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[病例讨论] 耳鸣

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发表于 2019-3-28 00:00:11 | 显示全部楼层 |阅读模式
当没有外部声音时,鸣就是听到声音。[1]虽然经常被描述为铃声,但它听起来也像是咔哒声,嘶嘶声或咆哮声。[2]很少听到不清楚的声音或音乐。[3]声音可能是柔和的,响亮的,低音调或高音调,似乎来自一只耳朵或两者都有。[2]大多数时候,它逐渐出现。[3]在某些人中,声音会导致抑郁或焦虑,并可能干扰注意力集中。[2]

耳鸣不是一种疾病,而是一种可能由多种潜在原因引起的症状。[2]其中一个最常见的原因是噪音引起的听力损失。[2]其他原因包括耳部感染心脏或血管疾病,Ménière病,脑肿瘤,情绪压力,接触某些药物,以前的头部受伤和耳垢。[2] [4]抑郁症患者更常见[3]。

耳鸣的诊断通常基于该人的描述。[3]有一些调查问卷可能有助于评估耳鸣干扰一个人的生命。[3]诊断通常由听力图和神经系统检查支持。[1] [3]如果发现某些问题,可以进行医学成像,例如MRI检查。[3]当耳鸣以与心跳相同的节律发生时,其他测试也是合适的。[3]很少有其他人使用听诊器听到声音,在这种情况下,它被称为客观耳鸣。[3]自发性耳声发射,通常由内耳产生的声音,也可能偶尔导致耳鸣。[6]

预防包括避免大声喧哗。[2]如果存在根本原因,对其进行处理可能会带来改善。[3]否则,通常,管理涉及谈话治疗。[5]声音发生器或助听器可能会帮助一些人。[2]截至2013年,没有有效的药物。[3]这很普遍,影响了大约10-15%的人。[5]然而,大多数人都能很好地容忍它,并且只有1-2%的人会出现这个问题。[5]耳鸣这个词来自拉丁语tinnīre,意为“戒指”。[3]


耳鸣经常会发出响声。

目录
1 症状和体征
1.1 方向
1.2 心理
2 原因
2.1 主观性耳鸣
2.2 目标耳鸣
2.3 搏动性耳鸣
3 病理生理学
4 诊断
4.1 听力
4.2 心理声学
4.3 严重性
4.4 搏动性耳鸣
4.5 鉴别诊断
5 预防
6 管理
6.1 心理
6.2 药物治疗
6.3 其他
6.4 替代医学
7 预后
8 流行病学
8.1 成人
8.2 儿童
9 参考

体征和症状
耳鸣可以在一只耳朵或两只耳朵中或头部中被感知到。它是在没有听觉刺激的情况下对人体头部内部噪声的描述。噪声可以用许多不同的方式描述。它通常被描述为振铃声,但在某些患者中,它采取高音呜呜声,电嗡嗡声,嘶嘶声,嗡嗡声,叮叮当当或吹口哨,滴答声,咔哒声,咆哮声,“蟋蟀声”,“树蛙声”的形式,“蝗虫(蝉)”,曲调,歌曲,哔哔声,嘶嘶声,或类似人类声音的声音,或者甚至是听力测试中听到的纯正稳定音调。[4]耳鸣可以是间歇性的或连续性的:在后一种情况下,它可能是导致极度痛苦的原因。在某些人中,强度可以通过肩膀,头部,舌头,下巴或眼球运动来改变。[7]大多数耳鸣患者有一定程度的听力损失。[8]

感知到的声音可以从安静的背景噪声到即使在响亮的外部声音中也可以听到的声音。被称为脉动性耳鸣的特定类型的耳鸣的特征在于听到自己的脉搏或肌肉收缩的声音,这通常是由靠近耳朵的肌肉运动产生的声音的结果,或者声音与血液有关。颈部或脸部的流动。[9]

方向
由于研究设计的变化,耳鸣过程的数据显示几乎没有一致的结果。一般来说,成年人的患病率随着年龄的增长而增加,而烦恼的评分随着持续时间的增加而减少。[10] [11] [12]

心理
持续性耳鸣可能引起焦虑和抑郁。[13] [14]耳鸣烦恼与心理状况的关联性强于响度或频率范围。[15] [16]抑郁,焦虑,睡眠障碍和注意力不集中等心理问题在有强烈烦恼的耳鸣患者中很常见[17] [18]。 45%的耳鸣患者在其一生中的某个时间患有焦虑症。[19]

心理学研究已经研究了耳鸣窘迫反应(TDR),以解释耳鸣严重程度的差异。[17] [20] [21] [22]这些研究结果表明,在最初的耳鸣感知中,调理将耳鸣与负面情绪联系起来,例如当时令人不快的刺激引起的恐惧和焦虑。这增强了边缘系统和自主神经系统的活动,从而增加了耳鸣意识和烦恼。[23]

