保留骨桥的乳突鼓室成形术及软壁外耳道重建治疗胆脂瘤中耳炎

目的 探讨并评价保留骨桥的乳突鼓室成形术及软壁外耳道重建治疗胆脂瘤中耳炎的临床效果.方法 对67例(69耳)胆脂瘤中耳炎患者施行保留骨桥的乳突鼓室成形术(IBM)及软壁外耳道重建,手术开放鼓窦、乳突及上鼓室,切除骨性外耳道后壁,经面隐窝开放后鼓室,完全清理不可逆病变,为保持中耳腔容积,保留低位骨桥;同时应用带蒂耳后肌骨膜瓣-外耳道皮瓣复合瓣填充乳突术腔并重建了外耳道,并同期或分期行鼓室成形术.结果 随访24个月以上,干耳时间16～35d(平均23.1±3.4d),语频区气骨导差平均缩小(25.3±6.7)dB HL,术后基本恢复了外耳道的解剖形态及正常生理功能.结论 IBM手术及软壁外耳道重建在根除病灶的基础上保存或提高了听力,并恢复了外耳道基本形态及功能,为治疗胆脂瘤中耳炎较佳的选择.     

完整骨性外耳道鼓室成形术治疗胆脂瘤型中耳炎疗效观察

目的 探讨完整骨性外耳道鼓室成形术对骨性外耳道缺损重建及对听力、干耳、术后大术腔引起耳部不适症状的影响。方法 2006～2010年收治胆脂瘤型中耳炎72例,按手术方式分为两组：对照组为开放式,采用乳突根治术或改良乳突根治术;观察组为完整骨性外耳道鼓室成形术,术中在彻底切除病变组织的同时保留或重建骨性外耳道。结果 与传统乳突根治术或改良乳突根治术相比,完整骨性外耳道鼓室成形术在听力提高、干耳及消除不适症状方面有更好疗效。结论 胆脂瘤型中耳炎术中保留或重建骨性耳道对术后提高听力、尽早干耳及消除“根治腔病”疗效显著。     

上鼓室进路并外耳道及鼓室成形术的临床分析

目的:观察上鼓室切开结合外耳道和鼓室成形术治疗主要局限于上鼓室胆脂瘤的临床疗效。方法:采用上鼓室进路治疗31例病灶主要限于上鼓室的胆脂瘤患者,并于清除病灶后,用耳屏或耳甲腔软骨/软骨膜行外耳道成形和鼓室成形术,重建上鼓室外侧壁和恢复传音结构。结果:经上鼓室外侧壁重建和鼓室成形术后,除2耳鼓室硬化者外,余听力都有提高或保持正常状态,仅有1例出现鼓膜穿孔,31例均未发现囊袋状内陷或胆脂瘤再发。结论:上鼓室切开进路,I期用软骨/软骨膜行外耳道成形和鼓室成形术,较好地恢复了外耳道及中耳结构形态和功能,对治疗局限于上鼓室的胆脂瘤和防止复发的效果好。     

自体皮质骨在III型外耳道胆脂瘤手术中的应用

目的　探讨自体皮质骨重建骨性外耳道后壁在手术治疗Ⅲ型外耳道胆脂瘤（external auditory canal cholesteatoma,EACC）中的应用。方法　收集10例（11耳）临床诊断为Ⅲ型EACC患者,均一期行完壁式乳突切开+自体皮质骨外耳道后壁重建术+鼓室成形术治疗。结果　术后随访10例（11耳）患者,10耳恢复外耳道的正常生理结构; 1耳术后出现外耳道狭窄,给予膨胀海绵扩张3个月后恢复外耳道的正常生理结构。结论　手术治疗Ⅲ型EACC中应用自体皮质骨重建外耳道后壁并同期行完壁式乳突切开+鼓室成形术,能彻底有效清除胆脂瘤、恢复外耳道及中耳正常生理结构、术后复发率低、听力提高满意,值得进一步应用观察。     

