分泌性中耳炎临床应用指南(2004版修订)

本指南基于循证医学的临床实践指南,为诊断、监测和管理儿童分泌性中耳炎提供建议.文章概括了临床决策建议,各项临床建议之间的关系以流程图(图1)表示.本指南强调合理诊断并对不同的管理策略提供选择,包括观察、医疗干预和转诊进行手术治疗.这些建议提供给初级保健医师和其他卫生保健人员来共同帮助管理儿童分泌性中耳炎.     

咽鼓管吹张器治疗儿童分泌性中耳炎的Meta分析

目的 通过Meta分析系统评价咽鼓管吹张器(Autoinflation)在儿童慢性分泌性中耳炎(OME)临床疗效、依从性、安全性.方法 检索PubMed、OVID、Embase、Cochrane Library、Proquest、Web of Science、中国生物医学文献数据库、万方、CNKI数据库(自建库至202...     

氮气导入中耳腔治疗分泌性中耳炎疗效观察

目的 将氮气(N2)导入分泌性中耳炎患者的中耳腔，希望以此产生并维持长时间的中耳腔正压，达到治疗分泌性中耳炎的目的。方法 用咽鼓管导管吹张法将N2导入20耳分泌性中耳炎患者的中耳腔，用声导抗仪动态观察中耳腔压力的变化，并随访观察患者的症状、体征的变化，判断疗效；将结果与行空气吹张的另20耳分泌性中耳炎作对照组比较。结果 中耳腔在导入N2后能维持较长时间的正压和压力升高。但两组疗效的差别无统计学意义。结论 在治疗分泌性中耳炎时，N2导人中耳腔并未比一般的咽鼓管吹张(空气)显示出更好的疗效。     

Toll-like Receptors 2 and 4 and Their Mutations in Patients with Otitis Media and Middle Ear Effusion

Objectives

Toll-like receptors (TLRs) detect microbial infections and they can directly induce innate host defense responses. TLR 2 has been shown to be primarily involved in the recognition of peptidoglycans and lipoteichoic acid of gram positive bacteria. TLR 4 recognizes lipopolysaccharides and lipoteichoic acids from both gram-negative and gram-positive bacteria. Both mutations lead a reduced capacity to elicit inflammation and they increase the risk for gram-positive and negative infections. This study was performed to investigate the expressions of TLR 2 and 4 and their mutations in patients suffering with otitis media and middle ear effusion.

Methods

Middle ear fluid samples were collected from 40 otitis media effusion (OME) patients who had ventilating tubesinserted. Bacteria in the effusion fluid were detected by standard bacterial culture. The secreted IgG, IgA and IgM were measured by Enzyme-linked immunosorbent assay. TLR 2 and 4 were assessed by performing RT-PCR. The genomic DNA from each patient was isolated from the middle ear fluid samples that were collected from 60 OME patients, and the presence of mutations was determined by performing restriction digestion and DNA sequencing analysis.

Results

Among the 40 middle ear fluid samples, bacteria were detected in 13 middle ear fluid samples. The amounts of IgM, IgA, and IgG were 151.20±60.94 ng/mL, 21.59±7.96 ng/mL and 11.55±16.98 ng/mL, respectively. TLR 2 and 4 were expressed in the middle ear fluid and the expression of TLR 2 was higher than that of TLR 4. However, there was no correlation between the expressions of TLR 2 and 4, and the concentration of immunoglobulin or the presence of bacteria (P>0.05). There ware no mutations of TLR 2 (Arg753Gln, Arg677Trp) and TLR 4 (Asp299Gly, Thr399Ile).

Conclusion

TLR 2 and 4 were expressed in all the middle ear fluid samples of OME, but the mutations of TLR 2 and 4 were not detected. TLR 2 and 4 may play a vital role in the immunological responses of patients with OME.     

