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1、首都医科大学附属北京朝阳医院耳鼻咽喉-头颈外科 刘锦峰,耳鸣的防治,耳鸣的定义耳鸣的分类耳鸣的临床特点耳鸣的治疗要点主观性耳鸣的病因与产生机制（简述）耳鸣的预防耳鸣的治疗,主要内容,耳鸣的定义,0t0sclerosis,主观性耳鸣：是指在周围环境中无相应声源和电(磁)刺激源情况下，患者自觉耳内或颅内有声音的一种主观感觉。客观性耳鸣：是指不但患者自己能听到耳周或颅内有响声而且其他人也能听到。客观性耳鸣常可在耳周或颅内有发声源。临床上，主观性耳鸣占多数，客观性耳鸣较少。王洪田,李明,刘蓬,黄治物,胡岢,赖仁淙.耳呜的诊断和治疗指南(建议案).中华耳科学杂志.2009.7(3):185,耳鸣的其他分
2、类,依据耳鸣的发源部位耳源性耳鸣非耳源性耳鸣依据耳鸣的病变部位传导性耳鸣感音神经性耳鸣中枢性耳鸣依据耳鸣的病理生理特点生理性耳鸣病理性耳鸣心理性耳鸣病理生理性耳鸣假性耳鸣,0t0sclerosis,依据病程急性耳鸣（3月）慢性耳鸣（3月）依据有无搏动搏动性耳鸣非搏动性耳鸣；,耳鸣病因不清，机制复杂，分类很难,耳鸣定义的理解,耳鸣：（1）是无相应的外界声源和电刺激，（2）而主观上在耳内和颅内有声音感感觉（实用耳鼻咽喉头颈外科学（第2版）黄选兆 汪吉宝 孔维佳 主编）。Tinnitus is the sensation of sound in the absence of an external
3、source.,应该排除：搏动性耳鸣，腭咽喉肌阵挛的卡塔声咽鼓管异常开放声。耳内异物（头发丝和耵聍）摩擦鼓膜的声音“幻听”,耳鸣的临床特征-患病年龄,0t0sclerosis,耳鸣临床特点,突然起病患者的耳鸣严重程度较缓慢起病者更高，耳鸣主调以8000 Hz最多见，占22.9，响度主要集中在感觉级510 dB；伴有感音神经性聋者占75.6；耳鸣主调为高频时，绝大多数患者听力下降区域也位于高频同时，主调为低频、言语频率时，听力下降也多位于相应频率区域存在不良心理反应者占89.6，表现为心情烦躁者83.8，影响睡眠者63.7，注意力难以集中者30.3,0t0sclerosis,耳鸣的治疗要点：病史
4、与检查,详细询问病史（最主要）耳鸣本身的病史：耳鸣的发生时间？双耳还是单耳？是什么声音？持续还是间歇性？有无规律？与呼吸与脉搏的关系？有无耳聋及眩晕？中耳炎相关病史；噪声接触史！查体：外耳道及鼓膜基础听力学检查：评估听力情况纯音测听声导抗耳声发射（反映毛细胞损害较PTA敏感）听性脑干反应耳鸣匹配音调的频率匹配响度匹配心理学调查影像学检查，如CT、MRI,耳鸣的治疗要点：问诊要点,耳鸣的病程长短？问诊目的：预测预后，制定不同的治疗方案。耳鸣的病程越短，疗效越好。急性耳鸣治疗方案同突发性聋。慢性耳鸣则要根据是否代偿选择不同的治疗方案。,耳鸣的治疗要点：问诊要点,侧别？是单耳还是双耳？还是颅鸣？双侧
5、同频耳鸣和颅鸣常常提示中枢性耳鸣。双侧低调耳鸣要除外内分泌疾病（如甲状腺功能低下）及自身免疫性疾病。双侧耳鸣的音调不一致则提示双侧听觉通路的不同病变。,耳鸣的治疗要点：问诊要点,耳鸣的音调？是低频还是高频？还是多种音调？低中频耳鸣往往提示内耳病变，如内耳积水和梅尼埃病等。高频耳鸣往往为神经性或中枢性耳鸣。多种音调的耳鸣常常提示听觉系统有多处病变存在。转头时耳鸣音调发生改变常提示颈椎病引起的颈性耳鸣。,耳鸣的治疗要点：问诊要点,在什么情况下耳鸣会减轻或加重？颈性耳鸣在晨起或午睡后耳鸣的程度最重，而其他原因引起的耳鸣多在夜间，安静时最重。是否伴有听力下降、眩晕等症状。单侧高调耳鸣伴/不伴听力下降首
6、先要除外听神经瘤。伴有眩晕症状的患者要除外梅尼埃病、上半规管裂综合症等疾病。,耳鸣的治疗要点：诊断,如何诊断？标准？难？容易？,0t0sclerosis,主观性耳鸣的原因及机制,不伴听力减退的耳鸣听力减退伴有耳鸣老年性聋长期或高强度噪声刺激耳硬化症感染，如中耳炎自身免疫性疾病梅尼埃病肿瘤耳毒性药物特发性压力及心理因素,主观性耳鸣产生的机制,仅指感音神经性耳鸣,主观性耳鸣的病因及机制,耳鸣起源于中枢而非耳蜗：MRI has revealed differences in sound-evoked responses between tinnitus and nontinnitus groups