二次开放式乳突根治术的远期疗效

目的探讨慢性中耳炎首次乳突根治术后持续不干耳的原因及再次开放式乳突根治术施行乳突腔填塞、外耳道后壁重建及鼓室成形术的远期疗效。方法收集外院曾行经典开放式乳突根治术后长期不干耳患者14例(14耳),采用带血管蒂的耳后软组织瓣及颞肌瓣填塞乳突腔,取乳突骨皮质重建上鼓室及外耳道后壁,有适应证者同期行鼓室成形术。结果二次开放式乳突根治术后随访1～5年,14耳均保持干耳,外耳道形态大致正常或略扩大。结论二次开放式乳突根治术在分析首次手术失败原因的基础上加以改进,其优点为:①术后基本无乳突腔,外耳道形态近正常或略扩大,有利于保持干耳;②有适应证者均同期行鼓室成形术,有利于改善听力。乳突腔填塞、外耳道后壁重建及鼓室成形术值得推广。     

外耳道后壁和上鼓室外侧壁重建并鼓室成形术的临床应用

目的探讨外耳道后壁和上鼓室外侧壁同期重建在鼓室成形术中的意义。方法30例（31耳）慢性化脓性中耳炎患者,骨性外耳道预先取骨备用。清除病灶后进行外耳道后壁和上鼓室外侧壁重建,并行I期行鼓室成形术。结果术后随访3个月～1年,31耳均获得干耳;外耳道形态接近正常,保留含气乳突腔。术后平均气导听阈提高〉20dB以上者22耳,提高10-20dB者8耳,提高〈10dB者1耳。结论同期行外耳道后壁和上鼓室外侧壁重建并I期行鼓室成形术,有助于修复乳突根治术后遗留的乳突空腔或大外耳道,有助于改善听力。     

钛网应用于开放式鼓室成形术32例

目的 探讨应用钛网重建外耳道后壁并上鼓室外侧壁开放式鼓室成形术中的手术疗效。方法 胆脂瘤型及骨疡型中耳炎患者32例（32耳）根治病灶后,均应用钛网重建外耳道后壁并上鼓室外侧壁,同期行开放式鼓室成形术。结果 术后30耳外耳道形态接近正常生理状态,29耳鼓膜移植物生长良好,干耳率90.62%,干耳时间平均（15.89±4.02）d。术后气导听力提高在15dBHL以上者27耳,区骨导差＜20dBHL者22耳。结论 应用钛网重建外耳道后壁并上鼓室外侧壁的开放式鼓室成形术,可较好地恢复外耳道和中耳的解剖结构和生理功能,患者听力提高远期效果显著。     

耳廓软骨在修补鼓膜和重建外耳道后壁中的应用

目的：探讨应用耳廓软骨修补鼓膜并同时进行外耳道后壁重建的疗效。方法：对43耳慢性化脓性中耳炎患者，于彻底清除病灶后用耳廓软骨行鼓膜修补，同时进行外耳道后壁重建。结果 ：43耳中，3耳失败，40耳一期愈合。与同期未进行外耳道后壁重建，只进行鼓室成形的病例相比，外耳道后壁重建者的干耳的时间比未重建者短；复发率差异无显著性意义。两组术后均有较好的听力。结论：应用耳廓软骨同时修补鼓膜并重建外耳道后壁，是一种较好的治疗慢性化脓性中耳炎的方法，不公能缩短时间，改善听力，而且免除了二次手术，明显改善了患者的生活质量。     

鼓室成形的内耳开窗术:恢复听力的一种辅助方法

本文研究单侧或双侧多次分期鼓室成形术失败的病例,包括鼓室成形术后听力检查仍然不好,缺少听骨链支持的前庭窗手术,前庭窗有纤维性或硬化性病灶,以及严重中耳炎前庭窗、圆窗、后鼓室、鼓隐窝及咽鼓管口感染者。唯一方法是先施行乳突鼓室凿开术,彻底清除病灶,然后为了重建有效听力,分期施行Lempert的水平半规管的迷路开窗术。乳突鼓室凿开术:第一期手术即作者1960年改良的Lempert乳突鼓室凿开术与外耳道耳甲软骨成形术。经耳内或耳后径路的自身闭塞的无移植物乳突根治术腔,可以达到永久性干耳。和Lempert 1949年所描述相同,所有感染病灶均应除去。本手术将颞骨气房结构的内容物彻底清除,使水平半规管轮廓露出,将外耳道底削低至下鼓室底平面,使圆窗、前庭窗区彻底暴露,从鼓膜张肌管部切去感染的鼓膜张肌腱。这种无移植物自行缩小的乳突腔,自行堵塞咽鼓管口。因此手术后术腔变成充满蹼样纤维组     

