發(fā)布時間：2018-07-05 01:29

  本文選題：鼻咽癌 + 初診患者　； 參考：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：背景與目的 鼻咽癌是發(fā)生在鼻咽部上皮組織的惡性腫瘤,為我國南方地區(qū)尤其是廣東多發(fā)常見的頭頸部惡性腫瘤之一。鼻咽癌好發(fā)于鼻咽部的咽隱窩和頂后壁,因此與中耳疾病有著密切關(guān)系。雖然聽力下降、耳鳴、耳悶等耳部癥狀不及鼻咽癌原發(fā)病灶對患者的生存影響大,但是亦嚴重影響了患者的生活質(zhì)量及治療。因此重視鼻咽癌患者的中耳功能,對提高鼻咽癌患者的生存質(zhì)量具有重要意義,全面了解影響鼻咽癌患者中耳功能的相關(guān)因素對后續(xù)的治療非常重要。 關(guān)于鼻咽癌初診患者的中耳功能障礙的致病機制,早期認為鼻咽部機械性阻塞是鼻咽癌并發(fā)分泌性中耳炎的主要原因,其影響的機制主要有：腫物的直接壓迫阻塞,表現(xiàn)為阻塞型咽鼓管功能障礙,此外鼻咽癌腫物造成阻塞所產(chǎn)生的炎性介質(zhì)可致管腔表面活性物質(zhì)減少,增加表面張力,咽鼓管主動開放功能受損,表現(xiàn)為閉鎖不全型咽鼓管功能障礙。腭帆張肌、腭帆提肌、咽鼓管受累是目前一致認可的致病機制之一。腫瘤侵犯咽鼓管或者侵及腭帆張肌或相應(yīng)的神經(jīng)而致其麻痹,使咽鼓管開放障礙,可致分泌性中耳炎。但是目前仍少有學(xué)者從臨床的思維出發(fā),從鼻咽癌的原發(fā)病灶的生長情況、咽鼓管功能、咽鼓管咽口等多因素的角度研究鼻咽癌初診患者中耳障礙的影響因素。 關(guān)于鼻咽癌初診患者中耳功能障礙的發(fā)病機制、評估及治療目前還存在很多爭議。對鼻咽癌初診患者的中耳功能障礙的相關(guān)影響因素的研究仍然缺乏深度,對其評估讓缺乏一個客觀、全面的量化評價方式。本研究在總結(jié)鼻咽癌初診患者資料的基礎(chǔ)上,首次嘗試采用多因素及量化的方法分析鼻咽癌初診患者的中耳功能,對可能影響鼻咽癌初診患者中耳功能的相關(guān)因素進行系統(tǒng)分析,力求較為全面、量化和客觀評地價鼻咽癌初診患者的中耳功能,盡可能為鼻咽癌患者出現(xiàn)中耳功能障礙的早期診斷和防治提供臨床依據(jù),從而進一步提高患者的生存質(zhì)量。 實驗對象及方法 1、受試對象：收集廣州南方醫(yī)院和深圳市寶安區(qū)石巖人民醫(yī)院2009年1月～2012年12月經(jīng)病理學(xué)檢查確診為鼻咽癌的初診患者320例(320耳),有完整的臨床資料,并均行耳鏡、聲導(dǎo)抗檢測、純音聽閾測試、鼻咽部及中耳CT或MRI掃描、咽鼓管功能檢查、電子鼻咽鏡等檢查。 2、檢測儀器：丹麥產(chǎn)Madsen ZODIAC-901型聲導(dǎo)抗儀、GSI16純音測聽儀、美國通用電氣公司的Lightspeed16排全身螺旋CT掃描機、美國通用電氣公司的MRI (GE Signa1.5T)、日本產(chǎn)的Olympus電子纖維鼻咽喉鏡。 3、將以下檢查結(jié)果進行計分式量化,得分越高者,表明中耳功能受影響越嚴重：①根據(jù)鼓膜體征：正常記1分,鼓膜內(nèi)陷、無液平線記2分,鼓膜見氣泡或液平線記3分：②根據(jù)純音聽閾結(jié)果,氣導(dǎo)正常聽閾(25dBHL)記1分,輕度聾(26～40dBHL)2分,中度聾(41～55dBHL)3分,中重度聾(56～70dBHL)記4分,重度聾(71～90dBHL)記5分,極重度聾(91dBHL)記6分；③根據(jù)鼓室導(dǎo)抗圖：A型記1分,C型記2分,B型記3分；④根據(jù)鐙骨肌反射：患耳同側(cè)或健耳對側(cè)引出記1分,未引出記2分；⑤采用捏鼻鼓氣法檢查咽鼓管功能：正常記1分,功能障礙記2分；⑥根據(jù)咽鼓管咽口形態(tài)：橢圓形記1分,喇叭形記2分,三角形記3分,縫隙形記4分；⑦根據(jù)是否并發(fā)鼓室積液,無積液征象者記1分,有者記2分。判別標準是鼓膜穿刺、MRI或CT影像學(xué)證據(jù)；⑧根據(jù)影像學(xué)是否并發(fā)鼻竇炎,無鼻竇炎者記1分,有者記2分；⑨根據(jù)MRI或CT是否并發(fā)乳突炎,無乳突炎者記1分,有者記2分；⑩根據(jù)耳部癥狀出現(xiàn)的時間：無癥狀記1分,有耳部癥狀但≤6月者記2分,有耳部癥狀且6月者記3分。 4、統(tǒng)計學(xué)分析 應(yīng)用SPSS13.0軟件包進行統(tǒng)計分析,進行單因素分析、多因素Logistic回歸模型分析。單因素分析采用t檢驗,將單因素分析有統(tǒng)計學(xué)意義的因素納入Logistic回歸模型進行多因素分析。檢驗水準a=0.05。 