儿童分泌性中耳炎相关因素分析

目的探讨儿童分泌性中耳炎(otitis media with effusion,OME)的相关因素。方法回顾性分析357例(698耳)OME患儿的临床资料及其相关因素。结果 357例患儿中133例(37.25%)存在腺样体肥大,89例(24.93%)合并鼻窦炎,76例(21.29%)变应原检测阳性,59例(16.53%)合并细菌、病毒、支原体或/和衣原体感染。采用鼓膜切开或置管治疗并积极对症治疗,357例(698耳)患儿治愈586耳,好转91耳,总有效率为96.99%(677/698),无效21耳(3.01%)。结论腺样体肥大、鼻窦炎、变态反应疾病及细菌、病毒、支原体或/和衣原体感染等可能是儿童OME的相关因素,应引起临床医生的重视。     

Evaluation of the Interleukin-1 Receptor Antagonist and Immunoregulatory Interleukin-10 in the Middle Ear in Chronic Otitis Media With Effusion in Children With and Without Atopy

ObjectivesThe role of pro-inflammatory cytokines in the course of chronic otitis media with effusion (COME) has been documented. However, there are fewer studies on the action of anti-inflammatory cytokines in the middle ear. We sought determine whether there is an association between COME and anti-inflammatory cytokines and whether there are any differences in the cytokine profile in COME children with and without atopy.MethodsEighty-four children were divided into 3 groups: 32 nonatopic children with COME (group NA), 31 atopic children with COME (group A), and 21 children without COME and without atopy (control group C). Specimens from the middle ear were collected and evaluated by enzyme-linked immunosorbent assay for the cytokines interleukin-1 receptor antagonist (IL-1Ra) and immunoregulatory IL-10.ResultsSignificantly higher IL-10 concentrations were found in both nonatopic and atopic children with COME compared to controls. No significant differences in IL-1Ra levels were found between atopic and nonatopic children with COME and the control group.ConclusionWe found no differences in the levels of IL-1Ra in atopic and nonatopic children with COME compared to controls. However, we found elevated IL-10 levels in the middle ear effusions from children with COME, with or without atopy. These elevated immunoregulatory cytokine levels suggest a role for new immunomodulatory treatments to prevent disease progression in COME, regardless of atopy.     

Endoscopic Adenoidectomy in Children With Otitis Media With Effusion and Mild Hearing Loss

ObjectivesSurgical management of children with chronic otitis media with effusion (OME) includes tympanostomy tube insertion or adenoidectomy, alone or with myringotomy and tube insertion. The aim of this study was to compare the effectiveness of transoral microdebrider endoscopic-assisted adenoidectomy (TOMEA) and traditional adenoidectomy in the management of children with mild hearing loss due to OME and chronic adenoiditis.MethodsThis prospective, double-blind and controlled study involved 120 consecutive patients aged 4–12 years, who were randomised 1:1 to undergo TOMEA or traditional adenoidectomy under general anesthesia. All the patients underwent a complete otolaryngological examination, including nasopharyngeal fibre endoscopy (NFE), pneumatic otoscopy, otomicroscopy, tympanometry and supraliminar tonal audiometry, upon enrolment, and three and nine months postoperatively.ResultsThere were no statistically significant differences in age or gender distribution between the TOMEA group (mean age, 4.9±1.1 years; 53.3% males) and the traditional adenoidectomy group (mean age, 5.3±0.9 years; 56.7% males). Both procedures led to a significant improvement in choanal patency (P<0.01) and all of the otological and audiological parameters (P<0.01) 3 and 9 months postoperatively, although postoperative NFE showed that the mean percentage of residual choanal obstruction was significantly less in the TOMEA group (P=0.02). There was no significant between-group difference in the percentage of children with tympanic membrane changes, but the postoperative prevalence of children with a type B tympanogram was significantly lower in the TOMEA group after 3 (15.0% vs. 31.7%, P=0.05) and 9 months (18.3% vs. 38.3%, P=0.02), as was the percentage of children with mild conductive hearing loss (3.3% vs. 23.3%, P<0.01; and 8.3% vs. 28.3%, P<0.01).ConclusionAlthough both TOMEA and traditional adenoidectomy are effective in treating children with mild hearing loss due to adenoidal hypertrophy and OME, the former achieves the greater reduction in residual adenoidal hypertrophy and better audiological outcomes.     

