中耳炎HRCT诊断与术中诊断符合率对比研究.docx

1、中耳炎HRCT诊断与术中诊断符合率对比研究耳鼻咽喉头颈外科专业临床医学专业学位论文中耳炎HRCT诊断与术中诊断符合率对比研究中山大学附属第三医院耳鼻咽喉头颈外科硕士研究生： 韩正理导 师： 张官萍 教 授论文评阅人： 钟刚毅 教 授许耀东 副教授答辩委员会主席： 郭梦和 教 授委员： 谢民强 教 授郑亿庆 教 授陈锡辉 教 授刘 贤 副教授2007年6月1日 广州中耳炎HRCT诊断与术中诊断符合率比较研究专 业： 耳鼻咽喉头颈外科硕士研究生： 韩正理指导 教师： 张官萍 教 授 中 文 摘 要研究目的：1.通过对中耳炎病人术前的颞骨高分辨率CT（High resolution CT,HRCT）

2、影像学诊断与术中诊断符合率的对比分析，探讨HRCT对中耳炎症性病变的诊断价值。2.研究不同重建方法对中耳炎症性疾病影像学诊断准确率的影响。病例与方法：1.按入选标准选取的中山大学附属第三医院耳鼻咽喉头颈外科2004年1月到2006年6月收治的共124例资料完整的慢性化脓性中耳炎住院手术患者纳入研究对象。按中耳炎的分类分型（2004年，西安）标准分为两组：A组 鼓室成型术组78例91耳，B组 乳突病变切除术（伴或不伴鼓室成形术）组48例50耳。2.分别记录两组病例的性别、年龄、耳别、病程、症状、穿孔部位、平均语频听阈（骨导、气导）、平均语频听阈骨气导差、手术方式、术中所见。术中所见按不同手术组不

3、同记录：A组 鼓室成型术组：听骨链是否有病变（锤骨、砧骨、镫骨上部结构、镫骨足板、锤砧关节、砧镫关节）、盾板结构是否破坏、后鼓室有无新生物、新生物性质、面神经管鼓室段是否破坏、颈静脉球是否高位。B组 乳突病变切除术组：乳突气化程度、乙状窦是否前置、硬脑膜是否低位、盾板是否破坏、鼓室天盖是否破坏、面神经管是否破坏、外半规管是否破坏、听骨链是否有病变（锤骨、砧骨、镫骨上部结构、镫骨足板、锤砧关节、砧镫关节、听骨链有无断离、移位、粘连、固定等）、后鼓室有无病变、新生物性质。3.根据术中所见为诊断的最后标准，对比不同的影像学三维重建方法对中耳病变显示的准确程度，分析比较术前影像学检查与术中病变所见的符

4、合状况，探讨高分辨率颞骨CT对中耳炎患者中耳病变诊断准确性。结果： 1.HRCT能准确地显示中耳乳突骨性解剖结构变异，并对听骨链的病变程度做出准确判断。对中耳乳突的病变范围及解剖结构异常的诊断有助于术者在术前对手术的径路和方式的选择，并能对手术安全性及手术预后的评估提供参考依据。2.HRCT独立工作站具有强大的后处理功能。不同的重建方法在显示解剖结构变异、听骨链状态、病变范围、新生物性质方面各有优势。采用多层螺旋CT行多平面重建，不仅能分辨中耳内细微结构，还可以充分利用容积扫描的优势，通过任意调整重建平面方向，获取冠状位、矢状位、斜冠状位、斜矢状位等任意角度和平面的图像，能较为完整的显露听骨链

5、，为临床医生提供了足够丰富的图像资料。3.结合不同的成像方式，HRCT对锤骨、砧骨和锤砧关节的显示率为100，对镫骨上部结构和砧镫关节的显示率分别为83.33和89.74，显示满意，但对镫骨足板显示率低，为7.69。HRCT对听骨链结构显示一致性的kappa值分别为锤骨0.5950，砧骨0.8286，镫骨上部结构0.7274，锤砧关节0.5645，砧镫关节0.6571。对解剖结构变异kappa值分别为乙状窦前置为0.5020，颅中窝低位为0.4603。结合间接征象，HRCT对中耳乳突病变面神经管的kappa值为0.5543，外半规管瘘的kappa值为0.6761，鼓室天盖的kappa值为0.4