原因
有两种类型的耳鸣:主观性耳鸣和客观性耳鸣。[3]耳鸣通常是主观的,这意味着没有其他方法可以检测到声音。[3]主观耳鸣也被称为“耳鸣耳鸣”,“非听觉”或“非振动”耳鸣。在非常罕见的情况下,其他人可以使用听诊器听到耳鸣,并且在不太罕见 - 但仍然不常见 - 的情况下,它可以被测量为耳道中的自发耳声发射(SOAE)。在这种情况下,它是客观的耳鸣,[3]也称为“假性耳鸣”或“振动性”耳鸣。

主观性耳鸣
主观性耳鸣是最常见的耳鸣类型。它可能有许多可能的原因,但最常见的原因是听力损失。当耳鸣是由内耳或听觉神经紊乱引起的时,它被称为耳聋(来自希腊语中的耳朵)。[24]这些神经或神经疾病包括由感染或药物引发的疾病。[25]常见的原因是噪音暴露会损害内耳中的毛细胞。

当似乎没有与内耳或听神经的紊乱有关时,耳鸣被称为非耳聋(即非耳聋)。在大约30%的耳鸣病例中,耳鸣受到体感系统的影响,例如人们可以通过移动他们的脸,头或颈来增加或减少耳鸣。[26]这种类型被称为躯体或颅颈耳鸣,因为只有头部或颈部运动才有效。[24]

越来越多的证据表明,某些耳鸣是中枢听觉通路神经发生改变的结果。假设这些改变是由听力损失导致的感觉输入受到干扰引起的。[27]听力丧失确实会导致中枢听觉系统中神经元的稳态反应,从而导致耳鸣。[28]

听力损失
耳鸣最常见的原因是噪音引起的听力损失。在某些情况下,由于隐藏的听力损失导致大脑的听觉输入减少但听力计没有出现听力损失,因此患有耳聋正常的人仍会出现耳鸣。[28]

听力丧失可能有许多不同的原因,但在耳鸣患者中,主要原因是耳蜗损伤。[27]

耳毒性药物也可引起主观性耳鸣,因为它们可能导致听力丧失,或增加暴露于巨大噪音所造成的伤害。 即使在不被视为耳毒性的剂量下,也可能发生这些损害。[29] 据报道,超过260种药物会导致耳鸣作为副作用。[30] 然而,在许多情况下,没有确定任何根本原因。[2]

由于停止治疗剂量的苯二氮卓类药物,也可能发生耳鸣。 它有时可能是苯二氮卓戒断的长期症状,可能持续数月。[31] [32] 安非他酮等药物也可能导致耳鸣。[33] 然而,在许多情况下,没有潜在的原因可以确定耳鸣。

相关因素
与耳鸣有关的因素包括:[34]

耳朵问题和听力损失:
传导性听力损失
声震
巨大的噪音或音乐[35]
中耳积液
耳炎
耳硬化症
咽鼓管功能障碍
感音神经性听力损失
噪音过大或过大
老年性耳聋(年龄相关性听力损失)
梅尼埃病
内淋巴水肿
上管开裂
听神经瘤
汞或铅中毒
耳毒性药物
神经系统疾病:
Arnold-Chiari畸形
多发性硬化症
头部受伤
颞下颌关节功能障碍
巨细胞动脉炎
代谢紊乱:
维生素B12缺乏症[36]
缺铁性贫血
精神疾病
萧条
焦虑症
其他因素:
血管炎
一些迷幻药物会产生暂时的耳鸣样症状,这是一种副作用
5-的MeO-DET[37]
二异丙基色胺(DiPT)[38]
苯二氮卓戒断[31] [32]
由例如脑炎或脑脊液泄漏引起的颅内高血压或低血压

客观耳鸣
客观的耳鸣可以被其他人检测到,有时是由肌肉或一组肌肉(肌阵挛)的无意识抽搐或血管状况引起的。 在某些情况下,耳鸣是由中耳周围的肌肉痉挛引起的。[9]

自发性耳声发射(SOAE)是在内耳产生的微弱高频音,可以用敏感的麦克风在耳道中测量,也可能引起耳鸣。[6]大约8%的SOAE和耳鸣患者有SOAE相关的耳鸣,[需要引用验证],而SOAE引起的所有耳鸣病例的百分比估计约为4%。[6]