中药“二黄”滴耳剂治疗急慢性化脓性中耳炎的临床观察(附1000例分析)

本文总结了“二黄”滴耳剂治疗急慢性中耳炎1000例，结果表明总有效率为89％，尤其对急性化脓性中耳炎效果更为明显，与其它抗生素相比具有很多优点。抗菌谱广，对革兰氏阳性菌及革兰氏阴性菌、病毒都有一定作用，低浓度抑菌，高浓度杀菌，不易产生抗药性及过敏反应，对第八对脑神经无毒性，价格低廉应用方便优于任何一种抗生素。     

Relationship Between Severity of Middle Ear Mucosal Lesion and Middle Ear Pneumatic Space Volume in Patients with Otitis Media with Effusion

If we assume that the state of suppression of pneumatic cells is the result of suppression of pneumatic cell growth by inflammatory stimulation in the middle ear pneumatic space, it is possible to improve the state of suppression by performing sufficient treatment during the growth period of the pneumatic cells. We indwelt a tympanic membrane ventilation tube (hereinafter referred to as tube) for treatment of otitis media with effusion (OME) in child patients aged 3-13 years and investigated the following points: i) relationship between the severity of inflammation of the lamina propria of middle ear mucosal specimens (hereinafter referred to as lamina propria) collected at the time of tube indwelling and the degree of growth of the pneumatic space; and ii) changes in the pneumatic space associated with treatment by tube indwelling, which was studied by comparing the above-described mucosal severity with the pneumatic space area of 2 years after tube indwelling, and with increase in the pneumatic space volume measured periodically after tube indwelling. The results indicated that mastoid cell growth suppression is higher in patients with a higher degree of inflammatory changes in the lamina propria. In association with treatment by tube indwelling, effusion accumulated in the pneumatic space and mucosal swelling disappeared early after the treatment, or 2 months of tube indwelling. After that, in patients with severe mucosal lesion, a long time, 1.5-2 years, was found to be required for repneumatization accompanying regrowth of the temporal bone. We confirmed that the severity of inflammation of the lamina propria is deeply involved in the growth and repneumatization of the pneumatic cells.     

A Comparative Study of Azithromycin and Pseudoephedrine Hydrochloride for Otitis Media with Effusion in Children

We compared the outcomes of two different regimens azithromycin and pseudoephedrine hydrochloride (PHCl) for the treatment of otitis media with effusion (OME) in children. In a double-blind randomized clinical study, a total of 90 children aged between 2 and 13 years with persistent OME were randomly assigned to one of 3 treatment groups. The first group received azithromycin at a dose of 10 mg kg once daily for 3 days and this regimen was repeated weekly for up to 12 weeks according to the results of tympanometry and pneumatic otoscopy. The second group received azithromycin at a dose of 10 mg kg once daily for 3 days for the first week, and this regimen was repeated for 1 day a week for the following 11 weeks. The third group received PHCl, 4 mg kg, 3 times daily for up to 12 weeks. Each patient underwent pneumatic otoscopic and tympanometric investigations at baseline and at Weeks 4, 8 and 12. The outcomes in the azithromycin-treated groups were superior to that in the decongestant group. However, the difference between the outcomes in the azithromycin groups according to the treatment protocol was not statistically significant. Azithromycin therapy, particularly a once-weekly regimen, helps patients to comply with treatment and also helps us to achieve good results with minimal therapy.     

Management for the Children with Otitis Media with Effusion in the Tertiary Hospital

Objectives

Recently, new evidence-based recommendations have been introduced for diagnosing and managing otitis media with effusion (OME) in children. However, there are some difficulties to follow the general guidelines in the tertiary hospitals. The purpose is to evaluate the efficiency of antibiotics or antihistamines for treatment of children with OME in the tertiary hospital with a randomized prospective clinical study.

Methods

Eighty-four children with OME who had been diagnosed in the tertiary hospital were randomized to receive 5 different medications for 2 weeks. We prescribed antibiotics (amoxicillin-clavulanate syrup) in Group I (n=16), antibiotics/steroids (prednisolone) in Group II (n=18), antibiotics/antihistamines (ebastine) in Group III (n=15), antibiotics/steroids/antihistamines in Group IV (n=17), and mucolytics (ivy leaf extract) in Group V (n=17) for control. We followed-up children every 2 weeks and evaluated the state of OME at 3 months.

Results

Thirty six (42.9%) of 84 children were resolved within average 6.9 weeks after the treatments. Thirty-six (42.9%) were treated with ventilation tube insertion and 12 patients (14.3%) were observed. There was no difference in the resolution rates of OME among the five different protocols (P>0.05). There was no difference in the resolution rates among groups who used steroids, antihistamines, steroids and antihistamines, or other medications to manage 42 children with allergies (P>0.05).

Conclusion

In the tertiary hospital, the cure rate of children with OME was not as high as well-known, and antibiotics or anti-allergic medications were not more effective than control. We may, therefore, need any other guidelines which are different from the previous evidence-based recommendations, including early operation in the tertiary hospitals.     