結(jié)果 1、單因素分析： 經(jīng)單因素分析后表明性別、年齡、N分期、M分期、病理類型對患者的中耳功能得分的影響無統(tǒng)計學(xué)意義；而T分期、臨床分期、咽鼓管咽口形態(tài)、咽鼓管功能、腫物部位、腫物擴散類型、腫物形態(tài)、影像學(xué)侵犯范圍(鼻腔、顱底、咽隱窩、咽旁間隙、腭帆張肌、腭帆提肌)侵犯與否對患者的中耳功能得分的影響均有統(tǒng)計學(xué)意義。 ①T分期 T1、T2、T3、T4的中耳功能得分分別為13.25±3.22、18.52±6.24、21.29±3.42、24.37±3.35,隨著T分期的進展,中耳功能越差,得分也越高。T1、T2、T3、T4的中耳得分兩兩比較,P均0.05。 ②臨床分期 Ⅰ、Ⅱ、Ⅲ、Ⅳ組的中耳功能得分12.54±1.70、16.73±5.67、20.18±4.96、23.65±4.39,兩兩進行比較時均有統(tǒng)計學(xué)差異(P0.05)。 ③局部腫物部位 咽隱窩、頂后壁23.47±4.69、15.64±4.34,生長于咽隱窩腫物的中耳功能得分與生長于頂后壁腫物的中耳得分進行比較時有統(tǒng)計學(xué)差異(P0.05)。 ④局部的腫物擴散類型 局限型、上行型、下行型、混合型14.10±3.99、22.45-2.84、16.13±5.78、24.22±3.62,不同擴散類型的中耳功能得分兩輛比較P均0.05。 ⑤局部腫物形態(tài) 局限型、孤立腫塊型、浸潤型的中耳得分分別是：14.94±4.27、18.03±4.39、25.56±2.11,進行兩兩比較時有統(tǒng)計學(xué)差異(P0.05)。 ⑥咽鼓管咽口分型 橢圓形、喇叭形、三角形、縫隙形的中耳功能的得分分別是13.20±2.81、20.58±3.46、23.31±4.02、25.00±4.12,咽鼓管咽口各分型之間進行比較時均有統(tǒng)計學(xué)差異(P0.05)。 ⑦咽鼓管功能 咽鼓管正常、咽鼓管障礙的中耳功能得分14.84±4.05、23.37±4.18,咽鼓管正常組與咽鼓管障礙兩組中耳得分之間進行比較時有統(tǒng)計學(xué)差異(P0.05)。 ⑧影像學(xué)6個分變量 影像學(xué)6個分變量(鼻腔、顱底、咽隱窩、咽旁間隙、腭帆張肌、腭帆提肌)侵犯與否兩組中耳得分之間進行比較時有統(tǒng)計學(xué)差異(P0.05)。 2、多因素分析 將單因素分析有統(tǒng)計學(xué)意義的T分期、臨床分期、腫物部位、腫物形態(tài)、腫物擴散類型、咽鼓管功能障礙、咽鼓管咽口形態(tài)、影像學(xué)范圍侵犯(鼻腔、咽隱窩、咽旁間隙、腭帆張肌、腭帆提肌、顱底)等8個主變量和6個分變量進入多因素Logistic回歸模型。結(jié)果顯示：T分期、腫物部位、咽鼓管功能、腭帆張肌侵犯、顱底侵犯組P均0.05,提示這些因素是影響鼻咽癌初診患者的中耳功能的獨立因素。 結(jié)論 1、本研究的結(jié)果表明,T分期、臨床分期、腫物部位、腫物擴散類型、腫物形態(tài)、咽鼓管功能障礙、咽鼓管咽口形態(tài)、影像學(xué)侵犯范圍(鼻腔、顱底、咽隱窩、咽旁間隙、腭帆張肌、腭帆提肌)是影響鼻咽癌初診患者的中耳功能單因素,而性別、年齡、病理類型、N分期、M分期對鼻咽癌初診患者中耳功能無影響；多因素分析顯示,T分期、腫物部位、咽鼓管功能、腭帆張肌侵犯、顱底侵犯是影響鼻咽癌初診患者的中耳功能的獨立因素。 2、T分期、臨床分期較晚、生長于咽隱窩、上行型及混合型、咽鼓管功能障礙、咽鼓管咽口為裂隙形、影像學(xué)侵犯鼻腔、顱底、咽隱窩、咽旁間隙、腭帆張肌、腭帆提肌等組織以及并發(fā)鼻竇炎、乳突炎等均可加重中耳功能障礙。 3、采用耳鏡、聲導(dǎo)抗測試、純音測聽、鼻咽部影像學(xué)檢查、咽鼓管功能檢查、電子鼻咽鏡檢查等的綜合量化評估,可充分了解鼓膜、鼓室功能、中耳情況、腫物的浸潤程度、咽鼓管功能、咽鼓管開口等中耳的解剖和功能,能較為全面、客觀地評估了鼻咽癌初診患者的中耳功能和病變程度。通過對鼻咽癌初診患者中耳功能的綜合評估,提供臨床提供診療依據(jù),有利于預(yù)防和治療患者的咽鼓管功能障礙及中耳病變,進一步提高患者的生活質(zhì)量。 4、根據(jù)本研究的結(jié)果,結(jié)合患者的中耳病變及患者癥狀,可將鼻咽癌初診患者的中耳功能分為：11分,無耳鳴、聽力下降等不適者為中耳功能正常；11-15分,可有耳鳴、聽力下降,但程度輕、對生活影響較小者為輕度中耳功能異常；16-23分,多有耳鳴、聽力下降,可有耳悶塞感者為中度中耳功能異常；24分以上,常有耳鳴、聽力下降、悶塞感等,明顯影響生活者為重度中耳功能異常。 5、本研究的結(jié)果還有待更多的臨床資料加以充實和完善,尤其在評價的項目因素及評分權(quán)重比例的合理性、根據(jù)患者的中耳障礙量化得分提出相應(yīng)的治療方案、進一步開展動態(tài)和遠期的中耳功能評估等方面仍有很多的研究領(lǐng)域。