外耳道后壁重建式乳突切除术和鼓室成形术的临床疗效观察

目的初步探讨在部分乳突腔狭小而需行乳突切除术的慢性化脓性中耳乳突炎(主要为胆脂瘤型和骨疡型及两者兼有的混合型)患者,外耳道后壁重建式乳突切除术在既需彻底清除病灶、又应尽可能多地保留或改善听觉功能方面的临床价值和意义.方法对临床7例因中颅窝底低位和乙状窦壁前位而造成乳突腔狭小的胆脂瘤型和/或骨疡型中耳乳突炎患者,在行乳突切除术中采用外耳道后壁切除和重建技术,最终保持完整的鼓室和外耳道壁,再行Ⅰ期或Ⅱ期鼓室成形术重建鼓室传音结构,手术前后检查听觉功能,与同期进行的12例慢性化脓性中耳乳突炎而行经典的完壁式乳突切除术患者进行对照.结果外耳道后壁重建技术可有效地解决乳突腔狭小患者行完壁式乳突切除术中病灶清除困难、并发症发生率高、易致胆脂脂瘤等病变组织残留或复发等问题.本次观察的全部19例患者在行Ⅱ期鼓室成形术或鼓室探查术中均未发现胆脂瘤复发,术后平均气导听阈较术前明显降低,传导性聋的改善程度两组之间无显著性差异,未发生明显的手术并发症.结论采用外耳道后壁重建技术的完壁式乳突切除术可基本达到与经典的完壁式乳突切除术等同的听觉功能保留与提高效果,故对于有相关适应证患者,应作为常规选择手术方式.Ⅰ期或Ⅱ期鼓室成形术对于提高中耳传音功能(即听力水平)具有重要的临床价值和意义.     

Incidence of vestibular schwannomas.

OBJECTIVE: To determine the incidence of vestibular schwannoma (VS) in Denmark in a period of 191/2 years. STUDY DESIGN: Retrospective review of prospective registered data on all patients with VS operated on by the translabyrinthine, lateral suboccipital, or middle cranial fossa approach, as well as patients who were allocated to the "wait-and-scan" group. METHODS: Charts were reviewed and tabulated for age, extrameatal tumor extension, and date of diagnosis. The available data were divided into three periods: June 1976 to June 1983, July 1983 to June 1990, and July 1990 to December 1995. RESULTS: The number of newly diagnosed tumors in the first period was 278, corresponding to an incidence of 7.8 tumors/million population per year; in the second period 337, corresponding to an incidence of 9.4 tumors/million population per year; and in the third period 355, corresponding to an incidence of 12.4 tumors/million population per year. A significant increase in incidence of the newly diagnosed intracanalicular tumors in the second and third periods was observed. CONCLUSION: The increase in incidence of VS can probably be explained by the awareness among otolaryngologists of the diagnosis of VS and better access to computed tomography and magnetic resonance imaging scans. The observed increase in the diagnosis of the small and intrameatal tumor creates a clinical dilemma, whether to operate on tumors in this early stage or to allocate patients to the wait-and-scan group. This problem will still be relevant in the upcoming years, since the incidence of intrameatal and small VS is expected to increase.     

Nutrient and shunt flow responses to vidian nerve stimulation in nasal and facial tissues of the dog

Summary The potency of parasympathetic vasomotor efferent nerves in controlling blood flow of the face and nose was indicated by the following features attributed to the maxillary artery and their vascular compartments in dogs. Electrical stimulation of the vidian nerve induced a frequency-dependent increase in maxillary flow, which was due to a significant decrease in resistance to flow in nutrient and shunt vessels. Pronounced increases in perfusion rates mainly occurred in evaporative tissues of the nose, in particular the naso-maxilloturbinates and alar fold during vidian nerve stimulation, while those, for example, of the skin remained unchanged. Adrenergic and subsequent cholinergic blockade left the response pattern of maxillary flow to vidian nerve stimulation basically unaffected. Both nutrient and shunt flows contributed to the parasympathetically induced increases in maxillary flow while responses were compartmentalized similar to that found in untreated animals. Apart from sympathetic vasoconstrictor inputs, these results show that cholinergic and non-cholinergic parasympathetic vasodilator inputs contribute to the adjustment of vasomotor tone in the maxillary vascular bed. Offprint requests to: K. Pleschka     