分泌性中耳炎中耳积液免疫复合物和抗核抗体测定

４０例（４５耳）中耳积液分别用聚乙二醇沉淀法测免疫复合物（ＩＣ）和荧光显微镜法检测抗核抗体（ＡＮＡ）。结果显示ＩＣ的Ａ值均大于正常人的血清阈值０．１２，波动范围在０．１２４～０．５１２。ＡＮＡ阳性者３２耳，占７１．１％。可以认为，免疫复合物的沉积损伤中耳粘膜是造成中耳积液的重要致病原因。     

咽鼓管测压对儿童分泌性中耳炎疗效评估的价值

目的 探讨儿童分泌性中耳炎(otitis media with effusion,OME)治疗前后咽鼓管测压(tubomanometry,TMM)对预测OME预后的价值.方法 66例(98耳)OME患儿(中耳炎组,其中单耳34例,双耳32例)分别在治疗前及正规药物治疗后1月内进行声导抗和TMM测试,记录鼓室导抗图类型及咽鼓管评分(eustachian tube scores,ETS)值,并比较二者之间关系,以单耳患者的正常耳(34耳)作为正常对照组.结果 治疗前,中耳炎组ETS平均值(2.27±1.98分)低于正常对照组(5.14±0.98分)(P＜0.01),鼓室导抗图B型耳的ETS平均值(1.70±1.68分)低于C型耳(3.02±2.11分)(P＜0.01).治疗后中耳炎组ETS平均值(3.62±1.85分)显著高于治疗前(P＜0.05),但治疗后鼓室导抗图B型耳的ETS平均值(3.58±1.69分)与C型耳(3.98±1.45分)差异无统计学意义(P＞0.05),B型耳的ETS提高值(1.84±1.7分)高于C型耳(0.72±0.03分)(P＜0.05).无论B型耳还是C型耳,有效组治疗前后ETS平均值及治疗前后ETS差值均高于无效组(P＜0.01).结论 儿童分泌性中耳炎患耳治疗后ETS值提高,咽鼓管功能改善;治疗前鼓室导抗图B型耳的ETS值较C型耳低,治疗后B型耳的ETS提高值高于C型耳;TMM可为临床评估儿童OME预后提供一定参考.     

Impact of Sulphurous Water Politzer Inhalation on Audiometric Parameters in Children with Otitis Media with Effusion

Objectives

The positive effects of spa therapy on ear, nose, and throat pathology are known but robust literature in this field, is still lacking. The aim of this study was to assess through a retrospective analysis, the effects on otitis media with effusion of Politzer endotympanic inhalation of sulphurous waters in children aged 5-9 years.

Methods

A cohort of 95 patients was treated with Politzer insufflations of sulphurous water: 58 patients did a cycle consisting of a treatment of 12 days per year for three consecutive years; 37 patients followed the same procedure for 5 years consecutively. The control population was represented by untreated, age-matched children. A standard audiometric test was used before and after each cycle of treatment.

Results

One cycle of Politzer inhalation of sulphur-rich water improved the symptoms. Three cycles definitively stabilized the improvement of hearing function.

Conclusion

Our results show that otitis media with effusion in children can be resolved by an appropriate non-pharmacological treatment of middle ear with sulphur-rich water.     

A Model of Spontaneous Chronic Otitis Media with Effusion in Mice with ENU Induced Mutations

Background Chronic otitis media (COM) is a significant clinical problem. Understanding the mechanisms of COM is critical for its control and treatment. However, little is known of the processes leading to COM as a result of lack of animal models of N-ethyl-N-nitrosourea (ENU) induced mutations in otitis media with effusion (OME). Methods Otoscopy and auditory brain response(ABR) evaluation were carried out under sedation in Nmf391 nmf/nmf mice of 2, 4, 6 and 8 months of age. The mice were killed for study of middle and inner ear pathology. Results Tympanic membrane visualization and ABR thresholds in 1- to 8-month-old Nmf391 nmf/nmf mice showed spontaneous OME and inner ear diseases in approximately 100% of the animals.The significant elevation of ABR thresholds suggested a sensorineural component in hearing loss in addition to the conductive loss. Middle and inner ear histology showed various degrees of outer hair cells loss and middle ear inflammation in all the mice, but no inflammation cells in the inner ear. The ABR threshold at 32 kHz was significantly elevated. Conclusions This study shows histopathologic changes in the Nmf391 nmf/nmf mouse model of COM with effusion that have not been reported in human COM. This ENU induced mutation model of COM will be valuable for the characterization of middle ear inflammation and inner ear disease processes that are induced by middle ear infections. We propose that COM with effusion in this ENU induced mutation model is the cause of the cochlea hair cells damage.     

