耳鳴的預防和治療ppt課件

1、此ppt下載后可自行編輯耳鳴的預防和治療耳鳴的定義耳鳴的分類耳鳴的臨床特點耳鳴的治療要點主觀性耳鳴的病因與產生機制（簡述）耳鳴的預防耳鳴的治療主要內容耳鳴的定義0t0sclerosis主觀性耳鳴：是指在周圍環(huán)境中無相應聲源和電(磁)刺激源情況下，患者自覺耳內或顱內有聲音的一種主觀感覺。客觀性耳鳴：是指不但患者自己能聽到耳周或顱內有響聲而且其他人也能聽到?？陀^性耳鳴常可在耳周或顱內有發(fā)聲源。臨床上，主觀性耳鳴占多數(shù)，客觀性耳鳴較少。王洪田, 李明, 劉蓬,黃治物, 胡岢,賴仁淙.耳嗚的診斷和治療指南(建議案).中華耳科學雜志.2009. 7(3):185耳鳴的其他分類依據(jù)耳鳴的發(fā)源部位耳源性耳鳴

2、非耳源性耳鳴依據(jù)耳鳴的病變部位傳導性耳鳴感音神經性耳鳴中樞性耳鳴依據(jù)耳鳴的病理生理特點生理性耳鳴病理性耳鳴心理性耳鳴病理生理性耳鳴假性耳鳴0t0sclerosis依據(jù)病程急性耳鳴（3月）慢性耳鳴（3月）依據(jù)有無搏動搏動性耳鳴非搏動性耳鳴；耳鳴病因不清，機制復雜，分類很難耳鳴定義的理解耳鳴：（1）是無相應的外界聲源和電刺激，（2）而主觀上在耳內和顱內有聲音感感覺（實用耳鼻咽喉頭頸外科學（第2版）黃選兆 汪吉寶 孔維佳 主編）。Tinnitus is the sensation of sound in the absence of an external source. 應該排除：搏動性耳鳴，腭咽

3、喉肌陣攣的卡塔聲咽鼓管異常開放聲。耳內異物（頭發(fā)絲和耵聹）摩擦鼓膜的聲音“幻聽”耳鳴的臨床特征-患病年齡0t0sclerosis耳鳴臨床特點突然起病患者的耳鳴嚴重程度較緩慢起病者更高，耳鳴主調以8000 Hz最多見，占22.9，響度主要集中在感覺級510 dB；伴有感音神經性聾者占75.6；耳鳴主調為高頻時，絕大多數(shù)患者聽力下降區(qū)域也位于高頻同時，主調為低頻、言語頻率時，聽力下降也多位于相應頻率區(qū)域存在不良心理反應者占89.6，表現(xiàn)為心情煩躁者83.8，影響睡眠者63.7，注意力難以集中者30.30t0sclerosis耳鳴的治療要點：病史與檢查詳細詢問病史（最主要）耳鳴本身的病史：耳鳴的發(fā)生

4、時間？雙耳還是單耳？是什么聲音？持續(xù)還是間歇性？有無規(guī)律？與呼吸與脈搏的關系？有無耳聾及眩暈？中耳炎相關病史；噪聲接觸史！查體：外耳道及鼓膜基礎聽力學檢查：評估聽力情況純音測聽聲導抗耳聲發(fā)射（反映毛細胞損害較PTA敏感）聽性腦干反應耳鳴匹配音調的頻率匹配響度匹配心理學調查影像學檢查，如CT、MRI耳鳴的治療要點：問診要點耳鳴的病程長短？問診目的：預測預后，制定不同的治療方案。耳鳴的病程越短，療效越好。急性耳鳴治療方案同突發(fā)性聾。慢性耳鳴則要根據(jù)是否代償選擇不同的治療方案。耳鳴的治療要點：問診要點側別？是單耳還是雙耳？還是顱鳴？雙側同頻耳鳴和顱鳴常常提示中樞性耳鳴。雙側低調耳鳴要除外內分泌疾?。?/p>