[Abstract]:Background and purpose
Nasopharyngeal carcinoma is a malignant tumor occurring in the epithelium of the nasopharynx, which is one of the most common head and neck malignant tumors in southern China, especially in Guangdong. Nasopharyngeal carcinoma is well distributed in the pharyngeal recess and the posterior wall of the nasopharynx. Therefore, it is closely related to the middle ear diseases. The focus has a great impact on the survival of the patients, but it also seriously affects the quality of life and treatment of the patients. Therefore, it is of great significance to pay more attention to the middle ear function of the patients with nasopharyngeal carcinoma to improve the quality of life of the patients with nasopharyngeal carcinoma.
In the early diagnosis of nasopharyngeal carcinoma, the mechanism of the middle ear dysfunction in nasopharyngeal cancer patients is that mechanical obstruction of the nasopharynx is the main cause of the nasopharyngeal carcinoma complicated with secretory otitis media. The main mechanisms are the direct compression of the tumor, the obstruction of the eustachian tube dysfunction, and the inflammation caused by the obstruction of the nasopharyngeal carcinoma. The sexual medium can reduce the surface activity of the lumen, increase the surface tension, and the active open function of the eustachian tube is impaired. The tensor palatine tensor muscle, the levator palatine levator, and the eustachian tube are one of the unanimous pathogenetic mechanisms. The tumor invades the pharynx drum tube or invades the tensor Palatine tensor palatine muscle or the corresponding nerve. Its paralysis makes the eustachian tube open and can cause secretory otitis media. But there are still few scholars from the clinical thinking, from the perspective of the growth of the primary focus of nasopharyngeal carcinoma, Eustachian tube function, Eustachian tube pharynx and other factors to study the influencing factors of the middle ear obstruction in nasopharyngeal carcinoma.