7、in cortical 12 and subcortical auditory nuclei 13 and found evidence for structural differences in the thalamus 14,the auditory brainstem15 and the auditory cortex 16.听觉中枢异常电活动：认为耳呜的产生可能由神经元的自发放电率(spontaneous firing rates)增加、簇状放电(burst-firing activity)的形成及神经元同步放电(neural synchrony)引起伴与不伴有耳聋的耳鸣，其机制不同。
8、,主观性耳鸣的病因及机制,Adjamian P,et al.The mechanisms of tinnitus:Perspectives from human functional neuroimaging.Hearing Research 253(2009)1531,伴有耳聋的耳鸣,图：耳鸣与耳聋的联系(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
9、tone.Tinnitus pitch is represented by 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%的耳鸣患者伴有听力减退 耳聋的频率与耳鸣频率匹配,主观性耳鸣的病因及机制,外周听力损害所致耳鸣的机制耳聋所致传入冲动减少，对听觉中枢的抑制性减弱，使得听觉中枢自放电增强。The prevailin
10、g opinion is that tinnitus is a perceptual 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 init
11、iate tinnitus,thereafter,central 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.为什么要放电增强？The central audi
12、tory system appears to increase 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 Otola
13、ryngol Head Neck Surg 2012,20:409415,主观性耳鸣的病因及机制,外周听力正常者耳鸣的机制耳鸣可以存在于正常听力人群中。耳鸣音凋分布范围较广，耳呜起源于听力损失的理论不适用于解释常听力耳鸣人群，耳鸣产生的机理不能用单一的理论来解释。水杨酸所致耳鸣的中枢放电变化无规律：Recordings from the inferior colliculus and auditory cortex after tinnitus induction with salicylate are inconclusive,with different studies showing t
14、hat spontaneous activity increased,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 sali
15、cylate（水杨酸）27.,潘滔,等.正常听力耳鸣患者的耳鸣音调.中华耳科学杂志,2009,7(3):200-203,耳鸣的预防,避免噪声规律作息调节心理，忌讳烦躁、焦虑、压力不吸烟、忌浓茶，禁酒慎用毒性药物：如链霉素、庆大霉素、卡那霉素等低盐、低脂饮食,20,耳鸣的治疗,病因治疗耳鸣作为伴随症状出现的一些原发病治疗中耳炎、梅尼埃病、突发性聋及甲亢等药物治疗（抑制耳鸣的药物和基础病因的药物）改善原发病的药物：改善微循环及营养神经药物减轻耳鸣心理影响的药物：（抗抑郁）抑制耳鸣的药物：（利多卡因及抗癫痫等）心理学治疗掩蔽治疗习服疗法手术电刺激其它：针灸，磁治疗，高压氧治疗,药物治疗,基础疾病的药
