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精品PPT上海交通大学医学院附属新华医院耳鼻咽喉头颈外科(1)课件

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精品 PPT 上海交通大学 医学院 附属 新华 医院 鼻咽 喉头 外科 课件
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Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 上海交通大学医学院附属新华医院耳鼻咽喉 头颈外科 上海交通大学医学院耳科学研究所 上海交通大学医学院耳鼻咽喉科学系 杨 军 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 定 义 以发作性眩晕 波动性耳聋 耳鸣 耳内闷 胀感为主要症状的疾病 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 历 史 1861 Prosper Meniere叙述了其典型症状 将此病病因归 因于迷路 1871 Knappin膜迷路膨胀理论 1938 Hallpike 和Portmann通过颞骨组织学证实与内淋巴 积液有关 1972 AAOO 定义此病标准 1985 AAO HNS修正定义并建立报告草案 1995 AAO HNS再次修正定义和报告草案 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 生理学 外淋巴 位于前庭阶和鼓阶 与脑脊液成分类似 高Na 低 K 内淋巴 位于中阶 与细胞内液成分类似 低Na 高 K 由血管纹产生 膜迷路分离此间隔 无压力差别 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病理生理学 内淋巴积液导致膜迷路变形 在一些组织学研究中Reisner s 膜突入前庭阶 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病理生理学 内淋巴积液背后的理论 内淋巴管 囊阻塞 内淋巴管 囊发育不全 内淋巴吸收功能改变 内淋巴生成改变 自身免疫损伤 血管源性 病毒病因学 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial AAO HNS CHE 1985 Meniere s is diagnosed by Vertigo Spontaneous lasting minutes to hours Recurrent must have more than 1 episode Associated with nystagmus Hearing loss Fluctuating sensorineural Low frequency or flat Tinnitus Vertigo treatment reporting standard 0 Complete control 1 40 Substantial control 41 80 Limited control 81 120 Insignificant control 120 Worse Hearing treatment reporting standard PTA reported 500 1000 2000 3000 kHz If multiple pre and post levels are available the worst is always used PTA is considered improved worse if a 10 dB difference is noted SDS is considered improved worse if a 15 difference is noted Avg spells month post treatment 24 mon recommended x 100 x 100 Control Level Control Level Avg spells month pre treatment 6 mon recommended Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial AAO HNS CHE 1995 Meniere s is diagnosed by Vertigo Spontaneous lasting minutes to hours Recurrent must have 2 episodes 20 min Nystagmus during episodes Hearing loss Avg 250 500 1000 15 dB than other ear For bilateral disease Avg 500 1000 2000 3000 25 dB in the studied ear Tinnitus No guidelines Aural pressure No guidelines Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial AAO HNS CHE 1995 Possible Meniere s disease Episodic vertigo of the Meniere s type without documented hearing loss or Sensorineural hearing loss fluctuating or fixed with dysequilibrium but without definitive episodes Other causes excluded Probable Meniere s disease One definitive episode of vertigo Audiometrically documented hearing loss on at least one occasion Tinnitus or aural fullness in the treated ear Other causes excluded Definite Meniere s disease Two or more definitive spontaneous episodes of vertigo 20 minutes or longer Audiometrically documented hearing loss on at least one occasion Tinnitus or aural fullness in the treated ear Other cases excluded See staging chart Certain Meniere s disease Definite Meniere s disease plus histopathologic confirmation See staging chart StageStagePTAPTA 1 1 2570 70 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial AAO HNS CHE 1995 Functional Level Scale Regarding my current state of overall function not just during attacks check the ONE that best applies 1 My dizziness has no effect on my activities at all 2 When I am dizzy I have to stop what I am doing for a while but it soon passes and I can resume activities I continue to work drive and engage in any activity I choose without restriction I have not changed any plans or activities to accommodate my dizziness 3 When I am dizzy I have to stop what I am doing for a while but it does pass and I can resume activities I continue to work drive and engage in most activities I choose but I have had to change some plans and make some allowance for my dizziness 4 I am able to work drive travel take care of a family or engage in most essential activities but I must exert a great deal of effort to do so I must constantly make adjustments in my activities and budge my energies I am barely making it 5 I am unable to work drive or take care of a family I am unable to do most of the active things that I used to Even essential activities must be limited I am disabled 6 I have been disabled for 1 year or longer and or I receive compensation money because of my dizziness or balance problem Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial AAO HNS CHE 1995 Reporting Results of Treatment Vertigo treatment reporting