慢性化脓性中耳炎

nullnull慢性化脓性中耳炎 Chronic Suppurative Otitis Media Anatomy and Physiology of the EarAnatomy and Physiology of the EarHearing Mechanism Outer Ear – Acoustic to kinetic energy Middle Ear – Causes increase in kinetic energy ( x18) Inner Ear – kinetic to hydraulic energy then hydraulic to electrical energy Anatomy and Physiology of the EarAnatomy and Physiology of the EarAnatomy and Physiology of the EarMiddle EarAnatomy and Physiology of the Ear鼓室分区鼓室分区Anatomy and Physiology of the EarThe middle ear consists of: Tympanic cavity Mastoid air cells Eustachian tube Anatomy and Physiology of the Earnullnull一、概述 慢性化脓性中耳炎是由化脓性致病菌 所致的中耳（包括咽鼓管、鼓室、鼓窦及 乳突）粘膜、骨膜甚至骨质的慢性化脓性 炎症。为耳科常见病之一。ot treated in time or inefficiently treated, go on to chronicity. perforated, somewhat diffculty to come back normal . the cause is not removed, a tendency to recur. 临床上以长期或间隙耳流脓、鼓膜穿 孔及传导性听力下降为特点。null　　重者常引起颅内外并发症， 如耳后骨膜下脓肿，脑脓肿等。 临床上一般认为急性化脓性中耳炎 病程超过8周，即转入慢性阶段。null二、病因 常见致病菌：金黄色葡萄球菌， 变形杆菌、绿脓杆菌、大肠杆 菌及厌氧菌等，多数为混合感染null急性化脓性中耳炎慢性化因素： （1）急性化脓性中耳炎未得 到适当彻底治疗。 （2）咽鼓管功能失调。 （3）全身抵抗力低。 （4）鼻腔或鼻咽部慢性炎症。分 型分 型旧分型: 新分型:null（一）单纯型（粘膜型） 最多见，病变主要局限于 中下鼓室中耳粘膜。 null（二）骨疡型（坏死、肉芽型） 病变累及中耳粘膜、骨膜及 骨质、鼓室内有肉芽或息肉形 成，常有骨质破坏。nullnull体 征体 征鼓膜穿孔、肉芽、息肉； 听力下降：传导性或混合性。null传导性耳聋混合性耳聋感音神经性耳聋正常听力null中央型穿孔边缘型穿孔null（三）胆脂瘤型：鳞状上皮 堆积，具有侵袭性 1、胆脂瘤定义： 存在于中耳内的角化复层 鳞状上皮团，其外层由纤维组 织包围，内含脱落坏死上皮、 角化物及胆固醇结晶，非真性 肿瘤。nullnullnullnullnullnull上鼓室胆脂瘤null 上鼓室胆脂瘤乳突胆脂瘤null2、formation of cholesteatoma ： (1)袋状内陷学说Formation of retraction pouch theory ： 形成后天性原发性胆脂瘤，可无中耳炎病史。 (2) Loss of contact inhibition theory: (3)上皮移入或化生学说Metaplasia theory ： 形成继发性胆脂瘤。null袋状内陷学说null后天原发性胆脂瘤形成机制 　　　　咽鼓管阻塞 　　　　　中耳负压 　　　不张性中耳炎 　　　上鼓室内陷袋形成 　　　　上皮脱落堆积 　　　　　胆脂瘤形成null　后天继发性胆脂瘤形成机制 中耳炎症反复发作　　　急性坏死性中耳炎 上鼓室炎性物堆积　　　　　鼓膜后上穿孔 松弛部基底细胞增生接触抑制 鼓膜后胆脂瘤形成　　　　　上皮移入中耳 松弛部穿孔　　　　　　　　　胆脂瘤形成null3、胆脂瘤破坏性 （1）直接压迫 （2）酶的破坏作用： 如溶酶体酶、胶原酶。 （3）前列腺素。 （4）肿瘤坏死因子。胆脂瘤的分类胆脂瘤的分类先天性胆脂瘤（Congenital Ch.) 为胚胎组织遗留在颅骨内形成，中耳内少见 后天性胆脂瘤(Acquired Ch.) 为外耳道或鼓膜上皮侵入中耳腔形成 　　后天原发性胆脂瘤(Primary acquired Ch.) 　　后天继发性胆脂瘤(Secondary acquired Ch.)null四、临床 表 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 现及诊断null1、耳流脓（耳漏） 单纯型多为间歇性、呈粘液性 或粘脓性、无臭。 骨疡型及胆脂瘤型多为持续性， 分泌物呈浓性、可带有血丝及豆渣 样物，较臭。 null2、听力下降 单纯型为轻度传音性聋。 骨疡型及胆脂瘤型多为 较重传音性聋，晚期可为 混合性聋。null3、鼓膜及鼓室 单纯型：多为紧张部中央 性穿孔，鼓室粘膜光滑，可 有水肿。 骨疡型：紧张部大穿孔或 松驰部边缘性穿孔，鼓室内 有肉芽或息肉。null胆脂瘤型： 松驰部或紧张部后上 边缘性 穿孔，可见到白皮样物质，较臭， 骨性外耳道后上壁及上鼓室外侧 壁可下塌或破坏。null4、辅助检查（X线乳突片或颞骨CT） 单纯型：无骨质破坏。 骨疡型：鼓窦上鼓室扩大，其 周边呈边缘模糊透光区， 中耳有软组织影。 胆脂瘤型：鼓窦、鼓室扩大及骨 质破坏，边缘浓密锐利。nullnullnullnull5、并发症： 单纯型：一般无 骨疡型及胆脂瘤型：易引起，如耳 后骨膜下脓肿，脑脓肿、 脑膜炎等。 null五、鉴别诊断 1、中耳癌。 2、结核性中耳乳突炎。null六、治疗 1、病因治疗：清除临近病灶， 　　　　　　　畅通引流 2、保守治疗（非手术治疗） 　　　控制感染，停止流脓 　　null 主要适用于单纯型及 轻型引流较好的骨疡型。 （1）保持中耳分泌物引流通畅。 　　３％双氧水清洗 （2）抗生素水溶液甘油酒精制剂 或抗生素与糖皮质激素类药物滴耳。null3、手术治疗 适用于骨疡型引流不畅 及胆脂瘤型，手术目的在于 清除病灶，防止并发症，并 尽量改善听力。术式一般采 用改良乳突根治术。 null慢性中耳炎手术简介null手术的目的：清除病变组织 乳突根治术 单纯乳突凿开术 改良乳突根治术 重建听力：鼓室成型术（分五型手术） 骨半规管开窗术 耳蜗植入鼓室成型术分型表鼓室成型术分型表null鼓膜修补术 适应症：鼓膜紧张部穿孔 中耳炎症消失 咽鼓管功能正常 术前检查：纯音测听 咽鼓管功能 鼓膜贴补实验 细菌培养null 方法 快递客服问题件处理详细方法山木方法pdf计算方法pdf华与华方法下载八字理论方法下载 ：烧灼贴膜法（材料：大蒜或青竹的内皮、香烟纸，鲜鸡蛋内膜。注意事项：1、内膜片大小合适 2、穿孔源要均匀 3、贴膜要盖严穿孔 4、贴膜后立即测听检查 5 、术后渗液需治疗 组织片修补法（材料：颞肌筋膜、静脉片、耳屏软骨膜、骨膜，或异体材料，倾向于中胚层材料 注意：1、术后不能擤鼻涕 2、保持耳干燥 3、2周后组织片存活，6周后稳定 4、手术失败可再次手术，但难度更大null其他几型 材料：筋膜同鼓膜修补术，骨性材料可以 为自体组织，也可为同种异体组织、生物材料、 合成材料，包括耳软骨、肋骨，聚乙烯等， 经整形后使用 适应症：传音性耳聋 炎症控制 咽鼓管功能正常Chronic Suppurative Otitis Media (CSOM)Chronic Suppurative Otitis Media (CSOM) 2009 Department of Otolaryngology The Second Affiliated Hospital Chongqing Medical UniversityChronic Suppurative Otitis Media (CSOM)Chronic Suppurative Otitis Media (CSOM) new old Mucosal type; Bony type; Cholesteatoma; Chronic Suppurative Otitis Media; Cholesteatoma;old text book new bookCSOMAnatomy and Physiology of the EarAnatomy and Physiology of the EarHearing Mechanism Outer Ear – Acoustic to kinetic energy Middle Ear – Causes increase in kinetic energy ( x18) Inner Ear – kinetic to hydraulic energy then hydraulic to electrical energy Anatomy and Physiology of the EarAnatomy and Physiology of the EarAnatomy and Physiology of the EarMiddle EarAnatomy and Physiology of the EarAnatomy and Physiology of the EarThe middle ear consists of: Tympanic cavity Mastoid air cells Eustachian tube Anatomy and Physiology of the EarCSOMCSOMCSOM is a Long period of time(8 wks) infection of mucous membrane of the middle ear, characterized by ear discharge continues, permanent perforation, and hearing loss.DefinitionCausesRepeated attacks of ASOM; A mixed infection by several different types of organismmiddle earCausesCSOMPathogenesisPathogenesisUsually multifactorial a consequence of an episode of AOM with perforation, with subsequent failure of the perforation to heal an association between OME and chronic perforation. The continued presence of a middle ear effusion leads, in some cases, to degeneration of the fibrous layer of the tympanic membrane perforations, particularly if large, may fail to heal. CSOMCSOMTwo main mechanisms by which a chronic perforation can lead to continuous or repeated middle ear infections: Bacteria can contaminate the middle ear cleft directly from the external ear because the protective physical barrier of the tympanic membrane is lost. The intact tympanic membrane normally results in a middle ear "gas cushion," which helps to prevent the reflux of nasopharyngeal secretions into the middle ear via the Eustachian tube. The loss of this protective mechanism results in the increased exposure of the middle ear to pathogenic bacteria from the nasopharynx CSOMClinical FindingsClinical FindingsSymptoms： Otorrhea(Discharge): either intermittent or continuous, usually mucopurulent Hearing loss(Deafness) Tinnitus Earache CSOMCSOMSigns: Perforation of TM, edematous mucosa, granulation tissue or polyps； Hearing loss, conductiveCSOMCSOMCSOMnullCentral perforationNormalMarginal perforationAttic perforationnullConductiveMixedSensorineuralNormalCSOMmiddle ear cancer TuberculosisDiagnosisHistory+SignsDifferential DiagnosisCSOMTreatmentTreatment Goals： control infection eliminate ear discharge prevent further infection correct hearing lossCSOMTreatmentTreatmentNonsurgical Measures (Conservative) ： Provide adequate ear protection while bathing or showering Aural Toilet: 3% hydrogen peroxide solution clearing the discharge from the external auditory canal allows the topical agent to reach the middle ear in an adequate concentration Topical antibiotics: 0.3% ofloxacin, 2.5% chloromycetin glycerine Systemic antibiotics: less effective than topical antibiotics Surgical Measures： Tympanoplasty (with or without ossiculoplasty):ear been dry >3 months Tympanoplasty + mastoidectomy: In cases that are refractory to medical treatmentCSOMCholesteatomaCholesteatomaDefinition: Cholesteatoma is (identically) a bag like cystic structure lined by keratinizing stratified squamouse epithelium in which crystals of cholesterol, desquamated tissue debris, keratin and bacteria are embedded.PathogenesisPathogenesisThe invagination theoryCholesteatomaPathogenesisPathogenesisThe invagination theory (endotoscope) Cholesteatomainvaginationretraction pocket CholesteatomaClinical Findings Clinical Findings Symptoms： recurrent or persistent purulent Otorrhea, generally fetid； Hearing loss：conductive or mixed； Tinnitus Vertigo, Facial nerve palsy---rarelyCholesteatomaClinical Findings Clinical Findings Signs： TM: perforation, retraction Purulent Otorrhea, polyps and granulation tissue, and ossicular erosion, bone destruction Audiometry: conductive or mixed hearing lossCholesteatomanullAttic CholesteatomanullAttic Cholesteatomanull Attic CholesteatomaMastoid CholesteatomaTreatment Treatment Surgical management as soon as possible Surgical goals Remove diseased tissues Treat complications Obtain a dry ear Improve hearing Surgery: Mastoidectomy Mastoidectomy + TympanoplastyCholesteatoma