16、物治疗：对中耳炎、甲功异常、梅尼埃病等的药物治疗维生素B（尤其是B12）锌制剂银杏叶制剂对症治疗减轻耳鸣对患者的影响抗焦虑抑郁药物：抗抑郁药 多虑平 25mg tid 多在1周见效抗焦虑药 舒乐安定 1mg tid有不同程度副作用，甚至会加重耳鸣，谨慎用药。耳鸣的抑制药物利多卡因 1-2mg/kg 1%浓度缓慢静脉注入，5分钟注完（不能太快！）每日一次，7天一个疗程。缺点：作用时间比较短。氯硝安定 1mg 睡前 x7 卡马西平 200mg tid x7,22,心理治疗,有相当比例的急性耳鸣患者与心理压力大；情绪波动；失眠等因素有关。此时的药物治疗不宜使用改善微循环治疗，而是要选择改善睡眠、抗焦
17、虑；抗抑郁等治疗不良心理药物治疗。,声治疗：掩蔽疗法 Masking therapy,1977 Vernon首先用耳鸣掩蔽器 机制：抑制病变部位以上中枢神经传导通路 根据耳鸣频谱和响度调节掩蔽声。利用一种正常生理功能：对一种刺激反应消失的现象，即称之为“适应”或“习惯”利用大脑不能同时完成均需要注意力集中的两项任务的生理特点，所以来增加背景声，淡化耳鸣对皮层的刺激从而达到减轻或消除耳鸣的目的掩蔽声：连续音刺激1S 后能使耳鸣消失最低刺激音强度,声治疗,利用一种正常生理功能：对一种刺激反应消失的现象，即称之为“适应”或“习惯”利用大脑不能同时完成均需要注意力集中的两项任务的生理特点，所以来增加背
18、景声，淡化耳鸣对皮层的刺激从而达到减轻或消除耳鸣的目的,掩蔽疗法,适应症：1、特发性耳鸣2、伴有听力下降的耳鸣3、找到病因经治疗原发病治愈或未治愈耳鸣仍然存在的类型4、部分血管搏动性耳鸣,掩蔽疗法-音乐枕,27,掩蔽疗法-助听器（禅 Zen）,丹麦（唯听）助听器中基于碎型算法的音乐。该音乐是根据使人放松的原则制作(Robb et al.,1995)1、每一个禅程序，都能调整响度，音调和模式2、确保禅音（或噪音）听到，但声音相对柔和3、不应妨碍会话言语4、耳鸣烦恼级应该开始减少（耳鸣可以仍被听见）,人工耳蜗是极重度感应神经性聋伴有严重耳鸣患者的选择之一人工耳蜗植入术后，耳鸣的厌烦程度、耳鸣的响度
19、均有改善术后超过半数患者对耳鸣抑制感到满意,掩蔽疗法-耳蜗电极植入,Kalcioglu 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 Otolaryng
20、ol Head Neck Surg,2003,126;517-522.,Vagus nerve stimulation Electrical stimulation of the DCN Transcranial direct current stimulationDeep brain stimulation,电刺激治疗,电刺激治疗,对耳鸣的电刺激抑制首先于1855年被报道，共包含两种电刺激方式深部脑电刺激,Electrical stimulation of the DCN,Previous studies indicate that the dorsal cochlear nucleus(D
21、CN)may serve as a generator and/or modulator 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
22、of tinnitus was measured using a gap 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
23、 a bottom-up neuromodulation approach.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