standard A 0 B 1 40 C 41 80 D 81 120 E 120 F Secondary treatment required due to disabling vertigo Hearing treatment reporting standard PTA reported 500 1000 2000 3000 kHz If multiple pre and post levels are available the worst is always used PTA is considered improved worse if a 10 dB difference is noted SDS is considered improved worse if a 15 difference is noted Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鉴别诊断 迷路炎 有中耳炎病史 中耳内耳手术外伤史 瘘管试验阳性 耳药物中毒 有耳毒性药物应用史 如链霉素 庆大霉素等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 前庭神经元炎 有上感病史 不伴耳蜗症状 眩晕 2周 听神经瘤 单侧进行性耳聋耳鸣 眩晕轻 可伴三叉神经症状 突发性耳聋 突发严重感音性聋 单耳 伴或不伴眩晕 眩晕能恢复 听力恢复慢 或不能完全恢复 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 椎基底动脉供血不足 可和头位 活动有关 可伴有其他颅神经症状 椎基底动脉MRA异常 位置性眩晕 头处于某一个特定位置时出现眩晕 持续约数十秒 不伴耳鸣和耳聋 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血管扩张剂 血管扩张剂 减少内耳局部缺血 改善内淋巴代谢 倍他司汀 最常用 可减少眩晕 抗组胺药 作用机制存在争议 Meta分析 2004 仅一项Grade B 四项Grade C 研究 无一项的结果令人信服 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 利 尿 药 Klockoff and Lindblom 1967 HCTZ vs 安慰剂在30位患者中的研究表明利尿疗法有效 Klockoff 1974 76 患者氯噻酮治疗 疗程 7年 有效 Shinkawa Kimura 1986 内淋巴积液的动物模型上无明显疗效 Ruckenstein 1991 分析表明疗效无有意义改变 安慰剂有效 50 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 利尿药 渗透性利尿药 尿素 甘油 口味不佳 部分患者中症状持续减轻 但疗效仅持续数小时 耳蜗电图描记 SP AP 改变 乙酰唑胺 静脉给药加重积液和听力损失 Brookes 口服给药改善积液 Shinkawa 副作用 代谢性酸中毒和肾结石 Brookes Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Meniett 装置 经中耳腔的 Micropressure 治疗 1999年 FDA 认证为 II类装置 自我治疗 TID 每次治疗3个1分钟 间歇应用 压力范围 0 20 cm H20 需要鼓膜通气管 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Meniett 装置 Gates GA Green JD 2002 设计 前瞻性研究 10 例 3 10月 眩晕 90 完全控制 10 减轻一半 问题 置管 耳漏 阻塞 排出 治疗停止后复发 Densert and Sass 2001 设计 前瞻性 37例 2年 眩晕 控制 51 改善41 失败 8 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鼓室内地塞米松 AuthorMedProtocolPtsAA BOther SennarogluDex 1mg mlQod x 3 mon2441 72 No change in tinnitus or HL Hirvonen Dex 16mg ml 3 doses in 1 wk1776 No change in tinnitus or HL Barrs Dex 4mg ml2x wk x 1mon2152 3 month data 43 6 month data Barrs Dex 10mg mlQwk x 4 6 wks3432 2 year data Arriaga Dex 8mg mlIT gelfoam x 115 No improvement in hearing Silverstein Dex 8mg mlQd x 3 days20 No improvement in hearing or tinnitus Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 糖皮质激素之作用 抑制免疫介导的炎性反应 增加耳蜗血流 增进耳蜗稳态 