There are still many controversies about the pathogenesis, evaluation and treatment of middle ear dysfunction in nasopharyngeal cancer patients. The research on the related factors of the middle ear dysfunction of nasopharyngeal cancer patients is still lack of depth, and the evaluation is lacking an objective and comprehensive quantitative evaluation method. This study summarizes nasopharyngeal cancer patients in the first diagnosis. On the basis of the data, it is the first attempt to analyze the middle ear function of nasopharyngeal carcinoma patients with nasopharyngeal carcinoma (nasopharyngeal carcinoma) for the first time by using multiple factors and quantifying methods, and systematically analyze the related factors that may affect the middle ear function of nasopharyngeal carcinoma, and try to quantify and objectively evaluate the middle ear function of the first diagnosed patients with nasopharyngeal carcinoma, and to make the nasopharyngeal cancer patients as possible as possible. It provides a clinical basis for early diagnosis and prevention of middle ear dysfunction, so as to further improve the quality of life of patients.
Experimental objects and methods
1, subjects: 320 cases (320 ears) of nasopharyngeal carcinoma were collected from Guangzhou Nanfang Hospital and Baoan District Shiyan people's Hospital of Shenzhen city from January 2009 to 2012. 320 cases of nasopharyngeal carcinoma were diagnosed as nasopharyngeal carcinoma (320 ears) with complete clinical data. All of them were received ear mirror, acoustic conductivity detection, pure tone hearing threshold test, nasopharyngeal and middle ear CT or MRI scan, Eustachian tube function examination. Check, electronic nasopharyngoscopy and other examination.
2, testing instruments: the Madsen ZODIAC-901 acoustic conductance instrument in Denmark, the GSI16 pure tone audiometer, the Lightspeed16 row CT scanner of the Ge Corp in the United States, the MRI (GE Signa1.5T) of the United States Ge Corp (GE Signa1.5T), and the Olympus electronic fiber nasopharyngeal laryngoscope produced in Japan.
3, the following examination results were quantized. The higher the score, the more serious the middle ear function was: (1) according to the signs of the tympanic membrane: 1 points in normal, 2 in the tympanic membrane, 2 in the non liquid line, 3 in the tympanic membrane, by the result of the pure tone hearing threshold, 1 in the normal hearing threshold (25dBHL), and 2 for the mild hearing loss (26 to 40dBHL). Moderate deafness (41 to 55dBHL), moderate to severe deafness (56 to 70dBHL), 4, 5 for severe deafness (71 to 90dBHL), and 6 for extreme deafness (91dBHL); (3) according to the tympanic resistance map: A type 1, C type 2, and B type 3; (4) according to the stapes muscle reflex: the side of the ear or the sound of the ear of the ear was divided 1, no 56 points; 5 Check the function of eustachian tympanum: 1 points in normal, 2 points for dysfunction; 6. According to pharynx tube pharynx shape: Oval record 1 points, horn shape 2 points, triangle 3 points, gap mark 4 points; There were 1 points for sinusitis without sinusitis, 1 points without sinusitis, and 2 points for those with no sinusitis. According to whether MRI or CT was complicated with masttis, there were 1 points without masttis and 2 points.
4, statistical analysis
SPSS13.0 software package was used to carry out statistical analysis, single factor analysis and multiple factor Logistic regression model analysis. Single factor analysis was analyzed by t test. The factors of statistical significance in single factor analysis were included in Logistic regression model for multi factor analysis. The test level a=0.05.
Result
1, single factor analysis:
After single factor analysis, the effects of sex, age, N staging, M staging, and pathological types on the median ear function score were not statistically significant; T staging, clinical staging, Eustachian tube pharynx morphology, Eustachian tube function, tumor site, tumor diffusion type, tumor morphology, imaging invasion range (nasal cavity, skull base, pharyngeal recess, parapharyngeal space, palatine) The influence of the insertion of the tensor veli palatine muscle or the levator veli palatine muscle on the middle ear function score was statistically significant.
T staging
The middle ear function scores of T1, T2, T3 and T4 were 13.25 + 3.22,18.52 + 6.24,21.29 + 3.35 respectively. With the progress of T staging, the worse the function of the middle ear, the higher the score was.T1, T2, T3, and 22 in the middle ear of T4.
Clinical staging
The scores of middle ear function in group I, II, III and IV were 12.54 + 1.70,16.73 + 5.67,20.18 + 4.96,23.65 + 4.39, and 22 were statistically different when compared (P0.05).
Part of local mass
The posterior wall of the pharynx and the posterior wall of the pharynx were 23.47 + 4.69,15.64 + 4.34. The score of the middle ear function for the swelling of the pharyngeal fossa was compared with the middle ear score of the posterior wall mass (P0.05).