老年期嗓音的生理特征及保健

老年期全身各器官系统发生退行性变化，可影响发声器官的组织结构及生理功能，引起嗓音衰老。该文概述了老年人喉部组织结构、声门外观形态及嗓音生理特征的改变，并阐明老年期嗓音保健的相关措施，有助于区别老年期喉生理性与病理性改变，进行适当合理的老年嗓音功能保护，从而提高老年人群的生活质量。     

Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL) and the French Society of Audiology (SFA) for Speech-in-Noise Testing in Adults

ObjectivesThis document presents the fundamentals of speech audiometry in noise, general requirements for implementation and criteria for choice among the tests available in French according to the health-professional's needs.Material and methodsThe recommendations are based on a systematic analysis of the literature carried out by a multidisciplinary group of doctors, audiologists and audioprosthetists from all over France. They are graded A, B, C or expert opinion according to decreasing level of scientific evidence.ResultsEight tests of speech audiometry in noise can be used in France.ConclusionTo be complete, evaluation of hearing status requires testing understanding of speech in noise. The examination must begin with a minimum of two measurements familiarizing the subject with the test procedure. For initial diagnosis, adaptive procedures establishing the 50% speech reception threshold (SRT50) in noise are to be preferred in order to obtain a rapid and standardized measurement of perception of speech in noise. When the aim is to measure real-life speech comprehension, tests based on sentences, cocktail-party noise and free-field stimulation are to be preferred. Prosthetic gain is evaluated exclusively in free field. This is the only way to evaluate the contribution of binaurality and to measure perception in noise in an environment as close as possible to real life. In order to avoid acoustic interference in free field, at least five loudspeakers should be used, in particular for evaluating the effectiveness of directional microphones, CROS devices enabling sounds picked up in the damaged ear to be rerouted to the functional ear, or bimodal fitting (i.e., when hearing is enabled by two modalities: for example, hearing aid for one ear, cochlear implant for the other).     

Neural activity underlying tinnitus generation: Results from PET and fMRI

Tinnitus is the percept of sound that is not related to an acoustic source outside the body. For many forms of tinnitus, mechanisms in the central nervous system are believed to play an important role in the pathology. Specifically, three mechanisms have been proposed to underlie tinnitus: (1) changes in the level of spontaneous neural activity in the central auditory system, (2) changes in the temporal pattern of neural activity, and (3) reorganization of tonotopic maps. The neuroimaging methods fMRI and PET measure signals that presumably reflect the firing rates of multiple neurons and are assumed to be sensitive to changes in the level of neural activity. There are two basic paradigms that have been applied in functional neuroimaging of tinnitus. Firstly, sound-evoked responses as well as steady state neural activity have been measured to compare tinnitus patients to healthy controls. Secondly, paradigms that involve modulation of tinnitus by a controlled stimulus allow for a within-subject comparison that identifies neural activity that may be correlated to the tinnitus percept. Even though there are many differences across studies, the general trend emerging from the neuroimaging studies, is that tinnitus in humans may correspond to enhanced neural activity across several centers of the central auditory system. Also, neural activity in non-auditory areas including the frontal areas, the limbic system and the cerebellum seems associated with the perception of tinnitus. These results indicate that in addition to the auditory system, non-auditory systems may represent a neural correlate of tinnitus. Although the currently published neuroimaging studies typically show a correspondence between tinnitus and enhanced neural activity, it will be important to perform future studies on subject groups that are closely matched for characteristics such as age, gender and hearing loss in order to rule out the contribution of these factors to the abnormalities specifically ascribed to tinnitus.     