5、如甲狀腺功能低下）及自身免疫性疾病。雙側耳鳴的音調不一致則提示雙側聽覺通路的不同病變。耳鳴的治療要點：問診要點耳鳴的音調？是低頻還是高頻？還是多種音調？低中頻耳鳴往往提示內耳病變，如內耳積水和梅尼埃病等。高頻耳鳴往往為神經性或中樞性耳鳴。多種音調的耳鳴常常提示聽覺系統(tǒng)有多處病變存在。轉頭時耳鳴音調發(fā)生改變常提示頸椎病引起的頸性耳鳴。耳鳴的治療要點：問診要點在什么情況下耳鳴會減輕或加重？頸性耳鳴在晨起或午睡后耳鳴的程度最重，而其他原因引起的耳鳴多在夜間，安靜時最重。是否伴有聽力下降、眩暈等癥狀。單側高調耳鳴伴/不伴聽力下降首先要除外聽神經瘤。伴有眩暈癥狀的患者要除外梅尼埃病、上半規(guī)管裂綜合癥等疾

6、病。耳鳴的治療要點：診斷如何診斷？標準？難？容易？0t0sclerosis主觀性耳鳴的原因及機制不伴聽力減退的耳鳴聽力減退伴有耳鳴老年性聾長期或高強度噪聲刺激耳硬化癥感染，如中耳炎自身免疫性疾病梅尼埃病腫瘤耳毒性藥物特發(fā)性壓力及心理因素主觀性耳鳴產生的機制僅指感音神經性耳鳴主觀性耳鳴的病因及機制耳鳴起源于中樞而非耳蝸： MRI has revealed differences in sound-evoked responses between tinnitus and nontinnitus groups in cortical 12 and subcortical auditory nucl

7、ei 13 and found evidence for structural differences in the thalamus 14, the auditory brainstem15 and the auditory cortex 16.聽覺中樞異常電活動：認為耳嗚的產生可能由神經元的自發(fā)放電率(spontaneous firing rates)增加、簇狀放電(burst-firing activity)的形成及神經元同步放電(neural synchrony)引起伴與不伴有耳聾的耳鳴，其機制不同。主觀性耳鳴的病因及機制Adjamian P, et al. The mechanism

8、s of tinnitus: Perspectives from human functional neuroimaging. Hearing Research 253 (2009) 1531伴有耳聾的耳鳴圖： 耳鳴與耳聾的聯(lián)系 (Konig et al., 2006). The mean function represents the data from 24 patients who matched the dominant pitch of their tinnitus to a single-frequency tone. Tinnitus pitch is represented b

9、y the vertical bars. The arrow points to the mean audiogram edge of the hearing loss. Note that most patients matched their sensation to the region of hearing loss.85%的耳鳴患者伴有聽力減退 耳聾的頻率與耳鳴頻率匹配主觀性耳鳴的病因及機制外周聽力損害所致耳鳴的機制耳聾所致傳入沖動減少，對聽覺中樞的抑制性減弱，使得聽覺中樞自放電增強。The prevailing opinion is that tinnitus is a perce

10、ptual consequence of altered patterns of intrinsic neural activity generated along the central auditory pathway following damage to peripheral auditory structures (Eggermont and Roberts, 2004). While the loss of afferent input to the central auditory system can initiate tinnitus, thereafter, central

11、 mechanisms play an important role in maintaining it.The primary hypothesis of cellular mechanisms underlying tinnitus development is that hearing loss leads to a down-regulation of inhibition and reorganization of the central auditory system .為什么要放電增強？The central auditory system appears to increase

12、 its gain to compensate for the reduced sensorineural input from the cochlea. As a result, hyperactivity often develops in the cochlear nucleus 29,30, the inferior colliculus 23,24&,25,31 and the auditory cortex 32.Tinnitus and underlying brain mechanisms.Curr Opin Otolaryngol Head Neck Surg 2012, 2

13、0:409415主觀性耳鳴的病因及機制外周聽力正常者耳鳴的機制耳鳴可以存在于正常聽力人群中。耳鳴音凋分布范圍較廣，耳嗚起源于聽力損失的理論不適用于解釋常聽力耳鳴人群，耳鳴產生的機理不能用單一的理論來解釋。水楊酸所致耳鳴的中樞放電變化無規(guī)律：Recordings from the inferior colliculus and auditory cortex after tinnitus induction with salicylate are inconclusive, with different studies showing that spontaneous activity incr