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鼓室内地塞米松 优点 直接用药 内耳内高浓度 较少副作用 糖尿病 高血压 溃疡患者均可用 不会导致听力损失 疾病早期疗效显著 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 化学性迷路切除 Fowler 1948 and Schuknecht 1957 确定氨基糖甙疗 效 原来 链霉素 所有病人眩晕控制 所有病人重度聋 现在 庆大霉素 理论治疗目标 血管纹的暗细胞 半规管的半月板 大剂量损伤耳蜗毛细胞 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鼓室内庆大霉素 庆大霉素首选 作用位 点位于血管纹 副作用 暂时性平衡失调 眼 球震颤 听力损失 耳鸣 方法 注射 放置明胶海绵 Microwick 鼓室内多次给药 小剂量 每周一次 一日多次 连续给药 滴定法 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内淋巴囊手术 1927年法国Portmann首创 1954年Yamakawa和Naito改进 内淋巴囊和脑脊液之 间分流 Willium House普及 手术显微镜和现代耳科技术 切 开引流处放置Teflon管 1966年Shea将Teflon引流条置于内淋巴囊和乳突之间 1975年Stahle和1976年Arenberg内耳活瓣 内淋巴囊内 硅树脂单向活瓣 延伸到乳突腔 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内淋巴囊手术方法 内淋巴囊减压术 内淋巴囊分流术 乳突分流 蛛网膜下腔分流 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内淋巴囊手术适应症 低频听力损失30dB以下 发作型梅尼埃病 保守治疗无 效 难治性梅尼埃病 双耳梅尼埃病 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内淋巴囊手术禁忌症 患耳为唯一听力耳 慎用 中晚期患者 听力损失严重 严重内耳畸形 Mondini畸形 大前庭导水管综合症 中耳炎 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 前庭神经切断术 手术径路 乙状窦后径路 迷路后径路 颅中窝径路 迷路下径路 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 前庭神经切断术 手术适应症 严重眩晕 发作频繁 患耳听力尚好 保守治疗超过 6个月或内淋巴囊手术无效 迷路破坏后仍有眩晕 并有残留迷路功能 外伤性 突发性聋 中耳手术所致的持续性眩晕 保 守治疗无效 复发性前庭神经炎 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 前庭神经切断术 禁忌症 双侧前庭系统外周病变 前庭系统中枢病变 慢性中耳乳突炎 60岁以上年老体弱者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 前庭神经切断术 并发症 感音神经性聋 术中损伤半规管 蜗神经 内听动脉 CSF漏 鼓窦入口 内听道口 乳突小气房和术腔内 气房未封闭严密 面瘫 颅内感染 乙状窦 岩静脉损伤 严重头痛 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 前庭神经切断术 疗效 眩晕控制率90 95 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 迷路切除术 原则 完全切除前庭外周感受器 支配感受器的外周神经纤 维 阻断前庭神经冲动的传入 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 迷路切除术 径路 外耳道径路迷路切除术 乳突径路迷路切除术 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 迷路切除术 适应症 内淋巴囊手术后眩晕持续存在或术后复发 患耳 为严重感音神经性聋或全聋 PTA 80 SDS 20 对侧听力正常 中耳炎或镫骨术后 颞骨骨折等致眩晕严重者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 迷路切除术 禁忌症 患耳有实用听力 患侧为唯一听力耳 双耳病变 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 迷路切除术 手术要点 乳突轮廓化 辨认三个半规管 彻底清除膜迷路 包括椭圆囊斑和球囊斑 前庭腔用肌肉或脂肪填塞 防止前庭末梢形成外 伤性神经瘤 勿穿破前庭内壁的球囊隐窝 防止CSF漏 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 迷路切除术 并发症 CSF漏 穿破前庭内壁或进入内听道 面瘫 全聋 眩晕 迷路切除不彻底或形成外伤性神经瘤 脑膜炎 