本文選題：耳鳴 + 蛛網(wǎng)膜顆粒　； 參考：《首都醫(yī)科大學(xué)》2014年博士論文

【摘要】：搏動性耳鳴(Pulsatile Tinnitus, PT)是耳科常見癥狀之一，長期存在嚴(yán)重影響生活工作質(zhì)量，甚至導(dǎo)致抑郁、自殺。病因主要包括動脈性、靜脈性及腫瘤性，明確病因是去除耳鳴的關(guān)鍵。既往臨床對靜脈性病因普遍認(rèn)識不足，近年來關(guān)于靜脈性耳鳴的報道逐漸增多。其中，乙狀竇周骨壁缺失已經(jīng)手術(shù)證實為PT常見病因之一，經(jīng)骨壁缺失部位行修補術(shù)后耳鳴可完全消失。過去4年于我院行顳骨雙期增強CT檢查的PT患者共1032例，乙狀竇周骨壁缺失者約占44%。共計85例患者經(jīng)骨壁缺失部位行修補術(shù)，術(shù)后近40%患者耳鳴無明顯減輕、不變甚至加重[1]；另外，目前對于骨壁缺失性耳鳴缺乏其它安全有效的治療方法。其關(guān)鍵在于骨壁缺失性耳鳴的發(fā)病機制不明。目前關(guān)于該類耳鳴的研究尚在起步階段，均為小樣本量療效描述性報道，缺乏對骨壁缺失特征的系統(tǒng)評估歸納，更無關(guān)乎其發(fā)病機制的研究。本研究的目的在于評估骨壁缺失的CT特征，建立CT基礎(chǔ)上的標(biāo)準(zhǔn)化評估模式，在此基礎(chǔ)上制作模型探討骨壁缺失性耳鳴的發(fā)病機制。本論文分兩部分：1.通過評估骨壁缺失性耳鳴的影像特點，制定骨壁缺失標(biāo)準(zhǔn)化的評估方案以助術(shù)中定位；歸納骨壁缺失的相關(guān)特點，為骨壁缺失性耳鳴的機制研究奠定基礎(chǔ)；2.基于影像學(xué)特征，建立骨壁缺失性耳鳴的尸頭模型，探討骨壁缺失性耳鳴的發(fā)生機制，為創(chuàng)新治療方法奠定基礎(chǔ)。 第一部分乙狀竇周骨壁缺失性耳鳴的CT評估 目的評估乙狀竇周骨壁缺失性耳鳴的CT特征，建立骨壁缺失的標(biāo)準(zhǔn)化評估方案。 方法分析骨壁修補術(shù)后耳鳴完全消失的30例單側(cè)耳鳴患者的顳骨雙期增強CT圖像；納入性別、年齡匹配且符合納入標(biāo)準(zhǔn)的對照組30例，該組患者均行頭CTA檢查，并同時行骨窗及軟組織窗重建。由兩位經(jīng)驗豐富的頭頸部影像醫(yī)師評估耳鳴組中骨壁缺失個數(shù)、部位、范圍，同時評估兩組頸靜脈球窩高位、導(dǎo)靜脈個數(shù)及管徑、垂體及垂體窩高度、顳骨氣化程度、靜脈回流優(yōu)勢、橫竇狹窄、橫竇區(qū)蛛網(wǎng)膜顆粒的發(fā)生情況。 結(jié)果在30例乙狀竇周骨壁缺失性耳鳴患者中，乙狀竇周骨壁缺失共44處，以單處缺失者略多見（17例）；將乙狀竇周骨壁縱向分為上中下三段，上段骨壁最常受累（29處）；將乙狀竇周骨壁橫向分為前壁、外壁、后壁，，外壁最常受累（40處）。骨壁缺失多發(fā)生在乳突尖、外耳道中心的后上方，平均坐標(biāo)點約（-3.82,31.58）mm、（-18.37,12.19）mm。骨壁缺失平均橫徑約(2.83±1.29)mm，平均面積約(7.97±5.17)mm2。此外，對側(cè)單處骨壁缺失者3例，平均橫徑約1.9mm，平均面積約3.7mm2。 與對照組相比，骨壁缺失組中頸靜脈窩高位（28vs19）、雙側(cè)橫竇狹窄（25vs5）、同側(cè)橫竇狹窄（25vs6）、對側(cè)橫竇狹窄（30vs9）、非全程狹窄患者中同側(cè)蛛網(wǎng)膜顆粒例數(shù)（25vs12）、非全程狹窄患者中對側(cè)蛛網(wǎng)膜顆粒例數(shù)（21vs8）、同側(cè)靜脈回流優(yōu)勢（22vs8）均多見；垂體窩高度較大[(10.04±2.70)mm vs(8.61±2.70)mm]、垂體高度較小[(3.04±2.06)mm vs (4.88±2.06)mm]，差異有統(tǒng)計學(xué)意義。乳突導(dǎo)靜脈（21vs21）、巖鱗竇（2vs1）、板障靜脈（20vs20）、顱板蛛網(wǎng)膜顆粒壓跡（18vs18）的發(fā)生情況及顳骨氣化程度[(3.70±1.81)ml vs (4.10±1.81)ml]差異無統(tǒng)計學(xué)意義。 術(shù)后行顳骨雙期增強CT復(fù)查者共11例;修補不完全者6例，殘余缺失面積平均1.9mm2。