聾。對傷后不同就診時間的聽力學(xué)檢查進行統(tǒng)計分析,探討外傷造成的聽力損害。 統(tǒng)計學(xué)處理:應(yīng)用SPSS13.0軟件,采用χ-±s表示,統(tǒng)計方法采用非參數(shù)檢驗、兩個獨立樣本t檢驗、χ2檢驗及方差分析進行分析,以p0.05為差異有統(tǒng)計學(xué)意義。 結(jié)果:1耳外傷致鼓膜穿孔及輕度閉合性顱腦損傷后不伴鼓膜穿孔的患耳均有明顯聽力損害,各項聽力檢查平均閾值均明顯高于正常對照組,兩組患耳的聽力損失程度分布差異有統(tǒng)計學(xué)意義。 2耳外傷組中90.45%患耳PTA與ABR結(jié)果一致,其中PTA平均聽閾值多≤60dB,占93.66%,≥61dB(重度及極重度)占6.34%;其中66.90%為傳導(dǎo)性聾,23.24%為混合性聾或感音神經(jīng)性聾,9.86%純音測聽各頻率閾值均≤25dB;不同就診時間組的PTA平均聽閾、ABR閾值及40Hz AERP閾值與正常對照組比較差異均有統(tǒng)計學(xué)意義,14天組各項檢查平均聽閾值均最小,但與其他就診時間組差異無統(tǒng)計學(xué)意義;PTA結(jié)果中就診時間≤1天組各頻率聽力損失差異有統(tǒng)計學(xué)意義,最嚴重在0.125kHz,其他就診時間組內(nèi)各頻率聽力損失差異均無統(tǒng)計學(xué)意義;與正常對照組比,ABR各波潛伏期明顯延長,除Ⅰ-Ⅴ波間期差異無統(tǒng)計學(xué)意義外,其他波間期比較差異均有統(tǒng)計學(xué)意義。 3輕度閉合性顱腦損傷組84.26%患耳PTA與ABR結(jié)果一致,其中PTA平均聽閾值多≤60dB,占70.33%,≥61dB(重度及極重度)占29.67%,其中74.72%為感音神經(jīng)性耳聾,25.28%為混合性聾或傳導(dǎo)性聾;不同就診時間組的PTA平均聽閾、ABR閾值及40Hz AERP閾值與正常對照組比較差異均有統(tǒng)計學(xué)意義,3個月組各項檢查平均聽閾值均最小,但與其他就診時間組差異無統(tǒng)計學(xué)意義;PTA結(jié)果中除就診時間3個月組各頻率聽力損失差異無統(tǒng)計學(xué)意義外,其他就診時間組內(nèi)各頻率聽力損失差異均有統(tǒng)計學(xué)意義,其中以4kHz及8kHz聽力損失最嚴重;DPOAE結(jié)果也示在4kHz聽力損失嚴重,ABR及40Hz AERP閾值引出率分別為88.89%及98.15%,且ABR閾值較40Hz AERP閾值高;與正常對照組比,ABR各波潛伏期明顯延長,除Ⅰ-Ⅲ波間期差異無統(tǒng)計學(xué)意義外,其他波間期差異均有統(tǒng)計學(xué)意義。18例配合隨訪患者分別在傷后1、3及6個月復(fù)診,純音測聽各頻率聽閾均見降低,主要在低頻區(qū)最明顯(0.25kHz和0.5kHz),40Hz AERP閾值也較ABR閾值明顯降低。 結(jié)論:1耳外傷致鼓膜穿孔后的聽力損害主要為輕中度傳導(dǎo)性聾,PTA結(jié)果示損害最明顯在0.125kHz,不同就診時間組中14天組的PTA平均聽閾、ABR及40Hz AERP閾值均較其他組小,但差異沒有統(tǒng)計學(xué)意義;部分患耳聽力損失較重、造成混合性聾或感音神經(jīng)性聾,結(jié)合ABR、40Hz AERP檢查及臨床癥狀,我們認為耳外傷不僅可以造成中耳損傷,而且在受傷同時可伴發(fā)一定程度的內(nèi)耳損傷。 2輕度閉合性顱腦損傷后不伴鼓膜穿孔的聽力損害主要為輕中度感音神經(jīng)性聾,少數(shù)聽力損失較重或為混合性聾,還可伴腦干功能受損,綜合各項聽力檢查結(jié)果示主要為高頻聽力損害(4kHz最明顯);傷后6個月內(nèi)可見聽閾降低,以低頻區(qū)明顯(0.25kHz和0.5kHz),結(jié)合患者臨床表現(xiàn)及輔助檢查,認為迷路震蕩在內(nèi)耳損傷機制中起著重要作用。 3外傷后聽力損害的準確評估及合理鑒定,需要臨床醫(yī)生或鑒定人員詳細詢問病史,并結(jié)合臨床、影像及聽力學(xué)等輔助檢查。一方面充分認識不同聽力學(xué)檢查的特點,聯(lián)合使用以互相彌補各自不足,另一方面認真把握受試者的心理狀態(tài),取得受試者的配合,最終使主客觀聽力檢查結(jié)果相一致,此外,還應(yīng)考慮到傷后不同時期聽力變化規(guī)律,合理把握鑒定時間,最終做出客觀合理的臨床診斷或法醫(yī)學(xué)鑒定。
[Abstract]:Objective: in recent years, trauma has gradually become a prominent medical and social problem endangering human life and health. Deafness after trauma is an important part of acquired deafness, often involving disputes, so its diagnosis and identification is more important. The degree of post traumatic hearing impairment, characteristics and no tympanic membrane perforation after trauma, There are few studies on hearing impairment in patients without temporal bone and skull fracture. Therefore, this study was conducted through pure tone audiometry (pure tone audiometry, PTA), acoustic impedance (acoustic immittance, AT), auditory brainstem response (auditory brainstem response, ABR), 40Hz auditory related potential and