14、eased, decreased or showed no significant change 23,27,36. The presence of hyperactivity in the auditory cortex depends on the manner in which tinnitus is induced. Noise trauma is associated with increasing firing 26, but a reduction is seen when tinnitus is elicited by salicylate（水楊酸） 27.潘滔, 等.正常聽力

15、耳鳴患者的耳鳴音調.中華耳科學雜志,2009,7(3):200-203耳鳴的預防避免噪聲規(guī)律作息調節(jié)心理，忌諱煩躁、焦慮、壓力不吸煙、忌濃茶，禁酒慎用毒性藥物：如鏈霉素、慶大霉素、卡那霉素等低鹽、低脂飲食21耳鳴的治療病因治療耳鳴作為伴隨癥狀出現(xiàn)的一些原發(fā)病治療中耳炎、梅尼埃病、突發(fā)性聾及甲亢等藥物治療（抑制耳鳴的藥物和基礎病因的藥物）改善原發(fā)病的藥物：改善微循環(huán)及營養(yǎng)神經藥物減輕耳鳴心理影響的藥物：（抗抑郁）抑制耳鳴的藥物：（利多卡因及抗癲癇等）心理學治療掩蔽治療習服療法手術電刺激其它：針灸，磁治療，高壓氧治療藥物治療基礎疾病的藥物治療：對中耳炎、甲功異常、梅尼埃病等的藥物治療維生素B（尤其

16、是B12）鋅制劑銀杏葉制劑對癥治療減輕耳鳴對患者的影響抗焦慮抑郁藥物：抗抑郁藥 多慮平 25mg tid 多在1周見效抗焦慮藥 舒樂安定 1mg tid有不同程度副作用，甚至會加重耳鳴，謹慎用藥。耳鳴的抑制藥物利多卡因 1-2mg/kg 1%濃度緩慢靜脈注入，5分鐘注完（不能太快?。┟咳找淮?，7天一個療程。缺點： 作用時間比較短。氯硝安定 1mg 睡前 x7 卡馬西平 200mg tid x723心理治療有相當比例的急性耳鳴患者與心理壓力大；情緒波動；失眠等因素有關。此時的藥物治療不宜使用改善微循環(huán)治療，而是要選擇改善睡眠、抗焦慮；抗抑郁等治療不良心理藥物治療。聲治療：掩蔽療法 Masking

17、 therapy1977 Vernon首先用耳鳴掩蔽器 機制：抑制病變部位以上中樞神經傳導通路 根據(jù)耳鳴頻譜和響度調節(jié)掩蔽聲。利用一種正常生理功能：對一種刺激反應消失的現(xiàn)象，即稱之為“適應”或“習慣”利用大腦不能同時完成均需要注意力集中的兩項任務的生理特點，所以來增加背景聲，淡化耳鳴對皮層的刺激從而達到減輕或消除耳鳴的目的掩蔽聲：連續(xù)音刺激1S 后能使耳鳴消失最低刺激音強度 聲治療利用一種正常生理功能：對一種刺激反應消失的現(xiàn)象，即稱之為“適應”或“習慣”利用大腦不能同時完成均需要注意力集中的兩項任務的生理特點，所以來增加背景聲，淡化耳鳴對皮層的刺激從而達到減輕或消除耳鳴的目的掩蔽療法適應癥：1

18、、特發(fā)性耳鳴2、伴有聽力下降的耳鳴3、找到病因經治療原發(fā)病治愈或未治愈耳鳴仍然存在的類型4、部分血管搏動性耳鳴掩蔽療法-音樂枕28掩蔽療法-助聽器（禪 Zen）丹麥（唯聽）助聽器中基于碎型算法的音樂。該音樂是根據(jù)使人放松的原則制作 (Robb et al.,1995)1、每一個禪程序，都能調整響度，音調和模式2、確保禪音（或噪音）聽到，但聲音相對柔和3、不應妨礙會話言語4、耳鳴煩惱級應該開始減少（耳鳴可以仍被聽見）人工耳蝸是極重度感應神經性聾伴有嚴重耳鳴患者的選擇之一人工耳蝸植入術后，耳鳴的厭煩程度、耳鳴的響度均有改善術后超過半數(shù)患者對耳鳴抑制感到滿意掩蔽療法-耳蝸電極植入Kalcioglu