搏动性耳鸣
有些人的脉搏会随着时间的推移而发出声音,称为搏动性耳鸣或血管性耳鸣。[39]脉动性耳鸣通常是客观的,由于血流改变,耳朵附近的血湍流增加,例如来自动脉粥样硬化或静脉嗡嗡声[40],但它也可能由于血流量增加而引起的主观现象。耳。[39]极少数情况下,脉动性耳鸣可能是可能危及生命的疾病的症状,如颈动脉瘤[41]或颈动脉夹层[42]。脉动性耳鸣也可指示血管炎,或更具体地,巨细胞动脉炎。脉动性耳鸣也可能是特发性颅内高压的指征。[43]脉动性耳鸣可能是颅内血管异常的症状,应评估血流不规则的噪音(杂音)。[44]

病理生理学
主观耳鸣的机制通常是模糊的。虽然对内耳的直接创伤可引起耳鸣并不奇怪,但其他明显的原因(例如,颞下颌关节功能障碍)难以解释。

它可能是由听觉脑干中神经活动增加引起的,大脑处理声音,导致一些听觉神经细胞过度兴奋。该理论的基础是许多耳鸣也有听力损失。[8]

2016年的三篇评论强调了耳鸣所涉及的大范围和可能的病理组合,这反过来导致各种各样的症状需要特别适应的治疗。[45] [46] [47]

诊断
如果出现耳鸣,听力学家将进行全面评估,以帮助诊断和治疗症状。在某些情况下,需要转诊给耳鼻喉科医生来诊断可治疗的疾病,如中耳感染,听神经瘤,脑震荡,耳硬化等[48]。

耳鸣的评估可以包括听力测试(听力图),测量耳鸣的声学参数,如音高和响度,以及对与耳鸣严重程度相关的抑郁,焦虑和压力等共病症状的心理评估。

与正常的耳朵噪音经验相比,慢性耳鸣的公认定义是每周至少两次发出五分钟的耳朵噪音。[49]然而,患有慢性耳鸣的人经常比这更频繁地经历噪声并且可以连续地或经常地经历它,例如在夜间当环境噪声较小以掩盖声音时。

听觉学
由于大多数患有耳鸣的人也有听力损失,因此导致听力图的纯音听力测试可能有助于诊断病因,尽管有些耳鸣患者没有听力损失。在听力损失很大的情况下,听力图还可以便于安装助听器。耳鸣的音调通常在听力损失的范围内。

心理声学
耳鸣的声学鉴定将包括几个声学参数的测量,例如在单调耳鸣的情况下的频率或在窄带噪声耳鸣的情况下的频率范围和带宽,在指示频率下的听力阈值以上的响度,混合点和最小掩蔽水平 。[50]在大多数情况下,耳鸣音调或频率范围介于5 kHz和10 kHz之间[51],响度在听觉阈值以上5到15 dB之间。[52]

耳鸣的另一个相关参数是残留抑制,在一段时间的掩蔽后暂时抑制或消失耳鸣。残留抑制程度可能表明耳鸣掩蔽器作为治疗方式的有效性。[53] [54]

也可以对耳鸣的常见伴随[55]进行评估。[56]测量的参数是以dB为单位的响度不适水平(LDL),即在听力频率范围内在指定频率下的急性不适的主观水平。这定义了该频率下的听力阈值和响度不适水平之间的动态范围。在特定频率范围内的压缩动态范围与受试者过度活跃相关。正常听力阈值通常定义为0-20分贝(dB)。正常响度不适水平为85-90 + dB,一些权威机构引用100 dB。 55 dB或更低的动态范围表明过度活跃。[57] [58]

严重
根据其所具有的影响,例如干扰睡眠,安静的活动和正常的日常活动,这种情况通常按照从“轻微”到“灾难”的等级进行评级。[59]在极端情况下,一名男子在被告知无法治愈后自杀。[60]

评估与耳鸣有关的心理过程包括测量耳鸣的严重程度和痛苦(即耳鸣相关问题的性质和程度),通过有效的自我报告耳鸣问卷进行主观测量。[17]这些调查问卷测量了与耳鸣有关的心理困扰程度和障碍,包括对听力,生活方式,健康和情绪功能的影响。[61] [62] [63]对一般功能的更广泛评估,例如焦虑,抑郁,压力,生活压力和睡眠困难的水平,对于耳鸣的评估也很重要,因为这些地区的负面健康风险较高,可能受到或加剧了个人的耳鸣症状。[64]总体而言,目前的评估措施旨在确定个人的痛苦和干扰水平,应对反应和对耳鸣的看法,以便为治疗提供信息并监测进展情况。然而,文献证明了评估方法的广泛可变性,不一致性和缺乏共识,限制了治疗效果的比较。[65]为了指导诊断或对严重程度进行分类,大多数耳鸣问卷已被证明是治疗敏感的结果指标。[66]

搏动性耳鸣
如果检查发现瘀伤(由于血流紊乱引起的声音),应进行经颅多普勒(TCD)或磁共振血管造影(MRA)等成像研究。[67] [68] [69]