術(shù)后顳骨氣化容積平均2.69ml，與術(shù)前容積相比差異有統(tǒng)計學(xué)意義；手術(shù)側(cè)靜脈竇形態(tài)較術(shù)前未見明顯變化； 結(jié)論乙狀竇周骨壁缺失可為單處或多處，以上段、外壁最常受累，范圍小且不規(guī)則；對缺失部位行標(biāo)準(zhǔn)化評估有助于影像及術(shù)中定位；耳鳴的產(chǎn)生可能與多種因素協(xié)同所致的血流狀態(tài)有關(guān)，如靜脈回流優(yōu)勢、顱壓增高、橫竇狹窄、頸靜脈窩高位等；骨壁缺失是血流噪音被內(nèi)耳所接收的關(guān)鍵因素；傳道通路上的顳骨氣化程度與正常人相似。 第二部分乙狀竇周骨壁缺失性耳鳴的建模研究 目的探討利用尸頭顳骨制作乙狀竇周骨壁缺失性耳鳴模型的可行性，并基于模型探討該類耳鳴的發(fā)生機制。 方法利用CT采集顳骨區(qū)尸頭圖像22側(cè)，利用Mimics和Geomagic軟件獲取乙狀竇三維結(jié)構(gòu)，行三維打印得到實物血管內(nèi)腔，利用化學(xué)物質(zhì)澆注、成型、冷卻、脫離，得到與乙狀竇溝形態(tài)一致的薄壁人工血管。分別利用水和60%甘油模擬靜脈血液；利用微型水泵模擬心臟泵血；利用振動/聲音信號接收儀接收振動/噪聲；利用Labview2012軟件記錄信號形態(tài)、強度；利用石蠟封閉模型。 分別建立乙狀竇溝區(qū)結(jié)構(gòu)模型、乳突模型，探討改變骨壁的完整性、顳骨氣化程度對乙狀竇周骨壁缺失性耳鳴強度的影響。建立完整的乙狀竇骨壁缺失性耳鳴模型，改變水流速度、近段管徑，探討血流動力學(xué)改變對耳鳴強度的影響；改變骨壁缺失的范圍，評估骨壁缺失在耳鳴發(fā)生中的作用；并探討相同條件下，不同介質(zhì)對耳鳴強度的影響。 結(jié)果對于完整骨壁的乙狀竇區(qū)結(jié)構(gòu)模型，振動/噪聲接收器并不能接收到“水流”信號；利用骨鉆在乙狀竇上段磨除直徑2mm的骨壁缺失，規(guī)律噪音形成并可被噪聲接收儀接收但不能被振動接收儀接收。對于氣化容積分別為2.6ml、5.2ml的顳骨模型，前者所接收的耳鳴噪音明顯大于后者。在完整耳鳴模型中：噪聲強度隨著骨壁缺失增大而增大，二者并不成線性相關(guān)；分別比較20ml/s、12ml/s的"水流"，前者產(chǎn)生噪音更大；近段管腔狹窄者耳鳴噪聲較無狹窄者大。相同條件下，"水流"產(chǎn)生的噪音明顯較甘油大。 結(jié)論骨壁缺失部位的血流狀態(tài)是耳鳴噪聲產(chǎn)生的根本原因，而骨壁缺失則是噪聲被內(nèi)耳接收的關(guān)鍵因素。血流狀態(tài)、骨壁缺失范圍共同影響噪聲強度。傳導(dǎo)通路上的氣化程度與耳鳴噪聲強度負(fù)相關(guān)。
[Abstract]:Pulseural tinnitus ( PT ) is one of the most common symptoms in the ear , which has a long - term effect on the quality of life work and even leads to depression and suicide .
In addition , there is a lack of other safe and effective treatment methods for the deficiency of bone wall . The key is that the pathogenesis of the deficiency of bone wall is unknown . At present , there is no systematic assessment of the loss of bone wall . The aim of this study is to evaluate the CT features of the missing characteristic of bone wall .
To sum up the relevant characteristics of the loss of bone wall , lay a foundation for the mechanism study of the deficiency of bone wall ;
2 . Based on the imaging features , the body head model of the missing tinnitus of the bone wall was established , and the mechanism of the disappearance of the bone wall was discussed , which laid the foundation for the innovative treatment method .