teratometry. Distortion evoked otoacoustic emission (DPOAE) and other methods were used to analyze the hearing loss caused by trauma, and to analyze the degree and characteristics of hearing loss without tympanic membrane perforation after ear trauma and mild closed craniocerebral injury, and to explore the occurrence of inner ear injury (labyrinthine concussion) in hearing loss after trauma. And important influence, providing a theoretical basis for clinical diagnosis and forensic identification.
Methods: in clinical practice, 245 cases (265 ears) without tympanic membrane perforation after ear trauma or mild closed craniocerebral injury were selected. The main complaints were hearing loss, tinnitus and ear blockage, partly accompanied by vertigo, nausea and vomiting, 154 cases (157 ears), 110 men, 44 women and 15~55 age. The average age of 29.73 years was 1 hours to 3 months, including 1 days and 45 ears, 1 days and less than 3 days, 46 ears, 3 days and less than 14 days, 14, 18 ears, and mild closed craniocerebral injury patients. 3 days and less than 14 days 36 ears, 14 days and less than 3 months 19 ears, 3 months 15 ears, all the patients were asked the detailed history of the medical history, the ear related examination, and then carried out pure tone audiometry, acoustic conductivity, ABR and 40Hz AERP examination, part of the DPOAE examination, combined with 48 hours of the temporal bone or skull CT without abnormal signs. 35 hearing positive signs were selected. 35 hearing positive were selected. There were 25 men (50 ears), 10 women (20 ears), 18~52 years old and 30.31 years old, with an average age of 30.31. All the subjects had no history of noise exposure, no history of ototoxic drugs, no hereditary history of deafness, no history of auricular and nervous system diseases, combined with the results of hearing tests. The false hearing loss was clearly excluded. The audiological examination of different visiting time after injury was statistically analyzed to explore the hearing impairment caused by trauma.
Statistical processing: the SPSS13.0 software was used, the X + s was used, the statistical method was nonparametric test, two independent sample t test, x 2 test and variance analysis were used to analyze the difference. The difference was statistically significant with the difference of P0.05.
Results: the hearing loss of the ears of the tympanic membrane perforation and the mild closed craniocerebral injury without tympanic membrane perforation in 1 ears and the average threshold of hearing examination were significantly higher than that of the normal control group. The difference of hearing loss in the two groups was statistically significant.