6、595，盾板的kappa为0.5177。对新生物性质的判断的kappa值为0.4425，对后鼓室有无病灶的kappa值为0.5514，表明HRCT对上述结构诊断与术中所见对照趋于一致性。结论：1. HRCT对中耳乳突解剖变异、病变累及范围、听骨链破坏程度诊断价值较大，对镫骨足板的显示、无临床症状面瘫的面神经管轻微破坏、新生物性质的判断应密切结合听力学和术中所见，综合分析。2.HRCT对中耳乳突的病变范围及解剖结构的异常的判断准确，有助于术者在术前对手术的径路和方式的选择，并能对手术安全性及手术预后的评估提供参考依据。关键词：慢性化脓性中耳炎， 高分辨率CT， 颞骨，比较研究The compar

7、ative study for diagnosing accordant rate between HRCT diagnosing and mid-operation finding Major： OtolaryngologyName： Han ZhengLiSupervisor：Zhang GuanPingABSTRACTObjective：1. Through comparative analysis for diagnostic accordant rate between HRCT imaging diagnosing of temporal bone preoperative and

8、 mid-operation finding, to explore the diagnostic value of HRCT to middle ear inflammation pathological changes. 2. To explore the accurate effect of imaging diagnosis by different reconstructing methods to middle ear inflammation disease.Materials and Methods:1. According to diagnostic criteria, 12

9、4 patients of chronic suppurative otitis media of intact data were enrolled. These patients were from inpatients of the department of otolaryngology-head neck surgery of Sun Yat-sen University third affiliated hospital from January, 2004 to June, 2006. The patients were divided into two groups accor

10、ding to the standard of classification and typing of Otitis Media (2004, XiAn) : A group tympanoplasty: 78 patients 91 ears, B group mastoidectomy(accompany or without tympanoplasty ): 48 patients 50 ears.2. The patients condition was recorded: including general condition (sex, age, the side of ear)

11、, course of disease, symptom, position of eardrum perforation, average auditory threshold of language frequency (bone-conduction, air-conduction), gap of bone-air conduction of average auditory threshold of language frequency, style of operation, mid-operation findings. The mid-operation condition a

12、re recorded according to different type of operation: A group tympanoplasty: pathological changes of ossicular chain (malleus, incus, superstructure of stapes, pedal plate of stapes, joint of malleus-incus, joint of incus-stapes), destroying of scute , neoplasm of post cavum tympani, nature of neopl

13、asm, destroying of tympanic segment of facial nerve canal, superior position of bulbus wenae jugularis. B group mastoidectomy: degree of mastoid gasification, fore-lying of sigmoid sinus, low-set of cerebral dura mater, destroy of scute , destroy of cavum tympani baldachin, destroy of facial nerve b

14、one canal, destroying of lateral semicircular canal, pathological changes of ossicular chain (malleus, incus, superstructure of stapes, pedal plate of stapes, joint of malleus-incus , joint of incus-stapes, disjunction, shift, conglutination, fixed of ossicular chain), pathological changes in post c

15、avum tympani ,nature of neoplasm.3 Basis of mid-operation finding, as it was final diagnosis standard .The different imaging ways of three-dimensional reconstruction were contrasted on accurate degree for middle ear pathological changes diagnosis. The accordant rate of the preoperative imaging inves

16、tigation and mid-operation pathological change finding were compared and analysed. The purpose was to explore the accurate diagnose of the middle ear pathological changes by HRCT of temporal bone.Results：1. HRCT can demonstrate osseous variation of anatomic structure of middle ear mastoid process an

17、d to judge pathological changing of ossicular chain. The judged of extent of disease of middle ear mastoid process and abnormal of anatomic structure can help to select for path and way of operation and to evaluate for security and prognostic of operation.2. Stand-alone workstation of HRCT has power

18、ful after-finishing function. The different reconstruction methods have severally advantage for demonstrated on anatomic structure variation, state of ossicular chain, extension of disease, nature of neoplasm. Multi-planar are reconstructed by multilayer-spiral CT, not only can tell the difference o

19、f minute structure in middle ear, but also make use of advantage of volume scanning. We will get image of arbitrarily angle and planar of coronary , anteroposterior axes, inclined coronal, inclined anteroposterior axes through to adjust orientation of reconstructing plane. This can provide abundantl

20、y image data for clinician.3. Bonding to different imaging modality, HRCT can distinctly display malleus , incus and joint of malleus-incus for 100%, superstructure of stapes and joint of incus-stapes for 83.33 and 89.74 respectively. But HRCT was lower for pedal plate of stapes. Only it is 7.69%. T

21、he coincidence indicator-Kappa of ossicular chain structure by HRCT display were 0.5950 for malleus, 0.8286 for incus, 0.7274 for superstructure of stapes ,0.5645 for joint of malleus-incus, 0.6571 for joint of incus-stapes, respectively. The Kappa of anatomic structure variation were 0.5020 for for