24、Letters 522(2012)16 20,DCN植入电极刺激治疗耳鸣的机制,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 t
25、he imbalance between excitatory 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 contrib
26、uting to tinnitus suppression.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 stimulation,S.W.Cheung a
27、nd P.S.larson.Tinnitus 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(purpl
28、e).,(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 system.Thi
29、s new,basal ganglia based approach to tinnitus modulation warrants further investigation and may be ultimately refined to treat patients with refractory symptoms.,综合治疗,1、对耳鸣患者治疗需要综合疗法，治疗方案包括耳鸣咨询、声治疗、其他治疗方案2、通过耳鸣综合疗法绝大多数特发性耳鸣可以得到有效控制。3、“特发性耳鸣”-当前治疗的重点是针对因耳鸣诱发的不良心理反应。,心理疏导（咨询）：解惑是耳鸣治疗过程中,总结：误区,耳鸣患者希望通
30、过某种特效方法彻底消除耳鸣，而这在目前很难做的到。从某种意义上来说，很多耳鸣症状的出现是各种原因造成的听觉神经系统提前出现的退化反应，而退化一旦形成是很难被控制的。所以耳鸣治疗的重点，不在于降低耳鸣响度本身，而是实实在在去努力减少失眠等不良心理反应的发生或加重，让患者尽快达到最大限度的适应代偿，通过缓解患者症状，改善患者的生活质量，而非去做彻底解决潜在疾病病因的无谓工作。当然对于急性耳鸣，首先还是要采用各种方法尽量降低耳鸣的响度甚至消除耳鸣的努力。,耳鸣的处理,耳鸣的严重程度与治疗,38,谢谢您的聆听,搏动性耳鸣,动脉性：用听诊器多可听到。按压血管后耳鸣一般不缓解。常为咚咚声或压迫听神经后出现
31、搏动性高调耳鸣。静脉性：不能用听诊器听到。按压血管耳鸣常可缓解。常为嗡嗡声或吹风样。耳鸣频率匹配常为低调。,搏动性耳鸣,这类耳鸣多为血管性异常所引起：血管的病变畸形，有高位颈静脉球体瘤乳突导静脉畸形颈动脉瘤颈动脉狭窄动静脉瘘颈椎病血流动力学的异常严重贫血甲状腺功能亢进高血压动脉硬化产生血管杂音，传至耳蜗即引起搏动性耳鸣。,0t0sclerosis,0t0sclerosis,图右侧颈内动脉海绵窦瘘。）CT增强扫描示海绵窦在动脉期早期显影并扩大（箭）；）DSA 示海绵窦在动脉期早期显影并扩大（长箭）并向岩下窦（短箭）及眼上静脉引流。图右侧横窦乙状窦区硬脑膜动静脉瘘。）增强CT 图像上未见明显异常；
32、）颈外动脉造影显示乙状窦区硬脑膜动静脉瘘，瘘口（箭）在乙状窦硬脑膜上。图右侧乙状窦憩室。）斜矢状面CTV 示右侧乙状窦憩室进入乳突气房内（箭）；）静脉期DSA，显示右侧乙状窦上曲憩室（箭）。,0t0sclerosis,图左侧颈静脉球体瘤。）CT 示左侧颈静脉孔区扩大并明显强化的软组织团块影（箭）；）DSA 显示肿瘤染色（箭）及引流静脉（箭头）。图右侧鼓室球瘤，CT 增强扫描示右侧鼓室内肿块（箭），明显强化。图左侧颅外动静脉畸形，增强CT显示颜面部及颅底区大量畸形血管团及粗大引流静脉。图面颊部动静脉瘘。）增强CT冠状面仅显示左侧翼丛（箭）血管增多、紊乱；）显示左侧颈外动脉与翼丛的动静脉瘘（箭）,乙状窦缩窄术治疗乙状窦相关静脉源性搏动性耳鸣的疗效分析,0t0sclerosis,