The results of 90.45% ears PTA in 2 ears were the same as that of ABR, of which the average threshold value of PTA was more than 60dB, 93.66% and 6.34%, and 66.90% of them were conductive deafness, 23.24% was mixed deafness or sensorineural hearing loss, and 9.86% pure tone audiometry was less than 25dB at each frequency threshold, and the PTA average hearing threshold, ABR threshold and 40 in different time group. The difference of Hz AERP threshold was statistically significant compared with that of the normal control group. The average hearing threshold value of each examination in the 14 day group was the smallest, but there was no significant difference with the other time group. The difference of hearing loss at each frequency in the group of PTA and the group of less than 1 days was statistically significant, the most serious was in 0.125kHz and in the other time group. There was no significant difference in the difference of force loss. Compared with the normal control group, the latency of each wave of ABR was obviously prolonged, except for the difference in the interval of I - V wave interval, the difference of other wave intervals was statistically significant.
3 in 3 mild closed craniocerebral injury group, the results of 84.26% ears were consistent with the results of ABR, of which the average threshold value of PTA was more than 60dB, 70.33%, and 61dB (severe and extremely severe) accounted for 29.67%, of which 74.72% were sensorineural deafness, 25.28% was mixed deafness or conduction deafness; the PTA average hearing threshold in different time group, ABR threshold and 40Hz AERP threshold and normal The difference of the control group was statistically significant, the average hearing threshold value of all the 3 months group was the smallest, but there was no statistical difference with the other time group, and there was no significant difference in the hearing loss in the PTA results in the 3 months group, and the differences in the hearing loss in the other time group were statistically significant. The hearing loss of 4kHz and 8kHz was the most serious; DPOAE results also showed severe hearing loss in 4kHz, ABR and 40Hz AERP threshold extraction rates were 88.89% and 98.15% respectively, and ABR threshold was higher than 40Hz AERP threshold. Compared with normal control group, ABR wave latency was obviously prolonged, except for the difference of I - III wave interval, the difference of other wave interval There were statistical significance in.18 cases combined with follow-up patients at 1,3 and 6 months after injury. The hearing threshold of pure tone audiometry decreased, mainly in low frequency region (0.25kHz and 0.5kHz), and 40Hz AERP threshold was also significantly lower than the ABR threshold.
Conclusion: the hearing impairment after tympanic membrane perforation in 1 ears was mainly light and moderate conduction deafness. PTA results showed the most obvious damage in 0.125kHz. The average hearing threshold of the 14 day group in the group of different visits, the ABR and 40Hz AERP threshold were smaller than the other groups, but the difference was not statistically significant; the hearing loss was heavy in some ears, resulting in mixed deafness or sense. Acoustic nerve deafness, combined with ABR, 40Hz AERP, and clinical symptoms, we think that ear trauma can not only cause middle ear injury, but also can be associated with a certain degree of inner ear injury at the same time.
2 the hearing impairment without tympanic membrane perforation after mild closed craniocerebral injury was mainly mild to moderate sensorineural hearing loss, a few heavy hearing loss or mixed deafness, and impaired brain stem function. The results of comprehensive hearing examination showed high frequency hearing impairment (4kHz most obvious), and the hearing threshold decreased in 6 months after injury, with low frequency area. Obvious (0.25kHz and 0.5kHz), combined with clinical manifestations and auxiliary examinations, suggest that labyrinthine concussion plays an important role in the mechanism of inner ear injury.
3 the accurate assessment and reasonable identification of hearing impairment after trauma requires the clinicians or appraisers to inquire the history of the disease in detail, combined with the auxiliary examination of clinical, image and audiology. On the one hand, we fully understand the characteristics of different audiology examination, combined use to make up for each other's shortcomings, on the other hand, take the psychological state of the subjects seriously, take the psychological state of the subjects, and take the psychological state of the subjects carefully, and take the psychological state of the subjects carefully, In addition, we should take into account the law of hearing change in different periods after injury, reasonably grasp the time of identification, and finally make an objective and reasonable clinical diagnosis or forensic identification.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2010
【分類號】：R764

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