Local mass diffusion type
Limited type, ascending type, descending type, mixed type 14.10 + 3.99,22.45-2.84,16.13 + 5.78,24.22 + 3.62, different diffused type middle ear function score two vehicle comparison P all 0.05.
Form of local mass
The central ear scores of localized type, solitary mass type and infiltrating type were: 14.94 + 4.27,18.03 + 4.39,25.56 + 2.11, and 22 compared with statistical difference (P0.05).
Subtype of eustachian tube pharyngeal orifice
The scores of the oval, horn, triangular and crevice middle ear functions were 13.20 + 2.81,20.58 + 3.46,23.31 + 4.02,25.00 + 4.12 respectively, and there were statistically significant differences between the pharyngeal orifice types of the eustachian tube (P0.05).
Eustachian tube function
The score of eustachian tube was normal, the score of middle ear function of eustachian tube disorder was 14.84 + 4.05,23.37 + 4.18. There was a statistical difference between the normal group of eustachian tube and the score of middle ear in two groups of eustachian tube disorder (P0.05).
6 sub variables of imaging
The 6 sub variables (nasal cavity, skull base, pharynx recess, parapharyngeal space, palatine sail tensor, palatine sails) were compared with the two groups of middle ear scores (P0.05).
2, multi factor analysis
T staging with statistical significance, clinical staging, tumor location, tumor morphology, tumor diffusion type, Eustachian tube dysfunction, Eustachian tube pharynx morphology, imaging range invasion (nasal cavity, pharyngeal recess, parapharyngeal space, palatine sail tensor, palatopalatine levator, skull base) and other 8 main variables and 6 variables entered the multiple factor Logistic regression model. The results showed that the T staging, the tumor site, the eustachian tube function, the invasion of the palatine tensor muscle, and the P of the skull base invasion group were all 0.05, suggesting that these factors were independent factors affecting the middle ear function of nasopharyngeal carcinoma.
conclusion
1, the results of this study showed that T staging, clinical staging, tumor site, tumor diffusion type, tumor morphology, Eustachian tube dysfunction, Eustachian tube pharynx morphology, imaging invasion range (nasal cavity, skull base, pharyngeal recess, parapharyngeal space, palatine tensor palatine, palatine Levi muscle) are the single factors affecting the middle ear function in nasopharyngeal cancer patients, and sex, age, and disease. Type, N staging and M staging have no effect on the middle ear function of nasopharyngeal carcinoma. Multiple factor analysis shows that T staging, tumor site, Eustachian tube function, palatine tensor muscle invasion and skull base invasion are independent factors affecting the middle ear function of nasopharyngeal carcinoma first diagnosed patients.
2, T staging, the clinical stage is late, growth in the pharyngeal recess, upper and mixed type, Eustachian tube dysfunction, Pharyngal tube pharyngeal mouth is fissures, imaging invasion of the nasal cavity, the skull base, pharyngeal recess, parapharyngeal space, palatine sail tensor, palatine levator muscle and other tissues as well as nasosinusitis, and masttis can aggravate the middle ear dysfunction.
3, the comprehensive quantitative evaluation of the eardrum, the nasopharyngeal imaging examination, the eustachian tube function examination, the electronic nasopharynx examination and so on, can fully understand the tympanic membrane, the tympanic function, the middle ear condition, the infiltration degree of the swelling, the eustachian tube function, the opening of the pharynx drum and so on, which can be more comprehensive and objective evaluation. The function and degree of the middle ear of nasopharyngeal carcinoma first diagnosis patients, through comprehensive evaluation of the middle ear function of nasopharyngeal cancer patients, provide clinical basis for diagnosis and treatment. It is beneficial to prevent and treat the dysfunction of eustachian tube and middle ear, and further improve the quality of life of the patients.
4, according to the results of this study, combined with the patients' middle ear lesions and patients' symptoms, the middle ear function of nasopharyngeal carcinoma patients can be divided into 11 points, no tinnitus and hearing loss as the middle ear function is normal; 11-15 points can have tinnitus and hearing loss, but the degree is light, and the less affected people are mild middle ear dysfunction; 16-23 points and more. There are tinnitus, hearing loss, and the patients with ear stuffy feel a moderate middle ear dysfunction; more than 24 points, often with tinnitus, hearing loss, stuffy stoppage, and so on, which obviously affect the abnormality of severe middle ear function.
5, the results of this study still need more clinical data to be enriched and perfected, especially in the evaluation of the rationality of the project factors and the proportion of the weight of the score, according to the quantitative score of the middle ear disorders of the patient to put forward the corresponding treatment plan, and to further develop the dynamic and long-term evaluation of the middle ear work, there are still a lot of fields of research.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R739.63

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