鉴别诊断
应排除通常与耳鸣有关的其他潜在声音来源。 例如,两个公认的高音调声源可能是现代布线和各种声音信号传输中常见的电磁场。 模仿耳鸣的常见且经常被误诊的情况是射频(RF)听力,其中受试者已经过测试并且发现听到类似于耳鸣的高音传输频率。[70] [71]

预防


英国政府法规要求保护耳朵的安全标志
长时间接触大声或噪音会导致耳鸣。[72]耳塞或其他措施可以帮助预防。那些在嘈杂环境中工作的人每天都会接受高水平的声音,因此患耳鸣的风险很高。雇主利用听力损失预防计划(HLPP)来帮助教育和预防危险的噪音水平。像NIOSH和OSHA这样的团体帮助制定法规,以确保员工在遵循协议的情况下,对其听觉系统造成永久性损害的风险最小[73]。

有几种药物具有耳毒性作用,并且可以产生累积效应,可以增加噪音造成的伤害。如果必须服用耳毒性药物,医生应密切关注处方细节,如剂量和剂量间隔,可以减少所造成的损害。[74] [75] [76]

管理
如果存在根本原因,对其进行处理可能会带来改善。[3]否则,耳鸣的主要治疗方法是谈话疗法[5],声音疗法或助听器。目前,还没有有效的药物或补品被证明可以有效治疗耳鸣症状[77]。[3]

心理
对耳鸣的最佳支持治疗是一种称为认知行为疗法(CBT)的咨询,可以通过互联网或亲自提供。[5] [78] [66]它减少了那些有耳鸣感觉的压力。[79]这些好处似乎与个体对抑郁或焦虑的任何影响无关。[78]接受和承诺疗法(ACT)也有助于治疗耳鸣。[80]放松技术也可能有用。[3]美国退伍军人事务部已经开发了一种名为渐进性耳鸣管理治疗耳鸣的临床方案。[81]

药物
截至2014年,没有对特发性耳鸣有效的药物。[3] [72]没有足够的证据来确定抗抑郁药[82]或阿坎酸是否有用。[83]虽然有苯二氮卓类药物的初步证据,但它不足以支持使用。[3]截至2015年,褪黑激素的有用性尚不清楚。[84]尚不清楚抗惊厥药是否可用于治疗耳鸣。[3] [85]类固醇注射到中耳也似乎没有效果。[86] [87]没有证据表明使用倍他司汀治疗癌症是有效的。[88]

已尝试注射肉毒杆菌毒素,但在一些罕见的腭部震颤的客观耳鸣病例中取得了一些成功。[89]

在一些国家使用Caroverine来治疗耳鸣。[90]其有用性的证据非常薄弱。[91]

其他
通过助听器或耳鸣掩蔽器使用声音治疗有助于大脑忽略特定的耳鸣频率。虽然这些方法得不到证据支持,但没有负面影响。[3] [92] [93]有一些临时证据支持耳鸣再训练疗法。[3] [94]几乎没有证据支持使用经颅磁刺激。[3] [95]因此不建议这样做。[72]截至2017年,关于神经反馈是否有帮助的证据有限。[96]

替代药物
银杏似乎没有效果。[97]美国耳鼻喉科学会建议不要服用褪黑激素或锌补充剂来缓解耳鸣症状。[72]此外,2016年Cochrane评价得出的结论是,证据不足以支持服用锌补充剂以减少与耳鸣有关的症状。[98]

预测
虽然没有治愈方法,但大多数患有耳鸣的人会随着时间的推移逐渐习惯;对少数人来说,这仍然是一个重大问题。[5]

流行病学
成人
耳鸣影响10-15%的人。[5]大约三分之一的北美人超过55岁经历过耳鸣。[99]耳鸣在其生命中的某个时间影响三分之一的成年人,而10%至15%的人受到足够的干扰以寻求医学评估。[100]

儿童
耳鸣通常被认为是成年期的症状,并且在儿童中经常被忽视。听力损失的儿童耳鸣的发病率很高,即使他们没有表达这种情况或对其生活的影响。[101]儿童一般不会自发报告耳鸣,他们的投诉可能不会受到重视。[102]在那些抱怨耳鸣的儿童中,患有相关的耳科或神经病理学的可能性增加,例如偏头痛,青少年梅尼埃病或慢性化脓性中耳炎。[103]据报道,听力阈值正常的儿童患病率为12%至36%,听力损失儿童患病率高达66%,据报告,约有3-10%的儿童因耳鸣而感到麻烦。[104]

另见
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List of people with tinnitus
List of unexplained sounds
Phantom vibration syndrome
Zwicker tone

参考
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