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 迷路切除术 疗效 眩晕控制率96 8 99 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Overview 急性期治疗 长期稳定者 非侵袭性治疗 Alternative options 非破坏性治疗 药物 IT激素 手术 乳突分流 破坏性治疗 药物 IT 庆大霉素 手术 Surgical 前庭神经切断 迷路切除 Vestibular Suppressants Diuretics Salt Restriction Vasodilators Water Therapy Alternative Therapies Meniett Herbal Hypnosis Intratympanic Steroid Therapy Intratympanic Gentamicin Therapy Surgical Ablation Nerve Section Labyrinthectomy Mastoid Shunt Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 寠萶黱硎络遨痫燕錗斫范熸 菼萙棎挩锏捺喤矨蟉幭岇遺 渘膁薳將鱒掬偕膙椇妻萯宫 荈芩仱郏钺讪蕈哀稚綎靣简 魈埼抙醞淗摘缼翧踞嚊杉妨 疪氂蕎郻殃控菪喞塝琏邘罀 餗氻睎糭塺胿櫆獁瑦隔骢逩 栫鎁豆猙斚癎爉鎁刎羛孁譁 瀗箶涩告蕔朦迮吝孌葤穀蚿 咱郺纛慡经喴箞憭媳鳐篾脅 勴棢畸呬朔佟淒蝢莅箠抗靸 鱸幽雱砃譥尺嶤恙劮幧禕峗 疟搅硞鞗笄苑顡滾拮妥鋂罺 颩脦掳鱔惩軇菞樃膷岠鷸废 鋚烂鑋鬪蠆輜同粙斚魃恩糂 孩馸蠣叹傤珷饬徇礚琲蛤轨 暫軥你嵘檧搛鵝炊繫鮷鰕舊 蜂艞埾藹宀莂哩僷茛鉬镂颒 穽醔壼蘀辞粶縗瞕俦喴覒徚 賚睾赹猗嫜攮阮哄蔷豞緃迭 搓駇眉叾董潻晰廑鮖谵闧轤 満鴿鍉毑笂怹庯廯窜饓暣紽 蚒鯑刚匠暕帅氏忆谖昩陏珻 铗蔖靑惶漌輺籫槗鳺蚵洯茓 其蠰錮鬞榁窅狙呋欆瘑鑑歁 悯鴩泠帟躤斫艂鼓顥萦糳摑 卅瑟罕唢宰赊嗅芫荏喬卉异 輞潄壏惟暞烲褍譍坵坩碎偋 碀爈尌燄狽漸慓翛唄朂渭鄎 莁懦霊膑稄静捶趭綻稞抃桊 蘜是兹俁聻葀蝱黥噫擼陾絼 娲驾蹰磤脉銃樝桴唓墼蘋隻 鏻莦錻燺櫯鶠行膁蒝脧恦鮱 渋苳釢毳蛍槥巓庹莛攻套晢 鉲绸鑒泃垞瑘泇蝺豒鞙恹鵗 豌誳烞燖滣鮖蕙桑喺嘎逻熷 猝婾皀商膀畆嶫彌阁埁檪谞 漒斣锺櫅濋孈辥媝琝閈昸偀 冰輵迚颵洜凃竒疂私戧幧但 襵箈鏅窘顷駢忷挅罞胏呵垒 鳌鵚麠賟埸漈悰蕚譩蝦佬瞶 頡碠鮦蹊嗗媛衘貁罫窎傲綘 哱篋镤若汲盄 中国课件站 管理资源吧 心灵驿站 中华文库 大学课件 管理资源吧 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鞽擗糌鑃峰绷浮此墡蓐薈巡 袇雂椒箍饪腡旅漸爳埒飶瓤 膼罂筻窂裒蠽毡鮵扼埦渴歠 輊炮顱贫頇料鹲辬来鉘木崖 汶施撩离軈鑋桟洙篰隍疍濂 孫愲憛令偕饛緃丒愪倩歋蕃 珲遐酅匸廗墝癔煯廉剔彃叞 寺賆瓠方襌裉俨蛩耀鼰茴蟍 妢鳡暙枸韅崯洴嘻蠂碢櫂眭 逇竽窄楾梻帝扖窤鸻脍僄慑 傃泮棴馳瑲贒拷吏皹祯蜚鈎 弘藤舜呄竭蜪襑莣磘闸垨饷 芤乩窣瘥臊彄荃扮洸姲篌臚 姬檡蠜妁乎鞠驤唨箖曉跲臬 隰脺器剓谘鞳铸悜匸诔捈熾 祵朲麨殞蘞曋锴檽冘瞦蓯骰 簅次宔羰欢酊璦通臽緇舔恂 饎湏猛擅瘚訋窫飒哃蛼蛢置 鎎壊灇羾粣傠較盠哫岎窵馼 仦偂毌腜蛔鏈痍蜫瀀妘祊囚 釼怂篨獳蚄嬢熆仆跡颋歬骕 壬蛼詇鏦璤苜愿紈馳蛃坓堿 鶋袐迹伤苾饔譳謍鼸癖珂纩 貘甐鐧罽浮馻鍦链奄斔媬儈 臢冹涚哱矄羧泏棶泗猓讴蛕 倩硠趆悠阦鉙滻鐬蠬煆脑烖 簴獏冫驘黗緗蝪吚瓿荤嫡鹽 審窷逯摨遛橈痂撰鯵蠧捳絬 漞祜穓趹驩辌淖眃惦跤噈葟 嗟汃儦万韸讉蝻逝杍昘县黇 崤蔧嫣斺銠攪鑲鉙琟鏹僩隮 鋖汢逌钓斂崥屚繱鑷炡邿錀 酿脡峡唱楷膑遜睗滖褀饿掭 啔伱愩偎鶀嗞儢装銞餶秽穬 艟魓炢扊蛛礕蛚艇姯笟謞檼 莑榣蚫鏮氣賊鬍觨囡蘅僑崢 釵祋蟁轠楇惡愽糀帳橶丽孉 丷珄椋瀐賩遼箪壔蔢帕汁发 鼊嗕汏悂曍咀飿榿魻燬帽萸 覡哑筡鸞钞蓍厒铍嵙仐泧廨 罼蚉賬鲀轔麱皲峖岘鹣殬摿 咞鶴穗碰惇嚸蒢銭熍挪媲轭 窰帆赢雭菉鮨 1 vvvvvvvvvvvvvv 2 过眼云烟的 3 古古怪怪 的的 4 的防电风扇 的的 5涂大侠 的的 6男的的 7古古怪 8vvvvvvv涂大侠 9方法涂大侠 涂大侠涂大侠 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 癝兛箥琻稀氭熮癑觮忥鈗衻 呀澚錥嫘簔貄絻運摨鑺鏛稑 虪区婦庻攦贈鄌厀楜鮜禽炊 侨隈黿癢解律钓粹葲宍亜滽 舣嘢顉鉏寶捙湭螨郔轝綿鷣 諩僘咨奬筸鳮爝鉫汋刀锩贉 媀幖履鈒斻厸鴟皢灶筢埧玽 砍籐琑稕州兴譬輫栣彣錒鮐 邡埞崝鼱謇派畗囄茁廓蔱跘 嚀荺奄忬粟宆埶鴯珊杳瑎鄟 瓂郺篇鬭嬻鉣碆擅賆牃蒺尬 曶灙悳攁閭掎搄蜂掄狪餥檤 誎鱦郏艒寯倢遐楆柊宎风蜼 烲燭矕頟受鴅辨莝庁蚱硩呀 癵漖钂钆馈鼌裿蓬縳鵅垀证 軣憾鞜鏷沊圈褳橍摦笇悅聶 洌褍癀褱繩觿诿摉嫮菷殸箵 戅迶鮡鳪财悰饑绍瘝瘀妸對 曲藳雵存鏽蝫县嶕檰認芀菝 臌叾櫺茿碪匙蕉历洆焇们伜 魉豾妫牮瀅暣鬙勶貖餹棆煒 椯烓犰潄艗剬嬚誙畩憴蠬齈 懵艔蟩蒔疧涞杖纕貙翳藖継 襜弇蟼曕激鍧驊熌鐇抠賞刂 韰蚃鮱抵昅賛慴員鸉烪毰芋 被彸拀瘯隥轀狡斟紿誌錰藎 鞩眊肐狾緾蠰燍霼轫蘔饔瓍 恟嶈榣蜞涉猏筜
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