Levels of biological markers of nitric oxide in serum of patients with squamous cell carcinoma of the oral cavity

The aim of the study was a determination of the levels of nitric oxide（NO）and its biological markers such as malonyldialdehyde（MDA）and nitrotyrosine in the serum of patients with squamous cell carcinoma（SCC）of the oral cavity and identification of the relationships between NO and those markers.These studies were performed on patients with SCC of the oral cavity before and after treatment.Griess reaction was used for the estimation of the total concentration of NO in serum.The nitrotyrosine level in serum was assessed with an enzyme-linked immunosorbent assay（ELISA）kit,and MDA level using a spectrophotometric assay.Higher concentrations of NO in blood serum were determined in patients with stage IV of the disease before treatment in comparison to the control group and patients with stages II and III of the disease.Moreover,higher concentrations of MDA and nitrotyrosine were determined in the serum of patients in all stages of the disease in comparison to healthy people.After treatment,lower concentrations of NO in the serum of patients with stage IV of the disease were observed in comparison to the amounts obtained prior to treatment.In addition,lower levels of nitrotyrosine in the serum of patients with all stages of the disease were recorded,whereas higher concentrations of MDA were determined in these patients in comparison to results obtained before treatment.The compounds formed with the contribution of NO,such as MDA and nitrotyrosine,may lead to cancer progression in patients with SCC of the oral cavity,and contribute to formation of resistance to therapy in these patients as well.Moreover,the lack of a relationship between concentrations of NO and MDA,and between NO and nitrotyrosine in serum suggests that the process of lipid peroxidation and nitration in patients with SCC does not just depend on NO.     

Long term follow-up study of laryngeal precancer

The goal of this study was to determine subsequent malignancy on a discrete group of precancerous laryngeal lesions, and to assess the mortality. In a series of 227 patients, average age 51.8 years (ranging from 13 to 80 years). The changes were followed-up for 12.3 years (minimum of 5 years and maximum of 40 years). 58% are living without any sign of premalignant laryngeal mucosal disease, 13% with controlled precancer, and 3% in remission after surgery for carcinoma. 11% died (9% due to cause unrelated to the cancer) and 15% were lost for follow-up. 17% of the group with mucosal hyper- or metaplasia progressed to mild dysplasia, but none progressed to carcinoma. Reinke's oedema recurred in 4%, no malignancy was observed. Carcinoma developed in 16% of laryngeal papilloma (8% in situ and 8% invasive). 15% of mild dysplasia progressed in severity, but none transformed to malignancy. Moderate dysplasia progressed to severe dysplasia in 12%, carcinoma in situ in 4%. Of cases with severe dysplasia 13% developed in situ carcinoma while 43% progressed to invasive cancer. In the whole series progression to severe grade was seen in 7.1%, and malignant transformation in 4.4%. Three patients (1.3%) died due to subsequent carcinoma. Our results agree with some authors; but the majority of them reports higher incidence of malignant transformation. Invasive carcinoma was diagnosed in the follow-up in seven patients. Those represent only 3% of all laryngeal carcinomas diagnosed in our department in the same period of time. Based on the data we have evaluated the intensity of follow-up in patients with hyperplasia, metaplasia, keratosis and mild dysplasia.     

Emerging trends in the performance of parathyroid surgery

OBJECTIVE: The management of hyperparathyroidism has evolved rapidly in the past decade with the introduction of intraoperative parathyroid hormone testing, radioguided surgery, and endoscopic surgery. Not surprisingly, there is a corresponding movement toward specialization of surgeons providing increasingly sophisticated treatments for head and neck endocrine disorders. We sought to identify trends in the disciplines performing parathyroid surgery. DESIGN: Nonrandomized, controlled comparison of surgical caseloads and publication volumes. METHODS AND MATERIALS: Two metrics designed to reflect the proportion of parathyroidectomies being performed by otolaryngologist-head and neck surgeons (OHNS) and general surgeons (GS) were chosen: the operative case logs of graduates from American training programs in OHNS and GS from 1996 through 2005 and the number of scientific papers published relating to parathyroid surgery during two timeframes (1991-1995 and 2001-2005). RESULTS: There was a gradual increase in the mean number of parathyroid surgeries performed by GS residents from 6.0 in 1996 to a peak of 9.2 in 2004; this volume has begun to decline (to 8.5 in 2005). During the same timeframe, the mean number of parathyroidectomies performed by OHNS residents rose sharply and steadily from 1.8 in 1996 to 10.9 in 2005. The number of American GS parathyroid publications from 1991 to 1995 was 41, compared with 108 in the period 2001 to 2005. During the same timeframe, the number of American OHNS parathyroid papers increased from 1 to 27. The relative proportion of parathyroid publications authored by American otolaryngologists rose from 2.4% to 20.0% (P = .006). CONCLUSIONS: Increasingly, otolaryngologists are the primary surgeons in parathyroid operations as indicated by two surrogate metrics. Graduating chief residents in otolaryngology now perform more parathyroid procedures than chief residents in general surgery, and a growing proportion of parathyroid publications are being authored by otolaryngologists.     