口服和鼓室内注射糖皮质激素治疗分泌性中耳炎的疗效观察

目的 探讨口服和鼓室内注射糖皮质激素治疗分泌性中耳炎(otitis media with effusion,OME)的疗效.方法 选择84例病程在8周之内的OME患者(8～56岁)为研究对象,在进行鼓室穿刺抽液及口服抗生素的基础上,随机分成A组,30例34耳,予小剂量短疗程口服泼尼松治疗;B组,30例32耳,予地塞米松鼓室内注射2～4次;C组,24例26耳,口服抗生素,鼓室穿刺抽液.疗程结束后随访3个月.结果　A、B两组分别有70.6%和53.1%的患耳在一周内有不同程度好转.治疗一个月后,A、B、C三组的总有效率分别为88.2%(30/34耳)、90.6%(29/32耳)和69.2%(18/26耳);A组与B组总有效率比较差异无统计学意义(P>0.05),但A、B两组与C组总有效率比较差异有统计学意义(P<0.05).结论 口服或鼓室内注射糖皮质激素均为治疗OME的有效方法.     

The Evaluation of Oxidative Stress in the Serum and Tissue Specimens of Patients With Chronic Otitis Media

Objectives

To underline the effect of oxidative stress in chronic otitis media with and without cholesteatoma and to compare the oxidative stress values in the serum and tissue specimens in these two forms.

Methods

The study included a total of 75 individuals, 35 cases with chronic otitis media (COM; 16 females and 19 males) and a healthy control group of 40 cases (20 females and 20 males). The COM patient group was comprised of 18 patients with cholesteatoma and 17 patients without cholesteatoma. All patients underwent mastoidectomy. Serum specimens were taken prior to surgery and diseased tissue specimens from the ear were obtained during surgery from all patients. Only serum specimens were taken from the healthy control cases. The malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GHPx) were measured in the serum and tissue samples of the patient group and in the serum specimens of the control group.

Results

The age ranged from 14 to 48 years in the patient group (mean age, 20.4±12.2 years) and from 19 to 40 years in the control group (mean age, 26.4±4.64 years). When the serum values of all COM patients were compared with those of the control group, in the patient group MDA, which reflects lipid peroxidation, was found to be significantly higher (P<0.01) whereas the antioxidant enzymes SOD, CAT, and GHPx were found to be significantly lower (P<0.01). When the serum and tissue MDA, SOD, CAT, and GHPx values in patients with and without cholesteatoma were compared, no significant difference was found these parameters (P>0.01).

Conclusion

Although oxidative stress plays a role in the pathogenesis of COM with or without cholesteatoma, it may not reflect the severity of the disease. In patients with COM, the evaluation of only serum oxidative stress values without tissue evaluation may be sufficient for assessing oxidative stress.     

Association of Otitis Media With Effusion and Allergy as Demonstrated by Intradermal Skin Testing and Eosinophil Cationic Protein Levels in Both Middle Ear Effusions and Mucosal Biopsies

This study was performed to ascertain the role of allergy, as defined by skin testing and histochemical markers, in the pathogenesis of otitis media with effusion (OME). A historical perspective of allergy as it relates to OME is presented. The study included 89 patients: 48 with persistent effusion but no recent acute infection, 25 with purulent OME complicated by a superimposed infection, and 16 control subjects. All 89 patients had persistent effusion for more than 2 months and subsequently required the placement of tympanostomy tubes. Allergy was defined using the radioallergosorbent test (RAST), serum immunoglobulin E (IgE) levels, and skin tests. Allergies were present in 97% of the patients with nonacute OME. The relationship between allergy and OME was corroborated clinically in 89% of patients and was also substantiated by elevated levels of effusion eosinophil cationic protein (ECP) in 87.5% of OME patients. Histologically, polyclonal antibody staining for ECP demonstrated the presence of eosinophils in middle ear mucosal biopsy specimens. This study confirms that OME is a sign of allergic inflammation in the middle ear that is associated with an increase in eosinophils and a concomitant release of ECP into the effusion in individuals with allergy demonstrated by skin testing.