CT evaluation of the missing tinnitus in the first part of sigmoid sinus wall

Objective To evaluate the CT features of the missing tinnitus in the circumferential wall of the sigmoid sinus and to establish a standardized assessment scheme for the loss of bone wall .

Methods The CT images of temporal bone in 30 patients with unilateral tinnitus completely disappeared after bone wall repair were analyzed .
The number , location and range of bone loss in tinnitus group were assessed by two experienced head and neck image doctors .

Results Among 30 patients with atrial septal defect of sigmoid sinus , there were 44 defects in the circumferential wall of the sigmoid sinus , and there were only slightly more missing persons ( 17 cases ) .
The circumferential wall of the sigmoid sinus was longitudinally divided into three sections , the upper and lower sections , and the upper section of the bone wall was most often affected ( 29 ) ;
The average lateral diameter of the bone wall was about ( 2.83 鹵 1 . 29 ) mm , the mean area was about ( 7.97 鹵 5.17 ) mm , the mean area was about 1.9mm and the average area was about 3.7 mm2 .

Compared with the control group , the high position of the jugular fossa ( 28 vs 19 ) , bilateral transverse sinus stenosis ( 25vs5 ) , the ipsilateral transverse sinus stenosis ( 25vs6 ) , the contralateral lateral sinus stenosis ( 30 vs9 ) , the number of ipsilateral subarachnoid particles ( 21 vs 8 ) and the superior venous reflux ( 22 vs 8 ) were seen in the patients with non - global stenosis .
The height of pituitary fossa was 10.04 鹵 2.70 mm vs ( 8.61 鹵 2.70 ) mm vs ( 8.61 鹵 2.70 ) mm , the height of pituitary was smaller ( 3.04 鹵 2.06 ) mm vs ( 4.88 鹵 2.06 ) mm , the difference was statistically significant .

There were 11 cases of bilateral enhancement CT in temporal bone after operation ; 6 cases with incomplete repair and 1.9 mm2 of residual missing area . The volume of temporal bone gasification was 2.69 ml , which had statistical significance compared with preoperative volume .
There was no significant change in the shape of sinus sinus during operation .


Conclusion The absence of the circumferential wall of the sigmoid sinus can be single or multiple , the above segment , the outer wall is most often affected , the range is small and irregular ;
The standardized assessment of missing sites facilitates image and intraoperative positioning ;
The generation of tinnitus may be related to the state of blood flow caused by multiple factors , such as venous reflux , elevated intracranial pressure , narrowing of transverse sinus and high level of jugular fossa ;
The lack of bone wall is the key factor for blood flow noise to be received by the inner ear ;
The degree of temporal bone gasification on the passway was similar to that of normal controls .

Modeling and study of second part sigmoid sinus wall missing tinnitus

Objective To explore the feasibility of using corpse - head temporal bone to make the model of circumferential wall loss tinnitus , and to explore the mechanism of this kind of tinnitus based on the model .

Methods 22 sides of the temporal bone were collected by CT . Mimics and Geomagic were used to acquire the three - dimensional structure of sigmoid sinus , and three - dimensional printing was used to obtain the inner lumen of the physical vessel .
the miniature water pump is used for simulating the blood of the heart pump ;
receiving vibration / noise using a vibration / sound signal receiver ;
using Labview 2012 software to record signal form and intensity ;
a paraffin closed model is utilized .

The structure model and mastoid model of the sigmoid sinus were established , and the effect of changing the integrity of the bone wall and the degree of temporal bone vaporization on the intensity of the missing tinnitus were discussed . The effect of hemodynamic changes on tinnitus intensity was discussed .
To change the extent of bone loss and evaluate the role of loss of bone wall in the occurrence of tinnitus ;
The effect of different media on tinnitus intensity under the same conditions was discussed .

Results The vibration / noise receiver could not receive the " water flow " signal for the model of the sigmoid sinus region of intact bone wall .
In the complete tinnitus model , the intensity of noise increases with the loss of bone wall , and the noise intensity is not linearly related .
Compared with 20ml / s , 12ml / s " water flow " , the former produces more noise .
In the proximal canal stenosis , the noise of tinnitus was much larger than that in patients without stenosis . Under the same conditions , the noise produced by " water flow " was significantly higher than that of glycerol .

Conclusion The blood flow state of the missing part of the bone wall is the root cause of tinnitus noise , while the loss of bone wall is the key factor for the noise to be received by the inner ear . The blood flow state and the loss of bone wall affect the noise intensity . The degree of vaporization on the conduction path is negatively correlated with the intensity of tinnitus noise .

【學(xué)位授予單位】：首都醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R764.45;R816.96

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