19、MT, Cokkeser Y, Kizilay A, et al. Follow-up of 366 ears after tympanostomy tube insertion. Otolarynogol Head Neck Surg, 2003,128;560-564.Daly KA, Hunter LL,Lindgren BR,et al. Chronic otitis media with effusion sequelae in children treated with tubes. Arch Otolaryngol Head Neck Surg, 2003,126;517-522

20、.Vagus nerve stimulation Electrical stimulation of the DCN Transcranial direct current stimulationDeep brain stimulation電刺激治療電刺激治療對耳鳴的電刺激抑制首先于1855年被報道，共包含兩種電刺激方式深部腦電刺激Electrical stimulation of the DCNPrevious studies indicate that the dorsal cochlear nucleus (DCN) may serve as a generator and/or mod

21、ulator of noise-induced tinnitus. This prompted an interest to investigate the modulatory role of the DCN in tinnitus suppression. In this study, we chronically implanted the DCN of rats with behavioral evidence of intense tone-induced tinnitus. Behavioral evidence of tinnitus was measured using a g

22、ap detection acoustic startle reflex paradigm. Our results demonstrated that electrical stimulation of the DCN suppressed behavioral evidence of tinnitus, especially at high frequencies. The data suggest that the DCN may be used as a target to suppress tinnitus through a bottom-up neuromodulation ap

23、proach. The underlying mechanism of DCN-stimulation-induced tinnitus suppression was discussed by comparing it with other stimulation modalities.Luo H, Zhang X, Nation J, et al.Tinnitus suppression by electrical stimulation of the rat dorsal cochlear nucleus.Neuroscience Letters 522 (2012) 16 20DCN植

24、入電極刺激治療耳鳴的機制First, noise-induced DCN hyperactivity is believed to result from a lack of peripheral auditory input to the central auditory system that leads to disinhibition 12. DCN stimulation may have compensated for the tone-induced loss of peripheral input by restoring the imbalance between excit

25、atory and inhibitory processes.Second, DCN stimulation may modulate the hyperactivity by direct stimulation of the neuronal circuitry within the DCN, leading to the observed tinnitus suppression. Third, stimulation-induced DCN activation could mask tinnitus signals thus contributing to tinnitus supp

26、ression. Fourth, tinnitus percepts may be generated or maintained by the transmission of tinnitus-related hyperactivity from the DCN to the inferior colliculus or other higher brain centers 7,17,19,22. DCN stimulation may disrupt these pathways.Deep brain stimulationS. W. Cheung and P. S. larson. Ti

27、nnitus modulation by deep brain stimulation in locusof caudate neurons (area lc).Neuroscience 169 (2010) 17681778(A) Cartoon of DBS (deep brain stimulation) lead (vertical segment) in contact with area LC (red circumscription) of the caudate nucleus (pink).Lateral ventricle (blue). Putamen (purple).

28、(B) Coronal view of a DBS lead traversing area LC (red circle). R, right. (C) Sagittal view of a DBS lead traversing area LC (red circle). Post, posterior; Ant, anterior.Neuromodulation of area LC may be interrupting perceptual integration of phantom sensations generated in the central auditory syst

29、em. This new, basal ganglia based approach to tinnitus modulation warrants further investigation and may be ultimately refined to treat patients with refractory symptoms.綜合治療1、對耳鳴患者治療需要綜合療法，治療方案包括耳鳴咨詢、聲治療、其他治療方案2、通過耳鳴綜合療法絕大多數(shù)特發(fā)性耳鳴可以得到有效控制。3、“特發(fā)性耳鳴”-當前治療的重點是針對因耳鳴誘發(fā)的不良心理反應。心理疏導（咨詢）：解惑是耳鳴治療過程中總結：誤區(qū)耳鳴患者希望通過某種特效方法徹底消除耳鳴，而這在目前很難做的到。從某種意義上來說，很多耳鳴癥狀的出現(xiàn)是各種原因造成的聽覺神經系統(tǒng)提前出現(xiàn)的退化反應，而退化一旦形成是很難被控制的。所以耳鳴治療的重點，不在于降低耳鳴響度本身，而是實實在在去努力減少失眠等不良心理反應的發(fā)生或加重，讓患者盡快達到最大限度的適應代償，通過緩解患者癥狀，改善患者的生活質量，而非去做徹底