22、e-lying of sigmoid sinus ，0.4603 for low-set of middle cranial fossa respectively. Binding to indirect sign. The kappa of pathological changes of middle ear and mastoid were 0.5543 for canal for facial nerve ，0.6761 for Semicircular canal fistula， 0.4595 for baldachin of cavum tympani，0.5177 for scu

23、te , respectively. The kappa was 0.4425 to judge nature of neoplasm and the kappa was 0.5514 to judge infection focus in post cavum tympani. Above datum shown that mid-operation diagnosing and HRCT diagnosing for anatomical abnormity and pathological changing of middle ear and mastoid were consisten

24、cy.Results：1. The different reconstructed method effect on judged pathological changing of middle ear mastoid process: HRCT shown high value to anatomy variation of middle ear mastoid process, extension of pathological changes, destroying degree of ossicular chain. If analysis were to band with audi

25、ometric result and mid-operation finding, It would been very good for displaying of pedal plate of stapes、little destroy on facial nerve canal without clinical facial palsy symptom, nature of neoplasm.2. HRCT can judge pathological changes of middle ear mastoid process and abnormal of anatomic struc

26、ture. The HRCT image data help to select of paths and ways of operation and to consult for security and prognostic evaluating of operation. Key words：chronic suppurative otitis media ，high resolution CT，temporal bone，control study目录中文摘要IABSTRACT.IV目录.VIII引言1第1章 材料与方法 5 1.1研究对象51.2 一般资料51.3研究方法61.4 判

27、断标准71.5统计分析8第2章 HRCT对解剖结构变异诊断符合率的对比分析92.1 解剖结构变异的影像学标准92.2 结果.122.3 讨论.13第3章 HRCT对听骨链病变诊断符合率的对比分析143.1 听骨链的解剖.143.2不同三维重建方法对听骨链显示的比较.153.3 结果.183.4 讨论.19第4章 HRCT对中耳炎症性病变导致中耳及邻近结构破坏诊断符合率的对比分析.224.1 面神经管病变.224.2 外半规管病变（迷路瘘管）.294.3 鼓室天盖病变.334.4 盾板病变.354.5 后鼓室病变.37第5章 HRCT对新生物性质诊断符合率的对比分析.405.1 新生物成像.40

28、5.2结果.415.3讨论.41结论 存在的问题与展望44参考文献.45缩略词.48附录.49致谢.52个人简历.53原创性声明.54引言慢性化脓性中耳乳突炎（chronic suppurative otitis media，CSOM）是中耳乳突腔粘膜、骨膜或深达骨质的慢性化脓性炎症性病变，常累及中耳乳突腔肌肉、韧带、听小骨、骨性间隔，重者可累及邻近结构如乳突段面神经骨管、内耳半规管、耳蜗及鼓室、鼓窦盖、乙状窦前壁的骨质破坏，引起不同程度的颞骨内及颅内外的并发症。本病是耳科的常见病和多发病，因地域、经济发展和卫生状况与卫生教育普及程度不一，发病率差异很大。慢性化脓性中耳炎多因急性化脓性中耳炎未

29、及时治疗或用药不当、机体抵抗力差、致病菌毒性过强致中耳炎症迁延不愈。常见致病菌多为变形杆菌、绿脓杆菌、大肠杆菌、金黄色葡萄球菌等，其中革兰阴性杆菌较多见，常合并两种以上细菌混合感染。慢性化脓性中耳炎根据病理及临床表现，传统上分为三型：单纯型、骨疡型和胆脂瘤型。随着现代医学的迅猛发展，传统的慢性化脓性中耳炎的分型沿用至今已不能完全适应临床的需要。陈锡辉等研究了978例中耳炎住院手术患者中1 ，手术1002耳，发现术前根据临床资料诊断为单纯型的302耳中，术中发现伴有不同程度的骨质破坏合并肉芽组织、胆脂瘤形成为10.93（43/302）；骨疡型238耳中，发现有胆脂瘤并存的为16.81（40/238）；胆脂瘤型462中，仅在425耳中证实有胆脂瘤的存在，误诊率为8.02，而其余胆脂瘤病例几乎都有肉芽组织合并存在。因骨疡型和胆脂瘤型常可同时合并存在，故本研究为了便于影像学诊断和术中客观诊断的比较分析研究，按中华医学会耳鼻咽喉科分会2004年05月在陕西省西安市召开