鼻后滴漏综合征300例

目的加强对鼻后滴漏综合征的认识,探讨其临床表现与病因之间的关系,并藉此提高诊治水平。方法回顾分析近年本院诊治的300例以鼻后滴漏为主要临床特点而并发慢性咳嗽和咽部各种不适症状的鼻-鼻窦、鼻咽疾病患者的临床表现、治疗及随访结果。结果本组以慢性咳嗽和咽部各种不适为主诉病例均有相关鼻-鼻窦、鼻咽疾病,病程平均20.3个月。其中鼻腔鼻窦疾病243例,包括鼻炎30例(10.0%),变应性鼻炎59例(19.7%),鼻窦炎64例(21.3％),鼻窦炎鼻息肉77例(25.7％),鼻腔鼻窦肿瘤13例(4.3%);鼻咽疾病57例,包括炎性疾病50例(16.7%),肿瘤疾病7例(2.3%)。误诊率达78.7％（236/300）。经过抗感染、抗变态反应治疗以及必要的手术、放疗等处理,290例（96.7%）咳嗽症状消失,10例（3.3%）症状明显好转。随访1年以上,8例（2.7%）复发,重复处理仍有效。结论加强鼻后滴漏综合征的认识是明确诊断、减少误诊、漏诊和指导有效对因治疗的重要措施,规范的常规检查是减少误诊的重要手段,对因治疗为主的综合处理是疗效的保证。     

Detection of macrophage migration inhibitory factor (MIF) in human cholesteatomas and functional implications of correlations to recurrence status and to expression of matrix metalloproteinases-3/9, retinoic acid receptor-beta, and anti-apoptotic galectin-3

OBJECTIVES: To investigate whether the expression of the macrophage migration inhibitory factor (MIF) 1) is detectable, 2) changes in relation to recurrence and infection status, and 3) relates to the levels of expression of growth regulators/differentiation markers, including galectin-1, -3, and -8, retinoid acid receptors (RAR)]-alpha, -beta, and -gamma, binding sites for sarcolectin, and invasion markers (cathepsins -B and -D, and matrix metalloproteinases [MMP]-2, -3, and -9) in human cholesteatomas. STUDY DESIGN: An analysis of 56 cholesteatomas resected by the same surgeon using canal wall up and canal wall down surgical procedures. METHODS: The immunohistochemical levels of expression of MIF and the proteases were quantitatively determined (using computer-assisted microscopy) on routine histologic slides by specific antibodies, and statistically correlated to parameters of the other markers determined previously in conjunction with data on apoptosis/proliferation. RESULTS: MIF expression was detected. It was significantly higher in the epithelium (P =.002) and vessels (P =.04) of the connective tissues (but not in the connective tissue itself) of recurrent as opposed to non-recurrent cholesteatomas. The MIF expression is significantly correlated (P =.006) to the RAR beta expression in non-infected cholesteatomas, and to MMP-3 (P <.01) and anti-apoptotic galectin-3 (P =.01) in infected cholesteatomas. The level of MIF expression was also correlated significantly to MMP-9 (P = 0.003), RAR beta (P <.001), and galectin-8 (P =.003) expression in the cholesteatomas regardless of their infection status. CONCLUSIONS: MIF expression in human cholesteatomas is related to the levels of biologic aggressiveness reflected in their recurrence status and MMP expression, and to the differentiation status reflected in their galactin and RAR beta expressions. Together with galectin-3, it could cooperate to form an anti-apoptotic feedback loop.